Medications discussed on this site include:
Tranxene (clorazepate dipotassium)
Valium / Diastat (diazepam)Xanax (alprazolam)
Primarily known as anti-anxiety medications and sleep aids, the benzos are actually anticonvulsants, and as such they do act as mood stabilizers. However, they are not a first-line mood stabilizer. They are weak ones at best, and their highly addictive nature and potential for abuse just don’t make their case for them. Their big advantage is that they act quickly. If seizures or mania or anxiety are happening right now then a benzo is just the thing. They are often listed in the package inserts as the thing to administer in case of seizures caused by other meds, probably because someone is far more likely to have some Ativan on hand than some phenobarbital. They are not the best drugs in the world for long-term control of epilepsy or mania in of themselves, but they can be a good option for long-term control of anxiety if SSRIs or antipsychotics just won’t work for you for whatever reasons. In the bipolar world, there is a downside to long-term use of benzos. Their long-term use aggravates depression, especially bipolar depression, which is just one more reason why they are not a good class of drugs for control of mania in of themselves.
For me all benzos are interchangeable, be they brand or generic, they all act exactly the same way; the first fifteen to twenty minutes they make me more nervous then they calm him down tremendously for six to ten hours before knocking him out. Even if I’m taking them to get my sleep cycle back in sync on the rare nights I don’t pass out before 10:30 they still make me nervous at first. I find them to be mildly addictive and I’m over taking them daily after just a couple days of mildly annoying withdrawal symptoms. We’re talking physical and psychological dependency on the level of a couple of espresso drinks a day. It really doesn’t matter which one I take, they all act like that. But I am a freak and an exceptional case. Only on days when I’m really flipping out is there a difference, and that’s a matter of dosage. Like on that day I needed most of a bottle of Valium (diazepam) to calm down. Or that one hospitalization in the 1970s (before there was such a thing as Ativan) where they just gave my shot after shot of diazepam to no effect.
For most people there are noticeable differences in the how quickly each benzo takes effect, how long it lasts, what secondary effects there are, and how addictive it is. These differences are especially apparently in the three most popular (in the US) benzos – Ativan (lorazepam), Klonopin (clonazepam) and Xanax (alprazolam) Some people can be addicted to Xanax after just a couple days on the minimum dose and go through the worst withdrawal symptoms possible when they stop.
All benzos do work basically in the same way; they enhance the way GABA works. GABA is the neurotransmitter that really mellows us out. There are specific benzodiazepine receptors in the brain, but they don’t seem to matter much to the desired effects of these meds. Those receptors may have plenty to do with the physical dependence and many drug-drug interactions. Everything else is all a matter of fine tuning specific effects.
So the question is, if anxiety is a problem, and it’s enough of a problem to require medication, is a benzodiazepine the answer?
First you need decide if it’s bad enough to require any form of medication, and for that you should be seeing a talk therapist and you should belong to a support group. A psychiatrist is basically going to figure out the right meds for you and that’s going to be about it. Sometimes they’ll do therapy, but often not. For more information on, and reasons why you should be seeing a talk therapist and belong to a support group, take a look at my page on support groups. Both will help you determine if you really do need some type of medication. And if you do, the services of both therapist and support group are vital to complete what the drugs do. Meds alone are not going to fix your problems!
Once that is out of the way, there’s another question – is the anxiety constant or is it something that just happens occasionally?
If it’s constant you’ll want to explore using an SSRI or an antipsychotic. If no medication from either of those classes seems to get along with you, then a benzo could be a good fit.
But if you suffer from anxiety or panic attacks, instead of constant anxiety or panic, then a benzodiazepine would be a better medication, something you could take when you need it that works quickly and is usually out of your system in a day or two.
They universally mess with your memory, but are otherwise generally side effect free. Sometimes doctors will use that stupid memory trick with some particularly anxious patients and give them a high dosage of a benzo in an injectable form prior to an operation. The result is not only a calm patient, but one who frequently can’t remember that a surgical procedure even happened! As long as you realize that the sedation is an expected side effect that may or may not go away, which is why you can’t rely upon them as a nightly sleep aid. The benzodiazepines are the safest of all psychiatric medications. You can’t overdose on them alone, although they can make other drugs, like alcohol, work a lot better. It’s not the Valium that kills you when you wash it down with Whiskey, it’s alcohol poisoning.
