Bridging the Benzo Divide: Iatrogenic Dependence and/or Addiction?

By Richard Lewis

As the benzodiazepine crisis spreads throughout the United States and other parts of the world so does the debate within the benzo victim/survivor community about important definitions of key medical terms and about safe and successful paths to healing and recovery. Does “iatrogenic benzo dependence” and “addiction” represent completely separate medical and social phenomena? If they are to have distinctly different scientific definitions, can they also (at the same time) intersect in multiple ways in people’s actual real life experience? And what is the medical and social significance of exploring these concepts and seeking unity of understanding and purpose? Before delving into the content of this debate let’s briefly review the social context from which this “Benzo Divide” has emerged.

With almost 100 million benzodiazepine prescriptions written per year in the U.S., combined with the fact that there is a total absence of proper regulations and safety standards for this category of drug, high levels of suffering have been caused by a disabling form of iatrogenic dependence affecting an untold number of unsuspecting victims. Victims whose only “mistake” was trusting in the recommendations of Big Pharma, Psychiatry, and medical doctors who erroneously believe that tranquilizing pills are the quickest and best solution for patients seeking better ways to cope with life’s stressors. Most often neither the doctor nor the unsuspecting patient in these situations has the remotest idea what long term misery lies ahead for those following this all too common medical advice.

The number of benzo victims, which is likely in the millions, most certainly involves a large segment of people (perhaps, even the majority) who have no life experience or connection to anything involving substance abuse or addiction. When patients in this group are viewed as if they are common “drug addicts,” cultural prejudices combined with bad medicine adds “insult to injury” by often dictating more harmful forms of treatment.

At the same time we also know that there are a significant number of people damaged by the proliferation of benzo prescriptions whose behavior patterns have involved some prior (or current) misuse or abuse of various mind altering substances. We know that for this segment of the population iatrogenic benzo dependence will frequently compound and accelerate their addiction and, in some cases, even be a causative factor in the etiology of their addiction. Additionally, with newer studies indicating that at least 30% of all fatal opiate overdoses in this country involve benzos being present in the drug cocktail, this scary statistic only adds to our current knowledge of the amount of overall harm being done and the often deadly nature of the growing benzodiazepine crisis.

It is both mind-boggling and infuriating to contemplate the fact that most of these 100 million prescriptions for benzodiazepines are being handed out for long-term use, when knowledgeable medical experts have given major warnings for many years that benzos should only be prescribed for 2-4 weeks, including the time required for a safe taper. Irrespective of any one person’s prior history (involving addiction or not), prolonged use of this category of drug on a regular basis will lead to a state of iatrogenic (that is, medically-induced and harmful) dependence. This all too common form of medical malpractice can result in a myriad of negative physical and psychological effects that can be disabling for months, years, and even decades, especially if a person fails to receive a proper diagnosis and a safely designed protocol of medical care. This much needed type of medical care often requires special forms of micro-tapering regimens that few people in organized medicine understand or know how to implement for their patients. In addition to issues of dependency, addiction, and involvement in drug overdoses, benzos also have documented connections to Alzheimers’ disease, dementia, greater number of fractures and falls, and higher overall mortality rates. Outside of a hospital setting, this makes benzodiazepines one of the most dangerous categories of drugs on the planet.

In many ways “citizen scientists” using their own painful life experience as a guide (along with a powerful survival incentive) are writing of their experiences on many nonprofessional internet websites such as Benzo Buddies.org, Beyond Meds.com, Benzo Beware on Facebook,Benzo Support.org, and Benzo.org.UK. As a result they have provided important emotional support for people affected, as well as helped develop some of the more cutting edge approaches to finding more successful tapering and withdrawal protocols. It is here in the trenches of these internet forums where very important discussions and sometimes contentious debates take place regarding the road forward for all the victims of dangerous benzodiazepine prescribing patterns.

We cannot understand the true nature of todays’ benzodiazepine crisis without examining key events that go back several decades in the historical development of modern Psychiatry. Space and time limitations preclude my going deeply into this history. It is accurate to say that it was collusion at the highest levels between the leaders of the pharmaceutical industry and the American Psychiatric Association in 1980 that led to the development of the DSM lll (the diagnostic Bible of “psychiatric disorders”) and the classifications for a particular set of anxiety and sleep disorders. This ongoing collusion between these two powerful institutions culminated with an arguably fraudulent campaign that created favorable conditions for FDA approval of Xanax (and other benzos) as a so-called, “safe  treatment,” for panic attacks and insomnia. The rest is (today’s) history, as the expression goes.

