A Near-Fatal Prescription Drug Underdose

It has now been seven days since I found myself fighting for my life in an emergency room. The events leading up to that critical moment where my life began rapidly slipping away have been progressing for over twelve years. The catalyst: a single panic attack resulting in a visit to an unscrupulous doctor resulting in the prescription of, and subsequently, a dangerous dependence to, a hypnotic tranquilizer in the benzodiazepine group, specifically, clonazepam.

The Beginning

I have suffered from panic disorder since the age of fifteen (in 1996). When my panic attacks began appearing in my life, I had no idea that such a thing had a name, or that it was an experience both shared and feared by many. This most likely reinforced my anxiety, for what I feared was the continuing waves of immense terror, disorientation, heart palpitations and, among other symptoms, a state of consciousness for which I had no foundation to understand. I shamefully dealt with what I could only assume was another defect of my psyche, existing alongside insomnia, social anxiety, agoraphobia, etc., and it would be another three years before I came across the term "panic attack".

In the years that followed my initial attack, I had developed various coping mechanisms such as avoiding certain triggers that I had begun to identify, and practicing steady, deep breathing during an episode. However, in 2003, I suffered a panic attack that left me emotionally paralyzed with insurmountable, overwhelming fear. This incident was followed by a steep increase in the frequency and intensity of attacks, with each episode reinforced by the previous, compounding the already debilitating symptoms. As my ability to sleep, maintain focus and even perform fundamental routine tasks had been disrupted, the severe nature of these attacks subverted my established psychological tools for regaining any sort of calamity. My psychological and physical well-being were declining at an alarming rate, and, moreover, I was running out of the strength needed to fight this battle on my own.

Having previously researched panic disorder to some extent, I was aware that pharmaceutical remedies existed to stave off and even prevent attacks altogether. While I was extremely weary of psychiatric drugs in general, given my past negative experiences with SSRI (Selective Serotonin Re-uptake Inhibitor) medications prescribed for depression, I was in a state of desperation and willing to do anything necessary to cease the perpetual cycle in which I was convinced I was trapped. I proceeded to seek the advice of a particular psychiatrist at the recommendation of a family member. While in the care of this professional I was introduced to what would become my single, most regrettable mistake: becoming dependent on benzodiazepines. The panic disorder I suffered from was soon to undergo a metamorphosis into an actual disability due to the pharmacological mechanisms by which benzodiazepines achieve their observed efficacy.

It was clear to me that my intentions were in favor of the improvement of my well-being, I also believed, rather naively, that my doctor's intentions were the same. I was intent on returning to what I considered my normal, functional self, I was soon left careening down the spiraling throes of an even greater threat: addiction to Clonazepam (brand name Klonopin in the U.S., and Rivotril in the U.K.). On my very first visit, I was prescribed 2mg of Clonazepam per day for 30 days. Looking back on that initial dosage now, I can easily see how criminal and irresponsible that prescription was for the management of panic disorder. It was this very first prescription that would be the planted seed for what would become the unraveling of any and all structure in my life.

That very first dose worked. My anxiety had substantially subsided, and my mental faculties had yet to suffer any ill-effects (as is common with any hypnotic, tranquilizer or sedative.) In fact, with the volume on the anxiety and panic turned down, I could do my work and function immensely better. It was absolutely perfect. I slept beautifully, and nothing could worry nor frighten me. I felt as though I was given a chance to live as myself again, without the fear and the crippling, painful anxiety that once consumed me.

Two weeks had yet to pass since I took my first dose, and within that time the symptoms I have since come to know all too well had begun to creep up on me. What I soon learned was that I was experiencing what is known as "tolerance withdrawal", which, in the case of benzodiazapines, occurs when the patient becomes "tolerant" to the dose they are taking, and as such, the efficacy of the drug subsides and the brain enters a state of withdrawal due to dependence (in this case, the symptoms began roughly 7 days after the beginning of my treatment.)

