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3. The Downside,
Up Close
Overdose: An Overview
Regardless of
their wide safety margin, benzodiazepines still manage to figure
into a large number of overdoses every year, OD's of both the
accidental and deliberate variety.
However, OD's
are rarely fatal when BZD's are used alone. According to the
U.S. Department of Health and Human Services' Drug Abuse Warning
Network, of the 17,833 emergency-room admissions in which Xanax
was mentioned in 1998, only 229 deaths were Xanax-related, and
of these only 2 were caused by use of Xanax alone.
Still, where
there's smoke there's fire, and many BZD users are often users
of other depressant drugs. And it's in combination with other
depressants that BZD's get really tricky -- and sometimes deadly.
That's because
BZD's produce a synergistic effect in combination with other
depressants that adds up to something more than simple arithmetic.
In fact, it's as complex as calculus, even trying to predict
the combination effects of BZD's and other depressants -- and
a lot more dangerous.
What all this
means is that a Valium user who takes a Seconal or a Placidyl
to get to sleep may have more to worry about than getting to
work on time in the morning. Waking up at all could be a problem
-- especially when you consider all the metabolites and miscellaneous
mischief rattling around in the background.
And it's not
only depressant "drugs" that cause problems. Alcohol
can also pose major risks when used in combination with BZD's.
In fact, in a
report on the health effects of benzodiazepines published by
the National Academy of Sciences, several deaths linked to BZD
alcohol combinations were found to be triggered by non-intoxicating
amounts of both substances.
That's not an
overdose, that's simple synergism-and a deadly one, at that.
That's also why
it's important not to play mix-n-match with BZD's and all other
psychoactive drugs. Because sometimes when your luck runs out,
it runs all the way out -- and playing chemical connoisseur can
make it run out for good.
Everyday Dangers,
Part I
Still, we should
make clear that the dangers cited above clearly don't apply to
everyone taking benzodiazepines. Three hundred and forty deaths
do not a killer drug make nor do the seven people who died with
a beer in their hand and a Valium in their bloodstream constitute
an epidemic. Nevertheless, Valium and the other benzodiazepines
do represent a pretty serious danger to people -- and not just
to the people taking them.
That's because
it's not just fatal overdoses that define a drug's "abuse
potential." It's also the kinds of problems that everyday
people live through every day, and there happen to be a lot of
those tied to the benzodiazepines, too.
Take impaired
mental and physical performance, for example. The early optimism
of the drug companies notwithstanding, the BZD's do interfere
with higher-level intellectual functioning and they do slow reaction
time and impede coordination -- all valuable skills to hang onto,
especially at school or work or when you're behind the wheel
of a car. One researcher estimates that as many as 80 percent
of Valium users have some degree of impaired intellectual functioning
at doses of 5-40 mg a day, which happens to fit well within the
therapeutic dosage range suggested by the manufacturer. This
impaired functioning can take the form of decreased attention
and concentration and can show up, particularly, in the form
of a diminished capacity to retain new information.
Driving ability
has also been clearly shown to suffer. In one study involving
Ativan, drivers exhibited a decreased ability to handle and brake
their cars properly following use of only 3 mg a day for three
days. Similar impaired performance would be expected with other
benzodiazepines, and could even be a factor hours or days after
use, given the long half-life of many BZD's in the body.
And it's not
just the person taking the tranquilizers who happens to be affected.
Some researchers
fear that BZD's may cause birth defects if taken during pregnancy,
and early studies back them up, showing a higher-than-normal
incidence of cleft lip and palate among rat embryos exposed in
utero. And even though there's far from conclusive proof at present
about a link between the BZD's and birth defects, the Food and
Drug Administration advises against use of the drugs during pregnancy,
particularly during the first trimester.
Everyday Dangers,
Part II
But perhaps the
most common, and sometimes the most lasting, dangers of benzodiazepines
happen below the surface and never leave a mark -- at least not
a physical mark -- on anyone.
These dangers
include the subtle personality changes that can occur in users
following extended benzodiazepine "therapy" -- a course
of treatment seldom therapeutic for anyone, except for the doctor,
who gets to take the afternoon off, and for the drug companies,
who wind up with bigger profits -- and bigger advertising budgets.
And the psychological
effects of extended use can be a big problem. That's because
BZD's plug into one of the most powerful drives that we all carry
around inside ourselves: The desire to not be afraid.
