Aims document

Action Against Tranquilliser Addiction

9th Novemember 2007

Released 6th March 2008

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 (AATA director)

Ross JM (AATA director)

Dr JG McConnell BSc MD FRCPEd FRCP (medical advisor)

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 push for action on benzodiazepines at the political level.

(2) End the discrimination against iatrogenic benzodiazepine addicts disabled by their medically induced addiction.

(3) Push for a 24 hour helpline for benzodiazepine addicts.

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

(5) Push for a medical investigation to establish whether long term benzodiazepine use causes permanent brain or neurological damage.

(6) Push for increased awareness of protracted benzodiazepine withdrawal syndrome.

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

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

(9) Raise awareness of the increased risks of benzodiazepines in the elderly.

(10) Raise awareness of the harm benzodiazepines have in young children and on the unborn child during pregnancy.

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

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

(13) To provide counsellors with the correct knowledge in benzodiazepine addiction and withdrawal and to then provide their services and support to benzodiazepine addicts and their families.

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

(15) Make withdrawal services available nationwide for iatrogenic benzodiazepine addicts so that they get at least the same access to specialised services that drug and alcohol users have access to.

(16) Campaign for the government to provide funding for local and voluntary benzodiazepine withdrawal organisations.

(17) Campaign for an independent public health inquiry into benzodiazepines.

(18) Push for home office reclassification of benzodiazepines from class C to class A drugs.

(19) To raise awareness of the reasons why people end up on benzodiazepines in the first place.

(20) To raise general awareness of the fact that all psychotropic drugs will cause a withdrawal syndrome.

The Aims of AATA

(1) Raise awareness and push for action on benzodiazepines at the political 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 up to 100% of prescribed long term users of benzodiazepines will suffer 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. The majority of healthcare providers who addict their patients to these drugs have no training in psychopharmacology, drug dependence and withdrawal management and are therefore ignorant and ill equipped to manage the benzodiazepine withdrawal process which can be potentially life threatening.[6],[7],[8] 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. We therefore need to put in place services that will allow addicts to safely withdraw. Due to the huge scale of benzodiazepine addiction only government action can effectively tackle the issue. So to enable us to do this we need to take our campaign to a political level.

(2) End the discrimination against iatrogenic benzodiazepine addicts disabled by their medically induced addiction.

As a result of the policy operated by the specialist drug dependency services prescription drug addicts are discriminated against. For example 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." This quote clearly demonstrates the discrimination against those people who have become addicted to benzodiazepines through no fault of their own but because they followed the advice of their physician or psychiatric services. This represents what can be described as legally induced and enabled involuntary tranquiliser addiction. 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." This clearly demonstrates NHS policy for specialist drug addiction services as a matter of national protocol discriminates against iatrogenic (medically induced) drug addiction.[9] Benzodiazepine legal addicts are therefore denied services by any healthcare professionals with training in drug dependence and withdrawal management. As an organisation our staff members see the real face of this discrimination from desperate people whose doctors clearly show lack of knowledge and often make poor and dangerous decisions. For example detoxifying people far too quickly provoking severe mental and physical withdrawal effects. We have known this to have had a severe effect, on some people, that were denied services, such that they have become suicidal due to poor withdrawal management and some have even gone on to commit suicide. We believe strongly that many of these suicides could have been prevented had these individuals had access to specialist drug addiction services. In 2004, the Department of Health stated that developing specialist benzodiazepine dependence services would not be appropriate or cost effective, a position subsequently reinforced by Caroline Flint, Minister for public health in 2006 who was quoted as saying that "there were no plans to develop specialised services for legal benzodiazepine addicts". Dedicated treatment services however are available for alcohol and illicit drug problems (including illicit benzodiazepines), in fact HM Prison Services have a statutory duty to provide specialist treatment and rehabilitation for prisoners illicitly addicted to benzodiazepines.[10] So clearly the discrimination against prescribed benzodiazepine addicts is supported at government level. It is both disgraceful and indefensible that a government which the public funds by taxation should then go on to discriminate against a significant number of it`s citizens, as a matter of deliberate policy, when they get addicted to drugs the Department of Health licences doctors to prescribe. As a result people’s lives get destroyed, marriages crumble, they often lose their jobs, end up on benefits and some commit suicide as a result. Not only is this discrimination and ethically wrong, but it may in fact be illegal for the government via the Department of health to discriminate against and deny specialist drug addiction services to prescribed drug addicts under the Disability Discrimination Legislation.[11] Where addiction to illicit drugs or alcohol is not considered to be a disability, medically induced addiction is considered to be a disability in law. The government's stance and policy which clearly results in discrimination against iatrogenic (medically induced) benzodiazepine addicts represents, in our view, a clear violation of the Disability Discrimination legislation. Therefore under UK law benzodiazepine addicts should receive at least the same access to specialist services as all other fellow citizens.