Readers are urged to read Dr. Peter Breggin’s book, Toxic Psychiatry (1991) and Robert Whitaker and Lisa Cosgrove’s Psychiatry Under the Influence (2015) for a comprehensive history of these events. In addition, it is helpful to explore the more recent history of how the explosion of prescribed benzodiazepines has paralleled the development of a similar epidemic of opiate pain drug prescriptions, and how this has impacted the rising death rate of prescription drug and heroin overdoses. Readers are also urged to review a prior blog written by this author titled, “Benzodiazepines: Psychiatry’s Weakest Link,” that further explores in a deeper way the social and political implications of these developments.

Given the dangerous levels of benzodiazepine drugs circulating within our society and the fact that they affect such a large and diverse sector of our population, how has it come to be that definitions of the terms “iatrogenic dependence” and “addiction” can carry so much meaning and at the same time be so contentious? And why is unity of understanding and purpose on this issue so important to achieve as we attempt to build a movement trying to end the harm done by the benzo crisis?

Activism in Support of Recognizing the “Ashton Syndrome”

Over the past several years there has been a growing and increasingly more vocal segment of the benzo victim/survivor community who are leading the charge in educating and challenging their community as well as the entire medical establishment, about the fundamental difference between “iatrogenic benzo dependence” and “addiction.” They have made a strong case for why these definitions can be critically important, and why they could actually make the difference between failure and success for some patient’s recovery from benzo dependence. In fact, in November of 2015 a very scientific and scholarly presentation of these differences was authored by J. Doe and published online at the Mad in America blog in a two part series titled “Don’t Harm Them Twice.”  For anyone seriously interested in this topic, either due to their own personal experience with these drugs or because they are devoted caregivers and/or activists for people negatively affected by them, this new document is a must read.

J. Doe, along with others with similar ideas, are following in the path of benzo crusader Dr. Heather Ashton who worked for many years (1982-1994) in England in a clinic that championed the cause of hundreds of victims of benzodiazepine dependence. It was out of this work that she developed the highly respected Ashton Manual, which designed a new path breaking tapering protocol that provides one important option for people trying to safely withdraw from this category of drug. As someone who has been a longtime critic of the Disease-based medical model, and involved in addiction support work for over twenty years, J. Doe’s new document was both illuminating and challenging. This work is definitely a “game changer” and will forever change the way myself and others use the language related to issues of drug dependency and addiction.

Everyone owes a great debt to the important contributions that J. Doe and others have made in carrying forward the torch of pioneers like Dr. Heather Ashton. Today, J. Doe and others are calling for the recognition of a newly identified medical condition related to iatrogenic benzodiazepine dependence, called “The Ashton Syndrome.” Their long term goal is  “…to educate medical providers about the complexities of iatrogenic benzodiazepine dependence and how it differs from addiction, abuse, or substance abuse disorders (SUD) so that it is treated as a legitimate medical problem as opposed to a behavioral issue.” We all must learn from, respect, and support J. Doe and other’s efforts to change both the language and the harmful treatment “That Harms Them Twice,” as well as, support their advocacy for recognition of the Ashton Syndrome.

Exploring the Interconnection Between Iatrogenic Dependence and Addiction

While we must overall give high praise to the work done by J. Doe and others, there is an unfortunate secondary countercurrent to their arguments that weakens their scholarship and threatens to possibly widen an already existing divide within the benzo victim/survivor community. While there needs to be a black and white distinction made between the scientific definitions of “iatrogenic benzo dependence and “addiction,” there is a lot of grey area between these concepts when examining the real life experiences of all those people being harmed by benzodiazepine drugs. J. Doe’s theoretical shortcomings tend to downplay, or even deny, the reality that there are many people who have BOTH iatrogenic benzo dependence AND addiction issues present in their current or past life experience. In their advocacy for establishing distinctly different definitions for these two phenomena, they have chosen to promote both a theory and practice that encourages distancing themselves from anything addiction related. This includes distancing themselves from those people in the benzo victim/survivor community who also suffer from addiction related problems in their life. If J. Doe and others fail to reconsider this approach it could place unnecessary limits on the potential to build broad support among activists for their advocacy work, as well as interfere with future efforts to build unity among all those damaged by benzos.

