“Mother’s Little Helpers” All Grown Up: A Brief Look at Some of the Current Research on Benzodiazepines

What a drag it is getting old
Kids are different today, I hear every mother say
Mother needs something today to calm her down
And though she’s not really ill, there’s a little yellow pill
She goes running for the shelter of a mother’s little helper
And it helps her on her way, gets her through her busy day”

– “Mother’s Littles Helper” Written by Mick Jagger and Keith Richards

What Are Benzodiazepines – Then and Now

Benzodiazepines were discovered almost sixty years ago, and for over ten years were extremely popular for handling everyday stress. Their use was so prevalent by housewives dealing with unruly children, and the daily stressors of the demands of achieving homemaking perfection à la June Cleaver and Donna Reed, that the Rolling Stones wrote the song “Mother’s Little Helper” that reached number eight on the Billboard Hot 100 singles chart in 1966. The adverse effects, addictive properties, and risk for dependence were not fully known at that time (Oldenhof, et al., 2019).

Now used for short-term treatment of insomnia and anxiety, this class of drugs has a risk for misuse and for development of benzodiazepine use disorders. Moreover, they have been linked to a variety of adverse health effects, such as impaired motor coordination and traffic accidents, overdose, and early death rates (Blanco, et al., 2018). Use of benzodiazepines is also linked to high rates of polysubstance use, and mood or anxiety disorders (Blanco, et al., 2018). Currently opioid analgesics and benzodiazepines comprise the two most common drug classes contributing to drug overdose deaths, with 75% of prescription drug overdose deaths involving opioid analgesics and 29% involving benzodiazepines (Jones, et al., 2015).

Diagnostic criteria for Sedative, Hypnotic and Anxiolytic Use Disorder

The recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013) category is Substance-Related and Addictive Disorders (APA, 2013). Sedative, Hypnotic and Anxiolytic Use Disorder DSM-5 304.1 (F13.1) combines substance abuse and substance dependence into Substance Use Disorder. The descriptive is “substance use results in distress or functional impairment, specified by drug and graded on a continuum from mild to severe.”

The new diagnosis requires at least 2 of the following criteria. The disorder is mild if 2-3 criteria are met, moderate if 4-5 are present and severe with 6-7 or more.

Continuing to use a substance, in this case a barbiturate, benzodiazepine or other sedative-hypnotic, despite negative personal consequences.
Repeated inability to carry out major functions at work, school, or home on account of use.
Recurrent use in physically hazardous situations
Continued use despite recurrent or persistent social or interpersonal problems caused or made worse by use.
Tolerance, as manifested by needing a markedly increased dose to achieve intoxication or desired effect, or by markedly diminished effect with continued use of the same amount.
Withdrawal with the characteristic syndrome or use of the drug to avoid withdrawal.
Using more of the drug or using for a longer period than intended.
Persistent desire to cut down use, or unsuccessful attempts to control use.
Spending a lot of time obtaining or using the substance or recovering from use.
Stopping or reducing important occupational, social, or recreational activities due to use.
Craving or strong desire to use.

Treatment for Sedative, Hypnotic and Anxiolytic Use Disorder

Treatment for benzodiazepine use disorder, dependence, overdose, and withdrawal is complex and requires professional medical involvement and, often, medications as well as behavioral health care. Cognitive behavioral therapy and twelve-step programs offer additional support. Professionals in a variety of treatment settings and populations can be guided by the following guidance documents from the Substance Abuse And Mental Health Services Administration (SAMHSA):

Protracted Withdrawal Substance Abuse Treatment Advisory, July 2010, Vol. 9, Issue 1

This advisory from defines protracted withdrawal and identifies specific withdrawal symptoms associated with alcohol, opioids, methamphetamine, cocaine, marijuana, and benzodiazepines. The advisory also explains how protracted withdrawal differs from acute withdrawal and gives tips to help clients manage it in recovery.

TIP 24: A Guide to Substance Abuse Services for Primary Care Clinicians

This document gives primary care clinicians specific guidance on identifying indications of substance abuse, how to broach the subject with a patient, and what screening and assessment instruments to use. It explains how to perform an office-based brief intervention in which patient and clinician set mutually agreed-upon goals and “contract” to stop or cut back the alcohol or other drug use.

Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants

This Clinical Guide provides comprehensive, national guidance for optimal management of pregnant and parenting women with opioid use disorder and their infants. The Clinical Guide helps healthcare professionals and patients determine the most clinically appropriate action for a particular situation and informs individualized treatment decisions.

Pharmacologic Guidelines for Treating Individuals with Post-Traumatic Stress Disorder and Co-Occurring Opioid Use Disorders

This manual offers guidelines for medication-assisted treatment for people, particularly veterans, living with post-traumatic stress disorder and co-occurring opioid use disorders. It covers screening, concomitant treatment, pharmacotherapy, and multiple misused substances.

TIP 37: Substance Abuse Treatment for Persons With HIV/AIDS

This manual helps clinicians improve care for people living with HIV/AIDS and substance use disorder conditions. It discusses prevention, assessment, and treatment of HIV/AIDS. The manual also examines mental illness, integrated services, case management, counseling, ethical and legal issues, and funding sources.

