Benzodiazepines: Our Other Prescription Drug Problem

There are newer benzos (and analogs) that have less negative effects than Valium or Xanax, but they don't seem to be popular in the developed world for whatever reason.

Etizolam is one such drug. It's prescribed in Japan and India, but not really anywhere else as far as I can tell. It has a lower potential for dependance than classical benzodiazepines and tolerance builds up a lot slower. Anecdotally from people I know who've taken it, its acute effects feel much more mild than Xanax or Valium. In my limited experience, Valium feels like you've been lobotomised, and Etizolam feels like you've been given a big hug.

I'm with you here.

The problem is that you look like someone who has done their research, is knowledgeable and self aware, and trying to (seemingly successfully) address a problem.

Lots and lots of people are nothing like that. They just want to get high. Escape reality at all costs, no matter the damage to themselves or others.

This isn't the drugs' problem or fault, obviously. Those people will use alcohol and other means to get fucked up and they will obtain the drugs they want illegaly anyway.

THE THING IS: While it's illegal to get those drugs, society can demonise those people and politicians can run with that as their platform.

Should drugs be made legal, all it will take is one idiot killing themselves or others while on drugs and suddenly it's the drugs' fault again, and the next politician running with a 'tough on drugs' stance will win.

People will look for blame and they will not do so rationally.

Self-driving cars will be dragged through the press for every accident there is, even if they are 10,000x less likely to crash. People are afraid of flying. Videogames are the reason for killing sprees, etc. etc.

I take 1mg xanax up to once a day (typically every other day) and it has completely changed my life for the better. In conjunction with propranolol taken regularly (20mg twice a day, roughly), my anxiety is finally in a fairly well-controlled state. Unfortunately, getting benzo prescriptions -- even for the low dosage and frequency I'm on -- is hard and getting harder. Ordering it online is possible but rife with scams and risks. I understand that some people abuse these medications but for me they're life-saving; in cracking down on benzo prescriptions, my anxiety medication is becoming a source of anxiety in itself.

> have become aware of many people who use opiods on a long-term, occasional basis to manage their pain

This is the correct way to use opioids for long term pain, but it's only useful for a small number of people.

https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-awar...

"A small proportion of patients may obtain good pain relief with opioids in the long term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation".

This "small proportion" is in the UK context, where we are already prescribing much less opioids.

The mistake people make is to think that opioids are effective to treat long term pain. For most people they do not work to treat long term pain. The patient develops tolerance, needs increasing doses, and eventually they're taking dangerously high doses and also not getting pain relief.

We need to understand that there are limited treatments for chronic pain. Some people will need to lose weight and exercise. Some people may find a psychological treatment useful to either treat the pain or come to terms to live with the pain.

https://www.rcoa.ac.uk/node/21134

"Chronic pain can cause low mood, irritability, poor sleep and reduced ability to move around. Unlike acute pain, chronic pain is difficult to treat with most types of treatment helping less than a third of patients. Most treatments aim to help you self-manage your pain and improve what you can do. Different treatments work for different people. Medicines generally and opioids in particular are often not very effective for chronic pain. Other non-medicine treatments may be used such as electrical stimulating techniques (TENS machine), acupuncture, advice about activity and increasing physical fitness, and psychological treatments such as Cognitive Behaviour Therapy and meditation techniques such as mindfulness. Helping you understand about chronic pain is important and in particular helping you understand that physical activity does not usually cause further injury and is therefore safe. It is important that you understand that treatments tend not to be very effective and that the aim is to support you in functioning as well as possible."

"Neuropathic pain is a type of chronic pain associated with injury to nerves or the nervous system. Types of neuropathic pain include, sciatica following disc prolapse, nerve injury following spinal surgery, pain after infection such as shingles or HIV/AIDS, pain associated with diabetes, pain after amputation (phantom limb pain or stump pain) and pain associated with multiple sclerosis or stroke. Neuropathic pain is usually severe and unpleasant. Medicines may be used to treat neuropathic pain but are usually not very effective and work for a small proportion of people. You may not benefit from the first drug tried so you may need to try more than one drug to try and improve symptoms."

I get the feeling that you're not aware of the scale of over-prescribing in the US. The US prescribes hugely more opioids than other countries. For example, for a while the US was using 99% of the world supply of hydrocodone.

The US could correctly treat the small number of people who'd get benefit from occasionaly tightly controlled opioid prescribing while also massively reducing the total number of opioidprescriptions.

And for anxiety the story is similar. The evidence for efficacy of benzos isn't great.

https://www.nice.org.uk/guidance/cg113/chapter/Key-prioritie...

You need a stepped approach:

individual non-facilited self help

individual guided self help

psycho-educational groups (for one example see Recovery Colleges https://www.health.org.uk/recovery-college

If these don't work you offer a high intensity psychological intervention, or a medication.

Notice that for medication they say "Do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises. Follow the advice in the 'British national formulary' on the use of a benzodiazepine in this context."

Every time the patient collects their benzos from the pharmacy there will be a patient information leaflet. Here's an example for diazepam: https://www.medicines.org.uk/emc/medicine/18061

I get the feeling that benzos are far more readily prescribed in the US, and for long times.

The Ashton Manual is good resource, but the state of the art taper method as far as I know is the liquid titration (via suspension, not solution) micro-taper. See, e.g., https://www.google.com/search?q=benzobuddies+micro+taper+liq... .