Aims document

Action Against Tranquilliser Addiction

9th Novemember 2007

Released 6th March 2008

Revised 6th March 2010

Click Here for a Printable PDF version of this document

The following document is the AATA aims fully explained and referenced. This document concerns serious problems associated with benzodiazepines and the Z drugs. These drugs are commonly prescribed for insomnia, anxiety, muscular disorders but are also a significant drug on the illicit drug market. Our organisation has serious concerns with these drugs including addiction, withdrawal problems, long term damage and crime. The reader should note that where it says benzodiazepines we also include the Z drugs which share very similar pharmacological actions, side effects, toxicities and addictive potential. The Z drugs include zopiclone, zolpidem and zaleplon.

The following authors contributed to this document:

Karen Lowles (Former AATA director - [now retired])

Ross JM (AATA chair)

Dr JG McConnell BSc MD FRCPEd FRCP (secretary)

Susan Bibby (AATA England coordinator)

Sir Bill Connor (AATA Political Advisor)

The Table below contains a list of the drugs which this document concerns

AATA Aims Navigational Menu

(1) Raise awareness and establish dedicated services for benzodiazepine addiction at the local level.

(2) Advocate for equality in services regardless of background.

(3) Raise awareness of the increased mental health problems associated with chronic benzodiazepine usage.

(4) To establish increased awareness of the protracted benzodiazepine withdrawal syndrome.

(5) Highlight the significant increased rate of criminal offending associated with the non medical use of benzodiazepines.

(6) Highlight the significant and rapidly escalating problem of benzodiazepine misuse throughout the UK.

(7) To raise awareness of the increased risks of benzodiazepines in the elderly.

(8) To raise awareness of the harm benzodiazepines have in young children and on the unborn child during pregnancy.

(9) To raise awareness that although benzo’s are harmful, stopping benzo’s too quickly without specialist management is much more harmful.

(10) To raise awareness of benzodiazepines and drug related deaths.

(11) Work in partnership with healthcare providers to provide best practice guidelines and healthcare for managing benzodiazepine dependency and withdrawal.

(12) To establish regional helplines for benzodiazepine addicts.

The Aims of AATA

(1) Raise awareness and to establish dedicated services for benzodiazepine addiction at the local level.

When benzodiazepines hit the shelves in the 1960's nobody was aware of the long term damage that they would cause.[1] Yet 40 years later there are 1.5 million benzodiazepine prescription drug addicts in the United Kingdom alone which is more addicts than figures for all illicit drug addiction combined.[2],[3] This is despite government medical guidelines from the Committee on Safety of Medicines as far back as 1988 stating that benzodiazepines should be prescribed for 2 - 4 weeks only.[4] Medical evidence shows that approximately 50% of long term users of benzodiazepines will suffer significant withdrawal symptoms including those on so called low doses.[5] 1.5 million are prescribed addicts and are now finding it extremely difficult to get help in withdrawing. Few healthcare providers have training or expertise in psychopharmacology, drug dependence and withdrawal management and are therefore ill equipped to manage the benzodiazepine withdrawal process which can be potentially life threatening.[6],[7] We need to raise awareness amongst the general public, healthcare professionals and the government that these drugs can have harmful effects. These drugs when taken long term have potentially devastating consequences on the quality of people’s lives and those around them. Therefore there is an urgent need to put in place services that will give addicts the knowledge and support that they need to safely withdraw. As benzodiazepine withdrawal can often take a year or more to complete, much longer than other drug classes and require regular support, regional helplines and support groups are the most cost-effective strategy for tackling the problem.

(2) Advocate for equality in services regardless of background.

It is our organisation's stance that regardless of how a person has become dependent on benzodiazepines, they should be given equal access to services. We believe that everyone deserves access to services. That means no one should be denied services based on their race, religion, social status or whether they used drugs illicitly or licitly. Specialist drug dependency services for example turn prescription drug addicts away from treatment. To quote Hertfordshire Specialist Addiction Services policy on prescription drug addiction "Within the current climate we are not in a position to take over treatment of clients in receipt of prescribed benzodiazepines." Their Specialist Services Policy document however states with regard to street benzodiazepine drug addiction "We will however consider prescribing benzodiazepines to clients who are ‘street users’ of benzodiazepines and who are judged to be dependent on them." AATA believes that dedicated services must be inclusive and open to all.[8] There are also no withdrawal services provided by local primary care trusts for benzodiazepine prescription addicts in the UK,[9] except for a single withdrawal service provided by Oldham Primary Care Trust. The Oldham service has been a great success and was only established after 20 years of campaigning for one by the charity Beat The Benzos. Barry Haslam won 'The Man of Oldham' award for helping to establish the first treatment services for benzodiazepine addicts and also for his over 20 years plus of campaigning against benzodiazepines.[10] However, there is still not a single residential treatment centre for prescription benzodiazepine addicts.[11] AATA believes that there is no reason why the success of the Oldham project cannot be rolled out on a nationwide basis. We at AATA believe there should be specialist services solely for the purpose of withdrawing benzodiazepine addicts and supporting them through the withdrawal process safely and successfully.

(3) Raise awareness of the increased mental health problems associated with chronic benzodiazepine usage.

