Benzodiazepines (Benzos)

What are benzodiazepines?

Benzodiazepines are medications that make your nervous system less active. The decrease in nervous system activity makes these medications helpful for a variety of symptoms and conditions.

Many countries, including the U.S., classify benzodiazepines (sometimes known by the slang term “benzos”) as controlled substances. That means you need a prescription to get them. It’s illegal to have or obtain them (depending on the laws where you are) if you don’t have a prescription.

IMPORTANT: Benzodiazepines are controlled because they can have dangerous effects, especially when misused. They can also be habit-forming. Because of these factors, healthcare providers use benzodiazepines cautiously. If your nervous system’s activity drops too low, it can have dangerous or even deadly effects.

How do benzodiazepines work?

Your nervous system uses chemical and electrical signals to send and relay messages throughout your body. The chemical signals, known as neurotransmitters, can attach to cells with the right receptors. Neurotransmitters and receptors work much like your car keys. Neurotransmitters (your car key) can only fit into the right receptor (your car ignition). If it fits, the neurotransmitter can activate a process within the cell (starting your car).

Benzodiazepines tell your brain to release a neurotransmitter, gamma-aminobutyric acid (GABA). This neurotransmitter has a specific job: It makes your nervous system less active. The slowed activity can have the following effects:

• Amnestic: This word comes from a Greek word that means “forgetfulness.” Benzodiazepines temporarily block the formation of new memories (known as anterograde amnesia).
• Anxiolytic: This term is a combination of two Greek root words, “anxio” for “anxiety” and “lytic,” meaning “to loosen.” While active, medications with this effect “loosen’’ anxiety’s hold on you.
• Hypnotic: While many people associate “hypnotic’’ with the practice of hypnosis, this word actually comes from the name Hypnos, the Greek god of sleep. Just like their namesake, hypnotic medications make you sleepy.
• Sedative: This term comes from a Latin word that means “to settle.” In this context, benzodiazepines help your nervous system “settle down” and have a quieting effect.

Other ways to classify benzodiazepines

There are two main ways that experts classify benzodiazepines:

• Strength: Some benzodiazepines are stronger than others (though potency can vary from person to person for varying reasons). For example, 15 milligrams (mg) to 30 mg of flurazepam is generally equivalent to 0.25 mg to 0.5 mg of clonazepam.
• Duration of action: Some benzodiazepines are short-acting and last only several hours. Some are long-acting and last several days. Most long-acting benzodiazepines aren’t as strong.

The strength and duration of action of benzodiazepines are important in what conditions they treat. Short-term or emergency conditions usually merit the use of stronger, short-acting benzodiazepines. Chronic, non-emergency conditions are usually treatable with lower-strength, longer-acting benzodiazepines.

What conditions do benzodiazepines treat?

These medications treat conditions based on which effect they cause. While there are separate types because they have different primary effects, there’s a lot of overlap between them. For example, most benzodiazepines have a sedative effect in addition to their primary effect.

• Amnestic: These are common for beginning general anesthesia before surgeries and other medical procedures.
• Anxiolytic: These treat anxiety disorders, such as social anxiety disorder and panic disorder.
• Hypnotic: These treat insomnia and related sleep disorders.
• Sedative: This effect has many uses. It can treat conditions and symptoms related to muscle control, such as muscle spasms. It can also treat more severe issues like catatonia (which often happens with mental health conditions like schizophrenia or bipolar disorder). These benzodiazepines are also very important in treating seizures (including those due to epilepsy) and status epilepticus, a seizure-related medical emergency.

What are nonbenzodiazepines?

A few medications mimic the hypnotic effects and work similarly to benzodiazepines, but they aren't the same. Experts call these nonbenzodiazepines. These drugs also activate the same receptors as benzodiazepines and cause GABA release. Because of how they work, these drugs are most effective in treating insomnia and related sleep disorders. They include:

• Eszopiclone (Lunesta®).
• Zaleplon (Sonata®).
• Zolpidem (Ambien®).

