Tranquilliser Addiction - A Medically-Induced Epidemic

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http://www.benzo.org.uk/

 

Tranquilliser Addiction -

A Medically-Induced Epidemic

 

Dr R F Peart

National Co-ordinator

Victims of Tranquillisers (VOT)

 

Presented at the Conference:

" Stress - A Change of Direction "

London, 15th June 1998

 

On 11th June, 1998 a BBC Radio 4 programme posed the question " who

are the biggest drug pushers in the country? " and gave the answer -

" the NHS and the medical profession. " During the last 15 to 20 years

there has been a lot of similar publicity in the press and other media

on the subject of tranquilliser problems, especially addiction to the

benzodiazepine group of drugs. This has largely been dismissed by the

authorities as " sensationalist. " The reality is that the most

sensational reports have appeared in the medical literature. Professor

Malcolm Lader of the Institute of Psychiatry has published many papers

on this subject. In the 1970s he called these drugs " the opium of the

masses " because of the very high prescribing rates. In 1981 he warned

that in the context of tranquilliser addiction " there is an epidemic

in the making " and in 1988 he stated that this was " the biggest

medically-induced problem of the late 20th Century. "

 

Recent estimates suggest that there are from 1/2 to 1 million

people addicted to these drugs. Many have asked the following questions:

 

1.

 

How did this happen?

2.

 

Why was it allowed to happen?

3.

 

What are the authorities doing about it?

4.

 

Why is it continuing?

 

I will try to answer these questions, but first I will briefly

describe some properties of the benzodiazepines - these include many

household names, Valium (diazepam), temazepam (a sleeping pill, now

injected by street addicts), Rohypnol (the so-called date-rape drug)

and Halcion (which caused a mass murder in the USA in the 1980s and

which was banned in the UK in 1991 because of the failure of Upjohn

(the manufacturers) to disclose information to the Committee on Safety

of Medicines about its psychotic and other side-effects).

 

The benzodiazepines are a class of drugs with sedative, anxiolytic

and hypnotic properties. There is relatively little difference between

the drugs in this group, the most significant being the rate at which

they are eliminated from the body. The elimination half-life varies

from 2 hours to 10 days and has no effect on the pharmacological

action but determines the duration of action. These drugs were

marketed and promoted as non-addictive, of low toxicity and safe in

overdose but these claims have turned out to be predictably untrue.

They are depressants of the central nervous system with marked

disinhibitory effects and as such have very similar properties,

side-effects and addiction potential as the barbiturates, meprobamate

(Equanol), alcohol and other sedative-hypnotic drugs used by the

medical profession since the middle of the last century. These drugs

are in principle prescribed for a wide range of clinical

indications[1] (see Table 1). In practice they have been prescribed as

" social medication " - a pill for all ills[2] as listed in Table 2 -

this dispels the myth propagated by prescribers and the drug companies

that the withdrawal symptoms are a return of the original problem.

 

The benzodiazepines act on at least two types of receptors:

 

1.

 

Central receptors in the brain, eyes, and spinal cord.

2.

 

Peripheral receptors over most of the body, in the skin,

membranes, muscles and tissues.

 

Also, because they are fat-soluble, they segregate in many parts

of the body and because of the long elimination time they can

accumulate at levels up to 10 times the daily dose, causing a wide

range of side effects. The list of adverse reactions for diazepam

reported by doctors to the MCA (Medicines Control Agency) from

1962-1997, shows over 200 adverse drug reactions were reported for

about 20 organ classes and over 100 sub-organ systems. It mirrors and

enlarges upon the side-effects given in the medical literature, the

WHO and advertisements by the drug companies. In the 1960s Apley[3]

gave a wide range of known physical, psychological and social

consequences of benzodiazepine ingestion. The title of his paper

illustrates a root cause of this epidemic, i.e. " Doctors who treat the

symptoms tend to give a prescription; doctors who treat the patient

are more likely to offer guidance. " See Table 3 for a list of

consequences.

 

A list of " socio-economic costs of long term benzodiazepine use "

was recently published by Professor Heather Ashton, Professor of

Psychopharmacology at Newcastle University.[4] (See Table 4).

 

On the problem of accidents a " World in Action " TV programme

(1995) concluded that deaths and accidents on the road caused by

prescribed drugs are on a par with those for alcohol, and that drug

tests were available and had been in use in other countries for some

years. Why are there no tests in the UK?