Long term use is associated with considerable morbidity in many benzodiazepine users with deteriorating mental and physical health problems including severe agoraphobia, gastrointestinal problems, misdiagnosis's of multiple sclerosis, panic attacks, paraesthesiae, depression, suicidal ideation and up to 20% of long term users making suicide attempts, despite in many cases no previous history of such mental or physical health problems. In some 86% of patients who have withdrawn from benzodiazepines such symptoms gradually improve after withdrawal from the drug. This undoubtedly suggests that chronic use of the drugs did directly cause the patients to suffer a deterioration in mental and physical health.[12] Hypnotic drugs cause a significant increased risk of developing depression and major depression disorder based on data released by the FDA. Hypnotic drugs are more likely to cause depression than to help it. Hypnotic drugs may be contraindicated in depressed individuals.[13] High rates of inpatient psychiatric care (35% of men and 21% of women) have been found in long term hypnotic benzodiazepine prescription drug users. Benzodiazepines therefore seem to cause a severe increased risk of developing mental health problems when used long term.[14] An increased risk of psychotic disorders is associated with daily users of anxiolytic benzodiazepines. Other drugs such as cannabis or stimulants also increased the risk of psychotic disorders. This suggests that the risk of developing psychotic disorders such as bipolar disorder or schizophrenia etc from benzodiazepine use is at least as bad as the risk from using illicit drugs. More worryingly is that daily alcohol misuse had the highest risk with an 800% increased risk of developing a psychotic disorder in men and a 300% increased risk in women for developing psychotic disorders.[15] It is worrying because alcohol shares a very similar pharmacological profile with benzodiazepines. Cannabis use causes at the most a 40% increased risk of developing psychosis. As an organisation we frequently hear of people experiencing psychotic phenomena from the chronic use of benzodiazepines especially during over rapid dose reductions and withdrawal but also sometimes from a stable chronic dose. Typically these drug induced mental health problems are not attributed to the toxic effect that benzodiazepines have on the central nervous system and many people end up misdiagnosed and trapped in the mental healthcare system with their lives ruined. These mental health problems do decline and improve and often disappear after a slow and gradual withdrawal and period of abstinence. The high risk of mental health problems associated with benzodiazepine drugs and the similar acting Z drugs calls for urgent action on the benzodiazepine problem. Many lives are being destroyed and as an organisation we believe this is costing Britain a fortune in terms of healthcare costs, disability benefits and putting people out of work. The cost of ruined lives is incalculable. Urgent action is therefore required from the government via the Department of Health as soon as possible. Any further delay can only prolong the misery of the many legally and medically induced benzodiazepine sufferers.

(4) To establish increased awareness of the protracted benzodiazepine withdrawal syndrome.

Benzodiazepines often cause a clinically serious and complicated protracted withdrawal syndrome.[20] Protracted benzodiazepine withdrawal is not widely known about by clinicians despite its often serious and debilitating nature. Protracted withdrawal syndrome is of clinical significance as it often mimics various psychiatric and medical conditions. This puts many patients at risk of misdiagnosis and mistreatment. Protracted withdrawal is by no means a mild condition. Serious protracted withdrawal syndromes such as protracted psychotic states persisting for at least a year have been described in the medical literature.[21] The protracted benzodiazepine withdrawal syndrome has been well documented in the medical literature but yet in our experience the vast majority of doctors are unaware and untrained to manage this syndrome and often deny its existence. Protracted withdrawal syndrome is a genuine iatrogenic induced condition and is thought to be the result of physiological changes directly induced by chronic exposure to benzodiazepines.[22] This was later confirmed in a placebo controlled study of the effect of flumazenil, a benzodiazepine receptor antagonist, versus saline infusions in patients suffering protracted benzodiazepine withdrawal symptoms from 5 - 42 months post withdrawal. It was found that in those receiving flumazenil there was a definite decline of between 5%-100% with a mean average of 48% reduction in symptomatology whereas with placebo there was little to no response in the volunteers. Symptoms which temporarily improved with flumazenil treatment included clouded thinking, tiredness, muscular symptoms such as neck tension, cramps and shaking and the characteristic perceptual symptoms of benzodiazepine withdrawal, namely, pins and needles, burning skin, pain and subjective sensations of bodily distortion, insomnia, depersonalisation, anxiety and depression.[23] Other medical papers have also reported protracted withdrawal syndromes from benzodiazepines including one studying protracted tinnitus and gastrointestinal disorders after discontinuation of benzodiazepines with relief of symptoms after taking test doses of diazepam, which is a benzodiazepine drug.[24] Withdrawal symptoms from benzodiazepines can persist for many months or in some people for years after discontinuation of benzodiazepines. Some withdrawal symptoms are similar to LSD experiences including perceptual disturbances, hallucinations and altered perception of their surroundings and body (depersonalisation and derealisation). Physical withdrawal effects can include gastrointestinal disturbances, muscular spasms, twitching, tinnitus and tingling and numbness. In some cases structural brain damage may be the cause for persisting symptoms although brain atrophy when it occurs may be reversible with abstinence from benzodiazepines.[25] Urgent government action needs to be carried out via the Department of Health to raise awareness of this serious medically induced disorder. As a matter of public health, action must be taken to minimise this disorder. In our experience slow withdrawal rates appear to significantly reduce the intensity and duration of the protracted withdrawal syndrome.

(5) Highlight the significant increased rate of criminal offending associated with the non medical use of benzodiazepines.

Benzodiazepines are strongly associated with crime. In Scotland a pilot study found that of arrestees benzodiazepines were 2nd only to cannabis as the most commonly detected class of drugs found in criminal suspects with 33% testing positive. This was ahead of opiates.[26] Those entering custody in the prison system report even higher levels of benzodiazepine misuse over and above levels of cannabis misuse and 2nd only to heroin. See the table below for statistics.