Substance Abuse Treatment for Persons With Co-Occurring Disorders: Quick Guide for Mental Health Professionals Based on TIP 42

This manual offers mental health professionals models and techniques for working with people living with co-occurring disorders. It describes screening and assessment and lists five guiding principles for effective management.

TIP 48: Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery

This guide helps substance use counselors treat clients with symptoms of depression and substance use conditions. Program administrators will learn how to integrate depression treatment into early drug treatment. The guidelines cover screening, assessment, treatment, counseling, cultural competence, and continuing care.

TIP 51: Substance Abuse Treatment: Addressing the Specific Needs of Women

This guide assists providers in offering treatment to women living with substance use disorders. It reviews gender-specific research and best practices, such as common patterns of initial use and specific treatment issues and strategies.

TIP 44: Substance Abuse Treatment for Adults in the Criminal Justice System

This manual offers guidelines to help counselors and administrators deliver substance use disorder treatment in criminal justice settings. It discusses aspects in providing substance use disorder treatment to people within the criminal justice system, including screening and assessment, and triage and placement in treatment services.

Training for Behavioral Health Professionals

Behavioral Health providers preparing for managing treatment and recovery from benzodiazepine disorder and seeking to learn the current treatment options for it will be interested in the following CASAT Training offering:

Management of Benzodiazepine Disorder

Learning objectives for this online class to be presented by Candy Stockton-Joreteg, M.D., FASAM on December 14, 2020 Time: 9:00 am – 12:00 pm (PST) will be:

Distinguish between benzodiazepine dependence and benzodiazepine use disorder
Appropriately use diagnostic criteria for benzodiazepine use disorders
Be familiar with the pharmacology of benzodiazepines
Understand risk factors for developing benzodiazepine use disorder
Describe benzodiazepine withdrawal
List common treatment options including the Ashton method for tapering
Understand how other substances, including opioids, interact with benzodiazepines
Respond to common liability concerns with appropriate documentation
The risks associated with MAT Treatment and benzodiazepines

Final Thoughts

Benzodiazepines are an important class of drug that has great potential to treat a number of disorders, and also the potential for abuse, dependence, or addiction. People do not always abuse this class of drugs deliberately, and dependence is not synonymous with benzodiazepine disorder. The issues surrounding benzodiazepine use disorder and dependence are complex and often involves polydrug use, and there are valid medical purposes that serve the use of this class of drugs by some people with proper medical and behavioral health care (O’Brien, 2005). The importance of knowledge, skills, and experience in treating and preventing benzodiazepine use disorders and dependence cannot be overstated.

What are your experiences in treating those with benzodiazepine disorder or dependence? Offer your thoughts in the comment section below.

References

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, ed. 5. Arlington, VA, APA Press.

Blanco, C., Han, B., Jones, C. M., Johnson, K., & Compton, W. M. (2018). Prevalence and correlates of benzodiazepine use, misuse, and use disorders among adults in the united states. The Journal of Clinical Psychiatry, 79(6) doi:10.4088/jcp.18m12174

Brett, J., & Murnion, B. (2015). Management of benzodiazepine misuse and dependence. Australian prescriber, 38(5), 152–155. https://doi.org/10.18773/austprescr.2015.055

Fluyau, D., Revadigar, N., & Manobianco, B. E. (2018). Challenges of the pharmacological management of benzodiazepine withdrawal, dependence, and discontinuation. Therapeutic advances in psychopharmacology, 8(5), 147–168. https://doi.org/10.1177/2045125317753340

Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical overdose deaths, United States, 2010. JAMA. 2013;309(7):657–659. http://dx.doi.org/10.1001/jama. 2013.272.

Jones, C. M., & McAninch, J. K. (2015). Emergency department visits and overdose deaths from combined use of opioids and benzodiazepines. American Journal of Preventive Medicine, 49(4), 493-501. doi:10.1016/j.amepre.2015.03.040

NIDA. 2020, May 5. Research suggests benzodiazepine use is high while use disorder rates are low. Retrieved from https://www.drugabuse.gov/news-events/science-highlight/research-suggests-benzodiazepine-use-high-while-use-disorder-rates-are-low on 2020, August 12

O’brien, C. P. (2005). Benzodiazepine use, abuse, and dependence. The Journal of Clinical Psychiatry, 66 Suppl 2, 28.

Votaw, V. R., Geyer, R., Rieselbach, M. M., & McHugh, R. K. (2019). The epidemiology of benzodiazepine misuse: A systematic review. Drug and Alcohol Dependence, 200, 95-114. doi:10.1016/j.drugalcdep.2019.02.033

Votaw, V. R., McHugh, R. K., Vowles, K. E., & Witkiewitz, K. (2020). Patterns of polysubstance use among adults with tranquilizer misuse. Substance use & Misuse, 55(6), 861.

“Mother’s Little Helpers” All Grown Up: A Brief Look at Some of the Current Research on Benzodiazepines