Ask the Pharmacist

Q) My mother has been taking a sleeping tablet for decades now and her new doctor wants to take her off of it. What’s the harm in a 75-year-old taking a single pill to sleep at night?

A) Not all sleeping pills are the same, but given the above scenario it’s a good bet that the drug in this case is in the class of sedatives called benzodiazepams (often referred to as benzo’s by the medical community).

There are a number of members in this group that can be identified by the last three letters in their generic names always ending in “pam”; Examples include lorazepam (Ativan), diazepam (Valium), alprazolam (Xanax) and clonazepam (Rivotril in Canada and Klonopin in the States).

All of these drugs are so well known that they have become the punchline of jokes and are frequently referenced in all forms of pop culture. One example can be seen with the classic song by the Rolling Stones from 1966 called Mother’s Little Helper.

For a class that has been with us since 1955, they still receive an inordinate amount of attention due to their controversial widespread use. Some critics have recently described their overuse as “the other epidemic” in reference to the opioid crisis that still rages on all around us.

In 2017, more than 26 million prescriptions for benzo’s and related drugs were written in Canada noting that both females and increased age are more likely to be prescribed these medications. In the early to mid 70’s, these drugs topped all of the “most frequently prescribed” lists and in the U.S. the number of people filling benzo prescriptions increased by 67% between 1996 and 2013.

Canada probably has not fared any better as we are currently ranked second in the world when it comes to the frequency of benzo use. Fortunately in the last few years, there has been a slow but steady decline in these numbers as prescribers, such as the one cited in the question above, began to seriously re-examine these drugs and have attempted to wean patients off of these, often against the wishes of the patient themselves. Still, there is a long way to go.

It has been estimated that 20% of Canadians over the age of 65 consume these at least on occasion and that if one were to go by the current Canadian guidelines for using these drugs only about 20-30% of those prescriptions are “appropriate”. So what are these drugs good for and why are they so dangerous?

Benzos work by depressing the body’s central nervous system making them relatively quick solutions in treating anxiety and insomnia, two incredibly prevalent health issues in our society. Ironically enough, they initially gained widespread popularity since they were considered (and in fact are) a much safer alternative to treating these conditions than the barbiturates which used to be the drugs of first choice for these conditions. They work quickly and effectively to alleviate these conditions which makes it easy to see why they are beloved and considered a saviour by many of their users.

They are fantastic drugs to help people get through an airplane flight or an MRI or feared dental or surgical procedure. They can be a life saver for helping someone get through severe alcohol withdrawal. Their ability to alleviate anxiety within minutes or insomnia on the first night they are taken can provide much needed relief to people who are really suffering.

Part of their problem in fact is their effectiveness. They work so well that people lose the incentive to build innate resiliency against their anxiety or to take the necessary lifestyle changes to combat insomnia. They learn or decide to rely on these pills alone which one expert likened it to prescribing a beer since they work on the same parts of the nervous system as booze does.

The drugs have lots of potential side effects including, but not limited to;

· Drowsiness
· Dizziness
· Confusion
· Slurred speech
· Muscle weakness
· Constipation
· Nausea
· Blurred vision
· Dry mouth

Unfortunately, these drugs present a myriad of potential complications above and beyond these types of side effects when they are used for an extended period of time. Even when they are taken in small doses and/or irregularly, they can lead to memory loss (they impair the process in which short term memories are transferred into long-term memory storage), an increased risk of falling and, hence suffering a fracture (remember, in our most elderly, the risk of dying from a hip fracture with a year may be as high as 50%), an increased risk of being in a motor vehicle accident as well as almost certainly making people dependent on them and possibly addicted to them as well.

The terms dependent and addicted are frequently misinterpreted. Dependence means that not taking them leads to withdrawal symptoms whereas addiction is a complex phenomenon in which the continued use of the substance becomes the main priority of the individual.

Addiction and dependence occur because within weeks of taking the medications, the nervous system adjusts to the effects of these drugs, a tolerance so to speak, necessitating higher doses to achieve the same sensations of calm and relaxation or a series of side effects when the brain no longer has these drugs exerting their effects. Even episodic use of these drugs is associated with harm.

A lifetime use of 90 doses, the equivalent of taking a single sleeping pill twice a week for a single year, has been shown to confer a 50% higher risk of dementia and to double the risk of death. These dementia claims are very open to debate as other recent studies have disputed whether these drugs are associated with an increased risk and more studies are needed to further clarify this question. Still, concern about a possible link does exist.

This preponderance of safety issues has led the FDA in the States to insist upon a new update as of this September to the entire class’ Boxed Warning, the agency’s most prominent warning. The new labelling is meant to strengthen the warnings about the risk of abuse, misuse, addiction, physical dependence and withdrawal reactions these drugs can cause in an effort to improve their safe use.

As you can hopefully see, there is a legitimate reason for a well meaning physician to want to at least try to get their patients off of these drugs. It should never be done abruptly, and in a few cases, it might be best for the patient to stay on their benzo. But in the majority of cases, the medical literature shows rather conclusively that most feel better when they eventually get off of these brain slowing drugs.

In the next two weeks, we’ll talk about the guidelines as to what constitutes appropriate use of these drugs, some further information regarding possible withdrawal symptoms and suggestions as to how to slowly get off of a benzo so as to avoid going through withdrawal. For more information about this or any other health related questions, contact your pharmacist.