Ironically, Dr. Heather Ashton (after whom J. Doe and others have patterned their advocacy work) clearly acknowledged in her writings the common intersection of “iatrogenic benzo dependence” and “addiction” in the lives of a number of her patients. In Dr. Ashton’s dedicated work she embraced the addiction community while questioning some aspects of the Disease-based 12-Step approach to recovery. Some related quotes by her on this topic are as follows: “A large portion (30-90 percent) of polydrug abusers world-wide also use benzodiazepines.”  (Ashton Manual, 2002) and “Initially prescribed benzodiazepines, if not carefully supervised, can lead to escalation of dosage and entry into illicit drug scene in vulnerable individuals.” (Drugs and Dependence, 2002).  And finally, what follows is a quote from some important questions and answers on the Ashton-inspired website Benzo.org.UK – FAQ File #38, that speaks directly to these very issues being discussed and debated today:

“It is important to note that a sizeable percentage of benzodiazepine dependents do exhibit patterns of abuse. The clearest signs are taking doses far in excess of what your doctor has prescribed, and/or having a history of abusing other drugs in the past or simultaneously with your benzodiazepine.”

In an effort to pursue these questions in a deeper way I am proposing one possible way to break down the different segments of people who are harmed by iatrogenic benzodiazepine dependence:

  1. People who have had no history or connection to substance abuse or addiction
  2. People who have had a prior history of substance abuse and are in a current state of abstinence
  3. People currently abusing or misusing other mind altering or addictive substances, including opiates
  4. People whose iatrogenic dependence on benzos was a contributing factor to them evolving into to abuse patterns with other substances such as alcohol, or a relapse back into addiction with a past “drug of choice,” and lastly
  5. People whose prescriptive use of benzos evolved into some type of abusive or addictive pattern with benzos, singularly, or with other categories of drugs.

As one can see from this breakdown, all those people included in groupings 2) thru 5) may have elements of both “iatrogenic benzo dependence” AND “addiction” in their life experience. This makes it obvious that there is NOT an impenetrable wall between these two concepts, nor could there be in a world where more and more people are polysubstance users and quite often, polysubstance abusers where the reality of “addiction” comes into play. Due to their powerful synergistic effects with other substances, benzos are an extremely popular option for many poly-drug users and many people acquire them through legal prescriptions. When looking at all opiate drug users (prescribed or not) at least 60% also use benzos, either daily or on a regular basis. Unfortunately it is very common for people receiving synthetic opiates, such as methadone and suboxone, to also have concurrent prescriptions for benzodiazepines.

While I have not attempted to actually define “addiction” in this context, let’s just say that leaving aside the common characteristics of physical dependence and tolerance, most people who identify as “addicts” will highlight all the “mind games” connected to the description of their addictive behaviors. They will often describe in great detail the duality of feeling like they are of “two minds”; one that wants to stop the use of a substance due to an excessive amount of negative consequences, and the other that wants to keep the substance in their life despite all the identified problems. Here we are talking about behaviors and thoughts that go well beyond simply following a doctor’s prescribing recommendations. Benzos are just one of several categories of drugs where people end up engaged in a serious form of cognitive dissonance about their choice to use certain mind altering substances given all the risks and benefits associated with their use.

This reality leads us to conclude that there are TWO main reasons why people include the use of addiction language to describe their relationship with benzodiazepine drugs. One reason would be the influence of certain cultural prejudices and the related long history of medical confusion and ignorance about terms such as “physical dependence” and “addiction.” J. Doe and others have correctly focused on this problem and brought greater clarity and understanding attempting to overcome these medical disparities and set forth a new scientific standard.