Are benzodiazepines commonly prescribed?

Yes, benzodiazepines are commonly prescribed and see widespread use. In a 12-month period spanning 2014 and 2015, experts estimate that at least 30.5 million people in the U.S. took benzodiazepines prescribed by a healthcare provider.

What are the most commonly prescribed benzodiazepines?

The most common benzodiazepines approved in the United States include (but aren’t limited to):

• Alprazolam (Xanax®): Approved for treating anxiety disorders, panic disorder and premenstrual dysphoric disorder.
• Chlordiazepoxide (Librium®; brand name is no longer available in the U.S.): Approved for treating alcohol withdrawal and anxiety-related conditions.
• Clobazam (Onfi®, Sympazan®): Approved for treating seizures and certain forms of epilepsy.
• Clonazepam (Klonopin®): Approved to treat agitation, anxiety and seizures.
• Clorazepate (Tranxene®): Approved for treating anxiety and seizures.
• Diazepam (Diastat®, Valium®, Valtoco®): Approved to treat alcohol withdrawal, seizures and muscle spasms. Also approved for use as pre-anesthesia for surgery and procedures. These can also treat toxic effects on the heart from chloroquine and hydroxychloroquine.
• Estazolam (ProSom®; brand name is no longer available in the U.S.): Approved to treat insomnia.
• Flurazepam (Dalmane®; brand name is no longer available in the U.S.): Approved to treat insomnia.
• Lorazepam (Ativan®, Loreev®): Approved for treating seizures, chemotherapy-related nausea and vomiting, anxiety, pre-anesthesia for surgery and procedures, and phobias.
• Midazolam (Nayzilam®, Seizalam®, Versed®; brand name Versed is no longer available in the U.S.): Approved to treat seizures, sedate people on a ventilator, and as pre-anesthesia for surgery and procedures.
• Oxazepam (Serax®; brand name is no longer available in the U.S.): Approved as a treatment for alcohol withdrawal syndrome, anxiety and agitation.
• Quazepam (Doral®): Approved to treat insomnia and sleep problems.
• Remimazolam (Byfavo®): Approved for pre-anesthesia before surgeries and procedures.
• Temazepam (Restoril®): Approved for treating insomnia.
• Triazolam (Halcion®): Approved for treating insomnia.

Unapproved benzodiazepines

Many benzodiazepines aren’t approved for use in the United States. Some of these have approval in other countries, and some don’t have approval anywhere.

One benzodiazepine that’s noteworthy — even though it’s not approved (and illegal) in the United States — is flunitrazepam. This drug is best known as Rohypnol (or by the slang term “roofies”), and it’s infamous for its use as a “date rape” drug. As a result, flunitrazepam is a well-studied drug in the U.S. (and in many places worldwide). Healthcare providers can test for it and treat people under its influence (see below under “What are the disadvantages, side effects and complications that are possible with benzodiazepines?”).

What are the advantages of benzodiazepines?

Benzodiazepines have several advantages:

• They have an established history.Benzodiazepines have been in widespread use since the 1960s. Decades of use mean these drugs are well-studied and well-understood.
• They’re much safer than their predecessors. Before benzodiazepines, doctors primarily prescribed barbiturates for treating anxiety. But these drugs came with significant risks of side effects and complications. Polish-American scientist Leo Sternbach accidentally discovered the first benzodiazepine, chlordiazepoxide, while trying to find an alternative to barbiturates.
• They treat many conditions. Benzodiazepines are useful for treating many conditions, some of which are likely to happen simultaneously. An example is the common combination of pre-surgery anxiety and the need for pre-anesthesia sedation, both of which are treatable with benzodiazepines like diazepam or midazolam.
• There’s one antidote for all of them. Benzodiazepines do have a risk of overdose. However, a drug called flumazenil is an antidote that rapidly reverses the effects of all benzodiazepines.

What are the disadvantages, side effects and complications that are possible with benzodiazepines?