(3) Push for a 24 hour helpline for benzodiazepine addicts.

In the United Kingdom there are an estimated 1.5 million benzodiazepine addicts.[1] No help is available for people wishing to free themselves from the grip of these harmful and dangerous drugs. Despite the huge scale of the benzodiazepine problem there are no government funded help lines for victims who have become, addicted often through no fault of their own. However, illicit drug misusers have access to a government funded 24 hour national drug helpline (frank) and a 24 hour national alcohol helpline (drinkline) as well as various other government funded help lines and organisations around the country. Denial of a helpline for benzodiazepine prescription drug addiction is a denial of human rights, equality and is, without doubt, discriminatory. There are inadequate services within the NHS and an insufficient number of help lines throughout the country. Services like 24 hour help lines are an invaluable source of support and reassurance when a person finds the strain of a benzodiazepine withdrawal intolerable and has nowhere to turn. These help lines would ultimately save many lives and improve the lives of countless people. 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 which would not be particularly expensive would ultimately save the government a great deal of money by reducing healthcare costs. We would like to see funding for such help lines and money to enable these call centres to be manned on a 24 hour basis. If the funding is provided we can provide volunteers to man the help lines similar to how other addiction help lines operate.

(4) 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.

(5) Push for a medical investigation to establish whether long term benzodiazepine use causes permanent brain or neurological damage.

There is an urgent need to investigate whether long term use of benzodiazepine drugs, at prescribed doses, cause structural or functional brain damage such as brain shrinkage or other abnormalities. Follow up studies also need to be carried out after withdrawal, over a period of years, to assess whether any such brain damage is reversible or not over time. Two studies have shown evidence of brain damage in prescribed benzodiazepine subjects but another study has disputed this. Of concern to AATA is that even those on low dose chronic benzodiazepines may also develop brain damage as was demonstrated in one study of 17 benzodiazepine dependent patients. The study also showed that the benzodiazepine induced brain damage is dose dependent, with those on higher doses showing more severe structural brain damage than those on lower doses.[16] Another study was carried out on 20 subjects on chronic prescribed benzodiazepines which also detected evidence of structural brain damage in some of the benzodiazepine users compared to a control group. The brain damage was not as severe as that seen in chronic alcoholics but was still clinically significant.[17] However, another study, again investigating the brain damage potential of benzodiazepines, whilst not ruling out brain damage, concluded that benzodiazepines do not cause any structural brain damage which can be demonstrated by CT scans.[18] Large scale independent trials must be carried out as a matter of urgency as this is a serious public health issue potentially affecting 1.5 million British citizens. Professor Heather Ashton has stated that to find out conclusively whether benzodiazepines cause structural brain damage in prescribed users specialised scans would need to be carried out. She believes that it could be established one way or the other definitively via pet scans, CT scans and MRI scans of benzodiazepine chronic users compared to controls matched for age and sex etc. Professor Ashton did apply for funding for such a study using MRI scans to test for brain damage in benzodiazepine users but was turned down. No study has been done using MRI scanning technology in benzodiazepine chronic users.[19] There is no reason why illicit drugs are tested extensively for the potential causing of brain damage but when it comes to benzodiazepines legally prescribed by doctors tests are not carried out and funding for such tests is denied.

(6) Push for increased awareness of 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.

(7) 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.

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] 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 prescribed benzodiazepine drug induced personality disorders.

(8) 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.[29] Benzodiazepines as with other drugs of addiction activate the reward pathway which can lead to compulsive use and misuse.[30] 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.[31],[32] 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.[33] Organic brain damage occurs from chronic high dose benzodiazepine abuse.[34] 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.[35] 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.[36] 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.

(9) 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.[37],[38] Older patients prescribed benzodiazepine drugs may also develop a pseudodementia type syndrome with combined confusion and depression which may get misdiagnosed as true dementia.[39] Benzodiazepines when given to elderly subjects has effects on the memory functions similar to dementia.[40] Up to 10% of patients diagnosed with dementia have an iatrogenic drug induced cause, most often either benzodiazepines or antihypertensives.[41] 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.[42] 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.

