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Scott Webb (Host): You may have heard of Valium, Xanax, Klonopin, or even lorazepam. These are benzodiazipines and are prescribed for anxiety, but are they effective medicines or just scary drugs. And joining me today to help answer this question and more including the benefits and side effects of benzos and whether or not the calming effects outweigh the risks is Dr. Eric Hansen. He's a Psychiatrist with Sierra Tucson. This is Let's Talk Mind, Body, Spirit by Sierra Tucson. Sierra Tucson ranked number one best addiction treatment centers 2020 in Arizona by Newsweek. I'm Scott Webb. Dr. Hansen, as a provider for the residential programs at Sierra Tucson, what makes this a compelling topic for you?

Eric Hansen, MD (Guest): Well, we have four main tracks here. There's addiction and co-occurring, there's the pain track. There's the trauma track. And then there's the mood track. And what this means is that I might be tasked in one situation with helping a patient who has a severe alcohol or a drug addiction. And the goal is to find them a way through the recovery journey.

Especially when they first come in, the psychiatrist and the medical doctors play a big role, but it also means that an hour later I might be tasked with helping someone with a pain condition or PTSD or severe anxiety. And usually if they're coming to us, there's a question or there's a part of their condition, which is only partially being treated successfully in the outpatient setting. And so interestingly on patient number one, I might be helping them with a problem with drug addiction and that might include benzodiazepines and in patients in the other programs or if there's crossover, they may actually come to me with a prescription for a benzodiazepine or a question, or even a demand for a certain dosage of benzodiazepine. And so I think it's, it's a complex dance that we do sometimes here with helping our clients.

Host: Yeah, I think that's a great way to put that. It does sound like a complex dance for you and one that you all do well. And so what are the medical uses for benzodiazepines? What, in a nutshell, do they do?

Dr. Hansen: Well, you mentioned a few of them in the intro. We're talking about examples like alprazolam, which is Xanax, lorazepam, which is Ativan, clonazepam, which is Klonopin and diazepam, which has the brand name Valium. That's been around a long time and a host of other less common ones that don't pop up as much in our clinical practice.

And so we might accept a patient who's having, for instance, a bottle of vodka every day. And they've decided to undergo detox and rehab at our facility and the detox is done on in our onsite Copper Sky section, part of our hospital facility. And they do it under close supervision. And since they're not at that point, having the heavy dose of alcohol each day, we're going to replace it with a carefully measured benzodiazepine dose, and then we taper the dose slowly so that their body and brain well isn't so dramatically shocked from the sudden absence of the vodka that they were drinking. And so the Valium taper during alcohol detox is a good example of this process and withdrawal protocols are another example where the nurses are tasked with rating every four hours, for example, rating the overall picture of a patient's withdrawal symptoms. And then they give the patient a certain score. And then the certain score is associated with a certain dose of a benzodiazepine to mitigate some symptoms.

And so in this case, benzodiazepines are part of a medical treatment for alcohol detox. And it's a really essential part We also, except patients who maybe they've stumbled into problems with overuse or abuse of benzodiazepines where they've sought out multiple prescribers, or they are buying it off the street, or they are stealing it from a college roommate or they found a way on the internet or the dark web or something like that, to get them from a different country.

And in this case, the medicine that we use or the class of medicine that we use comprises the substance use disorder itself. And in a strange twist, especially to people who are unfamiliar with addiction medicine, a person who might be using the triple recommended dose of Xanax comes in for detox. And they come in and they actually get another benzodiazepine, probably something similar to the alcohol detox patient with a Valium taper, for example. And it's the same idea that brain and the body need to adjust slowly in the detox situation. It's a friend and a foe potentially.

What do they do in a nutshell with, I don't want to get into the nitty gritty of chloride channels and the nervous system and some of the molecular science, but let's say like the brain activity, well, more specifically the nervous system activity has a certain level of neurons firing off and communicating with each other in the sense of like electrical impulses.

I always say, try to envision maybe an electrical circuit, but they also kind of communicate like an extremely fast chain reaction like a string of dominoes that a kid would set up and try to knock over. And benzodiazepines encourage the slowing of that process of slowing, of brain or nervous system activity.

And two major players are the chemicals. One's called GABA, which stands for gamma aminobutyric acid. And that slows down the brain. And then there's a counterbalance called glutamate also naturally occurring in the brain, which excites the brain. And it's like a seesaw or a lever scale. And what benzodiazepines do is they enhance the first one, the GABA chemical, which helps just slightly turn down brain activity.

And so benzos, I think in pop culture, they are thrown around a lot, the names, especially Valium or Xanax or Xani. The benzo class has been available since the 1960s, including Valium which was available in 1963. And we see them used in a number of clinical legitimate situations. Valium, for example, is FDA approved for, I have a list; generalized anxiety, short term anxiety, pre-procedure anxiety, convulsive disorder, alcohol withdrawal, muscle spasm from an injury, muscle spasm from a nerve problem, muscle spasm from cerebral palsy and other symptoms related to rigidness, certain seizure disorders.