The OTHER important reason for people using addiction language to describe their connection to benzodiazepine drugs is the fact that these drugs CAN BE, AND ARE, in some people’s real world experience, ADDICTIVE. This is why people on internet benzo forums feel compelled to discuss issues of addiction and recovery connected to benzos, even when they might sometimes misuse certain word terminology out of the confusion referred to above. For those people who ONLY want to focus on the issue of iatrogenic benzo dependence, this truth about benzos’ connection to addiction may be uncomfortable and inconvenient. However, it is critically important to acknowledge this truth and accommodate and support this other sector of the community harmed by benzos and attempt to find ways to build unity of understanding and purpose while engaging in principled dialogue.

Yes, we know that it can be terribly invalidating to label and treat a person as a “drug addict” that is only physically dependent on benzos and taking these drugs exactly as prescribed by a doctor. And yes, this frequently leads doctors to force rapid tapering protocols on vulnerable patients with no addiction history. However, it can be equally as invalidating to deny that “iatrogenic benzo dependence” intersects in multiple ways within the lives of many people struggling with “addiction;” people who will ALSO SUFFER when yanked off of their benzos or forced into similar rapid tapers when a doctor becomes aware of their addiction history. Is there not aspects of adding “insult to injury” to promote a view that people with addiction problems should be subjected to “distancing” or somehow be separated off from other benzo victim/survivors because they may have made past unhealthy choices in their lives?

To further illustrate specific examples of some disappointing secondary arguments presented by J. Doe in “Don’t Harm Us Twice, Part 2, we need to critically examine the following quotes:

J. Doe stated: “People taking benzodiazepines as directed by their providers do not identify with being addicts.”

Counterpoint: This statement ignores the fact that some people who suffer from iatrogenic benzo dependence ALSO identify with being “addicts” because of current or past problems with addiction. These people may have taken their benzodiazepines exactly as prescribed by a doctor, but also have a history (or current pattern) of addiction with other substances. They may have, at times, also used benzos as a separate (or additional) drug in addictive or abusive ways.

J. Doe stated: “How do we stop using the word “addiction” in relation to cases of iatrogenic benzodiazepine dependence?

Counterpoint: We do not have to stop using the word “addiction” in every situation, nor should we.

Yes, we need to identify those people who only have iatrogenic benzo dependence and NOT call them (or treat them) as “addicts” for all the reasons J. Doe has posited. However, the word “addiction” DOES apply to many people who also suffer from iatrogenic benzo dependence and they must be understood and supported as well. In fact, their particular medical cases are often far more complicated because of their addiction history, and they are much more likely to suffer from too rapid tapering protocols (or a total cut off) once a doctor becomes aware that some type of addiction has been involved in their lives with either benzos or some other drug. For these patients this will also cause great harm by worsening withdrawal syndromes and creating conditions for possible dangerous patterns of addiction relapse. While there are many services offered in our society for people with addiction problems, due to the dominance of Disease-based theory and practice that guides most treatment in detoxes and rehab centers, these programs are sorely lacking in quality, and their success rate mirrors these shortcomings.

In order to stop any group of patients from being incorrectly labeled an “addict” due to physical dependency on benzos, we need to challenge the hegemony of the Disease-based theories of addiction and the related dominance of 12-Step Philosophy that controls (90%) of all addiction treatment in this country and pervades the outlook of the medical establishment. We need to sharply pose the following question to those people caught up in Disease-based thinking: Name another “disease” in which a “decision” can lead to the end of all the related “symptoms.” We cannot “decide” to end cancer or diabetes, but we can decide to end an addictive behavior, even if these decisions are, by nature, very difficult and complex.

We need to respect the fact that 12-Step Programs DO work for some people, though for nowhere near as many as touted (see discussion at The Fix, regarding Dr. Lance Dodes’ new book, The Sober Truth (2014)). However, at the same it may be necessary to criticize 12-Step Program zealots (or doctors) who repeat ad nauseam “a drug is a drug is a drug…” and promote the view that everyone, addiction history or not, may be “a single drink or drug away from an addiction or relapse,” or that physical dependence equals addiction.

People who participate in 12-Step Programs are not an impervious monolith. There are widely divergent views within these recovery groups, and this includes some people who openly criticize aspects of the Disease Concept of Addiction and the more rigid “single blueprint” approaches to recovery. For these more open minded AA/NA attendees, their lives more closely embody the philosophy in the oft repeated cliché that makes perfect sense in these situations, “take what you need and leave the rest.” The growth over the past few decades of important alternatives to 12-Step Programs such as Rational Recovery, Women for Sobriety, and Smart Recovery etc. reveals a very unsettling reality facing people with addiction problems in our society; that is, the current Medical Model has no viable or highly successful solutions for their life’s dilemma.