Benzodiazepines are useful and effective, but some risks come along with them, including:

• There’s a potential for misuse. Benzodiazepine misuse is widespread. Experts estimate that 5 million or more people in the U.S. misused benzodiazepines in a 12-month period spanning 2014 to 2015.
• They can be habit-forming. Benzodiazepine use disorder is a possible complication from long-term use or misuse of these medications.
• There’s a risk of overdose. Misusing benzodiazepines can be dangerous because it can lead to an overdose, which can stop your breathing.
• They can interact dangerously with alcohol and certain drugs.Benzodiazepines can interact with drugs like opioid pain medications (such as oxycodone or hydrocodone) or with alcohol. Interactions like these can intensify the effects of the drugs and/or alcohol, which may have deadly results.
• They’re controlled. These medications are typically monitored and legally restricted depending on the laws where you are. While legal restrictions are there to prevent misuse, they also can make it harder for people who use these drugs for medical reasons to fill their prescriptions.
• They have the potential for use in sexual assault.The best-known example of this is flunitrazepam, also known as Rohypnol. This drug prevents the formation of new memories and causes sedation, both of which are reasons why perpetrators of sexual assault use it. However, perpetrators of these crimes also use other benzodiazepines like clonazepam and diazepam. Research shows perpetrators may also use nonbenzodiazepines like zolpidem for similar reasons.
• They can affect your ability to drive or do certain tasks. Benzodiazepines don’t affect your alertness, but they do slow down nerve signals. Slowed nerve signals can slow your reflexes, making it difficult or impossible to drive or do certain tasks safely. Your healthcare provider can guide you on whether or not it's safe to drive if you take a benzodiazepine medication.

What are the reasons I should not take benzodiazepines?

There are many reasons you shouldn’t take benzodiazepines. These include:

• Possible interaction. If you take medications like opioid painkillers, you should ask your doctor about possible interactions between those medications and benzodiazepines. While providers typically use caution with these drugs, you can also protect yourself. Talking to your provider to make sure you understand the possible risks can help you avoid problems in cases where a provider doesn’t know all the medications you take. Some potential examples include an emergency department visit while traveling, or if your provider mistakenly prescribes a benzodiazepine while you’re taking opioid painkillers, or vice versa.
• If you’re pregnant or may become pregnant. Benzodiazepines may disrupt the development of a fetus in ways that are dangerous to the fetus or the pregnant individual. Providers may still recommend them in situations with limited options. Still, you should generally avoid these drugs during pregnancy or if you’re trying to become pregnant.
• Other medical conditions or circumstances that benzodiazepines could affect. Benzodiazepines can intensify issues from other medical conditions. People with balance or movement issues may be more prone to falls if they take benzodiazepines.

What can I not eat or drink if I’m taking benzodiazepines?

You shouldn’t drink alcohol if you’re taking benzodiazepines. Alcohol can interact with these drugs, causing dangerous side effects or complications. There may be other circumstances where you shouldn’t take benzodiazepines with certain foods or beverages. Your healthcare provider can answer questions about whether to change what you eat or drink while taking these medications.

How long can I stay on benzodiazepines?

Because benzodiazepines have a higher risk for misuse and can be habit-forming, healthcare providers tend to prescribe them cautiously. They may prescribe them only for use as needed, not daily, and they may prescribe lower doses or pick benzodiazepines that aren’t as strong. Your healthcare provider can explain their recommendations for your treatment, including the timeline for which treatments you receive and why.

Can I work or drive if I’m taking benzodiazepines?

Your healthcare provider will likely recommend that you don’t work or drive right after you start taking benzodiazepines. You may be able to work or drive after you start taking them, depending on how these drugs affect you, the dose you take, how long the drugs last and other factors.

Before you drive, go back to work, use heavy tools and machinery, or participate in other potentially dangerous activities, talk to your healthcare provider. They can guide you on what you can do to take your medications as prescribed and stay safe at the same time.

When should I see my healthcare provider?

