The Language of Harmful Use

The language we use to describe a patient’s relationship with medications can have an outsized effect on the doctor-patient relationship and their compliance with the doctor’s orders.  This is particularly true for benzodiazepines and Z-drugs, where few patients view themselves as abusers or addicts, and the literature supports them in this view.[1]

ABUSE

“Abuse” is a term used frequently in relation to certain substance-related problems.  For benzodiazepines, abuse typically refers to their use without a prescription, or when patients obtain benzodiazepines from multiple prescribers without informing the prescribers of their other prescriptions.  Because of its pejorative tone and variable meaning over years, it is not ideal and the term “non-medical use” is preferred to describe use that lies outside that defined by a prescription.  See the full definition of “Abuse” on the Terminology page.

ADDICTION

Benzodiazepine-related problems are often categorized as “addiction”, when in fact, for the vast majority of those who have difficulties, that diagnosis simply does not apply. The disease of addiction is a disease of the brain reward system characterized by the three “C’s” – all of which must occur together in order to make the diagnosis [2]:

1) Compulsion to use for reasons other than for which they are prescribed.

2) Loss of Control with amounts used significantly increased over time and more than intended by the prescriber and the patient.

3) Continued use despite adverse consequences which are recognized by the user as problematic.

Although non-addicted benzodiazepine survivors may experience the third criteria, they are not driven to do so by craving that leads to inappropriate and excessive overuse. On the contrary, it is not addiction, but rather physiological dependence – including its overwhelming withdrawal symptoms – which binds them to continued use. They have what is probably better termed as a benzodiazepine brain injury – “benzo brain” – which results in the wide array of symptoms that differ from person to person and can be so devastating.

Misapplying these criteria is compounded by a misunderstanding of how to use the detailed criteria for addiction found in the Diagnostic and Statistical Manual, version 5 (DSM-5).  The DSM-5 criteria for addiction are replicated below, along with a description of how these apply to benzodiazepines.

PHYSIOLOGICAL DEPENDENCE

The terms “addiction” and “dependence” are used almost interchangeably throughout the literature on benzodiazepines.  However, there are several significant differences between these terms when referring to benzodiazepines:

1) As with the opioid crisis, most of the people who are physiologically dependent on benzodiazepines became dependent by taking the normal prescription of a physician, psychiatrist, or other prescriber.  Physiological dependence can occur after just using the drug per prescription in the absence of non-medical use.

2) From the medical perspective, dependence is more than simply “reliance upon”.  It embraces two primary aspects: tolerance and withdrawal, which are defined below in the DSM-5 criteria (numbers 10 and 11).

3) While most prescribers are aware that benzodiazepines are potentially addictive, many continue to prescribe them beyond manufacturer’s recommendations, and often without notice to the patient that the prescription is a use of the drug outside of FDA approval.

4) Few prescribers recognize the symptoms of benzodiazepine or Z-drug physiological dependence.

5) There is a much greater social stigma attached to the word “addict” than to the term “physiological dependence”.  Beyond this, however, the vast majority of those who struggle with benzodiazepine-related problems simply do not have addiction, and misdiagnosis will lead to ineffective and harmful treatment approaches.  Those with the disease of addiction, of course, should not be stigmatized as well.

For these reasons, throughout this site, we refer to “physiological dependence” on benzodiazepines instead of benzodiazepine addiction.  “Physiological” is used here because the condition may include physical but also psychological characteristics – both of which are not the result of the disease of addiction but of different neurophysiological processes.

THE DSM-5 ADDICTION CRITERIA AND BENZODIAZEPINES

The DSM-5 addiction criteria are listed below, followed by application of these criteria to benzodiazepine receptor agonists. A problematic pattern of sedative, hypnotic, or anxiolytic use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

1) Sedatives, hypnotics, or anxiolytics is often taken in larger amounts or over a longer period than was intended.

2) There is a persistent desire or unsuccessful efforts to cut down or control sedative, hypnotic, or anxiolytic use.

3) A great deal of time is spent in activities necessary to obtain the sedative, hypnotic, or anxiolytic; use the sedative, hypnotic, or anxiolytic; or recover from its effects.