Self-reported substance misuse at reception into custody (all sample, indicative only) Percentage reporting misuse of substance
Heroin	68
Benzodiazepines	59
Cannabis	53
Tobacco	34
Alcohol	25
Cocaine (Powder)	22
Prescribed Methadone	17
Ecstasy	14
Illicit Methadone	9
Crack cocaine	9
Amphetamine	9
Temgesic	1
LSD	-
Volatile Substances	-
Other	3
1 Drug percentages do not add up to 100% due to poly-drug abuse. Source : The Scottish Prison Service (SPS).

In Northern Ireland tests on drivers who were suspected of driving whilst intoxicated but who tested negative for alcohol were found in 87% of cases to test positive for benzodiazepines.[27] This suggests that benzodiazepines play a significant role in the crime of 'driving whilst unfit due to drink or drugs'. Low serotonin levels have been associated with a range of psychiatric disturbances especially suicidal, aggressive, antisocial and impulsive behaviour. Both acute and chronic use of benzodiazepines is associated with causing low serotonin neurotransmission. In a study comparing 58 patients on chronic benzodiazepines and another group of 58 patients who were instead receiving behavioural psychotherapy it was found that a staggering 53.5% of patients consuming chronic benzodiazepines reported aggressive, impulsive and violent behaviour whilst only 5.1% of patients who received psychotherapy showed such behaviours. Those who had a pre-existing history of such behaviour or those with alcohol or other addiction problems were ruled out from the study.[28] Alcohol and benzodiazepines are the most freqent drugs associated with violent offending in a report in Scotland of jailed young offenders. Illegal drugs are rarely reported to be the cause of violent offending, with the sole exception of diazepam, the most commonly available benzodiazepine in the UK, which offenders reported caused their violent offense. Similar findings were found with temazepam in the 1980's and 1990's when temazepam was the most commonly available benzodiazepine in the UK. Illegal drugs other than diazepam were reported by offenders to be more likely to reduce the risk of or have no effect on their violent offending. In most cases violence occured when benzodiazepines were combined with alcohol which produced a violent amnesic and fearless behavioural state of mind which can lead to acts of extreme violence. In most cases when diazepam is implicated in violent offenses it is when it is combined with alcohol. half of regular young offenders funded their benzodiazepine use via theft or robbery.[29] This clearly suggests that chronic benzodiazepines directly cause a significant change in personalities of previously non-violent people turning them into violence prone individuals. Urgent government action is required to tackle violent, impulsive and aggressive benzodiazepine drug induced personality disorders.

(6) Highlight the significant and rapidly escalating problem of benzodiazepine misuse throughout the UK.

Approximately 2% of the UK population abuse benzodiazepines problematically, with over a third of them injecting their benzodiazepines. 2% of the UK's 60 million population would be approximately 1.2 million people! With a third of this number injecting benzodiazepines this means nationally there may be over 400,000 people injecting benzodiazepines.[30] Benzodiazepines as with other drugs of addiction activate the reward pathway which can lead to compulsive use and misuse.[31] Benzodiazepine abuse is widespread in stimulant misusers. Stimulant users who also abused benzodiazepines were much more likely to report injecting amphetamines and also benzodiazepine misusers were much more likely to be poly drug misusers and have psychopathology, poorer health and poorer social functioning than stimulant misusers not abusing benzodiazepines. Injecting drug misusers who also misuse benzodiazepines were found to be almost 4 times more likely to report using a shared used needle to inject than injecting drug misusers who didn't use benzodiazepines as part of their drug habits. Higher levels of drug misusers who reported benzodiazepine misuse required drug treatment services than drug misusers not using benzodiazepines. It has been concluded that benzodiazepine misuse is associated with more increased risks and psycho-social dysfunction.[32],[33] Benzodiazepine misusers and opiate misusers were followed up over 6 years. Benzodiazepine abusers over time developed serious mental health problems, specifically severe depression, whereas the opiate abuser's psychiatric state changed very little.[34] Organic brain damage occurs from chronic high dose benzodiazepine abuse.[35] Benzodiazepine abuse seems to cause definite permanent brain damage in the form of cerebral disorder. A 4 - 6 year follow up of benzodiazepine misusers found that intellectual impairments had changed little over the 4 - 6 year period. The benzodiazepine misusers showed dilatation of the ventricular system. Brain damage was similar to that seen in alcoholics but unlike alcoholics did not show widened cortical sulci.[36] An earlier study by Borg et al found evidence of cerebral disorder in those who exclusively abused hypnotic benzodiazepines suggesting that cerebral disorder was not the result of other substances of abuse.[37] Benzodiazepines cause significant harm in the drug misusing section of society with profound and devastating adverse effects on their physical and mental health. In AATA's experience such individuals seem to get sucked into the psychiatric system getting misdiagnosed with all ranges of mental health disorders instead of getting accurately diagnosed and receiving appropriate treatment for the cause of their ill health i.e. benzodiazepine dependence and abuse disorder. The increased levels of sharing used needles amongst benzodiazepine misusers is almost certainly increasing the spread of diseases such as HIV-AIDS, hepatitis virus's and other contagious blood borne diseases. This is yet again another serious public health matter which has been either neglected or simply ignored by the government and requires urgent attention and action.

(7) To raise awareness of the increased risks of benzodiazepines in the elderly.