Your healthcare provider will schedule follow-up visits after prescribing benzodiazepines. It’s important to go to these visits as recommended. In some areas, providers can’t prescribe these medications without first seeing you for a follow-up visit. Your healthcare provider can tell you more about the laws surrounding prescribing these medications and the recommended schedule for you to return for a follow-up visit.

Can I become addicted to benzodiazepines?

Yes, benzodiazepines can be habit-forming. Taking these medications exactly as prescribed makes that unlikely, but it’s still possible. Your healthcare provider can tell you more about what you can do to avoid dependence on these drugs or developing benzodiazepine use disorder.

Can I have withdrawal from benzodiazepines?

Yes, withdrawal is a possible complication of misusing benzodiazepines. Unfortunately, it’s also possible with long-term use of these drugs even when you take them as prescribed. If you have concerns about dependence and withdrawal from benzodiazepines, your healthcare provider can help you plan the timeline for your treatment. They can also recommend switching you to longer-acting benzodiazepines, which are less likely to cause withdrawal symptoms.

What is the most commonly prescribed benzodiazepine?

According to a study from 2016, the most prescribed benzodiazepines are:

• Lorazepam (51%).
• Clonazepam (20%).
• Diazepam (14%).
• Alprazolam (14%).

Together, these four drugs make up 99% of benzodiazepine prescriptions.

What can I do to avoid dangerous events related to benzodiazepines?

IMPORTANT: Because of the risk of misuse, overdose or other dangerous events related to benzodiazepines, it’s essential that you take steps to protect yourself and others. The most important things you can do include:

• Take these medications exactly as prescribed. This is the best way to reduce your risk of side effects and complications.
• Keep these medications securely locked away in your home, and closely monitor access to them. The most common way for people to access benzodiazepines for misuse is to take these drugs from medicine cabinets or other unsecured locations in the homes of family, friends and other loved ones.
• Talk to your provider if you have concerns about dependency.Healthcare providers know that dependency is a possible complication of taking benzodiazepines. Your provider’s job is to care for your health and well-being, not judge you. If you have concerns about dependency, talk to your healthcare provider. They can help you by recommending a treatment timeline, reducing your dosage, or switching you to a medication with a lower potential for dependency.

Protecting yourself from unintended exposure to benzodiazepines

Benzodiazepines can pose a threat without you ever knowing it. Taking precautions is one of the best ways to protect yourself from unknowingly taking these drugs.

A “spiked” drink, meaning one with a drug added to it without your knowledge, is a threat to anyone, regardless of sex or gender. It’s also important to remember that you may not be able to taste a difference in a spiked drink.

The following precautions can help anyone avoid unintentionally consuming a drugged drink:

• Guard your drink. If you’re in public, such as at a bar, large social gathering or party, don’t leave your drink unattended for even a second. If you’re talking to someone, cover your drink with your hand or with an item like a bar coaster. It only takes a fraction of a second to spike a drink, so the best way to avoid a spiked drink is to pour it yourself or watch the drink from when it’s poured until it’s in your hand.
• Don’t accept a drink from anyone. In many cases involving date rape drugs, the perpetrator wasn’t a stranger. The assaulted person may have even considered the perpetrator a friend.
• Don’t use shared containers. Pouring a drink from a punchbowl, pitcher or a similar container is a potential hazard.
• Don’t take chances. If there’s even the slightest possibility that someone spiked your drink, don’t drink it. If you think you drank from a spiked drink, get help right away. If you’re with someone and you think they drank from a spiked drink, get help for them immediately.

A note from Cleveland Clinic

Benzodiazepines are among the most commonly prescribed medications. They’re an important means of treating many conditions, ranging from mental health disorders to brain-related diseases. While these medications can treat many conditions and help millions, they’re not without risks. If your healthcare provider prescribes one of these medications, don’t hesitate to ask for guidance, and take the medications exactly as prescribed. That way, you can benefit from these medications and reduce the risk of problems along the way.