Yes, it is understandable that some people in the benzo community might want to subjectively distance themselves from 12-Step Program rigidity and dogmatism that often promotes ignorance and attempts to paint everyone into an addiction box. The worst of the commonly repeated clichés such as “shut up and get stupid” or “your best thinking got you here” or “Addiction is the disease and AA/NA is the medicine; if you don’t take your medicine you are destine to relapse” are indeed difficult to hear repeated over and over again. This is especially true if you have no addiction issues present in your life.

Not all people with addiction problems are hopelessly under the sway of these forms of rigid 12-Step thinking. We must somehow resist any tendency to deny reality or invalidate other people’s addiction experience with benzos in order to justify a subjective need for distance from that which makes us uncomfortable. To bring clarity and scholarship to all the scientific issues related to “iatrogenic dependence” and “addiction” we (out of necessity) must dissect and deconstruct the Medical Model and the Disease-based thinking that permeates the entire addiction and “mental health” industry. When we do this in a comprehensive and challenging way we can raise principled struggle with those people negatively influenced by the Medical Model while still EMBRACING ALL people harmed by iatrogenic benzo dependence, INCLUDING those with addiction problems. 

J. Doe stated: “My argument has always been that anyone speaking out about benzo dependence and withdrawal carries a responsibility to honor and appropriately represent the people affected.”

Counterpoint: Yes, yes, yes, I would hope that everyone would follow the “High Road” implied by this statement. This must include understanding and honoring the experiences of people who suffer from iatrogenic benzo dependence AND have additional issues of addictive type behaviors and/or thoughts interwoven within the fabric of their lives.

J. Doe stated: “Just as it is intolerable to turn rape victims into the accused, it is also wrong to treat iatrogenic benzo sufferers as if they deserve their suffering by using terminology that implies that they brought it on themselves.”

Counterpoint: While I believe J. Doe and the others advocating for their position have no intentions to demean or stigmatize the addiction community (and they have even stated this desire), this was a poor choice of analogy in multiple ways, and it unfortunately ends up contradicting their good intentions.

Nobody in the benzo victim/survivor community (including those with addiction issues) “deserves their suffering.” nor does the statement “brought it on themselves” accurately describe people’s common path to addiction. Nobody really chooses to become an “addict.” Addiction is usually a process that creeps up on a person slowly until one day they realize the drug (or behavior) “controls them more than they control it.” Now they may find themselves stuck in a pattern of self-destructive or self-defeating behaviors that “cause more harm than good.” Perhaps, formerly successful coping mechanisms have now evolve into a pattern of behavior that has become so habitual that it is very difficult to stop despite the awareness that the negative consequences outweigh the benefits. Once a person becomes more aware of this reality, “recovery” then becomes an optional “choice” in their life, and may soon evolve into an actual “event.”

“Bridging the Benzo Divide,” and the Road Forward

On one level, when considering all the cultural prejudices against people with addictions, it is understandable how some strictly benzo dependent people might arrive at some of their conclusions about the need for distance from all things addiction related. This is especially true when these prejudices influence the actions of doctors who often treat them with disdain or force all too rapid tapering protocols on them. However, given the powerful forces in society who benefit from using psychiatric labels and also from the sale of massive amounts of psychiatric drugs, it is highly unlikely that a more narrow strategy of “going it alone” will be listened to or achieve the desired goals for those duly harmed. This is aside from the fact that this path can have the unfortunate effect of marginalizing or, perhaps even, invalidating the life experiences of another sector of the benzo victim/survivor community who face additional addiction problems.