And then, a lot of the medication, especially psych medications are prescribed off label. So, we see it prescribed for insomnia, catatonia, obsessive compulsive disorder, agitation in the hospital, and sometimes even a kind of a supplement or a buddy medication for a mood stabilizer when we treat people with bipolar mania.

We'll focus on common uses of something like Valium in psychiatry. And here's the thing is they can be remarkably effective at temporarily reducing symptoms of stress and anxiety. And that is unfortunately part of the problem. So, many patients when they're seeking relief from emotional distress and they're prescribed something like a Valium or a Ativan or a Xanax, they immediately recognize that other medications that they may take or that they have taken are not as dramatic or effective at globally reducing their subjective experience of anxiety. So, it's a very powerful medication, but it's also a very powerful experience for the person taking it.

Host: Yeah, I see what you mean. And we're going to talk more about use and abuse, but the natural question I think that comes up because it sounds a little bit like Prozac in a way, but I know that they're different, at least I believe that they're different. So really what makes these medications different than let's say an antidepressant, like Prozac?

Dr. Hansen: Good question. Important question. Let's compare something like escitalopram or the brand name Lexapro which is an SSRI class antidepressant, which is actually FDA approved for depression and generalized anxiety. And the basic framework I use a metaphor, sometimes I say some medications can help shelter us from the weather today and some medications can help change the climate. And so something like escitalopram or, Lexapro, it really, changes the climate. And what I mean, is it over the course of three, four or five weeks, the brain's signal of negative emotion becomes less negative. Stress might still be stressful, but in the case of anxiety or depression, the symptoms will be more tolerable, more subjectively weaker. And this happens over the course of weeks, sometimes, maybe a couple of months to adjust dosages and let the equilibrium set in.

So in the case of lorazepam, it should be, I would say, taken episodically. And so if Lexapro changes the climate, lorazepam can help with today's weather. And if a patient's having high anxiety, having a bad day, jumping on a plane and they're not so fond of flying, getting bad news, he or she can take a lorazepam and it provides noticeable relief, like right that moment within an hour, probably, in the case of lorazepam and right here, the patient begins a type of training, where there's a learned positive response. And really also a negative response, if the patient goes to the lorazepam bottle and it's empty and they don't get relief. So, there's a degree of, I guess, basic psychological conditioning or psychological dependence that can happen like almost immediately when someone actively realizes what it does or what it feels like.

But the real basis of the difference between something like Prozac or Lexapro and something like lorazepam or Valium is our two characters that I mentioned GABA and glutamate. So when we set out to enhance GABA, which is slowing the brain, reducing anxiety, the nervous system has a natural counterbalance with the glutamate in the brain is really good at engaging this counterbalance if there's a persistent, like daily increase in the GABA action and so in addition, once the scale is somewhat balanced, more GABA enhancement is required for the same effect. And unfortunately, if we decrease the GABA action, like someone stopping drinking suddenly, or stopping a daily dose of Valium suddenly, then the brain speeds up and it may speed up faster than it would like to.

And at the least, this is really uncomfortable and it flares anxiety, and in serious situations, the brain speeding up in this way can be dangerous causing certain kinds of psychosis or even putting someone at serious risk of a major seizure. And so this is one of the purposes of medical detox is to prevent that process from happening and getting in the way.

So the difference is something like a SSRI antidepressant like Prozac or Lexapro, it enhances serotonin, but we don't have such a seesaw battle. There's no major chemical in the brain, which battles and counteracts serotonin, and creates a dependence or a tolerance or deadly withdrawal symptoms that are acutely concerning.

This process happens. It happens in well-meaning patients. It happens in patients who are not so well-meaning and they're seeking out benzodiazepines for recreation or abuse. And it happens in patients who are desperate. They just want to feel less anxiety or less panic or less stress.

I mean, I have patients that say why can't I have Xanax every day. Do you think I'm the type of person that will abuse it and you have to convey, it's not personal. I want to sometimes say like, no, I don't think you're going to abuse it. I don't think you're an addict. I think you're a human and I think you have a human brain.

Host: You know, I know there's been a lot of talk about the opioid crisis in this country and benzos have been called America's other drug problem. Just wondering what your thoughts are about this.

Dr. Hansen: The opioid problem is of course, you know, very serious and ongoing, and there are many more deaths attributed to opioids than benzodiazepines, obviously. But the way that the benzodiazepines work, how they slow down the nervous system, it really makes combining the two medications extremely dangerous. And so the fact that there are a lot of benzos out there in the setting of an opioid crisis, exacerbates the dangers of benzodiazepine.

Some estimates show that up to 75% of benzo related deaths also involve opioids. So, it appears that benzo related tragedies, they sort of piggyback on the opioid problem. And we've seen that deaths attributed to benzodiazepines have increased 700% in the past 20 years. So, just as we've seen this opioid problem flare, we've seen a corresponding increase in the danger of these medications.

And I said over prescribing is a problem. And I think some people were questioning the pervasive use of benzos or chronic long-term use of benzos almost immediately after they came out and were invented and marketed in the 1960s and seventies. I have a stat from 1999 through 2013.