4) Craving, or a strong desire or urge to use the sedative, hypnotic, or anxiolytic.

5) Recurrent sedative, hypnotic, or anxiolytic use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences from work or poor performance related to sedative, hypnotic, or anxiolytic use; sedative-, hypnotic-, or anxiolytic-related absences, suspensions, or expulsions from school; neglect of children or household).

6) Continued sedative, hypnotic, or anxiolytic use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of sedatives, hypnotics, or anxiolytics (e.g., arguments with a spouse about consequences of intoxication; physical fights).

7) Important social, occupational, or recreational activities are given up or reduced because of sedative, hypnotic, or anxiolytic use.

8) Recurrent sedative, hypnotic, or anxiolytic use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by sedative, hypnotic, or anxiolytic use).

9) Sedative, hypnotic, or anxiolytic use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the sedative, hypnotic, or anxiolytic.

10) Tolerance, as defined by either of the following: a) A need for markedly increased amounts of the sedative, hypnotic, or anxiolytic to achieve intoxication or desired effect. b) A markedly diminished effect with continued use of the same amount of the sedative, hypnotic, or anxiolytic.

11) Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for sedatives, hypnotics, or anxiolytics. b) Sedatives, hypnotics, or anxiolytics (or a closely related substance, such as alcohol) are taken to relieve or avoid withdrawal symptoms.

Tolerance and withdrawal (numbers 10 and 11) are criteria that are not to be used when benzodiazepines are prescribed because these are expected responses to normal prescribing and do not reflect non-medical use in that context. It is easy to see how a medical provider might view many of the other criteria (1, 2, 5, 6, 7, 9 especially) applicable to those with major benzodiazepine adverse reactions. However as above, for most of these patients, the reason for continued benzodiazepine use despite bad outcomes is not craving or non-medical use but rather the inability to discontinue use successfully – often because of the inability of the medical provider to assist in withdrawal. These criteria, therefore, should not be applied to these individuals. Many medical providers do not understand this translation of the criteria to benzodiazepines and fail to act on it for a number of reasons:

1) Reliance on outdated information that overplays benefits, in particular, wrongly believing benzodiazepine long term use remains generally effective.

2) Absence of updated knowledge of alternative treatments that work better and are safer.

3) Absence of patient requests to increase dosing which could suggest non-medical use

4) Insufficient recognition that important symptoms could be due to benzodiazepines, thinking rather they are related to

5) Inadequate treatment of the medical condition treated (e.g., anxiety or insomnia),

6) Worsening of the medical condition treated, and/or

7) Development of a new medical condition.

8) Focus on other medical problems like opioid addiction or pain felt to be of higher priority.

9) Focus on other medications like opioids felt to be of higher priority.

10) Insufficient training, skills, and patient visit time to assist in the benzodiazepine withdrawal process.

11) Perception that withdrawal is more harmful and difficult than continued prescribing.

12) Absence of guidance from guidelines and key opinion leaders to highlight the evidence-based research and provide direction for best clinical practices.

13) Not listening closely enough to what patients are saying. Patient symptoms are highly variable and persistent and, most importantly, are real.

Persons with substance-related problems often feel stigmatized. For persons with a valid diagnosis of addiction, “addict” puts them in a box that implies that that is all they are, when, in fact they are so much more: a mother, a father, a daughter, a son with a life with a career, a family, interests, hopes, aspirations, and dreams. Though it should not be the case, “addict” can carry the tone of being weak-willed, inherently flawed, morally degenerate, even criminal – none of which is necessarily true. Neither persons with addiction nor those with non-addiction-related benzodiazepine problems should not be stigmatized, nor should they feel stigmatized.

For non-addicted persons with benzodiazepine-related trouble, it goes beyond this. Helping them manage and treat benzodiazepine trauma is entirely different from addressing benzodiazepine addiction.

REFERENCES

[1] Salzman C. The APA Task Force report on benzodiazepine dependence, toxicity, and abuse. Am J Psychiatry. 1991 Feb;148(2):151-2. PubMed PMID: 1987812.

[2] Smith DE. Diagnostic, treatment and aftercare approaches to cocaine abuse. J Subst Abuse Treat. 1984;1(1):5-9.  Abstract