Seeking another path towards “Bridging the Benzo Divide” has the potential of uniting all sectors of the people and their families harmed by benzodiazepine drugs. We must face the reality that we live in a very powerful and entrenched profit based system that has given rise to the current Medical Model. This model includes Biological Psychiatry’s Disease-based dominance and control over an omnipotent “mental health” system and almost all forms of addiction “treatment.” It is in this context that the current benzo crisis has arisen and caused so much damage. When looking at class, race, or gender divisions within our society, this profit based system and the powerful institutions that control it, have a thousand and one ways of creating divisions among the oppressed and exploiting those differences. When looking at the benzo victim/survivor community we must find ways to avoid allowing ANY unnecessary divisions or separations to take place among the ranks of those harmed by these drugs.

Given that the benzodiazepine crisis emerged from within Big Pharma, Psychiatry, and organized medicine, it is important that many doctors step forward and acknowledge the enormity of this problem and become active in being part of the solution. There is a desperate need for doctors who have the compassion and courage to take the necessary risks involved with helping patients deal with protracted withdrawal and the tapering complexities connected with benzos. This includes being willing to work with those patients whose cases are more complicated by having additional addiction related issues in their life.

Taking on all aspects of the benzodiazepine crisis, from its broadest and most inclusive perspective, will have the greatest potential to advance the cause of this very important human rights struggle. An overall strategic approach that recognizes the commonalities of life experience and attempts to “unite all who can be united” has a far better chance of achieving our goals related to obtaining safer medical care and ultimately ending all the ways benzodiazepines harm people, in this country and around the world.

* * * * *

(more related articles below the references)

References:

American Academy of Pain Medicine press release March 6, 2014, Stanford University researchers (Ming-Chi Kao) warn: Prescriptions for Benzodiazepines Rising and Risky When Combined with Opioid

Ashton, Dr. Heather; Ashton Manual (Benzodiazepines: How They Work And How To Withdraw, 2002) and Drugs and Dependence (2002), available at Benzo.org.UK

Benzo.org.UK; Benzodiazepine Dependence and Withdrawal; Frequently Asked Questions (FAQ file #38)

Breggin, Dr. Peter; Toxic Psychiatry: Why therapy, empathy, and love must replace drugs, electroshock, and biochemical theories of the “new psychiatry”, 1991

Dodes, Dr. Lance; The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, 2014

Doe, J; Don’t Harm Them Twice: When Language Surrounding Benzodiazepines Adds Insult to Injury, Part 1; and Don’t Harm Them Twice: What Can Be Done, Part 2, Mad in America blog, 2015

Fiore, Kristina; Killing Pain: Xanax Tops the Charts; MedPage Today; Feb. 25, 2014.

Hickey PhD, Philip; Benzodiazepines: Miracle Drugs; at Behaviorism and Mental Health.com

Jann, M; Kennedy, WK; Lopez, G; Benzodiazepines: a major component in unintentional prescription drug overdoses with opioid analgesics; J Pharm Pract.; Feb. 27, 2014.

Jones, Jermaine D.; Mogali, Shanthi; and Cormier; Sandra D.; Polydrug abuse: a review of opioid and benzodiazepine combination use; Drug Alcohol Depend.; 2012, Sept. 1; 125(1-2); 8-16.

Jones et al; Pharmaceutical Overdose Deaths, United States, 2010; Journal of the American Medical Association (JAMA)2013; 309:657-9.

Ornstein, Charles; Jones, Ryann Grochowski; One Nation Under Sedation: Medicare Paid for 40 Million Tranquilizer Prescriptions in 2013; Propublica.org; June 10, 2015

Skepticalscapel blogspot.com, Pain is Not the 5th Vital Sign; Aug 29, 2014

Whitaker, Robert; Cosgrove, Lisa; Psychiatry Under the Influence: Institutional Corruption, Social Injury, and Prescriptions for Reform; 2015

Addiction, Biological Psychiatry and the Disease Model: Richard D. Lewis, MEd, has worked with addictions for the past 19 years in New Bedford, MA. Richard discusses the relationship of addictions to severe psychological distress often labeled as a “disease” and/or a so-called “mental illness”.

More related from Beyond Meds (where the term addiction is often used as nomenclature for social commentary and not specifically about any drug user whether legal or illegal. The argument is that our culture is one of over-consumption and addiction in general, thereby affecting everyone regardless of whether one ingests any specific drugs at all. It’s a wider commentary that focuses on inclusion. That doesn’t mean that differences aren’t also a legitimate window some of the time it’s simply not what is being considered for the scope of this work):

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