In October 2019, 34-year-old Sundar, based in Delhi, India, had a cause for celebration. After being on the sedative drug benzodiazepine (often called “benzos”) for over three months to help with his anxiety and insomnia, the father of two was finally able to taper off the medication. Because suddenly stopping benzos can lead to seizures and delirium, Sundar diligently followed a six-week treatment plan laid out by his doctor to slowly get off his meds. He was finally able to get a good night's sleep without having to rely on benzos.
However, just six months into being benzo-free, Sundar started getting constant headaches and increased anxiety, with insomnia coming back full swing as well. This began with the lockdown due to the coronavirus pandemic, and Sundar—like many others around the world—started feeling anxious about the world at large. To him, the future seemed bleak. To keep his anxiety and insomnia in control, Sundar had to get back on his benzodiazepine medication as directed by his psychiatrist.
Benzodiazepine is a class of prescription psychoactive drugs used to treat conditions like anxiety, depression, insomnia, and seizures. They are widely prescribed, and as per the UK’s National Institute for Health and Care Excellence (NICE), taking benzos to treat short-term Generalized Anxiety Disorder is recommended for no longer than a month. The most well-known are Valium (a brand name for diazepam) and Xanax (alprazolam), the latter of which has become notorious for its popularity amongst young people.
However, long-term use of benzos is not recommended. This is due to the psychological dependence and tolerance that the drug can create. These drugs have been found to have serious consequences, including reduced inhibitions and delusions of sobriety leading to risky behaviour and compulsive redosing, addiction, and an exacerbated return of the treated symptoms after abrupt withdrawal. A study in the US National Library of Medicine states, “Because of tolerance and withdrawal symptoms, long-term use of benzodiazepines can lead to dose escalation and worsening of the underlying condition.”
Despite this, what Sundar went through is an experience shared by many since the pandemic kicked in, says clinical psychiatrist Dr Jai Mehar Singh. “There was an immediate and almost two-fold increase in new patients with recent lockdown related anxiety,” he tells VICE. “Nearly all of the patients who were tapered off, or were wanting to taper off benzodiazepines, had to be restarted with a majority going back to twice a day full dosage.”
All over the world, people are dealing with not just the economic and social fallouts of the pandemic and its resultant lockdowns but also the mental health toll it has taken. With job losses, fears over how the virus might affect people themselves or their loved ones, financial hits, and an inability to meet others or go outside, we have a looming mental health disaster made worse by a healthcare system that was inadequate to begin with.
While the uncertainties have led to anxiety among people at large, the problem is amplified for those who accessed mental health services even before the pandemic hit. “Subsyndromal anxiety and depressive symptoms are on the rise and consequently increased use of benzodiazepines is highly likely,” says Dr Shivani Aggarwal, a senior consultant psychiatrist at VIMHANS, New Delhi.
As per a report by NIMHANS on mental health in times of COVID-19, benzos also carry the risk of respiratory depression which can have adverse effects in COVID-19 patients. Whenever needed, a low dose of short-acting benzos such as lorazepam, midazolam could be used. But it’s also absolutely important that there is careful and thorough risk assessment involved when prescribing a benzo, else it may cause more harm than good.
But as the pandemic stretches on, so does the usage of benzos. “Anxiety and depression need to be adequately treated with medication like antidepressants and cognitive behaviour therapy,” says Aggarwal. “If at all benzodiazepines are prescribed they should be tapered off over a period of four to six weeks.”
However, this isn’t always the case, and sometimes people are prescribed benzodiazepines for longer durations, especially amid the pandemic. “Long-term anxiety is proven to give rise to cardiovascular diseases, like heart attack and heart related arrhythmias,” says Singh. “To prevent this life threatening eventuality, sometimes when antidepressants and low dose antipsychotics do not entirely remove anxiety, benzodiazepines are given for a longer time.”
28-year-old Suman* based in Kolkata was first prescribed benzos in 2017 to deal with her anxiety. “I wasn’t even aware that the medicine I was taking was a benzo and that it could have adverse side-effects,” she says. “So when I moved to Delhi and stopped taking it after two months of continuous medication, I started feeling extremely sick.”
The long-term effects of benzodiazepines are controversial as the side-effects can be intense. Some of the common side-effects include confusion, drowsiness, slurred speech, and can also affect one’s libido. However, the effects seem to get more intense the longer one takes the drug, and even when tapering it off. When Suman had to stop taking the drug cold turkey in 2017 on consultation with her psychiatrist, she faced withdrawal symptoms like palpitations, excessive sweating, shaky hands, difficulty sleeping, frequent nightmares, night-sweats, excessive negative thoughts and paranoia. She could hardly focus on anything. “I could no longer feel emotions as intensely as before,” she says. “I felt heavily dissociated from whatever task I was doing, like my body was going through the motions while I was watching from afar. It also led to a weight gain of around 10 kgs which made me depressed. The little things that had brought me happiness before no longer did anything for me.” When Suman reported her symptoms, she was put back on benzos by another psychiatrist who sought long-term benzo treatment. Her tapering journey was smoother this time because she researched the drug. She reduced the dose gradually and finally stopped taking the medication. “I am glad I got this done right before the pandemic though. However, I did have to go through the withdrawal during the lockdown which made it tougher than it would have been.”
Sleep medication like benzos are categorized as sedatives and hypnotics in India, and listed under the Schedule H of the Drugs and Cosmetics Act, which means they should not be sold over the counter. But a recent report by the International Narcotics Control Board in 2018 notes misuse of the over-the-counter medications with definite (like benzodiazepines, tramadol and codeine) or with possible addictive potential (like pregabalin). One of the primary ways of accessing such substances in India is reportedly through illicit internet pharmacies. For example, the report says, in February 2018, authorities in India seized 200 tablets of nitrazepam, a benzodiazepine class drug, concealed in a courier parcel originating in the United States. Since India has a history of unauthorised access to pharmaceutical drugs even before the pandemic hit, doctors we spoke to were worried that these channels are being used to get a hold of illegal benzos too. In April, 40,000 tablets of Xanax were seized in Dublin. The parcel is said to have been sent from India.
The report on drug market trends during the coronavirus crisis, published by the UN Office on Drugs and Crime (UNODC), highlights that many countries across all regions have reported a shortage of numerous drugs, in addition to a price increase among consumers on the black market and reductions in purity. A doubling of benzodiazepine prices has also been reported in some areas.
Data from the Global Drug Survey’s interim report showed what drug consumption looked like in the first few weeks of lockdown. When it came to benzos, 35.2 percent said their use had increased, with France showing the highest number of users (16.1 percent). Globally, 63.2 percent of these said that their reason for taking more was heightened anxiety.
What got me to research benzos in the first place was because I could see a loved one suffer. It’s important to be kind, supportive, and patient. It’s hard for them to maintain relationships, participate fully in ‘normal tasks’, and it will take a great deal of understanding and communication. There will be emotional highs and lows, and it’s important for one to be there for them. Yet, on other days, you will be required to give them adequate space and time. But what I’ve learned to find most important is to not take their lows personally, and to take time out for yourself and the things you like. You won’t be able to fully support them, if you’re not taking care of yourself.
It can be a long journey, and a bit of a roller coaster for all those involved. However, with time, patience, and the right kind of mental healthcare benzodiazepine use and taper can be managed effectively.