Benzodiazepines and Z type drugs are commonly prescribed for older patients for a variety of specific and non-specific reasons. Specific reasons may include acute anxiety following assault, abuse, house burglary, bereavement and motor restlessness including restless legs syndrome whereas non-specific reasons may include vague muscle cramps, mild insomnia, perceived neuralgias, back spasm, chronic simple headache and myalgias. Whilst the initiating prescriber's intention was for short term use commonly, this leads to long term usage via failure to review, reassess and the automatic triggering of long term repeat prescriptions. Longer term use in the elderly commonly results in interaction with other prescribed medications including anti-depressants and anti-hypertensives resulting in low blood pressure and postural falls in blood pressure, altered cognition, balance impairment and blunting of righting reflexes. This, in turn leads to increased risk of falls and injuries including major low impact fractures, especially hip fracture which has a 30% mortality rate for those aged 75 and over within 12 months of surgery.[38],[39] Older patients prescribed benzodiazepine drugs may also develop a pseudodementia type syndrome with combined confusion and depression which may get misdiagnosed as true dementia.[40] Benzodiazepines when given to elderly subjects has effects on the memory functions similar to dementia.[41] Up to 10% of patients diagnosed with dementia have an iatrogenic drug induced cause, most often either benzodiazepines or antihypertensives.[42] The combination of benzodiazepine and anti-depressant use in the elderly is a particularly potent risk factor for intrinsic falls. Also, since the elderly now comprise 60-70% of all acute hospital admissions and since many will have been taking long-term benzodiazepine and Z drugs, there is the potential for inexperienced junior hospital doctors to abruptly withdraw these drugs following admission resulting in a serious withdrawal syndrome including delirium and acute psychosis.[43] When this happens (as it does frequently), the patient may become severely agitated and restless, fall in hospital, sustain serious injury including major fracture and develop other significant complications including infection, pressure sores, dehydration, kidney failure and early death. The cost to the NHS of the hospital treatment and after care of low impact fractures in the elderly is estimated to be several hundred million pounds per year and chronic benzodiazepine drug usage is a major risk factor. Action is required to reduce benzodiazepine and Z drug prescribing levels in the elderly which will lead to an improved quality of healthcare for elderly patients and a significant reduction in the cost burden on the NHS.

(8) To raise awareness of the harm benzodiazepines have in young children and on the unborn child during pregnancy.

There are numerous dangers of benzodiazepines in pregnancy. In 1997 the Committee on Safety of Medicines acknowledged this in a reminder letter to doctors.[44] In the USA the FDA has placed benzodiazepines in pregnancy category D and X which is a higher category than opiates are placed in. Category D drugs should be avoided in pregnancy and category X drugs should never be taken during pregnancy as they are known to be harmful. Worldwide benzodiazepines make up an estimated 85% of all psychotropic medicines which are prescribed to pregnant women.[45] Also an area of concern that we have is the illicit use of benzodiazepines which are used by up to 90% of poly illicit drug misusers with 49% reporting injecting benzodiazepines.[46] In addition 90% of female drug misusers are of child bearing age.[47] A study comparing babies exposed to benzodiazepines versus babies not exposed revealed that the babies exposed to benzodiazepines had a smaller head circumference which appeared to be permanent. Neurodevelopmental and clinical symptoms and signs were common in infants exposed to benzodiazepines. Gross motor development was retarded for almost a year after birth in benzodiazepine affected babies and impaired fine motor functions were found on all follow-up occasions.[48] At a conference a paediatrician stated "Our experience tells us that people on benzodiazepines cannot be good mothers - because they're not in control - that is not a criticism of them as an individual but a criticism of them plus benzodiazepines. There is also very good evidence that your first 2 years of life are incredibly important."[49] Babies exposed to benzodiazepines during pregnancy are at risk of floppy infant syndrome or a severe benzodiazepine drug withdrawal syndrome. Symptoms in the newborn infant may persist for hours or months after birth.[50] Benzodiazepines are preferentially stored in some organs including the heart and also benzodiazepines are excreted in breast milk and should be avoided during breast feeding.[51] A study of young children treated with a benzodiazepine drug for epilepsy showed impaired development for example in the development of walking skills whereas young children treated with most other non benzodiazepine antiepileptic agents developed normally. It was recommended that children be tapered off their benzodiazepine medication.[52] Benzodiazepines administered to babies during their first year of life have been implicated in causing the death of the infant.[53] Smaller head circumference and mental retardation and lower intelligence has been reported in fetally exposed children.[54] Benzodiazepines can have a significant effect on the development of children both physically and mentally. It is of concern to our organisation that children exposed to benzodiazepines during pregnancy or raised by parents chronically under the influence of or impaired by benzodiazepines are likely to be compromised in a variety of ways which may have long lasting effects on the child's future. AATA staff continue to hear of mothers who have been prescribed benzodiazepines during pregnancy with no warning of the potential risks involved. Much stronger warnings to both doctors and patients is urgently required and further research especially more longer term follow-ups into the long term effects is vital.

(9) To raise awareness that although benzo’s are harmful, stopping benzo’s too quickly without proper guidance is much more harmful.