 

Home Office statistics for 1989-1996 show about 2,000 deaths by

suicide, accidents or other causes due to benzodiazepine ingestion,

more than any other illegal or prescribed drug. Using the number of

prescriptions to extrapolate this data suggests a possible

8,000-10,000 deaths from 1960-1997 due to these drugs.

 

Recently Charles Medawar (Social Audit Ltd) quoted the cost of

drug side-effects as being about 5 billion - more than the entire NHS

drugs bill - and this does not include the cost of problems due to

illicit use.[5]

 

The first benzodiazepine marketed was Librium in 1960 on the basis

of one set of clinical trials presented at a symposium at the

University of Texas. This was quickly followed by Valium (1963) and

Mogadon (1965), both with very limited trials prior to marketing.

Within months of these drugs coming on to the market papers were

published warning of the addictive nature and side-effects of these

drugs. During the first decade or so after their introduction

virtually all of the problems now accepted with benzodiazepines were

reported in over 300 medical papers and in many adverts in American

medical journals.

 

It is therefore quite astonishing that in the first data sheets in

the UK issued by Roche through the CSM that there was essentially no

mention of the known problems, and especially surprising when many of

these were given in data sheets in the USA, Canada and Scandinavia.

 

By 1980 there were there were over 700 medical papers on these

problems and the CRM (Committee on the Review on Medicines) belatedly

issued guidelines for data sheets on the benzodiazepines[10] but it

took years for some of these to filter into the data sheets and then

in a muted form, after protracted dispute with the drug companies.

 

Strong warnings about addiction, loss of efficacy and side-effects

were not given until 1988 by the CSM, about 25 years after these

problems were recognised and reported in other parts of the world.

 

As stated in the Medicines Act 1968, the CSM was established to

" give advice with respect to safety, quality or efficacy " of medicines

and to promote " the collection and investigation of information

relating to adverse reactions for the purpose of enabling such advice

to be given. " [6] Both UK and European law state that the principal

task of the licensing authority is to protect public health.

 

There are two points which require answers:

 

1.

 

Did Roche declare all appropriate information to the CSM,

and if so why did it not appear in the data sheets?

2.

 

If Roche failed to disclose all appropriate information,

then as the CSM members should have been aware of most of it, why was

it not included in the data sheets?

 

Unless the UK gets a very open Freedom of Information Act we will

probably never know the answers. What we do know is that as published

by the National Consumers' Council in recent years about two thirds of

the CSM and the CRM members have direct financial links, such as

consultancies, with the drug manufacturers[6], and that vested

interests overshadow the rights of the consumer[7]. Not surprisingly,

as a result of the paucity of information, in the UK the prescribing

rates have been two and a half times higher than in America. Over the

years at least one million people have become dependent on these drugs

in the UK.

 

Since 1960 there have been over 700 million prescriptions for

benzodiazepines in this country. At its peak there were about 31

million per year in the late 70s and this has reduced currently to

about 18 million per year. The attitude of the government to the

overall situation has been to introduce measures to reduce prescribing

such as restricting the number of these drugs on the NHS list. These

have been to some extent successful, along with highly increased

public awareness and the fear of litigation by the prescribers.

 

Both the government and the prescribers have paid very little

attention to those who are chronically addicted. The number of these

has reduced very little in the last ten years.[7] The current level of

prescribing is totally inconsistent with the 1988 CSM guidelines that

these drugs be prescribed for short periods only (2-4 weeks maximum)

because of the loss of efficacy and the occurrence of withdrawal

symptoms for therapeutic doses given for short periods of time. The

total of 18 million prescriptions per year translates to about 700,000

people on these drugs continuously: in other words, they are dependent.

 

There are many myths and, quite frankly, a lot of nonsense talked

about addiction - e.g. stress causes addiction. Addiction to drugs is

a physical problem, with psychological and social consequences.

Chronic addiction is the repeated use of a drug to alleviate the side

effects/withdrawal symptoms produced by that drug. In 1983 a panel of

international experts in a WHO report rejected the concept of

psychological addiction unless it was used in the context of

physiological changes produced by a drug: in other words all aspects

of drug addiction can be explained in biological terms. Use of the

term " psychological addiction " in isolation is like " a desire to

scratch without an itch. " Unfortunately many prescribers use this

outmoded concept to blame the patient and avoid taking responsibility

for their own actions.

 

The attitude of prescribers is largely one of silence or denial.

