Benzo Illness, not Benzo Dependence or Benzo Addiction.
One of the great stumbling blocks in
educating doctors, health workers, patients and the wider community about the
nature of benzo illness has been the inappropriate and confusing use of the
words ‘addiction’ and ‘dependence’ to describe the condition. The first word is
a complete red herring, the second subtly but powerfully misleading.
A small minority of benzo casualties are struggling with problems of addiction (and they also deserve assistance and compassion) however the overwhelming majority are not drug 'addicts' but simply obedient patients following doctors’ orders. Mis-information has been the problem for them, not uncontrolled desire for a particular substance. When serious physical illness is caused by a prescribed medicine, taken in small doses, as directed, the issue can hardly be one of ‘drug abuse’.
The penny will not drop while these terms are being used - they imply that the problem lies with the patient not the pill.
Addiction.
Most sufferers of benzo illness are not, and never were, addicted to benzodiazepines. Addiction implies a fundamental weakening of the will, and indicates a tendency to use a substance even when the user knows it is damaging them. Most benzo patients do not fit this picture - they and their doctor believe they are doing the right thing, that their pills are good medicine.
Benzo patients may well become psychologically or physiologically reliant on the medication but that is not ‘addiction’ and the subtle distinction is an important one to make if we are to understand the illness and help the patient.
Because the first problem health authorities noticed with the benzoes in the early years was the withdrawal syndrome, and because withdrawal syndromes are usually associated with drugs of addiction and drug abuse, the simplistic conclusion seems to have been drawn that benzo patients who suffer withdrawals must be either addicts or drug abusers. That is to say, the problem was blamed on the patient rather than on the harmful effects of the medication. This misapprehension has bedevilled the field of benzo recovery for the past fifty years. Instead of asking the appropriate question; ‘what can we do about this harmful medication?’ the tendency has been to ask ‘what can we do with these problematic people?’
In the absence of appropriate knowledge and services, patients suffering a nasty withdrawal, or those who could not manage to withdraw at home, have been recommended to a drug and alcohol facility where the dominant culture was often a subtly punitive one urging the patient to ‘take responsibility for her addiction’, for her supposed history of ‘abuse’ and ‘denial’. Benzo patients who had been prescribed a regular low dose of valium and who took the medicine in good faith, exactly as prescribed, would be challenged to admit they were substance abusers. If they had sometimes upped their dose over the years to help cope with the painful symptoms of physiological dependence (see below) that would be seen as proof of their compulsive, addictive personalities.
Many many benzo patients have endured great suffering, and continue to endure great suffering, due to this misguided and cruel treatment approach; an approach which may be ideal for certain addiction problems but which is like salt in the wound for most benzo sufferers.
Australian Psychiatrist Dr Jean Lennane, a pioneer in the field of benzo recovery, made the distinction between classic drug addiction and benzo-related problems during an interview I conducted with her in the early 1990’s.
I had already observed in my work with the Benzodiazepine Research Group in Melbourne that long term benzo patients seldom craved the pills, or fantasised about them, the way an alcoholic might crave or dream about a drink. Sure, they relied on them to alleviate the mental and physical pain they were living with, but that is different from the desire for a substance because of a compelling, addictive thirst for the substance itself.
Dr. Lennane revealed that most benzo patients she treated didn’t seem to have the underlying issues consistent with classic drug and alcohol addiction. As Dr. Lennane said; ‘Once off their pills, they simply get on with their lives’.
Dependence
In an attempt to acknowledge the distinction between drug addiction and the illness and withdrawal syndrome produced by benzoes, health services finally came up with the unfortunate term ‘benzodiazepine dependence’. An inappropriate term which muddies the waters.
‘Benzodiazepine dependence’ intends to indicate that what most benzo casualties are experiencing is physiological dependence (understandably a psychological reliance can also develop but the core of the problem is physiological).
Here is my understanding of the mechanisms involved:
The complex chemical composition of the body rearranges itself to accommodate the alien benzo as best it can: a new bio-chemical status-quo is established in the body as it adapts to, and attempts to manage, the chemical effects of the benzoes.
Maintaining this new, artificial status-quo creates unusual biological stresses within the system hence the often severe health problems and peculiar symptoms developed by so many long term benzo patients (and misunderstood by so many of them, and their doctors).
Because the body is adapting its chemistry to accommodate the regular dose of benzoes, any attempt to reduce or remove the drug, disturbs this new delicate balance - its like a card being removed from a house of cards; physiological chaos ensues. Hence the withdrawal syndrome and the great danger involved in stopping benzoes abruptly (‘cold-turkey’).
The phenomenon of ‘tolerance’ also upsets the status quo. ‘Tolerance’ refers to the situation wherein the desired effects of the drug become weaker over time because the body has become ‘tolerant’ to the substance. When a state of tolerance is reached, this also sends shock waves through the body’s new status quo. These shock-waves are alleviated by increasing the daily dose of the drug.
So, generally speaking, to avoid chaos, the regular dose of the benzo must be maintained or increased. This is a state of ‘dependence’. Maintaining the body’s new status quo ‘depends’ on the benzo.
Why is the term ‘benzodiazepine dependence’ problematic?
In common use, particularly in popular psychology, the word ‘dependence’ often implies a deficiency, a need, or a problem of some kind in the dependent person. The subtle implication therefore in the term ‘benzo dependence’ is, once again, that the source of the benzo problem lies with the patient not the pill. I know from my many conversations with medicos over the years, and from the experiences related to me by ex-benzo users, that many doctors have been misled by that term. If you believe benzoes are fine but that certain people might become ‘dependent’ on them you’ve missed the point. It’s the medicine which causes the damage, not the attitude of the patient.
In 2007 some doctors continue to think that it is only problematic people, those who have a ‘dependent personality’ or ‘addictive nature’, who ‘get into trouble’ with benzoes. Some seem to believe they can assess a patient’s susceptibility to benzo illness simply by having a chat with them to ascertain whether they are at all ‘compulsive’. If their benzo patients are not craving more pills or dramatically upping the dose these doctors think everything must be OK. The term ‘benzo dependence’ reinforces such misapprehensions. They just don’t get it that benzo illness essentially has nothing to do with personality traits, addiction or compulsive behaviour: a well-balanced, hard working, middle-aged woman who takes no more than four half tablets a week may wind up suffering benzo illness with continued use. It is a primarily physiological problem, a physical condition, caused by the medicine and is not determined by a perceived or actual ‘weakness of will’. They don’t get it that a regular low dose, taken exactly as prescribed, can be insidiously fostering or worsening a patient’s anxiety or insomnia, as well as producing significant ill-health, even while the patient experiences the desired feeling of sedation shortly after taking each tablet. When confronted with symptoms of benzo illness in these compliant, low-dose, ‘non-compulsive’ patients, mis-led doctors continue to mistake the benzo symptoms for further signs of anxiety, hypochondria etc.
I suggest we stop using the misleading terms benzo addiction and benzo dependence to describe this pharmaceutically-produced illness. If we call it ‘benzo illness’ the penny is more likely to drop.