Manufacturing Addiction: The Over-Prescription of Tranquilizers and Sleeping Pills to Women in Canada

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by Janet C. Currie with the British Columbia Centre of Excellence for Women’s Health

The addictive nature of tranquilizers, also known as benzodiazepines, and their profound effects on the brain and body have been known for over 40 years, yet these drugs are among the most widely prescribed in Canada and the world today. The over-prescription of benzodiazepines to women in Canada was first identified as a critical health care issue in the 1970s. Yet in the year 2000 alone, there were more than 15.7 million prescriptions for benzodiazepines filled by Canadian retail pharmacies -- an increase of 12.8% from 1996.

Physicians prescribe benzodiazepines and sleeping pills to help women cope with work or family stress, pre-menstrual syndrome, grief, and adjustment to life events, such as childbirth and menopause, or for chronic illness and pain. Non-drug treatments for these circumstances and conditions continue to be under-promoted and under-used.

Benzodiazepines impair cognitive functioning, memory and balance and because they are often prescribed to women for longer than the recommended time period (a maximum of two to four weeks), women are also at particular risk of involuntary addiction. The majority of those who take the drugs for more than one or two months will become dependent. Fifty to 100% will experience difficulties withdrawing and recovering. Short-term use also puts women at risk of a variety of other health problems. Sleeping pills, while not technically benzodiazepines, act by the same mechanisms and have the same serious effects.

What are Benzodiazepines?
The first benzodiazepines (commonly known as tranquilizers) were marketed in 1960. They were initially described as a safe, non-habit-forming substitute for barbiturates which, after many years of being prescribed, were found to be dangerously addictive. Only one year after benzodiazepines appeared on the market, the first report in the medical literature describing their addictive nature was published.

Benzodiazepines are central nervous system depressants that act in complex ways on the neurotransmitter GABA (gamma-aminobutyric acid), which transmits messages from one brain cell to another. Directly or indirectly, benzodiazepines influence almost every brain function and ultimately most biological systems, including the central nervous, neuromuscular, endocrine and gastrointestinal systems.

About 16 benzodiazepines are available in Canada today. Among the most common are Ativan (lorazepam), Serax (oxazepam), Rivotril and Klonopin (clonazepam), Xanax (alprazolam) and Valium (diazepam). Sleeping pills (hypnotics) such as Ambien (zolpidem) and Imovane (zopiclone) are not technically benzodiazepines, but they act by the same mechanisms and have the same effects on the brain and body.

All benzodiazepines and sleeping pills are similar chemically but differ in potency (equivalent doses may vary as much as twenty-fold), and the speed at which they are metabolized (processed by the body). These differences affect symptoms and are important considerations when understanding addiction and developing appropriate plans for tapering off the drugs.

Benzodiazepines have five short-term medical uses: anxiety relief, sleeping aid, muscle relaxant, anti-seizure and pre-operative (amnesiac) uses. They are sometimes inappropriately prescribed for depression, but they are themselves central nervous system depressants.

Accidental Addiction: Women at Risk
There is a consensus that benzodiazepines should not be prescribed on a regular basis (or intermittent regular basis) for more than two weeks of use, but longer-term prescribing, particularly to women, is common.

In the 1970s Dr. Ruth Cooperstock and her colleagues reported that Canadian women are prescribed benzodiazepines at twice the rate of Canadian men. Recent data suggest that women are also more likely to be prescribed benzodiazepines for longer periods of time.

When women go to their doctor with comparable symptoms as men, they are more likely to be prescribed benzodiazepines. Women are also more likely than men to be prescribed benzodiazepines and sleeping pills for non-medical reasons such as coping with grief or stress. They are also prescribed these drugs when adjusting to natural processes such as childbirth and menopause.

Because of the multiple roles carried by many women in Canada and the “double workday” of paid labour and domestic work that many perform, the work stress of women in the 20 to 44 age group is much higher than that of men. Other conditions such as poverty, which affect women disproportionately as compared to men, also make women particularly vulnerable to anxiety, depression and sleep problems for which they may be prescribed benzodiazepines or sleeping pills.

Benzodiazepines and sleeping pills also impair and compromise a wide range of basic skills that are necessary for coping with the intellectual and psychological demands of everyday living. They impair memory and reasoning, produce forgetfulness and disrupt the process of memory retrieval, affect flexibility of thoughts and motor control, eye/hand coordination, mental reaction, information processing and focus. Balance control is affected by benzodiazepine use leading to an increased risk of falls and hip and femur fractures, especially among the elderly. Benzodiazepines are also a common cause of confusion and dementia in seniors.

Long-term (more than several months) benzodiazepine use can cause or aggravate depression, memory impairment, emotional blunting and suicidal tendencies. When prescribed for trauma they may delay shock and grief, which surface only after the individual stops taking them. Agoraphobia (fear of public or open spaces) and other phobias are common side-effects from longer-term benzodiazepine use. Benzodiazepines sometimes cause paradoxical excitement, anxiety, hallucinations and rage. Cases of wife assault, baby battering and homicide have also been attributed to these drugs.