Management of benzodiazepine withdrawal must be carried out under the guidance of people knowledgable and experienced in its management. We routinely hear of people being withdrawn from benzodiazepines by doctors who have no training in drug dependence and little or no experience in managing drug withdrawal. This has led many people that we have been in contact with to develop very serious withdrawal syndromes which are intensely distressing and sometimes life threatening, leading to medical and mental health misdiagnosis. Admissions to psychiatric hospitals are also frequent outcomes when benzodiazepine dependence is mismanaged. The most serious outcome from abrupt or over rapid discontinuation of benzodiazepines is death from either convulsions or catatonia.[55],[56],[57] Other severe withdrawal syndromes from abrupt or over rapid benzodiazepine withdrawal include severe delusions,[58] rage reactions with homicidal ideation,[59], violence,[60], postural hypotension, hyperthermia, confusional states, psychosis,[61],[62], mania[63] and suicide.[64] Furthermore it should be noted that most patients consuming benzodiazepines have no idea of the serious nature of benzodiazepine dependence and most don't even know that they are dependent and thus discontinue their benzodiazepines without expecting any adverse reaction. They often find that they experience distressing and severe symptoms and often don't connect it with stopping their pills and nor do the doctors. This leads again to misdiagnosis and mistreatment and wasting NHS funds chasing the wrong diagnosis and treatment for such patients. All of this can be avoided by experienced volunteer services working with benzodiazepine addicts and their doctors, providing needed knowledge and guidance to withdraw at a sensible rate.

(10) To raise awareness of benzodiazepines and drug related deaths.

Drug related deaths caused by benzodiazepines can be in nature accidental, suicidal or related drug addiction.[65] A study in Sweden showed that benzodiazepine drug related deaths predominate over other drug related deaths and in up to 72% of cases benzodiazepines are the sole drug involved.[66] The overdose potential of benzodiazepines is significantly increased when abused in combination with opiates which synergistically enhance the toxicity of one another. Benzodiazepines are more likely than not to be found to be involved in opiate related deaths.[67],[68] Drug related deaths statistics released by the Home Office to the charity Beat The Benzo’s from the years 1990 - 1997 showed that benzodiazepines which are class C drugs caused more deaths than all class A drugs combined. Also the statistics showed that benzodiazepines during this time caused more than 6 times the number of deaths caused by heroin.[69] There has however from 1999 - 2004 been a decrease in benzodiazepine related drug deaths and a major increase in heroin and methadone drug related deaths. Benzodiazepines now rank 2nd behind opiate (methadone and heroin) drug related deaths.[70] In Scotland in 2003 benzodiazepines still remained the most common cause of drug related deaths with 69% of all drug related deaths being caused by benzodiazepines exceeding heroin and opiate drug related deaths.[71] As benzodiazepines seem to cause similar death rates to heroin and opiates as a drug class the government needs to take strong action against benzodiazepines. Unfortunately there seems to be continued silence on the serious problem of benzodiazepine drug related deaths which is unjustified based on the figures and requires urgent attention to this serious public health problem.

(11) Work in partnership with healthcare providers to provide best practice guidelines and healthcare for managing benzodiazepine dependency and withdrawal.

We at AATA will aim to work in partnership with counsellors and doctors to provide a best practice policy for the management of benzodiazepine dependency. We strongly feel that by doing so we can have a significant positive effect on the benzodiazepine problem. Another organisation called BCNC has worked successfully in cooperation with doctors in Cumbria with evidence and anecdotal evidence from pharmacists of a significant reduction of benzodiazepine and Z drug prescribing levels and greatly improved quality of NHS services for patients.[72] Co-operation by both existing healthcare providers, AATA and benzodiazepine trained counsellors is extremely important and by working together the benzodiazepine addict will reap the benefits with the return of their health and quality of life. We would like to see all healthcare providers referring their patients to counsellors who are knowledgable in benzodiazepine dependency for accurate specialist advice, support and reassurance. In order to work alongside healthcare providers within the NHS it is important to make them aware that in the past many doctors have mismanaged patients coming off of benzodiazepines and misdiagnosed when in fact they were just in withdrawal or suffering side effects. The healthcare profession must look at the way they have dealt with benzodiazepine withdrawal in the past and realise that mistakes have been made and enact changes so that such mistakes no longer occur in the future. Doctors need to be able to refer such patients to trained counsellors who can then counsel the patients in the correct ways to withdraw by following the guidance by Professor Heather Ashton in The Ashton Manual. The counsellors can also provide the necessary support structure to the patients through the withdrawal process. Counsellors are also cheaper than doctors to employ so it will be more cost effective for counsellors to manage benzodiazepine dependent patients rather than frequent attendances at GP surgeries by such individuals undergoing benzodiazepine withdrawal. We also feel that listening to people who have been through withdrawal themselves will help to educate counsellors and doctors. AATA are more than willing to liaise with any counsellors or doctors who are looking for specific information on benzodiazepine dependency.

(12) To establish regional helplines for benzodiazepine addicts.

In the United Kingdom there are an estimated 1.5 million benzodiazepine addicts.[1] At present only Bristol has regional helpline for benzodiazepine addicts.