The withdrawal symptoms are often initially rather elusive, making it difficult to differentiate between normal fluctuations in mood, comfort, etc., and what is the direct result of a dependency not being fulfilled. Beginning with generalized anxiety, depression, joint pain, lethargy, difficulty maintaining focus, disruption of memory recall, an inability to fully "wake up", and a general sense of impending doom, the intensity of the symptoms continue to grow in waves. It wasn't until I put the introduction of the drug into my life and symptoms together that I was prompted to research the causes of my increasing suffering. What I soon discovered paralyzed me with yet another fear. It was only going to get worse.

Background

Klonopin - Roche employs cute marketing strategies right into the pill itself.

Benzodiazepines are one of three commonly prescribed (and/or abused) substances that can have fatal consequences due to rapid or immediate cessation from their intake in a dependent individual. The other two, barbiturates and ethanol, have very similar mechanisms that can, during rapid or immediate detoxification, trigger a fatal seizure (generally, these are "grand mal" seizures preempted by lack of endogenous GABA_A neuroreceptor activity due to the regular intake of exogenous substances that mock the behavior of the central nervous system's receptor regulation).

In essence, when one introduces a chemical that regularly binds to a neuroreceptor previously managed by endogenous receptors, the endogenous receptors, in this case, simply cease to be effective on their own. Removing the chemical too rapidly becomes a mortal danger as the time it takes for the CNS to return to it's normal receptor activity takes significantly longer than it does to experience a fatal seizure from the lack of the foreign substance. One has effectively trained the CNS to rely on the behavior of the external chemical to regulate CNS activity, and ceases the efficacy of, in this case, GABA_A receptors, leaving the dependent user's fate up to their conscience decision and ability to maintain intake of the exogenous drug.

In a society where dependent users are treated like fiendish addicts and criminals, this is quite a dangerous predicament to find oneself in, as the ability to seek continued treatment begins to wane due to mass paranoia and misinformation (fear) regarding drug abuse, even when it involves a technically legitimate and common prescription.

Living With Dependency

Even tolerance withdrawal can become an overwhelming weakness to the strongest, most resilient individuals. The extreme torment one must endure, even if given just a glimpse into what this pharmaceutical has actually done to their well-being, can bring about such a shock as to undermine any sense of confidence and perseverance.

Having witnessed firsthand the breaking point at which I personally determine that it is significantly easier to experience life subservient to the regular intake of this drug than to suffer the consequences involved in escaping it, it is painfully clear how easily one can begin this mode of thought, and choosing instead to perpetuate this vicious cycle. Continuance of the drug intake is infinitely easier than the dreaded alternative that is the excruciating withdrawal period. However, from experience and insight combined with the observation of others in my life in regards to behavioral anomalies (e.g., erratic, self-defeating decisions, noncommittal attitudes about important life matters, an almost complete indifference and lack of response to what should be deeply emotional situations, etc.,) it seems that the continuing presence of the drug is what has truly brought about the series of self-defeating decisions and consequences thereof. When confronted with concern about the erratic and nonsensical decisions being made, it is all-to-easy to become defensive, as there is no indication in the mind of the user that an emotional stimuli is not present to indicate a lack of good judgement. Without a clear source for the changes seen in the individuals life, the causes of any failure or sense of disenfranchisement is quite often displaced in relatively destructive ways.

Now, we have an exponentially more complex set of problems at hand. Not only can the lack of emotional response alienate one by unintentionally offending those around him or her, but the severe disconnect between cause and effect, the plunging of one's self into dangerous situations (as the normal hesitancy brought on not only by an emotional trigger, but also by a general sense of responsibility and ownership of one's actions are severely suppressed) all too often leads one to commit acts of self-destruction, and self-destruction has the inevitable effect of harming, on varying levels, those the individual is close to. Without any conscious decision, awareness of the consequences of one's actions, or the empathy needed to maintain existing relationships and/or develop new bonds, the benzodiazepine addict unknowingly pulls oneself into a vacuum, barricading one's self into self-constructed shell devoid of purpose and meaning. Meanwhile, the user's brain is continuing to adjust, to increasingly develop tolerance to the presence of the current dose of benzodiazepine, filling the surrounding void with a insufferable agony. It is at this point that the user might begin to show signs of "drug-seeking" behavior, and this compounds the complexity of the issues already manifesting and spiraling out of control from simply maintaining the prescribed dosage of the benzodiazepine.