The vast majority of those who take benzodiazepines on a regular (or intermittent regular) basis will become addicted, probably within a few months, although the exact time is highly individual and impossible to predict. Tolerance to the sleep effects of benzodiazepines and sleeping pills may occur within seven days. Symptoms of tolerance are identical to drug withdrawal symptoms, but occur while a woman is taking the drug and include numerous physical and psychological symptoms such as increased anxiety/panic, severe insomnia, muscle pain and stiffness, digestive problems, heart and lung problems, depression, headaches, thoughts of suicide, rage and agoraphobia.

Drug-related tolerance withdrawal symptoms are frequently not identified by physicians or patients, leading to an exploration of other causes for the symptoms. A lack of understanding of the symptoms of tolerance withdrawal often results in the addition of other prescription drugs (for example, antidepressants or anti-psychotics), with increased side effects, leading to further involvement of women in the health or mental health systems.

What Can Be Done?

Tighter Government Restrictions
Despite the effects of benzodiazepines and sleeping pills on women, families and society in Canada, no comprehensive policy or intervention strategy exists to address this serious health issue. No specific Canadian guidelines exist to govern prescribing or to ensure that women are prescribed these drugs for the appropriate reasons or time period.

Health Canada must establish Clinical Practice Guidelines on the use and prescribing of benzodiazepines and sleeping pills, and provide these to physicians and other health care providers. The guidelines should limit prescriptions of benzodiazepines to no more than two weeks of use and discourage benzodiazepine and sleeping pill prescriptions at the first office visit.

Informed Health Providers
Also, health care providers and addictions specialists are often unaware of or cannot identify characteristics of physical dependency and do not know how addiction can occur or the time required for symptoms to develop. Governments need to work together to develop and distribute information on the physical characteristics and signs of benzodiazepine dependency to health care professionals, addictions treatment staff and the general public.

In comparison with other drugs, such as alcohol and heroin, the personal and societal costs associated with benzodiazepines and sleeping pills have had a limited profile among policy makers, government, health care and addiction treatment providers. Funding should be provided through governments to support those involuntarily addicted to benzodiazepines and sleeping pills, and to provide community-based clinics specializing in benzodiazepine and sleeping pill tapering, including peer support and counseling to address the unique characteristics and needs of involuntary addicts.

Informed Patients
Women must be supported to make informed choices about the use of prescription drugs. General public and drug insert information must be accessible, comprehensive, accurate and objective (not controlled by drug companies). Physicians should be obliged to fully disclose all of the potential risks of prescription drugs.

Other Options
Non-drug treatments and resources to enhance women’s ability to cope with depression, anxiety, grief, stress, natural processes and difficult life events are under-promoted and under-used. Health Canada and the provincial/territorial governments should provide funding and support to community-based organizations to explore and provide free of charge non-drug advice and options that support women’s well-being and help women cope.

By allowing the over-prescription and inappropriate use of benzodiazepines and sleeping pills to women in Canada, we are “manufacturing addiction” and contributing
both to the suffering of women and their families and to escalating
health care costs. The benefits of acting on this problem are many and clear. Action to address this problem is long overdue.

For more information, see the full study at: www.bccewh.bc.ca/policy_briefs/Benzo_Brief/benzobriefv3.pdfOr call (604) 875-2633.


If you or someone you know is possibly addicted to sleeping pills or tranquilizers, contact: 1-888-818-9172 for more information.

Common benzodiazepines (tranquilizers) available in Canada include:

  • Ativan (lorazepam)
  • Serax (oxazepam)
  • Rivotril and Klonopin (clonazepam)
  • Xanax (alprazolam)
  • Valium (diazepam)

Common sleeping pills available in Canada include:

  • Ambien (zolpidem)
  • Imovane (zopiclone)

*Aboriginal Women: One in three status Aboriginal women over 40 in Western Canada was prescribed tranquilizers or sleeping pills in 2000. Aboriginal women are almost twice as likely to receive tranquilizer prescriptions as Aboriginal men.

*Senior Women: 20-50% of all women over 60 in Canada may be prescribed tranquilizers or sleeping pills. Long-term care facilities, which have a higher proportion of female residents, also have high levels of benzodiazepine prescription rates. These drugs are a common cause of confusion, cognitive decline and dementia. Long-term tranquilizer use has also been linked to an increased risk of falls and hip and femur fractures among the elderly.

*Pregnant Women: Tranquilizers and sleeping pills have been linked to floppy infant syndrome, failure to suckle, and withdrawal symptoms in the child. It may also impair fetal growth and retard brain development, leading to learning and emotional difficulties for the child later in life.

*Poverty: According to BC’s Provincial Health Officer, Dr. Perry Kendall, benzodiazepines may be used to numb patients to the physical and mental pain of poverty and harsh reality.


Caution
Marketing of Prescription Drugs to Women

In drug company advertising, women are a heavily targeted “market”. In direct-to-consumer advertising (DTCA) of drugs on television and in magazines in the US, it has been found that women are targeted more than twice as often as men and the volume of DTCA is highest in women’s magazines.

Prescription drugs advertised directly to consumers are now the largest and fastest selling medications in the US. This has resulted in more prescription drug use among women. As these ads easily make their way across the border, women in Canada face additional pressure to view life events and natural processes as medical conditions for which medication is needed.

As direct-to-consumer ads have been shown to be a poor source of information about prescription drugs it is important that federal legislation in Canada be strengthened to protect women from DTCA.