In those 14 years, benzo prescriptions per year went from 8 million to 13.5 million. Those are outpatient benzo prescriptions that doesn't include procedural uses of them or periods when they were in the hospital. So, that's a 67% increase. And I don't think anyone believes that there's a 67% increase in legitimate and serious mental health ailments that require a benzodiazepine in those years.

When the opioid problem's under control, and I hope it will be soon, the mainstream will turn more attention to maybe some of the possible problematic trends and over-prescribing overuse and the street market of benzos.

Because sadly there's a lot of examples of synthetic benzodiazepines out there. One of them is sort of a hybrid name, clonazalam. And these are created in illegal laboratories, and they literally have no defendable medical use. They're for recreation and they're for selling and that's popping up more and more, unfortunately.

Host: Yeah, there's some alarming statistics. I'm still stuck on that. Just been shaking my head the 700%. That's incredible. So, what can doctors, a nurse practitioner do to address some of these concerns?

Dr. Hansen: Well, I think just being frank with the fact that it can be a good medication, an effective medication, but also just like a stove you can burn yourself on a stove, even though it's an essential part of cooking. And so just being upfront there's short-term risks, like coordination impairment, just like alcohol can do to someone. Accidents, falls and injuries, older folks breaking their legs or their hips, memory and concentration problems, even just with a one-time use.

And then the long-term risks are being described more and more in the medical literature. Higher risk of dementia in chronic users. I use that one a lot because I inherit many patients who are on two or three times a day prescription, higher risk of depression because it's slowing the brain down.

Well, the brain doesn't like to be slowed down chronically, and in the same way that someone who drinks every day might have a higher risk of depression. And here we talk a lot about a phenomenon where chronic or frequent benzodiazepine use in a patient can get in the way of trauma therapy where this affected brain, the slowed down brain can't create all the good rewiring that happens in trauma therapy from something like EMDR or really good psychotherapy work.

You ask what can be done and other than being frank about all these things that I'm talking about, I think it is important to realize that there are real uses for this medication, as much as I've explained the dangers. There's people who 100% should be on morphine, for example.

And there are people that should be at least in that situation on a benzodiazepine, but it's a certain situation. It's usually, temporary and sort of aggressive type of treatment. Oftentimes it's in a hospital or in a residential setting. And oftentimes the prescription itself is short to the point where it limits the chance for developing the dependence that I talked about.

I've met some outpatient psychiatrists who have a very sort of narrow lane, who they brag about never giving out a benzodiazepine. And of course there's providers who how do I say it, they prescribe very liberally. They don't have a game plan or the patient doesn't have a game plan or the patient doesn't have proper followup for a game plan.

I think it's about finding the sweet spot while keeping the dangers in mind. And a lot of that's having an uncomfortable conversation sometimes with patients who might have differing feelings on the issue. I guess that's the second thing is just having the conversation. If there's time, doing some education about what does happen to the body, what happens to brain chemistry.

And I found that patients are really receptive to that. They're fascinated by a little miniature lecture sometimes. Having the conversation where you illustrate some of those long-term risks, having the conversation that it's not personal. That you are trying to be careful. It's like, if you suggest someone needs to put on a seatbelt, it's not cause we're expecting an accident and it's not because we're accusing that person of being a bad driver or a bad person or having bad motives, it's because driving a car is dangerous in certain ways for everybody. So, I think helping our patients understand that as providers, as doctors, we form our plan. We form our opinion and give our opinion based on all the dangers in mind. And it takes the sting out of some of these conversations that our patients need to hear.

Host: So doctor, as we wrap up here today, anything else you want people to know, listeners, potential patients, to know about benzodiazepines, the dangers and what Sierra Tucson can do to help?

Dr. Hansen: The different areas that we covered today sort of illustrate that it is a different animal and it can be super useful while at the same time have dangers that don't occur in a lot of the other medications that we help people with, not just in psychiatry, but in primary care, other realms. And so, I'd encourage everybody to take caution if they are thinking about taking one of these things or if they are taking one of these things, consult with a psychiatrist or your primary doctor, or whoever might have been prescribing it, if you feel like there's ever a problematic pattern. Definitely don't be combining them with opioid pain medication prescriptions. Don't make it part of your recreational drug use and stay honest with yourself about the role of something like this in your life. That'd be my parting advice.

Host: Yeah, and I think that's great advice. And you mentioned earlier that some people like, you know, little mini lectures or conversations, they like to be educated and you can count me Dr. Hansen among those that like to be educated. This was really educational and fascinating today. And, you know, as you've said benzos get thrown around in popular culture, but I feel like I know a lot more about them today that I didn't know before we started. And I hope that listeners have the same reaction and got as much out of this as I did. So, thank you so much for your time and you stay well.

Dr. Hansen: You as well. Thanks for having me.

Host: For more information, visit Sierratucson.com or call 800-842-4487. Sierra Tucson, we work with most insurance. And if you found this podcast helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest.

This is Let's Talk Mind, Body, Spirit from Sierra Tucson. I'm Scott Webb. Stay well.