Tolerance withdrawal never fully goes away during the course of any treatment with benzodiazepines. It merely increases the longer one has been regularly taking the substance. This can seem to be a subtle nuisance at first, until one realizes the actions they begin taking as a result of a desperate need to feel, to think, to be human. There is a continued suffering involved, and as this is such a protracted process, it is most often attributed to other sources such as depression, returning anxiety, chronic pain, etc., when in fact, it is the continuing, lingering increase in tolerance and the symptoms that continually appear. It is at these many junctures that one might fall into other addictions. The easiest is alcoholism. Alcohol (ethanol) is easily accessible and it relieves the "benzo addict" of their symptoms, acting upon the same parts of the brain's nervous system regulation. While opiates may relieve some or most of the pain experienced in withdrawal of any kind, they do very little to calm (or serve as a depressant to) the CNS excitation resulting from a lack of GABA_A receptor agonist activity, leaving the dependent user anxious and turning to higher quantities and increasingly more dangerous mixtures simply to return to some sort of "normality". The level of suffering, in any of these cases, is never fully diminished.

One may have no idea that this is why they take the actions they do, but they know one thing for sure: certain drugs and drug combinations help with the symptoms, regardless of any knowledgeable association between the continuing tolerance withdrawal of benzodiazepines and the extreme, debilitating withdrawal symptoms they've come to endure. Addiction to any "remedy" of these symptoms actually seems very logical. Especially knowing the dangers and horrors of benzo withdrawal, one knows he or she can successfully function more effectively with the introduction of other substances. These substances could be opiates, alcohol, amphetamines, etc., essentially, anything that changes the state of one's mind in a seemingly positive and revitalizing manner.

A recurring theme in the benzo addict's self is the lack of identifiable emotions. The introduction of various, unrelated substances gives rise to experience, and consequently, emotions, to some extent. This is a substantially easier path from the perspective of the benzo user than suffering through the torments of withdrawal. It is a possible path that, if managed even somewhat responsibly, is far safer than rapid succession of the benzodiazapine originally prescribed.

Withdrawal

Sometimes green. Sometimes blue. This 1mg tablet might someday kill you.

For many reasons, I do not wish anyone who has never experienced withdrawal from such a substance as a benzodiazepine tranquilizer to ever truly understand the vast and endless torture that one is forced to endure when attempting to quit this substance. On the other hand, I believe that it is of vital importance that it be known to prospective and current patients, healthcare professionals, friends, and of course family members of those struggling with a dependence of this nature, that the mortal danger one is in when suffering from benzo withdrawal is shockingly real. The limitations of medical terminology to describe what one is truly experiencing must also be noted. A doctor will prefer to use the word "discomfort" to describe the experience of cessation from a benzodiazepine addiction. To the addict, this "discomfort" is nothing short of an immense, hellish and seemingly endless torture. There are very valid reasons to be afraid when coming off of benzodiazepines, with very real and possibly permanent consequences (including, but not limited to: memory damage, dementia, paralysis, etc.).

To compare and contrast, one distinct difference between withdrawal from opiate and opiate-like substances and benzodiazepines is this: in opiate withdrawal, the individual may feel as though his or her life is ending (and suffers minor to severe and unbearable pain, depression, and a sense of impending doom that may conjure up feelings of extreme regret in some), when in fact, as this is a result of low-levels of endorphin being produced, they are actually healing, and healing rather quickly. In benzo withdrawal, similar, often much more intense feelings of these types persist, and for the one withdrawing, his or her life is actually in critical danger, unless some kind of benzo or an analog thereof is introduced into the system immediately. Withdrawal from an opiate and synthetic opioids will not be fatal. It might involve a level of suffering one has never before known and wishes never to experience again, but it will get better. Withdrawal from a benzodiazapine, a barbiturate, or even alcohol, will not end easily nor well in most cases. The symptoms rapidly increase and can last months to years. Organs may fail. Hallucinations (visual, auditory, tactile, olfactory, etc.) ensue, pushing the limits of one's sanity. Blood pressure, heart-rate and body temperature increase. Insomnia gives way to disjointed, scattered and psychotic thoughts exacerbated by intense fear. Reality has long since been replaced by the waking nightmare that consumes one's entire being, and regardless of his or her acknowledgment and understanding of this journey through hell, the experience only becomes worse.

