The Council For Involuntary Tranquilliser Addiction BENZODIAZEPINES AND THERAPIES
Pam Armstrong
Seven years working as Director of CITA (The Council For Involuntary Tranquilliser Addiction) has
convinced me that withdrawal from long term use of these drugs should be a very practical and
directive process. I firmly believe that the cognitive and behavioral aspects cannot normally be
separated and much of my work with anxiety favours the use of Ellis's Rational Emotive Therapy in
order to facilitate less rigid thinking in the anxious client. However, with those addicted to
benzodiazepines, I see withdrawal as almost totally behavioral; cognition is enormously impaired
by the drugs. Therapy which involves anything beyond the most superficial cognition is thus
rendered virtually ineffective. Only when withdrawal is complete can work on thought processes
begin.
Benzodiazepines work by impairing the ability of receptors in the brain to receive stress
stimulating messages from the outside world. In the anxious client this quickly has the effect of
improving his or her sense of well being as it means that natural pain and stress coping chemicals -
called endorphins - have less to contend with and the client's perception is that he/she feels
calmer. This situation, however, does not continue indefinitely. Endorphins are controlled by a
use-it or lose-it type mechanism, so that gradually the quality of available endorphins is drastically
reduced, resulting in a renewed and greater perception of anxiety. at this point the client is likely to
return to the GP and ask for a higher dose of benzodiazepines in the belief that this will relieve
symptoms.
In addition to the effect on receptors and endorphins, benzodiazepines also alter the precisely
balanced adrenaline reflex, which normally responds to danger signals resulting in blood being
pumped into the right place at the right time to produce the flight-or-fight response. The effect of
benzodiazepines is to throw this delicate mechanism into confusion producing inappropriate bursts
of adrenaline resulting in panic attacks and fear of what this perceived sensation of panic means.
Benzodiazepines are also fat soluble which means that they are extremely slow to leave the body:
months after the last tablet has been taken the drugs are still present in fat cells.
POOR CONCENTRATION:
So what do all these properties of benzodiazepines mean to the client and what are the
implications for the therapist? They mean that the former is often inexplicably full of panic and fear
which interferes with concentration and consequently with the ability to attend for meetings and
consultations. Benzodiazepines affect memory which is one of the reasons We have found it cruel and wasteful of resources to attempt to use psychotherapy or counselling
for those who are still taking benzodiazepines and who have been long term. Clients will almost
certainly vote with their feet and not attend for appointments if they are required to use skills which
they - at least temporarily - cannot call upon. We believe very directive measures are called for -
such as help in planning ways to carry out decisions - with a great deal of support from family,
friends and primary health care teams: particularly GP self help groups of knowledge counsellors.
While reducing the drugs, many people also find anxiety management and relaxation of little use.
Commonly any efforts to use these skills frustrate the individual and exacerbate the condition. An
understanding of the way the drugs affect the client makes it clear why this happens, revealing that
a lack of endorphins combined with indiscriminate rushes of adrenaline make relaxation almost
impossible. In such cases gentle exercise may help to use up adrenaline in a natural way. However,
some clients have reported that exercise must not be overdone, as this may result in extreme
fatigue. Another property of benzodiazepines is that they act as a muscle relaxant, which after long
term use may produce some levels of dysfunction in muscles; in withdrawal this may even produce
pain and muscle spasm.
SYMPTOM REVERSAL
All symptoms created by long term benzodiazepine use appear to be reversible, but if recovery is
to occur, full withdrawal from the drugs must take place. In order to facilitate this, clients are
asked to transfer to a long acting benzodiazepines. These produce a gentler effect so that the user
is not continually aware of when the next dose is due. Diazepam is the drug of choice here: it is
conveniently shaped and can be broken up accurately to vary the dose as required. There is also a
liquid dilution method, comprising concentrated liquid and a buffer agent, used to gradually bring
about reduction. Transferring patients to diazepam also makes them more aware how much
benzodiazepines they are actually taking, in a way that drugs in small doses may not.
As a rough guide, a rate of reduction of about 1mg. every two to three weeks should be
considered. When the overall dose is below 5mg., this increment may need to be smaller. If the
client is on a dose of over 30mg., then the reduction may be in larger amounts at any one time as
the proportion reduced is a smaller percentage of the overall dose.