The UK government recently published a report calling for more funding for support services for benzodiazepine users, pointing out that many benzodiazepine users are ashamed of their problem and prefer support from anonymous resources such as online groups (or in this case a helpline). They also point out that 24 hour services would be particularly valuable to benzodiazepine users.[73]

A systematic review of the medical literature conducted by the Cochrane Database found that helplines for tobacco addiction have been found to have a significant benefitial effect on increasing cessation of tobacco use.[74] The Department of Health published guidelines for drug misusers stating that benzodiazepine misusers benefit from increased support including counselling, I believe that my helpline can provide a critical support structure and counselling service.[75] This is not a unique problem; similarly very few tobacco addicts would telephone the likes of FRANK, but many feel comfortable telephoning a dedicated service such as QUIT which also is very successful otherwise it would not receive funding. A very important impact of helplines is that they can reach individuals and provide a service to individuals who cannot be reached by clinics.[76]

Successful withdrawal from benzodiazepines leads to a very significant reduction in use of outpatient mental health services and GP visits per year, thus making benzodiazepine withdrawal a very cost effective strategy.[77],[78] As an organisation we have seen many people no longer requiring mental health services and other medical health services after they have withdrawn from benzodiazepines. Therefore we believe that such funding for helplines which would not be particularly expensive would ultimately save the government and local authorities a great deal of money by reducing healthcare costs. If the funding is provided we can provide volunteers to man the helplines similar to how other addiction helplines operate.

Recommended Reading

The Ashton Manual - Benzodiazepines How They Work and How to Withdrawal. Professor Heather Ashton 2002

References

(1) Sternbach LH. 1972. The discovery of librium. Agents Actions 2 (4): 193-6.

(2) Lucy Johnston (Health Editor). 1.5 Million patients at risk from danger pills - Tranquillisers are linked to brain damage. Sunday Express, May 13, 2001.

(3) BBC. Panorama uncovers major addiction problem. Sunday, 13 May 2001, 08:29 GMT 09:29 UK.

(4) Committee on Safety of Medicines. 1988. Jan. BENZODIAZEPINES, DEPENDENCE AND WITHDRAWAL SYMPTOMS. MHRA. 21.

(5) Onyett SR. 1989 The benzodiazepine withdrawal syndrome and its management. J R Coll Gen Pract 39 (321): 160–3.

(6) Haque W, Watson DJ, Bryant SG (1990). Death following suspected alprazolam withdrawal seizures: a case report. Texas medicine 86 (1): 44-7.

(7) Rosebush PI, Mazurek MF (1996). Catatonia after benzodiazepine withdrawal. Journal of clinical psychopharmacology 16 (4): 315-9.

(8) Dr Geraldine O’Sullivan. HERTFORDSHIRE PARTNERSHIP NHS TRUST. PRESCRIBING POLICY FOR SPECALIST ADDICTION SERVICES IN HPT.

(9) Morgan K; Dixon S, Mathers N, Thompson J, Tomeny M. Psychological treatment for insomnia in the regulation of long-term hypnotic drug use. National Institute for Health Research. Feb 2004.

(10) Oldham Chronicle. BARRY SCOOPS MAN OF OLDHAM AWARD. May 4, 2007.

(11) Oldham Chronicle. NEW HOPE ON BENZO SUPPORT. April 5, 2005.

(12) Professor C Heather Ashton DM, FRCP. (1987). Benzodiazepine Withdrawal: Outcome in 50 Patients. British Journal of Addiction 82: 655-671.

(13) Kripke DF. (2007). Greater incidence of depression with hypnotic use than with placebo. 7:42. Aug 21. BMC Psychiatry.

(14) Allgulander C, Näsman P. (1991). Regular hypnotic drug treatment in a sample of 32,679 Swedes: associations with somatic and mental health, inpatient psychiatric diagnoses and suicide, derived with automated record-linkage. Jan-Feb; 53(1):101-8. Psychosom Med.

(15) Tien AY, Anthony JC. (1990). Epidemiological analysis of alcohol and drug use as risk factors for psychotic experiences. Aug;178(8):473-80. The Journal of nervous and mental disease.

(16) Schmauss C, Krieg JC. (1987). Enlargement of cerebrospinal fluid spaces in long-term benzodiazepine abusers. Nov;17(4):869-73. Psychological medicine.

(17) Lader MH, Ron M, Petursson H. (1984). Computed axial brain tomography in long-term benzodiazepine users. Feb;14(1):203-6. Psychological medicine.

(18) Busto UE, Bremner KE, Knight K, Brugge K, Sellers EM. (2000) Long-term benzodiazepine therapy does not result in brain abnormalities. Feb;20(1):2-6. Journal of clinical psychopharmacology.

(19) Professor C Heather Ashton. CLARIFICATION ABOUT BRAIN DAMAGE. August 29, 2002.

(20) O'Connor RD. (1993) Benzodiazepine dependence--a treatment perspective and an advocacy for control. 131:266-9. NIDA research monograph.

(21) Modell JG. (1997) Protracted benzodiazepine withdrawal syndrome mimicking psychotic depression. Mar-Apr;38(2):160-1. Psychosomatics.

(22) Higgitt A, Fonagy P, Toone B, Shine P. (1990) The prolonged benzodiazepine withdrawal syndrome: anxiety or hysteria? Aug;82(2):165-8. Acta psychiatrica Scandinavica.

(23) Malcolm H. Lader, Sally V. Morton. (1992) A pilot study of the effects of flumazenil on symptoms persisting after benzodiazepine withdrawal. 6(3) (1992) 357-363 Journal of Psychopharmacology.

(24) Busto U, Fornazzari L, Naranjo CA. (1988) Protracted Tinnitus after Discontinuation of Long-Term Therapeutic Use of Benzodiazepines. Oct;8(5):359-62. Journal of clinical psychopharmacology.

(25) Ashton CH. (1995) Protracted Withdrawal From Benzodiazepines: The Post-Withdrawal Syndrome. March 25:3, 174-179. Psychiatric Annals.