(10) 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.[43] 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.[44] 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.[45] In addition 90% of female drug misusers are of child bearing age.[46] 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.[47] 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."[48] 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.[49] 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.[50] 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.[51] Benzodiazepines administered to babies during their first year of life have been implicated in causing the death of the infant.[52] Smaller head circumference and mental retardation and lower intelligence has been reported in fetally exposed children.[53] 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.

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

Management of benzodiazepine withdrawal must be carried out under the guidance of specialist services. We routinely hear of people being withdrawn from benzodiazepines by doctors who have absolutely 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 all sorts of medical and mental health misdiagnosis. Admissions to psychiatric hospitals are also frequent outcomes when benzodiazepine dependence is mismanaged by doctors who are not adequately trained in drug dependence management. The most serious outcome from abrupt or over rapid discontinuation of benzodiazepines is death from either convulsions or catatonia.[54],[55],[56] Other severe withdrawal syndromes from abrupt or over rapid benzodiazepine withdrawal include severe delusions,[57] rage reactions with homicidal ideation,[58], violence,[59], postural hypotension, hyperthermia, confusional states, psychosis,[60],[61], mania[62] and suicide.[63] 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. Much to their horror 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.

(12) 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.[64] 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.[65] 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.[66],[67] 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.[68] 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.[69] 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.[70] 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.

(13) To provide counsellors with the correct knowledge in benzodiazepine addiction and withdrawal and to then provide their services and support to benzodiazepine addicts and their families.

Unfortunately the NHS and illegal drug services are not adequately equipped with the correct information on dependence, tolerance and withdrawal advice on benzodiazepines. There are no trained counsellors specifically for benzodiazepines or even prescription drug addiction in general so it is therefore one of our aims to arm counsellors with the correct information about benzodiazepine addiction and withdrawal. At present there is no specific training in benzodiazepine withdrawal but by studying the withdrawal techniques as laid out by leading specialists in this field it will be possible to gain such experience. Simply reading The Ashton Manual would give a greater understanding of benzodiazepine dependence and withdrawal in itself and perhaps if necessary a short course in drug dependency could give the counsellors the knowledge required and basic skills to provide services for prescription drug addiction. Training of such counsellors need not be expensive either. Once we have trained and qualified counsellors we then need to implement their services and make them readily available to addicts and their families. We would like to see doctors referring patients onto these counsellors. As withdrawal from these drugs puts a strain on the addict and their surrounding family, putting a trained counsellor in place would enable the addict to have the correct information on how to withdraw safely, what to expect whilst in withdrawal and how to cope with their symptoms. Reassurance and support is invaluable whilst withdrawing and a trained counsellor would provide this to the addict and their families. We at AATA feel that in our experience this kind of service is very important and nesessary.

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

Once we have achieved our aim to have trained benzodiazepine counsellors available throughout the UK we need to implement a scheme in which we have a working partnership with all healthcare providers. We at AATA will aim to work in partnership with these counsellors and doctors and 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.[71] 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 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.

(15) Make withdrawal services available nationwide for iatrogenic benzodiazepine addicts so that they get at least the same access to specialised services that drug and alcohol users have access to.

Drug and alcohol services are available nationwide but as a matter of policy they refuse treatment for benzodiazepine prescription drug addiction.[72] There are also no withdrawal services provided by local primary care trusts for benzodiazepine prescription addicts in the UK,[73] 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.[74] However, there is still not a single residential treatment centre for prescription benzodiazepine addicts.[75] 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. We believe that there is absolutely no moral or ethical reason why those who get addicted to drugs because of following doctor’s instructions should be denied services to help them to withdraw whilst alcohol and illicit addicts get a wide range of specialist treatment services. We have never heard any rational justification for this discrimination. Therefore our aim is to get at least the same access to specialist services for prescription benzodiazepine addiction that those dependent on alcohol or illicit drugs get and that any such services provided are suitable for prescription drug addicts.

(16) Campaign for the government to provide funding for local and voluntary benzodiazepine withdrawal organisations.