The supporter working with the clients needs to provide information, reassurance and a place of
safety for the person to be themselves and pour out their fears. Very often, those around them at
work and home do not know what is going on, and the client does not which to tell them.
Withdrawal may take over twelve months, depending on the dose from which reduction occurs
steadily. The client should not proceed too slowly however, as he/she may lose concentration, and
such slow reduction could interfere with the outcome. It is important that the client takes control
of recovery now, since for so long control has been taken away.
SELF HELP
Some people benefit from self help groups, others prefer to work one-to-one with the therapist.
as fear may prevent them from joining a group. Some patients may also feel embarrassed to admit
to a group that they are addicted to benzodiazepines, and may think it amounts to washing dirty
linen in public.
When total withdrawal has finished the story does not necessarily end. It is at this time that
healing and rehabilitation must take place - for here is a human being who has lost many life skills
-an important point to consider.
While stress is lessened by benzodiazepines, the skill of adapting behavior to cope with stress
can be forgotten, and the ability to grow and learn consequently much diminished due to lack of
concentration and poor memory. At this stage, clients are often extremely immature emotionally,
especially those who have been prescribed benzodiazepines from as early age. There may be an
enormous amount of time to make up, and a terrific amount of stimuli impinging on the central
nervous system and on a mind which has been impenetrable for so long. Clients often report
colours seeming excessively bright, sounds extremely loud and smells unexpectedly pungent: the
responses of a central nervous system returning to life.
Another common response to benzodiazepine withdrawal is anger. With returning awareness
comes the sudden realization of what has gone on, For many, this emergence form benzodiazepines is a process of rebirth, and certainly a time for
refinding themselves and re-establishing their personality. Now is the time for anxiety
management to be taught: psychotherapy, acupuncture, counselling, aromatherapy and any number
of therapies may be of use to clients as their needs emerge. I am particularly excited about work
being carried out using acupuncture, for the reduction of adrenaline and improvement of available
endorphins, to facilitate recovery.
Whatever the therapy, I believe the therapist needs to fully understand what has gone on, and
what benzodiazepines do to human beings, before embarking on a course of recovery with a client.
About CITA
The council for Involuntary Tranquilliser Addiction (CITA) was founded in 1987 to respond to
concerns about addiction to tranquillisers. The most recent figures put the number of prescriptions
written annually by doctors in Britain for these drugs at 20 million, which translates as 3 million
people taking tranquillisers every day.
CITA's aims are:
- to raise awareness about addiction to benzodiazepines, tranquillisers and sleeping pills.
- to support withdrawal and rehabilitation of those addicted to tranquillisers.
- to train doctors and health workers concerning benzodiazepine withdrawal.
- to help doctors in their efforts to support patients in withdrawal.
Since its inception the organization has dealt with 61,000 calls and advised over 8,000 people
towards withdrawal from tranquillisers. It offers the only national help line for those dependent on
the drugs - all staff are specially trained by CITA - five days a week with limited service at
weekends (all calls are returned within 24 hours.)
National and local training is available through CITA. Several training days are held each year for
those working with benzodiazepines and anxiety management, both in Liverpool and throughout
the country, many commissioned by FHSAs and Health Authorities. Post Graduate Accreditation has
been acquired through Liverpool University.
CITA's information service can supply a letter of introduction and guidelines for patients to take
to their doctors, books and self-help tapes on addiction and anxiety.
For more information contact:
Presents:
by
they are popular as pre
medications before surgery. This factor, coupled with lack of concentration, are the main reasons
why thought processes are so greatly impaired. Simple behavior remembering by rote learning is
not damaged and since this level of function may appear normal, long term users of benzodiazepines
may not be so easily detected. However, thinking at a higher level is,
in the opinion of our
organization, often precluded to a great extent.
of the many years that have been lost and the
memories which will never return. This anger needs to be worked through, and some clients do get
stuck at this point.
Council for Involuntary Tranquilliser Addiction
Cavendish House, Brighton Road,
Waterloo, Liverpool, ENGLAND L22 5NG
Helpline: 051 949 0102