To obtain a sick note with benzodiazepine addiction on it is a rarity

and to receive disability benefits for long-term damage caused by

these drugs is even more unusual. The chances of getting residential

treatment and rehabilitation is one-fiftieth of that for an alcoholic

or an illegal drug addict. One of the reasons for this is the cost:

the length of time for detoxification and withdrawal is much longer

than for alcoholics and hard drug addicts and the withdrawal syndrome

is very much worse. There are many who have been addicted to these

drugs who have to come to terms with huge losses that have occurred

because of addiction e.g. loss of career, marriage, family,

possessions and sometimes their sanity. So it is not surprising that

some suffer from PTSD (post-traumatic stress disorder) problems in

recovery. This often requires long and sensitive therapy which is

unlikely to be obtained on the NHS. The correlation between high

cortisol levels and stress is well established, but for PTSD

sufferers, low levels have been reported[10] and those with base line

levels are said to be more likely to have PTSD. Many benzodiazepine

addicts in early recovery and withdrawal have a compromised endocrine

system with low cortisol and ACTH levels and will therefore be

predisposed to PTSD. Many believe they have suffered PTSD in recovery

and that the symptoms have been incorporated into the protracted

withdrawal syndrome that can last for many years.

 

A measure of the interest, or lack of it, by prescribers is the

very few reports that they have submitted using the yellow card system

for benzodiazepine dependence, e.g. for diazepam from 1963-1997 there

were only 16, compared with at least a quarter of a million people

addicted to this drug.

 

A final aspect of this overall problem is the fact that these

drugs are still being dispensed with few or no warnings from doctors

or pharmacists. They are dispensed under their generic names which

most people do not relate to their commercial names, e.g. diazepam for

Valium and lorazepam for Ativan.

 

I recently submitted a briefing for the chairman of the Health

Select Committee in the House of Commons. In this I highlighted areas

of ongoing concern[8] (as per Table 5).

 

It appears that the dream of the perfect sedative/hypnotic has not

come true: the lessons from the past have not been learnt. For many it

has been a recurrent nightmare. Chloral hydrate, the bromides, heroin,

the barbiturates and the benzodiazepines have all been touted by

vested interests as the ideal non-addictive, anti-anxiolytic drug.

Until and unless this country obtains independent committees to

control medicines and a Freedom of Information Act with teeth the

nightmare will continue. The next line of " non-addictive " drugs is

already on the market and these act upon the same receptors as the

benzodiazepines. Needless to say reports on their addictive properties

are already proliferating.

TABLE 1

Some Clinical indications claimed for benzodiazepine prescribing

Psychiatric: Hypnotic.

Anxiety. Tardive dyskinesias, dystonias.

Alcohol/drug withdrawal reactions.

Night terrors and somnambulism.

Neurological: Epilepsy, febrile seizures.

Spasticity.

Spasmodic torticollis.

Migraine prophylaxis.

Vertigo.

Gastrointestinal: Irritable bowel syndrome.

Obstetric: Eclampsia, pre-eclampsia.

Anaesthetic/surgical: Operative premedication,

general and local anaesthetic.

Endoscopy.

Induction.

Neuroleptanalgesia.

Intensive care.

Dermatology: Oral lichen planus.

General: Potentiation of analgesics.

 

 

TABLE 2

Reasons for prescribing benzodiazepines to people who became addicted

 

Bereavement.

Emotional upsets.

Nursing sick wife

after operation.

Husband's accident.

Socialising.

After-flu virus.

Dry eyes.

Alcohol problem.

Alcoholic father.

Sex abuse.

Stomach trouble.

Hysterectomy.

Business problems.

Handicapped child.

Shiftwork.

Bankruptcy.

Thyroid problems.

Demanding mother.

Driving test.

Scared of dying.

Cat died.

Lack of confidence.

Redundancy.

Homelessness.

Hay fever.

Mother committed suicide.

Vertigo.

Jury service.

Palpitations.

Work pressure.

Moving house.

Loss of hearing.

Cooker blew up. Claustrophobia.

Illness.

Post natal depression.

Exam nerves.

Fatal illness.

Disc trouble.

Divorce.

Menopause.

Bad fall.

Rugby injury.

Rape.

Car crash.

Headaches.

Back pain.

Mastectomy.

Interview nerves.

Retirement.

Dizziness.

Abortion.

Stroke.

Active/crying baby.

Shyness.

Childhood insecurity.

Isolation.

Family problems.