In order to set up and keep voluntary benzodiazepine organisations running, funding would need to come from the government. There are many things which require money for example, the costs of running websites, administration costs, promotion, travel costs, posters, leaflets, stationary etc. Voluntary organisations however do not generally require a huge amount of funding as such organisations tend to have only limited costs. So there should be no reason why a relatively small amount of funding cannot be given by the government to voluntary benzodiazepine organisations who after all are only trying to help people, raise awareness and improve the quality of people’s health and quality of life and at a low cost! There is little or no funding given to benzodiazepine addiction organisations from the government whilst lots of funding goes into other addiction organisations such as those catering for addiction to smoking, gambling, alcohol or illicit drugs. We believe that there should be equality in the funding and that the government should therefore provide funding to voluntary benzodiazepine addiction organisations. The NHS is government funded and the benzodiazepine addiction problem is largely an NHS induced addiction problem. Therefore we feel it is the government’s responsibility to aid organisations who are trying to pick up the pieces and help benzodiazepine addicts.

(17) Campaign for an independent public health inquiry into benzodiazepines.

A public health inquiry into benzodiazepines is urgently needed given the very large number of benzodiazepine addicts (both legal and illicit) and the serious health and social consequences of long term benzodiazepine usage. We feel that an independent and full public inquiry is urgently required to establish the degree of damage that benzodiazepines cause, how long symptoms persist after withdrawal, the level of support and rehabilitation services to sufferers, degree and frequency of disablement and the social effects that benzodiazepines have, to name but a few. Of particular concern to AATA is the long term damage and protracted withdrawal. Professor Ashton acknowledged in a letter to Mr Barry Haslam that benzodiazepines were synthesised by a chemist by the name of Leo Sternbach from industrial textile dyes, chlordiazepoxide (librium) being the first benzodiazepine synthesisied. The textile dyes which benzodiazepines were synthesised from is an organic solvent and is known to be neurotoxic. Benzodiazepines are also closely related in molecular structure to insecticides used in sheep dip. Professor Heather Ashton a world leading expert on benzodiazepines stated that "Organic solvents, as well as organophosphates, are well known to be capable of causing brain damage. The fact that Librium is chemically related to some dyes, and also insecticides, does not mean that it causes the same damage, but I agree that it raises suspicions."[76] Calls for a public health inquiry into benzodiazepines is nothing new and is something which various MPs have called for. The government turned down a public health inquiry into benzodiazepines in 2007. In a letter to several MPs, Mr Barry Haslam and Dr JG McConnell the MP Mr Kevin Barron who is the chairman of the Health Select Committee and the All Party Pharmaceutical Group stated that "There is a large number of pressing issues affecting the health service at this time and, unfortunately, it is not possible for us to undertake an inquiry". This in our opinion is unacceptable, negligent and shows a cynical disregard by the government to the 1.5 million British people currently hooked on chronic benzodiazepines.

(18) Push for home office reclassification of benzodiazepines from class C to class A drugs.

