Benzodiazepines and Alternatives

No doubt, benzodiazepines (BZD) have their place in psychiatric care, but are they justified for sleep and anxiety? More than 30 million people use benzodiazepines annually for different reasons and one in twenty filled a prescription in the last year. Interestingly enough, Benzodiazepine misuse without a prescription is the most common type of misuse, and a friend or relative is the most common source according to a recent review. (R) And yes, I see this in my practice as well. You can remember benzos with the "Pam" ending; Diazepam, Clonazepam, and Lorazepam etc. There's many, and all are similar in targeting the GABA receptor subunits, but slightly different with half-lives and potency. Basically, BZDs interact with GABA-A receptors, and increase the inflow of chloride ions, which then increase membrane polarization and inhibit neuron firing resulting in central nervous system (CNS) depression. In other words, it's almost like the neurons become sleepy and take a nap, or go into a deep relaxation state. As a result, this medication class results in anxiolytic, sedative, hypnotic, anticonvulsant and skeletal muscle-relaxing effects.

Benzodiazepine Use:

Benzos are most commonly used for anxiety and sleep and considered a schedule 4 medication. This means to say, they are highly controlled substances and come with dependence, withdrawal and side effects. (R) Some would say that after using this class of medication once, a level of addiction develops. The pathway gets primed and patients have cravings, and more cravings, just like alcohol or illicit drugs.

Benzodiazepine Side Effects:

Benzos come with their share of side effects including toxicity. The largest absolute growth was in benzodiazepine-related poisonings while benzodiazepine-related overdose mortality grew nearly fivefold from 1996 to 2013. Common side effects may include sedation, falls, brain fog, confusion, and bone fractures (with long term use). Misuse is common among youth with more than 10% reporting this and Alprazolam being the most common benzodiazepine misused.

Alternatives to Benzodiazepines:

As mentioned earlier, benzodiazepines have an end target of the GABA receptor and cause drowsiness while decreasing anxiety. Fortunately, we have alternatives. Many dietary supplements and herbs have a similar target and positively influence GABA metabolism as well. Some herbs I commonly suggest include Passion Flower, Valerian, L theanine, Chamomile, Lavender and KAVA. Glycine is also another inhibitory neurotransmitter used for sleep, and works in a similar fashion to other GABA-based herbs. If using medication, one alternative may be Buspirone, a 5-HT1a agonist. In a comparison study, Buspar showed comparative efficacy to benzodiazepines without the side effects. (R) So, we have options here.

Anxiety:

In regard to anxiety, I find many patients that have underlying biochemical imbalances. Some have low blood sugar, which can lead to counter-regulatory hormone release of cortisol and other stress hormones. Others may have Candida, biotoxin illness that is driving their anxiety, progesterone or testosterone deficiency, and thought patterns that resemble perfectionism. Or, just maybe, gastrointestinal dysbiosis is driving their anxiety where nourishing and loving the gut with dietary improvements is all that's needed. It's usually multifactorial and seeking the root cause may be a better avenue then taking a Benzo. Hope this helps.