The minor tranquilizers, including xanax, valium, buspar, ati.

The Minor Tranquilizers, Including Xanax, Valium, BuSpar, Ativan, an.
WARNING!
When trying to withdraw from many psychiatric drugs, patients can develop serious and even life-threatening
emotional and physical reactions. In short, it is dangerous not only to start taking psychiatric drugs but also can
be hazardous to stop taking them. Therefore, withdrawal from psychiatric drugs should be done under clinical
supervision. Principles of drug withdrawal are discussed in Your Drug May Be Your Problem: How and Why to
Stop Taking Psychiatric Medications, by Peter R. Breggin, M.D. and David Cohen, Ph.D. Other information on
Prozac and Prozac-like drugs can be found in Talking Back to Prozac by Peter R. Breggin, M.D. and Ginger Ross
Breggin.
Excerpts from Toxic Psychiatry, Chapter 11
by Peter R. Breggin, M.D.
Suppressing the Passion of Anxiety Overwhelm with Drugs: The MinorTranquilizers, Including Xanax, Valium, BuSpar, Ativan, and Halcion,and the Antidepressant Anafranil Just as the 1980s was the decade in which those suffering from various forms of depression were identified and
treated, so, [NIMH director Lewis] Judd and other specialists hope, the 1990s will be the era when the recognition
and treatment of anxiety disorders predominate. Judd recently announced that NIMH will launch a national
education and prevention campaign, which, he says, "will be pointed toward early identification and diagnosis."
—Washington Post Health, May 22, 1990
From the U. S. Congress to the American public, psychiatry's marketing strategy for the 1990s aims at
people who feel anxious. It has become an axiom within modern economics that advertising actually
creates consumer needs. By targeting people suffering from anxiety, psychiatry should be able to
generate an unlimited demand for its drugs. Prescriptions for one class of these drugs, the
benzodiazepines, already are estimated at nearly one hundred million a year in the United States, for a
cost of about $500 million. Some estimates place the total cost at $800 million or more.
This chapter will give special attention to two minor tranquilizers that have drawn considerable
publicity. One is BuSpar (buspirone), whose potentially damaging effects have been largely ignored,
even in the psychiatric literature. The other is Xanax (alprazolam), one of the most intensively
marketed and yet dangerous drugs in psychiatry. Then chapter 15 will focus on the political campaign
that made Xanax so successful. [webmaster note: this information can be found in Toxic Psychiatry by Dr.
Breggin]
Unlike most of the drugs discussed in this book, the minor tranquilizers are highly sought after. Even
without doctors pushing them, people would want them. Indeed, they are actively sold illegally on the
street. This is not surprising, since people often resort to taking anything that promises even
temporary relief from anxiety. Millions drink alcohol, smoke cig-arettes, and use marijuana, opiates,
and other street drugs. Others eat excessively, exercise compulsively, work to exhaustion, watch TV
endlessly, escape into books, relentlessly pursue sex, and overindulge any number of otherwise
harmless habits in an attempt to escape their tensions and apprehensions. In chapter 10 we saw that
obsessions, compulsions,and phobias also can be seen as efforts to control anxiety. Overall, psychiatric
interventions play a relatively minor role in humanity's never- ending struggle to deal with anxiety.
The Minor Tranquilizers and Other Sedative-Hypnotics
Among psychiatric medications for the treatment of anxiety, the most commonly used are the minor
The Minor Tranquilizers, Including Xanax, Valium, BuSpar, Ativan, an.
tranquilizers, starting in 1957 with the introduction of Librium (chlordiazepoxide). In the 1970s the
minor tranquilizer Valium (diazepam) topped the charts as the most widely prescribed drug in
America, to be replaced by Xanax in 1986. Most of the minor tranquilizers belong to the group called
benzodiazepines and are closely related chemically to Librium, Valium, and Xanax. They differ mostly
in their duration of action and in the dosage required to achieve the same effect. They have nearly
identical clinical effects.