There are many compelling reasons, some of which we have highlighted in previous aims in this document which call for the reclassification of benzodiazepines to Class A drugs. These drugs have caused so much harm and suffering to society and the damning evidence against these drugs only continues to mount. These drugs are associated with causing mental health problems in many users and are associated with self harming and suicide.[77] Self harm and overdose involving benzodiazepines is common and seems to be more common in older subjects.[78] The majority of opiod overdoses (66%) involve combination with either benzodiazepines or alcohol.[79] The number of people consuming benzodiazepines is huge, with 10 million prescriptions for benzodiazepine or Z drug sleeping tablets issued in the UK.[80] This does not include figures for people taking benzodiazepines for anxiety or other conditions. The Z Drugs, zopiclone, zaleplon and zolpidem all work on GABA-benzodiazepine receptors and according to a report by the National Institute for Clinical Excellence there is little difference between benzodiazepines and Z drugs and N.I.C.E stated that Z drugs cause tolerance, dependence and withdrawal syndromes similar to benzodiazepines. N.I.C.E also stated that there is evidence that abuse of zolpidem is increasing.[81] Benzodiazepines have also been linked to cases of rape with 9% of people alledging drug rape testing positive for benzodiazepines. However, alcohol remains the most commonly detected drug involved in drug assisted rape.[82] Severe benzodiazepine dependence is associated with a more severe crack cocaine habit and those with severe dependence on crack cocaine were twice as likely to test positive for blood borne diseases.[83] Benzodiazepines meet all of the criteria for drug dependence and prescribed benzodiazepines leak onto the illicit drug market.[84] Benzodiazepine misuse and opiate misuse tend to go hand in hand and are predominant drugs of misuse with 2% of the population misusing either benzodiazepines or opiates.[85] The Australian government carried out a study into crime associated with benzodiazepine use which provided damning evidence against benzodiazepines. In the survey of police detainees carried out by the Australian Government, both legal and illegal users of benzodiazepines were found to be more likely to have lived on the streets, less likely to have been in full time work and more likely to have used heroin or methamphetamines in the past 30 days from the date of taking part in the survey. Benzodiazepine users were also more likely to be receiving illegal incomes and more likely to have been arrested or imprisoned in the previous year. Benzodiazepines were sometimes reported to be abused alone but most often formed part of a poly drug using problem. Female users of benzodiazepines were more likely than men to be using heroin whereas male users of benzodiazepines were more likely to report amphetamine use. Benzodiazepine users were more likely than non users to claim government financial benefits and benzodiazepine users who were also poly drug users were the most likely to be claiming government financial benefits. Problem benzodiazepine use is strongly associated with crime. Those who reported using benzodiazepines alone were found to be in the mid range when compared to other drug using patterns in terms of property crimes and criminal breaches. Of the detainees reporting benzodiazepine use, one in five reported injection use, mostly of illicit benzodiazepines but some reported injecting prescribed benzodiazepines. Injection was a concern in this survey due to increased health risks. The main problems highlighted in this survey were concerns of dependence, the potential for overdose of benzodiazepines in combination with opiates and the health problems associated with injection of benzodiazepines.[86] To our knowledge such a wide ranging study has not been carried out in the UK but collectively evidence in the medical literature suggests that benzodiazepine use and misuse in the UK is associated with the same risks found in the Australian Government research study. A review into the current classification of benzodiazepines as class C drugs is urgently needed and we at AATA are of the strong view that benzodiazepines need to be rescheduled to class A status. In the UK, Professor David Nutt who is a consultant for numerous pharmaceutical companies including Roche a major manufacturer of benzodiazepines and is the chair of the Advisory Council on the Misuse of Drugs (ACMD), and Chair of its Technical Committee published a study into which drugs cause the most harm to society and the user of the drug.[87],[88]

In the study in which Professor David Nutt was the lead author, benzodiazepines were ranked by a survey of experts in drug and alcohol as being more harmful overall to the user and society than LSD, amphetamines, solvents or ecstasy but yet benzodiazepines remain as class C drugs.[89] This has to change, the Home Office needs to reclassify benzodiazepines to Class A drugs.

(19) To raise awareness of the reasons why people end up on benzodiazepines in the first place.