(26) Neil McKeganey, Clare Connelly, Janusz Knepil, John Norrie4, Lesley Reid. Crime and Criminal Justice Research Findings No. 48: Interviewing and Drug Testing of Arrestees in Scotland: A Pilot of the Arrestee Drug Abuse Monitoring Methodology. July 25, 2000. The Scottish Government Publications.

(27) Cosbey SH. (1986) Drugs and the impaired driver in Northern Ireland: an analytical survey. Dec;32(4):245-58. Forensic science international.

(28) Mathew VM, Dursun SM, Reveley MA. (2000) Increased aggressive, violent, and impulsive behaviour in patients during chronic-prolonged benzodiazepine use. Feb;45(1):89-90. Canadian journal of psychiatry.

(29) William McKinlay, Alasdair J. M. Forsyth and Furzana Khan. Alcohol and Violence among Young Male Offenders in Scotland (1979-2009), January 2009. Glasgow Centre for the Study of Violence, Scottish Centre for Crime & Justice Research, Glasgow Caledonian University

(30) Gordon Hay, Maria Gannon, Neil McKeganey, Sharon Hutchinson & David Goldberg. Estimating the National and Local Prevalence of Problem Drug Misuse in Scotland. November 2004 Issued January 2005. Scottish Centre for Environmental Health NHS.

(31) Söderpalm B, Svensson L, Hulthe P, Johannessen K, Engel JA. (1991) Evidence for a role for dopamine in the diazepam locomotor stimulating effect. 104(1):97-102. Psychopharmacology.

(32) Darke S, Ross J, Cohen J. (1994) The use of benzodiazepines among regular amphetamine users. Dec;89(12):1683-90. Addiction (Abingdon, England).

(33) Williamson S, Gossop M, Powis B, Griffiths P, Fountain J, Strang J. (1997) Adverse effects of stimulant drugs in a community sample of drug users. Mar 14;44(2-3):87-94. Drug and alcohol dependence.

(34) Mc Lellan AT, Woody GE, O'Brien CP. (1979) Development of psychiatric illness in drug abusers. Possible role of drug preference. Dec 13;301(24):1310-4. The New England journal of medicine.

(35) Kitabayashi Y, Ueda H, Narumoto J, Iizumi H, Tsuchida H, Murata N, Nakajima S, Fukui K. (2001) Chronic high-dose nitrazepam dependence 123I-IMP SPECT and EEG studies. Jul;6(3):257-261. Addict Biol.

(36) Bergman H, Borg S, Engelbrektson K, Vikander B. (1989) Dependence on sedative-hypnotics: neuropsychological impairment, field dependence and clinical course in a 5-year follow-up study. May;84(5):547-53. British journal of addiction.

(37) Bergman H, Borg S, Holm L. (1980) Neuropsychological impairment and exclusive abuse of sedatives or hypnotics. Feb;137(2):215-7. The American journal of psychiatry.

(38) Wagner AK, Zhang F, Soumerai SB, Walker AM, Gurwitz JH, Glynn RJ, Ross-Degnan D. Benzodiazepine use and hip fractures in the elderly: who is at greatest risk? Archives of internal medicine. 2004 Jul 26;164(14):1567-72.

(39) Bass E, French DD, Bradham DD, Rubenstein LZ. Risk-adjusted mortality rates of elderly veterans with hip fractures. Annals of epidemiology. 2007 Jul;17(7):514-9. Epub 2007 Apr 8.

(40) R.J. Ancill, G.D. Embury, G.W. MacEwan, J.S. Kennedy. Lorazepam in the elderly—a retrospective study of the side-effects in 20 patients. Journal of Psychopharmacology, Vol. 1, No. 2, 126-127 (1987).

(41) Block RI, DeVoe M, Stanley B, Stanley M, Pomara N. Memory performance in individuals with primary degenerative dementia: its similarity to diazepam-induced impairments. Experimental aging research. 1985 Autumn-Winter;11(3-4):151-5.

(42) Starr JM, Whalley LJ. Drug-induced dementia. Incidence, management and prevention. Drug safety: an international journal of medical toxicology and drug experience. 1994 Nov;11(5):310-7.

(43) Wetterling T, Backhaus J, Junghanns K. [Addiction in the elderly - an underestimated diagnosis in clinical practice?] Der Nervenarzt. 2002 Sep;73(9):861-6.

(44) Committee on Safety of Medicines Bulletin, 1997 Reminder: Avoid benzodiazepines in pregnancy and lactation.

(45) Marchetti F, Romero M, Bonati M, Tognoni G, CGDUP. Use of psychotropic drugs during pregnancy. Eur J Clin Pharmacol 1993;45:495-501.

(46) Department of Health Scottish Office Department of Health Welsh Office Department of Health and Social Services, Northern Ireland. Drug Misuse and Dependence – Guidelines on Clinical Management. 1999

(47) Institute for the Study of Drug Addiction. Department of Health. Drug situation in the UK - trends and update, 24 .01. 2000.

(48) Laegreid L, Hagberg G, Lundberg A. Neurodevelopment in late infancy after prenatal exposure to benzodiazepines--a prospective study. 1992 Apr;23(2):60-7. Neuropediatrics.

(49) Robertson J., Paediatrician, Arrowe Park Hospital, The Wirral, Merseyside, UK. Presentation at ‘Beat the Benzos’ Campaign launch conference, November 2000.

(50) McElhatton PR. The effects of benzodiazepine use during pregnancy and lactation. 1994 Nov-Dec;8(6):461-75. Reproductive toxicology (Elmsford, N.Y.).

