Let’s say you have an upcoming medical procedure, and you’re terrified. Your worries about everything that could go wrong are overwhelming, and you struggle with the idea of even showing up for your appointment, even though you know the procedure is important for your health.
That’s an instance when your doctor may consider a medication known as a benzodiazepine. There are more than a dozen benzodiazepines, but some of the most common include clonazepam (Klonopin), diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan) and triazolam (Halcion).
These medications are known for working quickly when you take them—your anxiety could be reduced in just half an hour, depending on which benzodiazepine you use.
They’re safe when used as directed. But because there is a high risk for misuse and dependence, your provider will be careful when prescribing them. We talked to UNC Health psychiatrist Jonathan Gerkin, MD, to learn more.
When are benzodiazepines prescribed?
Different benzodiazepines have different uses, but generally, they are prescribed for generalized anxiety disorder, social anxiety and panic.
“They’re meant to help people quickly calm themselves,” Dr. Gerkin says. “If you have a severe fear of flying, they can help you get on the plane.”
If you experience ongoing circumstances resulting in occasional episodes of anxiety, you may be prescribed benzodiazepines to take as needed. For those with severe social anxiety, a low dose prior to a social event could be appropriate.
Some benzodiazepines may be prescribed for short-term treatment of insomnia, to help control the symptoms of alcohol withdrawal or to stop seizures.
“They’re most safely intended for short-term, infrequent use for a specific reason,” Dr. Gerkin says.
How do benzodiazepines work?
When you’re anxious, the neurons in your brain act differently than normal. They become more excited, firing more frequently, and that increased activity causes the psychological and physical symptoms of anxiety, such as obsessive thoughts, overwhelming worry, restlessness, increase in heartbeat, sweating and trembling. You’re in fight-or-flight mode.
Benzodiazepines work by enhancing a neurotransmitter in your brain known as GABA. GABA stops that abnormal activity very quickly.
“The medications chill out the brain by going right to those excitable neuron receptors,” Dr. Gerkin says.
As a result, you’ll feel more relaxed and at ease, and the issue causing your stress won’t seem as overwhelming. How long the effect lasts depends on which benzodiazepine you use—some may have effects for a few hours, while others can last for several days.
If the stressful event is over when the drug wears off, you’ll feel like yourself again. But if you’re in a continued state of stress or worry, you may feel the need to take another pill to feel calm again.
“They can almost work too well, in a very short time,” Dr. Gerkin says, noting that it’s extremely easy to keep taking something that provides such a rapid calming effect.
“But the brain senses that you’re trying to put it to sleep, so it works to overcome the effects of the drug by increasing its activity in response. Then you might find yourself reaching for them more regularly than what was discussed while experiencing diminishing effect. People on benzodiazepines might rate their anxiety as worse while taking them.”
As a result, benzodiazepines have a high risk of misuse, abuse and dependence, making it hard for some people to stop taking them.
What are the potential side effects of benzodiazepines?
Because benzodiazepines quiet your nervous system, they can cause a variety of sedative effects. You might feel drowsy or slow. Your muscles may feel relaxed, and that can affect how you move. It may not be safe for you to drive, and it could affect your ability to perform your job. It might feel difficult to focus or pay attention.
“Most people become accustomed to that sedating effect pretty quickly. People new to the medication may appear intoxicated with initial doses,” Dr. Gerkin says.
Some people have headaches or nausea.
While benzodiazepines may initially help with sleep, they can eventually affect the quality of your sleep by preventing deeper stages of sleep, which can impact learning and memory.
These side effects become particularly concerning for older adults.
“As you get older, your gait and stability is already affected by age-related changes to the musculoskeletal and nervous systems, so for someone in their 60s or 70s and beyond, these drugs can be really problematic for falls,” Dr. Gerkin says. “Confusion is an issue. I’ve seen older patients who seem like they have dementia until they get off chronic benzodiazepines, so they need to be really carefully considered, if used at all, for older adults.”
It’s important to discuss the risk of misuse and abuse with your provider, so that you don’t become dependent on escalating doses of the drug. Once you are dependent, going off them is often difficult, and stopping too quickly can cause potentially life-threatening withdrawal.
“You can’t suddenly stop, and it can take weeks or months to effectively taper off,” Dr. Gerkin says. “How long that process takes depends on what dose you’ve been taking and how long you’ve been taking it.”
If you are interested in stopping use of a benzodiazepine, Dr. Gerkin recommends finding a provider skilled in tapering use of these medications.
How do benzodiazepines compare to other treatments?
If you’re dealing with an anxiety disorder or constant worry, antidepressants are considered a more effective option for long-term use because they don’t have as many risky adverse effects such as drowsiness or developing dependence. They work on different neurotransmitters and networks in the brain, reducing anxiety not by tamping down the activity of neurons but by increasing the activity of transmitters that support improved mood.
Antidepressants typically take a few months to reach full effect, so your provider may consider prescribing benzodiazepines to take as needed for severe panic or emotional distress during that time.
“With something like trauma or PTSD, it can be complex,” he says. “The medication can seem to be the only effective way of surviving and functioning in the short-term.”
Some people need short-term support from medication to be able to function and engage in the work of psychotherapy. When appropriate, that can be a benzodiazepine, but Dr. Gerkin says there are other medications to consider that can limit anxious distress, including beta blockers, alpha blockers or alpha agonists.
Therapy can provide you with the long-term tools you need to deal with those events that make you stressed. Think of benzodiazepines as a temporary support.
“When you sprain an ankle, your doctor gives you crutches,” Dr. Gerkin says. “If you never take the crutches away, your ankle will stop working. Similarly, if you rely on a benzodiazepine as a crutch for very long, your innate capacity to tolerate and manage anxiety and other strong emotions will degrade.”
A benzodiazepine can feel like the easy option in the moment, when they work so quickly, but investing the time to build resilience and coping skills is important for the long-term, Dr. Gerkin says.
“It’s a tricky situation for some people, because these drugs help them to get by, but they can also keep you from learning to effectively work with inevitable stress so you can thrive,” he says.
If you’re struggling with anxiety or depression, talk to your doctor or find one near you.