This is a state of mind and physical crisis that is rather difficult for me to describe. I had recently been without my medication for so long that the symptoms I experienced were far more intense and varied than any I have ever before witnessed. I cannot be sure that I am simply too afraid to fully remember the pain and suffering I experienced, or that I was so badly damaged and critically ill that I could not form any sort of identifiable definition of what was happening. What I remember is the pain, the rapid changes in body temperature, the overwhelming fear, the sound of blood pumping through my veins, the hallucinations that became increasingly more difficult to stave off, the pacing, the never-ending muscle spasms, the horrifying visions, the jumping out of my skin, the rapid breathing, the complete disassociation of my personality, the "acceptance" of my own mortality, the strive to live, and the resulting default survival mode I found myself in. One of the more interesting, albeit horrifying, effects that is commonly observed is the recall of distant memories. These memories are so vivid, so removed from any present day state of being that it feels one is regressing to a former self. In my case, I regressed throughout my entire life, reduced to infantile states of minds and as such I was helpless. All I knew at that point was that either I went to the emergency room or waited for that dreaded, fatal seizure to take me out of this world.

One milligram of Ativan (Lorazepam) administered intravenously at the ER and about thirty minutes later, I can form thoughts again. I stopped shaking. The withdrawal was still in full-force, but the volume was turned down - the mortal danger was out of the way. I was still alive. Upon my discharge I was prescribed, ironically, Librium. It is ironic to me simply because it was the first benzodiazepine to be synthesized, it's therapeutic effects a mere accident, and here I lay in a hospital bed, taking the original substance that began the mass-marketing (and mass-addiction) of benzodiazepines.

Present Day

The day after I was admitted to the hospital was nothing short of strange. It began with hours of adjustment to the new medication, a rather painful adjustment at that, to finally feeling, for the first time in days, like myself. In fact, it ultimately felt very good. My coordination returned. My thoughts normalized. I could function. My greatest fear of all was apparent: It was not death, but rather, the thought of being completely, utterly helpless in this corporeal form. I was indeed in that state just the day before. The horror of the previous day's experiences lingered on, but I was far enough passed it that it was brilliant to simply feel good. The days to come will be met with similar (yet hopefully much less intense and dangerous) obstacles, as my continued cessation of benzodiazepines brings about more difficulties. To me, it is worth the suffering now.

Seven days later, I'm still popping these horrible little pills. Klonopin, Xanax, Librium, Valium, Ativan, anything benzo, just to stay alive. I know I will be taking these cursed things for some time to come. My one success story, within the context of this desperate mess, is the fact that I had been maintained at 4mg clonazepam for nearly a decade, and just this year have successfully halved my dose to my original 2mg (relative to 100mg Librium daily). Switching to a benzo with a longer half-life helps the weaning process as it gives the CNS more time to restore endogenous GABA_A receptor activity. Benzodiazepines do indeed cause brain damage. Memory loss, blackouts, sleeping and eating disorders, various addictions, breakdown of self and the loss of the ability to socialize, etc., all are a result of simply taking this medication on any kind of regular basis. Removing this medication too rapidly, or even immediately (in many of my cases), brings about a level of suffering no individual should ever be expected to endure.