They plug into
this drive so well, in fact, that they can easily rein force
a kind of "learned helplessness" on the part of the
user that, often as not, powered the nervous ness or insomnia
or fear to begin with. As a result, a BZD user can forget to
take on the important challenges of life and retreat into a warm,
fuzzy zone of artificial tranquility.
And even though
that tranquility zone may be warm and fuzzy, it's also artificial
as can be, and temporary, at that.
And what often
gets lost in the process are users' perceptions of themselves
as competent, effective people -- and powerful forces in their
own lives.
The temptation
for many BZD users is to see themselves simply as psychological
"cases" -- walking, talking bags of skin and blood
and symptoms -- that do little more for themselves than swallow
Tranxene or Librium or Serax and wait for things to get better.
And perhaps this
is at the core of what's really dangerous about the benzodiazepines
-- the mistaken belief on the part of users (and sometimes even
doctors) that the drugs actually do something other than disguise
the symptoms of emotional problems. All too often, BZD's are
prescribed instead of (not in addition to) therapy, and they're
taken in the hope that they can do something to clear up underlying
problems.
They can't. Benzodiazepines
aren't medicine. They're drugs. And all they can do is do what
they do very well: disguise symptoms.
And that's the
rest of the problem.
Because sometimes
they disguise symptoms so well that you almost need a trained
archaeologist, a detective, and a social worker to figure out
what the problems were to begin with -- before they got covered
over with months or years or decades of emotional dry ice and
pharmacological "tranquility."
And that's why
getting strung out -- and getting unstrung, later -- can be such
a difficult, long, hard time.
Strung &
Unstrung: Addiction & Withdrawal
And as if learning
to be helpless isn't bad enough, consider what happens when a
long-term BZD user discovers they're addicted to their "medicine."
First of all,
they might come to this realization when they discover that their
problems are back -- and look a few times scarier than before.
The first real
notice they get along the way may come with the increasingly
distressful thought that the drugs don't work anymore -- or at
least not as well as they used to, which is cause for serious
concern, either way.
At this point
they might increase dosage and that might work for a while, but
only for a while, and before very long the same unpleasant scared-to-death
feeling that says Something's Wrong Here descends again, this
time with considerably more force. And here they either talk
their situation over with their doctor or tough it out alone,
and one of two things happens: The situation gets better. Or
it gets worse.
If it gets better,
it gets better because the person faces up to the problem and
does something to make it better.
If it gets worse,
it gets worse because they don't.
Either way, the
process of kicking a long-time BZD habit is tough, agonizing
even. Withdrawal symptoms can include anxiety, convulsions, hallucinations,
insomnia, headache, depression, transient psychosis, muscle pain
and twitching, restlessness, and a general sense that some unnamed
and undefined doom or catastrophe is about to happen -- a full
parade, in short, of the original problems that started the addiction,
and then some. Seizures represent a particular danger, and can
occur as late as the 12th day of withdrawal.
And it's important
to note that even low doses can cause physical and psychological
dependence. One study of 32 people who quit cold turkey after
taking an average of only 10 mg of Valium a day (for periods
ranging from four months to several years) showed that half experienced
withdrawal symptoms, including insomnia, depression, headache,
and convulsive seizures.
Another study
(this time focusing on 10 Valium users averaging 17 mg a day)
reported that all developed withdrawal symptoms. Anxiety, paranoia,
and loss of touch with reality predominated. And these people
were only averaging 17 mg a day, far below many dosage regimens.
The timetable
for the appearance of withdrawal symptoms depends very much on
the particular drug a person happens to be strung out on. Symptoms
appear much more quickly (sometimes as fast as a single day)
with the short-acting BZD's, like Ativan and Serax, and more
slowly with the longer-acting drugs, like Valium and Librium.
In fact, Valium
is so slowly eliminated that severe withdrawal symptoms may not
show up fully for three to six days.
This isn't to
say that Valium addicts don't get tense or irritable in the meantime;
they do, extremely so. But the full range of problems associated
with full-scale withdrawal doesn't start in earnest until all
the psychoactive metabolites of the drug clear out of the body.
But when the symptoms finally do show up, they show up with a
vengeance, easily making up for the lost time.
Do they ever.
Withdrawal from
the benzodiazepines can be a torturous, life-shattering experience.
The withdrawal process is a lengthy one, typically following
a bi-phasic (or two-staged) course in which symptoms reach a
peak of severity (usually within a week), subside for a while,
then come screaming back.
The entire panoply
of physiological symptoms usually abates within six weeks, but
the psychological scars -- the anxiety and dread and "learned
helplessness" -- can take much longer, even a lifetime,
to fully heal.
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