AATA has for a number of years now been involved in running a support forum called The Trap (The Tranquilliser Recovery and Awareness Place) which has close to 1000 members. Some of our members have experience with drug and alcohol services and thus we have developed a large understanding of what leads people to benzodiazepine dependency in the first place. What we have learnt is that contrary to popular opinion the vast majority of people who end up on chronic benzodiazepines did not have serious mental health problems before the benzodiazepines. What we have learnt collectively from running a support group and attending other support groups is that the same reasons keep cropping up time and time again. The reasons tend to be normal emotional upsets such as bereavement, relationship breakups, abusive relationships, loss of job and similar. Also benzodiazepines are commonly misprescribed to people with mental and physical health problems stemming from alcohol misuse. Alcohol misuse causes a wide range of neuropsychiatric and cognitive dysfunction problems as well as withdrawal symptoms such as anxiety, paranoia, psychosis, mania, depression, muscular disorders etc. Another extremely common reason for people to be prescribed benzodiazepines is due to typically misdiagnosed adverse reactions to drugs or withdrawal symptoms from prescription drugs. Often the same names crop up. Fluoroquinolone antibiotics which are structurally related to Mefloquine (lariam) and interact with various CNS receptor systems seem quite prominant in provoking "unexplained" anxiety, psychosis, insomnia, muscular and other syndromes which lead to benzodiazepine prescriptions. Other adverse reactions to psychotropic medications e.g. stimulants, antidepressants, antipsychotics, opiates, anticonvulsant medications, hormonal drugs, corticosteroids etc provoke symptoms such as anxiety, agitation, akasthesia or sometimes psychosis which often leads to misdiagnosis as "acute anxiety" or "bipolar" disorder etc. This in turn leads to the prescription cascade of taking one drug to treat the symptoms misdiagnosed of the other drug. Also very commonly we hear of people who have been abruptly taken off CNS acting drugs e.g. stimulants, antidepressants, antipsychotics, opiates, anticonvulsant medications, hormonal drugs, steroids etc which leads to acute withdrawal syndromes, which again seem to often get misdiagnosed as some sort of a mental health disorder and gets mistreated with other drugs, often benzodiazepines. Another category of people who end up taking benzodiazepines are those with muscular problems, insomnia, physical pain or irritable bowel syndrome. However, there is a minority of people who did have pre-existing anxiety disorders or have issues stemming from, for example child abuse or neglect who end up on benzodiazepines. However, a couple of things are common to all people regardless of the reason for originally taking benzodiazepines. They typically report that after the first few weeks of use the drug stops working, due to tolerance and most reported, the development of various new symptoms or side effects after prolonged use especially depression sometimes with suicidal thoughts, cognitive deterioration, worsening quality of sleep, agoraphobia, muscular complaints, gastrointestinal complaints, development of or worsening of anxiety, panic attacks and social deterioration and social isolation. The development of these symptoms seem to occur regardless of whether the person initiated the prescription due to a mental health problem or a physical health problem. This suggests strongly that prolonged usage of these drugs leads to the development of a wide range of physical and mental health problems which will be costing the individual incalculably in terms of suffering and loss of quality of life. In terms of taxpayers’ money it will be draining the resources of the healthcare system by treating these drug induced symptoms and in disability and income support payments to such individuals who are incapacitated by these drugs. The solution to this must come from the government and the medical profession. The government through the Department of Health needs to come up with solutions to these misdiagnosis and very poor medical care to end the suffering induced by these benzodiazepine drugs. Medical education needs an urgent revamp with a focus on improving the awareness of both adverse drug reactions and drug withdrawal reactions with strict limits needing to be placed on drug company sponsored education e.g. drug company seminars and drug reps etc. More services involving non-drug therapies need to be put in place, including more trained counsellors. Those suffering acute crisis such as bereavement or relationship problems would have the opportunity to spend a couple or more sessions with appropriately trained counsellors being helped through the crisis instead of getting hooked on powerful addictive drugs. Such an obvious and sympathetic approach would help to avoid them becoming lifelong customers of the drug companies, losing their jobs and becoming chronic users of the mental health and benefits system. The medical profession needs to refocus itself not just on treating the symptoms but on treating the cause. Simply treating the symptoms with benzodiazepine drugs does no good in the long run and often leads to serious consequences such as drug addiction or serious chronic adverse drug effects. So for example if someone is in an abusive relationship the answer is not drug therapy but the answer should be that the doctor refers such a patient to services, support groups or help lines specific for their complaint. Another example is a patient with mental or physical health problems caused or worsened by alcohol or illicit drug misuse should be referred to the appropriate services, support groups or help lines. Drugging drug induced symptoms will have no long term benefit and the patient is more likely to deteriorate without appropriate treatment for the cause of their symptoms. Such a change in medical practice is only likely to come about with changes in the medical education system and action from the department of health to highlight these problems. It should be noted that the Committee on the Safety of Medicines stated that benzodiazepines tended to lose their sleep promoting properties within 3 - 14 days of continuous use and in the treatment of anxiety the committee found that there was little convincing evidence that benzodiazepines retained efficacy in the treatment of anxiety after 4 months continuous use due to the development of drug tolerance.[90] This means that people taking benzodiazepines for more than a few months are deriving no benefit from their chronic use of benzodiazepines except for the suppression of withdrawal symptoms and in many cases are suffering harmful consequences from their benzodiazepine prescriptions. We at AATA believe that the government needs to investigate ways of tackling these problems that we have raised and look into ways of reforming the medical educational system.

(20) To raise general awareness of the fact that all psychotropic drugs will cause a withdrawal syndrome.