The benzodiazepine minor tranquilizers include Xanax, Valium, Librium, Tranxene (clorazepate),
Paxipam (halazepam), Centrax or Verstran (prazepam), Klonopin (formerly Clonopin) (clonazepam),
Dalmane (flurazepam), Serax (oxazepam), Ativan (lorazepam), Restoril (temazepam), and Halcion
(triazolam).
An older minor tranquilizer is Miltown or Equanil (meprobamate). (*The drugs are called "minor"
tranquilizers to distinguish them from "major" tranquilizers, but nowadays the latter are called
neuroleptics or antipsychotics.While the minor tranquilizers might now simply be called tranquilizers,
that term itself is somewhat misleading. Basically they are sedatives.)
Other minor tranquilizers are chemically antihistamines, such as Atarax or Vistaril (hydroxyzine).
Sleeping medications also have tranquilizing effects. These include Doriden (glutethimide), Noludar
(methyprylon), Placidyl (ethchlorvynol), and Noctec, Somnos, or Beta-Chlor (chloral hydrate), and the
various barbiturates, including Seconal (secobarbital), Luminal (phenobarbital), Butibel
(butabarbital), Amytal (amobarbital), Nembutal (pentobarbital), and Tuinal (amobarbital and
secobarbital).
All of these drugs have the potential for abuse and addiction. Since all have a calming or sedative
effect, people addicted to these "downers" use many of them interchangeably, depending on what is
available, often mixing them with alcohol. The minor tranquilizers and alcohol make a very dangerous,
frequently lethal, combination.
BuSpar, the most recent addition to the minor tranquilizers, is being promoted as nonsedative,
nonaddictive, and relatively safe.
The Most Widely Used Psychiatric Drugs
According to FDA data reported by Carlene Baum and her associates in the February 1988 Medical
Care, there was a dramatic decline in the use of minor tranquilizers and other antianxiety drugs, from
a peak of 103 million prescriptions in 1975 to 67 million in 1981 in the United States. There are no
complete totals available for recent years, but the APA's task force report, Benzodiazepine Dependence,
Toxicity and Abuse (1990), estimates that annual prescriptions for benzodiazepines have leveled off
since the mid-1980s at about 61 million.
The minor tranquilizers, now led by Xanax, remain by far the most commonly prescribed psychiatric
medications. In some countries, such as France, the use of these agents continues to escalate.
Most minor tranquilizer prescriptions—65 percent—were for women in 1984. However, women
predominate in all psychiatric drug categories. Thirty-five percent of all patients were sixty years of
age or older.
Are the Minor Tranquilizers Something New?
Because of the popularity surrounding the minor tranquilizers, we tend to think that they represent
The Minor Tranquilizers, Including Xanax, Valium, BuSpar, Ativan, an.
something very new and radically different among drugs; but I recall my medical school professor of
psychopharmacology reminding us in 1960 that the sedative attributes of minor tranquilizers differ
little from those of the barbiturates, such as phenobarbital….
Sedative-Hypnotics and Central Nervous System Depression
All of the commonly used minor tranquilizers—with the possible exception of BuSpar—are central
nervous system depressants very similar to alcohol and barbiturates in their clinical effects. Along with
alcohol and barbiturates, they are classified as sedative-hypnotics,3 meaning that they produce
relaxation (sedation) at lower doses and sleep (hypnosis) and eventually coma at higher ones. It is
important to grasp the principle that minor tranquilizers are central nervous system
depressants—and, in particular, sedative-hypnotics—because this classification removes the mystery
surrounding these "tranquilizers." The so-called antianxiety effect is merely an early stage of central
nervous system depression—sedation.4 The basic clinical effect on the mind cannot be distinguished
from alcohol or barbiturates.
It should be emphasized again that all minor tranquilizers combine with each other or with other
central nervous system depressants—such as barbiturates, antidepressants, neuroleptics, lithium, and
alcohol—with a potentially fatal result. While they can be lethal when taken alone, they are especially
dangerous in combination with these other drugs. A large percentage of drug-related emergency room
visits involve minors tranquilizers.