Floater in the eye.

Broken neck.

Changed job.

Violent husband.

Infertility.

Prison.

Asthma.

Cystitis.

 

 

TABLE 3

Physical, mental & social consequences and problem areas caused by

benzodiazepine ingestion

abuse

accidents

aolescents

addiction

aggression

amnesia

anxiety

apnea

children

cognitive impairment

confusion

costs

dependence

dependence

depersonalisation

depression

detoxification

driving

drug accumulation the elderly

encephalopathy

fatigue

fractures

hallucinations

headaches

hostility

hypnotics

infants

insomnia

long-term effects

low Apgar scores

mania

memory impairment

multiple prescribing

nightmares

OCD

oral cleft

paranoia paradoxical effects

phobias

poisoning

polypharmacy

pregnancy

protracted withdrawal syndrome

psychomotor impairment

psychosis

rebound

respiratory depression

seizures

shoplifting

social decline

suicide

teratogenic effects

tinnitus

tolerance

traffic accidents

withdrawal

withdrawal psychosis

 

 

TABLE 4

Some Socioeconomic Costs of Long-Term Benzodiazepine Use

 

 

1. Increased of accidents - traffic, home, work.

2. Increased risks from overdose if combined with other drugs.

3. Increases risk of attempted suicide, especially in depression.

4. Increased risk of aggressive behaviour and assault.

5. Increased risk of shoplifting and other antisocial acts.

6. Contributions to marital/domestic disharmony

(due to emotional and cognitive impairment).

7. Contributions to job loss, unemployment, loss of work

through illness.

8. Cost of hospital investigations / consultations / admissions.

9. Dependence and abuse potential (therapeutic and recreational).

10. Costs of drug prescriptions.

11. Costs of litigation.

 

 

TABLE 5

Ongoing Areas of Concern relating to Benzodiazepine Use

 

 

1. The large number of benzodiazepine addicts (approximately

1 million).

2. Misprescribing, misdiagnosis and mistreatment.

3. Lack of appropriate medical treatment.

4. Deaths by suicide and accident.

5. Need for scrapping the Medicines Control system.

6. Need for a Freedom of Information Act free from

commercial secrecy to protect consumers.

7. Rescheduling of benzodiazepines to Schedule 3 at least.

8. Need for establishment of no-fault compensation scheme

to replace litigation in medical negligence.

9. Need for epidemiological surveys of benzodiazepine-related

problems.

10. Need to upgrade Data Sheets and the BNF.

11. Lack of recognition of long-term / permanent damage

and consequent lack of state benefits.

 

REFERENCES

 

1.

 

" The Benzodiazepines in Current Clinical Practice " , Eds. H.

Freeman, Y. Rue, Royal Society of Medicine Services, Jan.1987 p 48.

2.

 

" The Lost Years " , Joan Jerome, Virgin Books,1991 p 24.

3.

 

Apley J, Journal of Royal College of Gen. Pract. 1978, 28,

pp 515-522.

4.

 

" Toxicity and Adverse Consequences of Benzodiazepine Use " ,

Ashton H, Psychiatric Annals. 25, 3, 1995, pp158-165.

5.

 

Medawar C, press release from Social Audit Ltd, " The

Antidepressant Web " , Dec 1997, p3.

6.

 

National Consumer Council, 1993 - " Balancing Acts -

Conflicts of Interests in the Regulation of Medicines " .

7.

 

National Consumer Council, 1994 - " Secrecy and Medicines in

Europe. "

8.

 

" Current Problems " , Committee on Safety of Medicines, No 21,

Jan 1988.

9.

 

" Psychobiology of Post Traumatic Stress Disorder " , Annals of

the New York Academy of Sciences 821, June 1997, pp 57-75.

10.

 

" Systematic Review of the Benzodiazepines " , British Medical

Journal, March 1980, pp 910 - 912.

 

Dr Reg Peart

Victims of Tranquillisers (VOT)

Flat 9, Vale Lodge, Vale Road,

Bournemouth, BH1 3SY,

England, United Kingdom

Telephone/Fax : 01202-311689

 

Definition of Denial = I don't even know I am lying.

 

At the end of this presentation one of the doctors approached the

organiser and said, " Of course it is not like this any more. "

 

" Physicians pour drugs of which they know little, to cure diseases

of which they know less, into humans of whom they know nothing. " -

Voltaire 1694-1778.

 

LITTLE HAS CHANGED.