(51) Olive G, Dreux C. [Pharmacologic bases of use of benzodiazepines in peréinatal medicine] 1977 Jan;34(1):74-89. Archives françaises de pédiatrie.

(52) Dennis J, Hunt A. Prolonged use of nitrazepam for epilepsy in children with tuberous sclerosis. 1985 Sep 14;291(6497):692-3. British medical journal (Clinical research ed.).

(53) Figols J, Cervós-Navarro J, Wolman M. Encephalopathy with astrocytic residual bodies. Report of a case and review of the literature. 1986 Jan;1(1):59-67. Histology and histopathology.

(54) Laegreid L. Clinical observations in children after prenatal benzodiazepine exposure. 1990;15(3-4):186-8. Developmental pharmacology and therapeutics.

(55) Metten P, Crabbe JC. (1999) Genetic determinants of severity of acute withdrawal from diazepam in mice: commonality with ethanol and pentobarbital. Jul;63(3):473-9. Pharmacology, biochemistry, and behavior.

(56) Rosebush PI, Mazurek MF. (1996) Catatonia after benzodiazepine withdrawal. Aug;16(4):315-9. Journal of clinical psychopharmacology.

(57) Haque W, Watson DJ, Bryant SG. (1990) Death following suspected alprazolam withdrawal seizures: a case report. Jan;86(1):44-7. Texas medicine.

(58) Keshavan MS, Moodley P, Eales M, Joyce E, Yeragani VK. (1988) Delusional depression following benzodiazepine withdrawal. Oct;33(7):626-7. Canadian journal of psychiatry.

(59) Risse SC, Whitters A, Burke J, Chen S, Scurfield RM, Raskind MA. (1990) Severe withdrawal symptoms after discontinuation of alprazolam in eight patients with combat-induced posttraumatic stress disorder. May;51(5):206-9. The Journal of clinical psychiatry.

(60) Citrome L, Volavka J. (1999) Violent patients in the emergency setting. Dec;22(4):789-801. The Psychiatric clinics of North America.

(61) Pétursson H. (1994) The benzodiazepine withdrawal syndrome. Nov;89(11):1455-9. Addiction (Abingdon, England).

(62) Bismuth C, Le Bellec M, Dally S, Lagier G. (1980) [Benzodiazepine physical dependence. 6 cases (author's transl)] Jun 28;9(28):1941-5. La Nouvelle presse médicale.

(63) Turkington D, Gill P. (1989) Mania induced by lorazepam withdrawal: a report of two cases. Jul-Aug;17(1):93-5. Journal of affective disorders.

(64) Murphy SM, Tyrer P. (1991) A double-blind comparison of the effects of gradual withdrawal of lorazepam, diazepam and bromazepam in benzodiazepine dependence. Apr;158:511-6. The British journal of psychiatry : the journal of mental science.

(65) Ericsson HR, Holmgren P, Jakobsson SW, Lafolie P, De Rees B. (1993) [Benzodiazepine findings in autopsy material. A study shows interacting factors in fatal cases] Nov 10;90(45):3954-7. Läkartidningen.

(66) Carlsten A, Waern M, Holmgren P, Allebeck P. (2003) The role of benzodiazepines in elderly suicides. 31(3):224-8. Scandinavian journal of public health.

(67) Lai SH, Yao YJ, Lo DS. (2006) A survey of buprenorphine related deaths in Singapore. Oct 16;162(1-3):80-6. Epub 2006 Aug 1. Forensic science international.

(68) Dietze P, Jolley D, Fry C, Bammer G. (2005) Transient changes in behaviour lead to heroin overdose: results from a case-crossover study of non-fatal overdose. May;100(5):636-42. Addiction (Abingdon, England).

(69) Home Office. (12.5.1998) Drug Related Deaths - EXTRACT FROM HOME OFFICE STATISTICAL BULLETINS. Barry Haslam.

(70) National Treatment Agency. Drug related death trends in England. NTA.

(71) Deborah Zador, Brian Kidd, Sharon Hutchinson, Avril Taylor, Matt Hickman, Tom Fahey, Andrew Rome, Alex Baldacchino. National Investigation into Drug Related Deaths in Scotland. August 08, 2005.

(72) Andrea Loudon. MANAGING BENZODIAZEPINES. 2006.

(73) Gemma Reay, Dr Brian Iddon MP. All-Party Parliamentary Drugs, An Inquiry into Physical Dependence and Addiction to Prescription and Over-the-Counter Medication, 2007-2008

(74) Stead, LF.; Perera, R.; Lancaster, T. 2006. Telephone counselling for smoking cessation. Cochrane Database Syst Rev 3: CD002850

(75) National Treatment Agency for Substance Misuse 2007. Drug misuse and dependence - UK guidelines on clinical management. United Kingdom: Department of Health

(76) Gilbert, H.; Sutton, S.; Sutherland, G. (Oct 2005). Who calls QUIT? The characteristics of smokers seeking advice via a telephone helpline compared with smokers attending a clinic and those in the general population. Public Health 119 (10): 933-9

(77) Burke KC, Meek WJ, Krych R, Nisbet R, Burke JD - February 1995. Medical services use by patients before and after detoxification from benzodiazepine dependence. Psychiatr Serv 46 (2): 157–60

(78) Longo LP, Johnson B April 2000. Addiction: Part I. Benzodiazepines--side effects, abuse risk and alternatives. Am Fam Physician 61 (7): 2121–8