All of the minor tranquilizers impair mental alertness and physical coordination and can dangerously
compromise mechanical performance, such as automobile driving.
At low doses the minor tranquilizers are sufficiently potent to impact noticeably on the brain waves on
routine EEGs, especially in the frontal lobe region. However, they do not typically have the
lobotomizing impact epitomized by the neuroleptics.
Addiction, Tolerance, and Withdrawal Symptoms
All hypnotic-sedatives, including the minor tranquilizers, are habit forming and addictive and can
produce withdrawal symptoms or an abstinence syndrome when they are stopped. In the extreme, the
abstinence syndrome can cause life-threatening neurological reactions, including fever, psychosis, and
seizures. Less severe withdrawal symptoms include increased heart rate and lowered blood pressure;
shakiness; loss of appetite; muscle cramps; impairment of memory, concentration, and orientation;
abnormal sounds in the ears and blurred vision; and insomnia, agitation, anxiety, panic, and
derealization. Obvious withdrawal symptoms typically last two to four weeks. Subtle ones can last
months.
Consistent with the principle that the minor tranquilizers differ little in their clinical effect from other
sedatives, the Xanax write-up in the 1991 PDR acknowledges that withdrawal symptoms are "similar
in character to those noted with barbiturates and alcohol."
Studies of Xanax (see ahead) show that most patients develop withdrawal symptoms during routine
treatment lasting only eight weeks. Tolerance, or the need for increasing doses to achieve the same
psychoactive effect, is the underlying physical mechanism of addiction. Within two to four weeks,
tolerance can develop to the sedative effect of minor tranquilizers taken at night for sleep. 5 This again
warns against the use of these drugs for more than a few days at a time.
The short-acting benzodiazepines can produce especially severe withdrawal symptoms, because the
The Minor Tranquilizers, Including Xanax, Valium, BuSpar, Ativan, an.
drug is cleared from the body at a relatively rapid rate. These include Xanax, Halcion, Ativan,
Restoril, and Serax. However, according to expert Louis Fabre in a February 1991 interview with me,
tightness of binding to receptors is probably more indicative of addictive potential, and the most
tightly binding are Xanax, Halcion, Ativan, and Klonopin.
Individuals who take only one pill daily for sleep or anxiety are not exempt from withdrawal problems.
In my private practice during the last few years I have worked with several people who were unable to
stop taking a once-a-day standard dose of Xanax, Ativan, Klonopin, or other minor tranquilizers. In
each case, the attempt to stop the medication led to a disturbing degree of anxiety or insomnia within
twenty-four hours. The problem seemed to be caused by rebound anxiety or rebound insomnia (see
ahead). In a personal communication in late December 1990, internist John Steinberg confirmed that
patients taking one Xanax tablet each day for several weeks can become addicted. Steinberg is medical
director of the Chemical Dependency Program at the Greater Baltimore Medical Center and president
of the Maryland Society of Addiction Medicine. He points to research that Xanax and other
short-acting benzodiazepines can cause a reactive hyperactivity of the receptors that they block. The
hyperactive receptors then require one or more doses of Xanax each day or they produce anxiety and
emotional discomfort. Steinberg calls the impact of Xanax "a fundamental change in the homeostasis
of the brain." After the patient stops taking the Xanax, according to Steinberg, it takes the brain six to
eighteen months to recover. Xanax patients should be warned, he says, that it can take a long time to
get over painful withdrawal symptoms. Since doctors frequently don't realize this, they, too, are likely
to be confused and to continue the drug in the hope of "treating" the patient's drug-induced anxiety
and tension.
Many detoxification beds are occupied by patients addicted to minor tranquilizers and even more by
those who are cross-addicted with alcohol and other drugs. Steinberg says that Xanax is "by far and
away" the worst offender and that it definitely causes addiction without being mixed with other
sedatives. Steinberg estimates that one in ten patients receiving Xanax will become addicted. * (Based
on an estimated fifteen million people receiving Xanax each year in the United States, Steinberg
concludes that 1.5 million Xanax addicts are produced each year.