And they are all addictive, so they do have a withdrawal syndrome. Abrupt discontinuation of high doses can lead to seizures in addition to dysphoria, insomnia, muscle cramps, vomiting and sweating. If you do wind up taking them daily for longer than four weeks and don’t build up a tolerance and don’t abuse them, be sure to refill your prescription a few days before running out, just in case something happens to prevent you from getting that refill when you do run out. Just like any other medication that is addictive, if you need to stop you work out a discontinuation schedule with your doctor. I think the issue of the addictive nature of benzos is way overblown. Yes, they are addictive, big deal. So are SSRIs and other anticonvulsants. You don’t want to stop medications from either of those classes cold turkey.
While popular as a sleep aid, tolerance to them builds up quickly for a lot of people. They’re great for occasional insomnia, but you’re probably better off looking into something else if you can’t get to sleep every night. Some people can take them every night for as a sleep aid. Keep in mind that the sedation thing is a side effect and is expected to go away with continued use.
Most benzos come in an injectable form, kept at hospitals for last-minute anxieties before surgical procedures, making use of that memory side effect, and for epileptic emergencies. I’ll just deal with the tablet forms.
Don’t mix booze and benzos, unless you want to end up like some of your favorite dead rock stars. OK, if you’re on low doses of benzos one bottle of beer or a glass of wine isn’t going to make you choke on your own vomit or stop breathing, but moderate to high amounts of either just might. Keep the half-life in mind. If you had to take a lot one day and plan on drinking a lot the next day, you could find yourself in deep shit.
Because benzos feel really nice, and for some people they feel especially nice, they shouldn’t be used by anyone with a history of substance abuse. Or a family history of substance abuse. Let’s be clear here about what substance abuse is. Past use of illegal drugs alone is not substance abuse, past use of illegal drugs is breaking the law. Physical and/or psychological dependence on recreational substances, be they legal or illegal, that’s substance abuse. A diagnosis of OCD makes things a bit tricky, and a long talk with your doctor is in order when going over the pros and cons of benzos, because you could wind up taking too many, using up your prescription, not being able to get a refill and then getting to enjoy the withdrawal syndrome.
Because of FDA scheduling you can’t buy any benzodiazepines from an overseas pharmacy. Even buying them from an Internet pharmacy can be tricky sometimes. Several people have reported fraudulent pills from places that promise cheap benzos and/or benzos without a prescription. See the article on how to select a good Internet pharmacy for more information. Any site promising you cheap benzos from an overseas source is probably going to rip you off one way or another.
As there appears to be little difference between the brand and generic forms for the majority of people, just get the generic form of the preferred benzodiazepine from a local pharmacy. That’s inexpensive enough.
Only brand Klonopin and generic clonazepam have had reports of significant differences in effect for mood stabilization and anti-seizure effect. See the article on Brand vs. Generic Meds for more information.
Here are the dosage equivalents of benzodiazepines: 1mg Ativan = 0.5mg Klonopin = 25mg Librium = 15mg Tranxene = 10mg Valium = 0.5mg Xanax. If you need to suddenly switch from one to another because of a sudden bad reaction you’re pretty much OK swapping any benzodiazepine for any other in case of emergency. Unless you’ve been taking Xanax for long enough to become dependent upon it. Then you’re hosed. Xanax requires Xanax for discontinuation. You can try switching between brand and generic and that’s it.
Until I get around to doing the drug-to-drug comparisons for benzodiazepines, like I have for some of the atypical antipsychotics like Seroquel (quetiapine), here is a handy Benzodiazepine Comparison Chart. Courtesy of Brent Jensen of Queen’s University School of Medicine, Kingston Ontario. Of course it applies only for meds available in Canada, eh. But it’s better than nothing.