Harriet Williamson Wednesday 19 Sep 2018 8:12 am Last November, Christina Craig died after taking a fake Valium pill. The tablets were known as ‘Blue Plague’. She was the fourth in a group of six friends in Glasgow to lose her life to what she believed to be Valium.
Scottish police estimate that there could be millions of fake Valium pills on the streets. Why is there a thriving market for the drug? Why aren’t users getting it on prescription?
Valium, also known as Diazepam, is part of a group of drugs called benzodiazepines. It’s a sedative recommended for short-term treatment only because it can quickly become addictive.
Valium isn’t usually prescribed for longer than two to four weeks at a time, and some GPs are uncomfortable prescribing it at all. The NHS lists the side effects of benzodiazepines as including drowsiness, difficulty concentrating, vertigo, low sex drive, headaches and the development of a tremor.
After four weeks of use, benzodiazepines may start to lose their efficiency, meaning that you need a higher dose to get the same effect. The way Valium loses potency and the potential for addiction are two reasons why GPs don’t regularly prescribe the drug for long-term conditions like anxiety, as they did when it was first released. Valium was created by Leo Sternbach and released in 1963. It became one of the most frequently prescribed medications in the world, and between 1968 and 1982, it was the highest selling medication in the US. More than two billion tablets were sold in 1978 alone.
Anxiety and insomnia had previously been treated with barbiturates, which caused extreme withdrawal symptoms, were highly addictive and easy to overdose with. Benzodiazepines like Valium seemed like the safer and more effective option, and they became the prescription solution for every problem.
The drug was particularly associated with women, and in 1966, the Rolling Stones even wrote a song about it, entitled ‘Mother’s Little Helper’. It took a long time for the addictive nature and negative side-effects of benzodiazepines to be recognised, despite research in the 1980s linking the long-term use of this drug group to brain damage and calling the drug ‘more difficult to withdraw people from than heroin’.
The NHS is now supposed to prescribe benzodiazepines for a maximum of four weeks to curb the potential for addiction. However, some doctors are failing to stick to guidelines published more than 20 years ago.
There exists a large, mostly-underground, growing community consisting of those iatrogenically harmed by benzodiazepines. Guilty only of following doctors orders, these patients are marginalized and misunderstood. This has been enabled, at least in part, by poor terminology………
Physical dependence and addiction are not synonymous (see: patient education materials that accompany some benzodiazepine prescriptions). Yes, physical dependence can manifest from both abuse and compliant use. But physical dependence can stand alone. Signs of its development — tolerance, interdose withdrawal, and/or withdrawal symptoms with dose reduction — are not an accurate indicator that addiction is co-occurring. So then why are terms like “addictive,” “addicted,” and “hooked” utilized by many experts and media outlets to describe what is actually prescribed physical dependence? I believe the answer is two-fold: (1) confusion (lingering from a history of bastardized language) or a lack of education; and (2) the media’s desire for a sensational headline. The latter alienates the as-prescribed population and comes at the expense of accurate reporting.
When examined objectively, it is obvious that this terminology approach is illogical.
It also has considerable cost in the following ways:
1. By providing a false sense of security to the prescribed physically-dependent population. Drug abusers know they are at risk of harm. Patients compliantly taking benzodiazepines, long-term (>2-4 weeks), often do not. Stories encountered about “benzodiazepine addiction” are dismissed as irrelevant and fall on deaf ears. Instead of an informed warning, patients and their prescribers are left incorrectly reassured that any problems with benzodiazepines lie solely with the user’s behavior as opposed to being inherent to the drug class itself.
2. It results in misdiagnosis and dangerous mistreatment. Physically dependent patients who do accurately identify symptoms as originating from their benzodiazepine may seek out or be referred to addiction-based “treatments,” like rehab or “detox,” if they are left under the impression that they are “addicted.” At such facilities, the “law of the instrument” often manifests when all patients are universally “treated” under the “addiction model,” consisting of abrupt discontinuation of any drug deemed “addictive,” irrespective of abuse history. This practice defies all respected benzodiazepine withdrawal guidelines (calling for slow, patient-guided tapers). The result is often disastrous, increasing the risk of severe symptoms (seizures, psychosis, suicidality, akathisia, etc.) and protracted neurological insult.
Similarly, in the outpatient setting, physically dependent patients mistaken for “addicts” are sometimes “fired” or have their prescription “cut off” by misinformed prescribers. For best outcomes, patients require understanding, patience, and withdrawal guidance that facilitates slow tapering, usually over many months and years.
3. It causes displaced blame. Compliant patients are too often on the receiving end of misdirected blame when they are mistakenly believed to be “addicted” to benzodiazepines. This literally adds insult to injury. Worse, it enables the problem to persist because fault is directed away from actual causes like prescribing practices which ignore well-documented long-term risks and harms, inadequate pharmacovigilance, lack of truly informed consent, etc. Since fault is assigned solely to patients, there is no impetus for change.
To tackle this terminology hurdle effectively, clinicians, educators, the media, etc. need to present benzodiazepine issues in a way that makes clear there are four distinct problems: (A) adverse effects; (B) iatrogenic physical dependence (including tolerance and interdose withdrawal) and subsequent withdrawal reactions; (C) post-withdrawal (protracted) neurological insult; and (D) addiction/misuse.
Collectively, these encompass all potential complications but each has individual problems deserving of their own platforms. Prescribed harm advocates are attempting to spotlight the first three (A-C), those being the most common yet most unrecognized and overlooked. Doing so proves difficult, however, because there is a lack of meaningful discussion as a consequence of the language of condition D eclipsing everything. The dominant narrative is that everything falls under the addiction umbrella, regardless of whether that narrative applies. Case in point: cardiologist Dr. Christy Huff recently told her story of prescribed physical dependence to Xanax on “NBC Nightly News with Lester Holt” (the news story referenced in the above tweets). Her story is a cut-and-dry case of elements A (adverse effects appearing after only a few weeks) and B (physical dependence that developed, as could be pharmacologically expected, shortly after being prescribed Xanax for insomnia), with no trace of D. Much to the chagrin of everyone championing for accurate benzodiazepine safety information, the newscast was riddled with addiction terminology. The narrator misrepresented Dr. Huff’s story, proclaiming she was “hooked” on the longer-acting Valium she’s using to taper. Meanwhile, the following caption trailed beneath her on-screen image: “Doctors warn of addiction risk from anti-anxiety drugs.” More inaccurate information. More false security. More misplaced blame.
Unfortunately, public commentary beneath the news segment on social media consisted largely of finger-pointing at the “addicts” for “ruining it for everyone else who takes them appropriately!” Another missed opportunity to warn the public with the message that Dr. Huff set out to convey — that anyone who takes benzodiazepines, even exactly as prescribed, is at risk for potentially severe adverse outcomes (physical dependence, painful and/or lengthy withdrawal, protracted neurological insult, etc.)
A popular children’s rhyme concludes, “… words will never hurt me.” But this isn’t just a case of hurt feelings over a botched news story or labeling people addicts when they aren’t. It’s much more serious than that. In this case, misapplied words do grave harm. Many people’s lives and health hang in the balance. By taking great care with the terms we use to discuss benzodiazepines, we can alleviate unnecessary suffering, provide the information needed for consent to be truly informed, and save as many patient lives as possible.
Nicole Lamberson is a physician assistant and serves on the medical advisory board, Benzodiazepine Information Coalition.