(* Steinberg does not use the term addiction loosely. By addiction he means that the patient
periodically loses control of his or her drug intake and has a pattern of compulsive use, despite adverse
consequences. If Steinberg were merely speaking of habituation, or difficulty stopping the use of the
drug, his estimates would be much higher. He considers Xanax "very easily habituating" and observes
that people are especially susceptible to the initial "euphoria or disinhibiting effect" that it has in
common with alcohol. l)
Rebound Anxiety and Insomnia
Rebound anxiety is one of the common reactions to withdrawal or to dose reduction of a minor
tranquilizer. As with most psychiatric drugs, the use of the medication eventually causes an increase of
the very symptoms that the drug is supposed to ameliorate, and thus rebound anxiety can lead to a
false diagnosis of chronic anxiety disorder. As noted in the American Psychiatric Press Textbook of
Psychiatry, long-term treatment can be erroneously maintained or reinstated when drug-induced
rebound anxiety occurs. Addiction is the ultimate outcome.
Some experts, such as John Steinberg, disagree with my assertion that there is no difference between a
tranquilizing and a sedative effect. They suspect that in addition to the obvious sedation, minor
tranquilizers probably also produce a specific inhibition of anxiety. If true, this means that they also
cause a specific rebound anxiety as the blocked receptors become hyperactive.
The Minor Tranquilizers, Including Xanax, Valium, BuSpar, Ativan, an.
Rebound insomnia also results from taking most sleeping medications, because the brain reacts against
the central nervous system (CNS) depressant effects by becoming more aroused or alert. Medications
for sleep generally should not be taken for more than a day or two at a time.
Addiction Can Go Unnoticed
Seriously addicted patients may show no outward signs to their family or physicians until accidentally
removed from the medication — for example, following surgery or during a medical emergency. Their
withdrawal symptoms may then be wholly misinterpreted as an aspect of some other disorder or as a
psychological problem. Marked withdrawal symptoms, including persistent rebound anxiety, can
begin as much as five to seven days after stopping the medication and can last up to a month.
Paradoxical Reactions .
The minor tranquilizers can produce paradoxical reactions—acute agitation, confusion, disorientation,
anxiety, and aggression—especially in children, adults with brain disease, and the elderly. The Xanax
report in the 1991 PDR states, "As with all benzodiazepines, paradoxical reactions such as stimulation,
agitation, rage, increased muscle spasticity, sleep disturbances, hallucinations and other adverse
behavioral effects may occur in rare instances and in a random fashion."
In nursing homes the medications may seem to help the insomnia of an elderly patient for a night or
two, only to produce generalized brain dysfunction as the medication accumulates in the system. The
agitated patient may then be mistakenly overdosed with further medication, perhaps a neuroleptic.
According to Robert Hales and Stuart Yudofsky's Textbook of Neuropsychiatry (1987), the "routine"
prescription of these medications in nursing homes and hospitals "should be avoided," especially for
anything but brief periods of insomnia related to a particularly difficult or stressful situation.
As in response to alcohol, some people more readily lose their self control and become violent when
taking minor tranquilizers. There are frequent references to this in the literature, including cases of
murder under the influence of minor tranquilizers. Partly because of this disinhibiting effect, the drugs
cannot be used effectively for purposes of controlling behavior within institutions.
Halcion has been especially implicated in causing aggressive and suicidal behavior, as well as delirium,
hallucinations, and seizures.