It seems very common for doctors to be ignorant of the addictive potential of CNS drugs in terms of drug withdrawal. What can be said with reasonable certainty is that all drugs will cause a degree of drug withdrawal symptoms (aka rebound or discontinuation syndrome). The severity of withdrawal from prescription drugs will vary from drug to drug and individual to individual. However, without doubt benzodiazepines cause the most severe withdrawal syndrome of all the commonly prescribed drugs. This is most likely because between 60 and 75% of brain cells are GABAergic and GABA is the chemical which benzodiazepines work on, meaning in theory that 60 -75% of the brain is potentially malfunctioning during drug withdrawal from benzodiazepines.[91] When drugs act chronically on the brain (or body) at receptors, ion channels or uptake sites on cells a degree of adaption in the form of tolerance will occur as the body tries to overcome the drug’s effects and restore normal cellular functioning. This then leads to the body adapting to a state of functioning in the presence of the drug. When the drug is rapidly removed before new adaptions are made withdrawal symptoms, sometimes profound, occur as a result.
Withdrawal symptoms from other drugs are not necessarily benign. Beta Blockers which are prescribed for heart and anxiety problems and have the common side effect of insomnia can lead to the opposite of its effects when abruptly withdrawn with withdrawal symptoms including tachycardia (increased heart rate), anxiety, drowsiness, agitation and nausea.[92]
The British National Formulary warns of the need to avoid abrupt withdrawal from antipsychotics which can lead to acute discontinuation syndromes.[93] The British National Formulary however does not mention what withdrawal symptoms are typical when discontinuing antipsychotics. We as an organisation have known of cases where people have been prescribed antipsychotics for anxiety or agitation and when they have discontinued them abruptly they have reported psychotic like symptoms, movement disorders, anxiety, twitching, nausea and severe insomnia although the withdrawal syndrome does appear to be less intense than the benzodiazepine withdrawal syndrome. The withdrawal syndrome is likely due to tolerance in dopamine receptors leading to dopamine hypersensitivity. Lack of awareness of the risks of withdrawal effects of antipsychotics both by the patient taking the drug and the doctor could lead to disastrous consequences. For example a schizophrenic may discontinue an antipsychotic abruptly due to for example side effects without realising that not only may his underlying condition come back it is likely to come back much more severely due to abrupt withdrawal which as we know from the media can lead to disastrous consequences.
Withdrawal syndromes from all classes of antidepressants also appear to be common but in our experience mirtazapine seems to cause the most severe withdrawal syndrome. Personal experience of two members of AATA who abruptly discontinued antidepressants resulted in severe depression with intense suicidal thoughts despite the fact the drugs were prescribed for agitation or anxiety and not for depression. Other withdrawal effects included loss of balance, electrical shocks and hyperactivity etc.
Other withdrawal syndromes occur from steroidal drugs and antiparkinsonian drugs.[94] Anticonvulsant drugs if abruptly withdrawn may cause a withdrawal syndrome which with some antiepileptics may be similar to benzodiazepine or alcohol withdrawal.[95] Other withdrawal effects may include sleep disturbances, paranoia, hostility, agitation, sudden unexpected death in epilepsy (SUDEP) and increases in seizure intensity.[96],[97],[98]
Stimulants can produce tolerance, psychological addiction, psychosis, hypertensive crisis, and major depression following withdrawal after long-term use.[99] Abrupt stimulant withdrawal mimicking mania has been reported in a child treated chronically with stimulant medication which leads to the misdiagnosis of bipolar disorder.[100] Stimulant withdrawal often includes a reversal of the drug’s effects, presumably due to the development of drug tolerance and dependence.[101] The medical literature has acknowledged that there is a need to ease stimulant withdrawal effects.[102] We believe that gradual tapering of stimulants over a period of 6 months (or longer in some patients) is the best way of managing stimulant or other drug withdrawal.
To improve knowledge of drug dependence on prescribed drugs education of doctors should begin at university level and include basic medical knowledge of tolerance, physiological dependence and withdrawal and rebound syndromes. Doctors should be taught that all CNS acting drugs can produce withdrawal syndromes and that when drugs are being discontinued after prolonged use, gradual tapering over a period of months should be carried out prior to complete discontinuation.
The government through the Department of Health needs to issue guidance to doctors on the discontinuing of all CNS drugs in general and the need to gradually taper the dose down prior to stopping any CNS prescription drug after prolonged use. Doctors should be made aware that benzodiazepines cause the most serious withdrawal syndrome and of its protracted nature.
We feel at AATA that such a policy would have significant cost saving effects and would significantly reduce the number of patients who suffer distressing withdrawal syndromes at the hands of ignorant doctors which will in turn reduce negative press that the medical profession gets. Implication of our suggestions we feel will benefit everyone concerned.

Recommended Reading

The Ashton Manual - Benzodiazepines How They Work and How to Withdrawal. Professor Heather Ashton 2002 available for free www.benzo.org.uk/manual/

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