Separating Truth from Fiction: Dispelling the Myth of "Benzo Addiction."
Benzodiazepines, or "benzos," as they are colloquially known, are a class of prescription drugs extensively used to treat anxiety, sleeplessness, epilepsy, and other related illnesses. Common trade names in the US are Xanax, Klonopin, Ativan, Diazepam, and Temazepam. In 2015, about 12.5% of the US population used benzodiazepines and 25.7 million adults received benzos from outpatient retail pharmacies, while in 2020, 90 million prescriptions were dispensed (1,2).
Benzodiazepine use is generally recommended for no more than two to four weeks due to the hazards of physical dependence and loss of effectiveness; nonetheless, half of the patients prescribed benzodiazepines in 2020 took them for two months or longer, and nearly a third took them for five months or more (2).
Extended use of benzodiazepines can lead to tolerance and physical dependence due to the body's adjustment to the substance and reliance on it to function normally. If the medication is abruptly discontinued or reduced, the body reacts with physical withdrawal symptoms including anxiety, panic, and insomnia. In fact, discontinuing benzodiazepines can cause more than 200 recorded symptoms (3). Regrettably, doctors, federal organizations, and society often mislabel this physical dependence as “addiction” or “Substance Use Disorder,” to use the new and less stigmatizing term.
People who use these medications as directed are, unfortunately, being greatly harmed by the prescribing of benzodiazepines for extended periods and the medical community's tendency to misdiagnose tolerance and physical dependence as addiction. For decades, both benzodiazepine users and practitioners have voiced concerns about this misclassification, as it not only stigmatizes patients but also often leads to ineffective and sometimes hazardous treatment protocols. These may include abrupt discontinuations, inappropriate transitions to a different benzodiazepine, and rapid discontinuations over a few days to weeks for those who want to cease their benzodiazepine use.
Benzodiazepine misuse, abuse, and addiction are infrequent occurrences among prescription users, but when they do occur, they are often linked to adolescents and young adults, as well as individuals who use other substances like opiates, alcohol, or cocaine.
Here are four compelling reasons why the physical dependence fostered by taking prescribed benzodiazepines should not be labeled “addiction.”
1. Benzodiazepine use disorder is uncommon among benzodiazepine users.
According to a recent nationwide survey on benzodiazepine use, just 1.5% of persons who used benzodiazepines met the criteria for benzodiazepine use disorders (1).
The Substance Abuse and Mental Health Services Administration conducted a survey on benzodiazepine use among US adults in 2015-2016, finding that an estimated 30.5 million adults had used benzodiazepines in the previous year, with 83% (25.3 million) taking the medication exactly as prescribed by a medical professional. Of the remaining 17% (5.2 million), the majority (70%) reported using the medication for relaxation, tension relief, or sleep, while only 12% reported using it to get "high/hooked."
The authors state that benzodiazepine use is widespread, and “misuse appears related to attempts to relieve symptoms of tension or to help with sleep, suggesting that improved treatment of these symptoms might decrease benzodiazepine misuse” and that “benzodiazepine use disorders [read addiction] are relatively rare among benzodiazepine users."
2. According to the DSM-5, symptoms of tolerance and withdrawal do not imply addiction.
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a guide used by mental health professionals to diagnose and categorize mental illnesses, the mere presence of tolerance and withdrawal symptoms, indicating physical dependence, is not enough to diagnose addiction in patients receiving medical treatment for an underlying condition, as stated in the 2013 revision (4).
Prolonged use of benzodiazepines can lead to a neuroadaptation process in the brain, resulting in tolerance and physical dependence. (Neuroadaptation is the process by which the nervous system, including the brain, adapts to changes in its environment or to the presence of a drug or substance. This adaptation can result in changes in the structure and function of the different parts of the brain and nervous system.) Tolerance refers to the body's requirement for higher dosages of a substance to achieve the same effect, which can arise due to adaptive changes, such as a decrease in the number of receptors or a faster breakdown of the benzodiazepine. Physical dependence, on the other hand, is the occurrence of unpleasant or painful symptoms when the substance is withdrawn, or the initial dose is reduced.
Addiction, in contrast, is a disorder that involves compulsive drug seeking and use, despite negative consequences. It involves changes in neurotransmitters and in specific brain circuits, leading to a loss of control over drug use. Per the DSM-5, there are 11 criteria for substance use disorders, and an individual must meet at least two of these within a 12-month period to receive a diagnosis. The manual also states that “substances can produce tolerance and withdrawal [criteria 10 and 11] as normal physiological adaptations when used appropriately for supervised medical purposes. Under these conditions, tolerance, and withdrawal, in the absence of other criteria, do not indicate substance use disorders and should not be diagnosed as such” (4).
The lack of understanding among professionals about the difference between addiction and dependence, as well as the impact of benzodiazepines on the brain, can lead to misdiagnosis of use and physical dependence as addiction, which may result in inappropriate treatment choices such as sudden discontinuation or rapid tapering. If withdrawal from benzodiazepine is required, it is advisable to gradually taper over several months to years, depending on the patient's ability to tolerate the discontinuation. Abruptly discontinuing the drug can cause seizures, insomnia, confusion, disorientation, and an increased risk of developing neurological symptoms.
The table below is from a recent paper (5) that differentiates between Benzodiazepine Use Disorder and (Complex Persistent) Benzodiazepine Dependence using DSM-5 criteria.
3. Minimal effect of benzodiazepines on the brain's "reward center."
There is little neurobiological evidence that benzodiazepine use causes addiction. In fact, very few studies on how prescribed benzodiazepine use might lead to addiction have been published.
All addictive substances have two features in common: a short-term rise in dopamine in the mesolimbic area (the brain's "reward center") and long-term synaptic alterations in this area. There is no substantive evidence that benzodiazepines cause either of these alterations.