Memory Dysfunction from Minor Tranquilizers
Recently there has been much-publicized concern about Halcion producing amnesia for events prior to
the taking of the drug. However, this has long been an unheralded problem with minor tranquilizers in
general. Years ago I recall noticing that patients who mixed alcohol with Valium the night before a
psychotherapy session sometimes would have severe black-out spells and could not recall much of the
prior evening. It is well known that the intravenous infusion of benzodiazepines, such as Valium or
Ativan, typically produces a similar amnesia for the several hours surrounding the infusion. While this
may be a benefit in forgetting the painful effects of surgery, it becomes a potentially serious problem in
the routine use of the minor tranquilizers for anxiety or sleep disorders and can interfere with
psychotherapy, studying, learning anything new, or recalling previously retained memories. 7
Long-Term Effects on Mental Function from the Minor Tranquilizers
Despite the obvious need for concern, few studies have attempted to measure the impact of long-term
minor tranquilizer usage on overall mental function. Susan Golombok and her colleagues from the
The Minor Tranquilizers, Including Xanax, Valium, BuSpar, Ativan, an.
Institute of Psychiatry in London published "Cognitive Impairment in Long-Term Benzodiazepine
Users" in the 1988 Psychological Medicine. Using a variety of neuropsychological tests to evaluate the
impact of minor tranquilizers on cognitive function in patients who were administered the medication
for at least one year, they found chronic impairment in measures of visual-spatial ability and attention
span.
Golombok and her coworkers were unable to follow up with tests after drug termination. However,
these findings of chronic brain dysfunction raise a serious concern about possible permanency. The
investigators comment: "It is impossible to determine how long it is safe for a patient to continue to
take benzodiazepines, or at what dose, before cognitive ability will begin to deteriorate. Nevertheless, it
is clear from the inspection of our data that taking a low dose for a short time has little effect, while a
high intake is almost always certainly harmful." (P. 371)
The test results indicate that "these patients are not functioning well in everyday life," while they
remain unaware of their impairment: "This is in line with clinical evidence that patients who
withdraw from their medication often report improved concentration and increased sensory
appreciation and that only after withdrawal do they realize that they have been functioning below
par. It appears, therefore, that not only are long-term benzodiazepine users at risk of dependence,
but that cognitive impairment also represents a very real hazard." (P. 373)
It cannot be overemphasized that brain-disabling treatments render patients less able to evaluate their
own dysfunction. The Golombok study is exceedingly important from the viewpoint of the patient who
wishes to avoid brain dysfunction and from the viewpoint of the ethical physician who wishes to avoid
causing it in his or her patients.
If doctors wish to prescribe minor tranquilizers or if patients want to take them, it would be prudent to
follow the advice of The New Harvard Guide to Psychiatry ( 1988): "The main usefulness of the
antianxiety agents is in general medicine in the short-term treatment of relatively transient forms of
anxiety, fear, and tension" (p. 524).
Brain Shrinkage from Long-Term Minor Tranquilizer Use
An even more terrifying specter haunts the long-term use of minor tranquilizers—the possibility of
brain atrophy. Although rarely mentioned in establishment books or reviews, in their letter to the
editor in the July 1989 Archives of General Psychiatry, Isaac Marks and his ten colleagues summarize
the as yet brief literature: "The cerebral ventricular enlargement reported in patients with
anxiety/panic disorders who were long-term benzodiazepine users could be due to the disorder or to
other factors rather than to the drugs, but wisdom advises caution" (p. 669). In fact, the cerebral
ventricular enlargement—the equivalent of atrophy of the brain—is most likely due to the drugs. C.
Schmauss and J-C. Kreig in "Enlargement of Cerebrospinal Fluid Spaces in Long-Term
Benzodiazepine Abusers" in the 1987 Biological Medicine found that "our data suggest that the
increase in the VBRs [ventricular enlargement] is dose-dependent on long-term BDZ [benzodiazepine]
medication" (p. 873).
I mentioned the studies on brain atrophy to one expert who replied that although he had not heard of
them, he was not surprised. "The minor tranquilizers are like alcohol," he observed, "and alcohol
when used long-term causes brain shrinkage." He asked to remain anonymous for fear of offending
other drug experts.
[webmaster note: full references, footnotes and further sections of this chapter can be found in Toxic
Psychiatry, by Peter R. Breggin, M.D.]
The Minor Tranquilizers, Including Xanax, Valium, BuSpar, Ativan, an.
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