What I Have Learned

Aside from realizing that when presented with the reality of death, even in my darkest hour, my weakest state, that I held on and wanted to live, I learned something that absolutely everyone who is dependent on benzodiazepines needs to know, and that is this: If you are in fact dependent on this type of medication, and you are faced with rapid withdrawal, you are in danger! It might not be apparent at first, but there is a steep drop-off after the initial "feeling weird" stage that might render you unable to make the right decision to save your life. Death from fatal seizure as a result of benzo dependence is not a dignified death. You will experience new depths of suffering never thought possible, and being floored with the onset of terror, you will be immersed in a battle to maintain your sanity. It isn't worth it to suffer through this. Do whatever you can to get yourself in front of any healthcare professional should you find yourself in this situation. Make it their problem, their responsibility, to treat you. It is their job as emergency care workers to see that you do not die in their care. Getting past the fears of the emergency room, the expenses, and the possibility of rejection for proper treatment were among the hardest obstacles to overcome for me to seek the help I needed. It simply isn't worth the risk.

Resources

1. http://www.benzo.org.uk/
2. http://benzowithdrawalhelp.com/letter-to-all-doctors/
3. http://en.wikipedia.org/wiki/Benzodiazepine
4. http://en.wikipedia.org/wiki/Benzodiazepine_withdrawal_syndrome
5. http://en.wikipedia.org/wiki/Benzodiazepine_dependence
6. http://en.wikipedia.org/wiki/Post-acute-withdrawal_syndrome

Support Forums

1. http://www.benzobuddies.org/
2. http://benzowithdrawal.org/

"I've met people who've been addicted to benzodiazepines for 20 or 30 years - wrecked their lives, wrecked their jobs, wrecked their families. It's a silent addiction. We all know about illegal drugs, we all know about alcohol, we don't know about this group... I think there has been some denial of the problem and I think that when you're talking about drugs that are legally, albeit unwisely, prescribed causing a problem - you know it's never really fitted anywhere, nobody wanted to grab hold of it - certainly not in denial now. We are going to get a grip of this and it needs to be dealt with on a number of different fronts, there's no doubt about that... I'm taking this very seriously. It's an issue that's fallen through the cracks. We want to make sure that training and awareness is raised so that GPs know how to prescribe well and then we need to make sure that we've got the right services in place to give them the help and support they need to get off these drugs and get back and enjoy lives as they should be able to."

- Anne Milton MP, Public Health Minister

Addendum

I am certainly not a doctor, nor am I a psycho-pharmacologist. However, I believe that twelve years of experience with this particular group of medications has given me the experience and insight necessary to stand behind my critiques with the utmost confidence. I urge anyone currently taking, or considering taking, medicines in the benzodiazepine group to do as much research as possible. Knowledge of any substance that you consume is empowering (and can be critical to your well-being), and I believe that research into any and all medications that a licensed physician has prescribed you is the best action you can take to ensure that what you are taking and how you are taking it remains in your best interest (which I will assume is wellness). Simply because a doctor issues a prescription does not guarantee that it will be effective or safe. This isn't to say that every doctor who has prescribed a benzodiazepine, anti-depressant, or a plethora of other psychiatric medications is doing so maliciously. Rather, he or she may be acting with the best of intentions, following standard prescribing procedures once a prognosis or diagnosis has been made.

The unfortunate truth is that it can take a great deal of time, and years of clinical studies for the dangers of certain types of medications to become known. Once these dangers are known, it can take a substantial amount of time before the medical community uniformly recognizes this. In the case of habit-forming drugs, the reaction by medical professionals is all too often that of damage-control. It seems apparent why an entire class of prescription drugs cannot simply be recalled. The long-term maintenance of dependence-forming psychiatric medicines requires that the appropriate options remain on the market.

The more you can learn about the nature of these various substances, and any insight you can gather about how your own body reacts during regular usage and cessation will only increase your chances of success in both treating the original condition, and managing withdrawal from it once its purpose has been fulfilled. Human beings are complex entities, our brain chemistry and psychology a wondrous and seemingly endless realm of discovery. There is no single solution for the problems we face as complex beings. There is no single cure for anxiety or panic that will save present and future generations from the horrible grip of panic, anxiety and other disorders that have been misdiagnosed or involved the over-prescribing of dangerous medications. The best chance we have is to educate ourselves, know what options we have and hold accountable medical practitioners for the actions they advise us to take. We, as human beings, are entitled to make the ultimate decision when it comes to our health and well-being.