In one study (6), the benzodiazepine midazolam (brand name Versed) "elicited a 22% decrease in dopamine, rather than an increase that would be expected with most addictive substances," like cocaine or opioids. Previous studies with different benzodiazepines also showed the same result—that benzodiazepines either decrease or have little effect on dopamine release.
Regarding the second aspect of addiction, synaptic plasticity, this article (7) states that the remodeling and adaptation of brain reward circuitry, as documented in many other substances of abuse, has yet to be established following extended exposure to benzodiazepines.
When benzodiazepine addiction, abuse, or misuse is detected, other well-known addictive substances, such as alcohol, opiates, or cocaine, are typically consumed concurrently, as these substances likely "prime" the reward circuit, impacting the effects of benzos.
4. Patients report tolerance, dependency, and neurotoxicity—but not addiction. Yet healthcare often fails them.
Individuals who use or discontinue benzodiazepines frequently encounter symptoms of tolerance, dependency, and neurotoxicity. These symptoms differ from those of addiction, which involves cravings and compulsive use. Yet healthcare providers typically fail to differentiate, and patients often express frustration and dissatisfaction with the inadequate level of care and understanding they receive, in addition to not being offered appropriate treatment alternatives.
According to the results of a study (8) done among online support groups, patients face considerable challenges when seeking to cease benzodiazepine use. The patient statements below are from that recent paper:
“If I could think of the one worst possible thing you could do to a person, it would be benzo withdrawal. Beats cancer and Alzheimer’s combined. If I could make it go away by chopping my arms and legs off, I would!”
“I’m treated like I did something wrong for taking the prescription as prescribed and never told what it was, and when I looked at medical information years ago, she [my doctor] told me not to because I was making up symptoms by reading medical information.”
“My doctor cut me off without warning. I believe doctors who do this should lose their license... I went to the emergency room within days of being discontinued and was ‘locked down’ in a mental health unit for 9 days with no treatment except coloring in a room full of dangerous patients.”
“Benzos ruined my life. I have been benzo-free for two years and [am] still in protracted withdrawal.”’
“Very difficult to find a health provider that will taper me off these awful chemicals.”
Meanwhile, an informal survey done on a harm-reduction website found that Benzo withdrawals were the worst among the many withdrawals.
“What is the worst drug to have withdrawals from?”
Based on both the medical literature and my personal experience with benzo tapering, I typically divide individuals into three categories: the first, which includes approximately 20% of prescribed benzo users, can discontinue the medication abruptly with minimal side effects; the second, which contains 60% of individuals, requires a gradual taper over several weeks or months under medical supervision and generally results in a positive outcome; and the remaining 20%, need an extremely slow taper over a prolonged period, potentially spanning years, to maximize neurological recovery.
As the healthcare community and medical professionals frequently overlook individuals' tapering needs, many turn to online forums and "The Ashton Manual" for guidance.
Published in 2002 by the beloved Dr. Heather Ashton, a British physician who managed a benzodiazepine withdrawal clinic, “Benzodiazepines: How They Work and How to Withdraw” (aka “The Ashton Manual”) is a comprehensive, updated guide that outlines the risks and potential dangers of benzodiazepine usage, as well as detailed instructions on how to stop using them.
Despite evidence suggesting that benzo prescriptions should be limited to short-term use, typically lasting no more than two to four weeks due to concerns about dependence, tolerance, and long-term efficacy, many medical professionals are unaware of this recommendation. According to previously presented data, 70% of patients who received benzodiazepines had been prescribed them for over two months, and nearly a third for five months (2).
Furthermore, many clinicians lack an understanding of the distinction between addiction and dependence, as well as the effects of neuroadaptation on the brain. Misdiagnosis of benzodiazepine dependence as addiction can have serious repercussions, such as abrupt termination of prescribed medications or referrals to detox clinics for risky rapid tapering.
It is essential to highlight that stopping the use of benzodiazepines is not necessary for everyone, and this choice should be made jointly by the patient and the doctor.
1- Blanco, C., Han, B., Jones, C. M., Johnson, K., and Compton, W. M. (2018). "Prevalence and correlates of benzodiazepine use, misuse, and use disorders in adults in the United States." Journal of Clinical Psychiatry, 79(6), 1865.
2- Dr. Jana McAninch, Office of Surveillance and Epidemiology, FDA, presented data during the
Conference on the Safe Use of Benzodiazepines: Clinical, Regulatory, and Public Health Perspectives - Duke Margolis Center for Health Policy, 2021.
4- Hasin, D. S., O’brien, C. P., Auriacombe, M., Borges, G., Bucholz, K., Budney, A., ... & Grant, B. F. (2013). DSM-5 criteria for substance use disorders: recommendations and rationale. American Journal of Psychiatry, 170(8), 834-851.
5- Peng, L., Meeks, T. W., and C. K. Blazes (2022). Complicated persistent benzodiazepine dependence—when benzodiazepine deprescribing goes wrong. JAMA psychiatry, 79(7), 639-640.
6- Finlay, J. M., Damsma, G., and H. C. Fibiger (1992). "Benzodiazepine-induced decreases in extracellular dopamine concentrations in the nucleus accumbens following acute and repeated dosing." Psychopharmacology, 106, 202-208.
7-- Tan, K. R., Rudolph, U., & Lüscher, C. (2011). Hooked on benzodiazepines: GABAA receptor subtypes and addiction. Trends in neurosciences, 34(4), 188-197.
8- Reid Finlayson, A. J., Macoubrie, J., Huff, C., Foster, D. E., & Martin, P. R. (2022). Experiences with benzodiazepine use, tapering, and discontinuation: an Internet survey. Therapeutic Advances in Psychopharmacology, 12, 20451253221082386.