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Welcome back to the Easing Anxiety blog series, "What We Learned from the Benzo Survey," where we dive deep into the data from the Benzodiazepine Survey of 2018/2019 to learn more about benzos, BIND, and the individuals who have taken these medications.
In our first two posts in this series, we explored age groups, gender, and country. Today, we move past the initial demographics and investigate the types and classes of medication taken. I hope you find this post both informative and enlightening.
*** Scroll to the end of this post for details about the survey and research team. ***
MEDICATION TYPE
As you can see by the data listed below, the most commonly taken medication from the survey was Klonopin/clonazepam. In fact, over half (52.9%) of the respondents had taken clonazepam at one time or another. This was followed by Xanax/alprazolam (41.7%), Ativan/lorazepam (36.1%), and Valium/diazepam (32.1%). It is important to remember that the respondents could select more than one medication, and many did.
Question (n=1,207):
Which medication did or do you take? Choose all that apply.
MEDICATION CLASSES
Another way to look at the data above is by the specific classes. The following data represents the number of respondents who reported taking any medication in these designated classes (n=1,207).
Benzodiazepines: 1,190 (98.6%)
Nonbenzodiazepines (Z-drugs): 247 (20.5%)
Anti-psychotics: 167 (13.8%)
GABA Analogues: 222 (18.4%)
Antidepressants: 558 (46.2%)
When comparing the above classes of medication, the one most commonly associated with benzodiazepine use is antidepressants. Of those who took or are still taking benzodiazepines, 46.0% also took antidepressants. This is not unexpected since SSRIs and SNRIs are often prescribed to benzodiazepine users during their taper, or as an adjunctive medication during use.
When reviewing individuals who took more than one type of medication, the most common overlap was alprazolam (Xanax) and clonazepam (Klonopin). Of the survey respondents who had taken alprazolam, 255 (20.2%) were also taking, or had taken, clonazepam. In some of these instances, clonazepam may have been prescribed as a substitution benzodiazepine during taper.
WHY IS CLONAZEPAM (KLONOPIN) USE SO HIGH?
As mentioned earlier, over half (52.9%) of the respondents reported taking Klonopin/clonazepam at some time. The numbers for Xanax/alprazolam (41.7%) and Ativan/lorazepam (36.1%) were lower, even though they are more frequently prescribed in the U.S.
Here is an excerpt from our second research paper on the survey where we address this finding:
A potentially important finding in the survey was that a disproportionate number of respondents had taken clonazepam [Klonopin]. This was surprising because clonazepam is not the most frequently prescribed benzodiazepine in the United States. In 2019, there were 2.3 million Americans taking clonazepam compared to 3.9 million taking alprazolam and 2.8 million taking lorazepam. The percentage for alprazolam prescribing according to these figures from 2019 is 70% higher than that of clonazepam, and yet clonazepam usage in this survey is 27% higher than alprazolam. — Huff 2023
This leaves us with an interesting question.
If alprazolam and lorazepam are prescribed more often, then why is clonazepam usage significantly higher in the survey than these other two? Here is a bit more from the research paper that may provide some insight:
These findings mirror claims by benzodiazepine support groups that patients who have taken clonazepam appear to have a higher incidence of enduring symptoms than those who took other benzodiazepines, although little if any research has been published on this topic. Another possible explanation is that until recently, clinicians tended to switch the most severe benzodiazepine users to long-acting clonazepam for detoxification rather than simply tapering the first drug; this is no longer considered the treatment of choice. — Huff 2023
Since the majority of individuals who participated in the survey were struggling with long-term symptoms from benzodiazepine use, the fact that clonazepam was the most widely taken medication is telling. This is the first evidence we have seen which backs up anecdotal observations from the benzo support community regarding a possible link between clonazepam use and a higher incidence of protracted symptomatology, in comparison to other benzodiazepines.
I am just one of those individuals who has made this observation. Anywhere from 50% - 75% of the individuals who reach out to me for benzodiazepine support through my podcast (The Benzo Free Podcast) have taken clonazepam, and I have heard similar reports from my fellow benzo organizers and coaches. These anecdotal observations appear to agree with the data above.
As mentioned in the above quote, there are other possible explanations for clonazepam's high numbers. Clonazepam was widely used for substitution protocols until more recently, and thus more individuals may have been prescribed this drug for their taper. Also, I took clonazepam for over 12 years and discuss it on my podcast. This fact may attract clonazepam users to my channel more than others, and equally may have attracted me to news about clonazepam more than other types during my research.
Regardless if clonazepam use does appear to be linked to a higher rate of protracted symptoms or not, all benzodiazepines can cause long-term effects and I have worked with many individuals dealing with protracted benzodiazepine withdrawal (BIND) who have had no exposure to clonazepam (Klonopin).
References
Survey papers are listed below.
About the Benzodiazepine Survey
About the Research
The largest survey of its kind, "The Benzodiazepine Survey of 2018/2019" was created and administered by Jane Macoubrie, PhD and Christy Huff, MD. Over 1,600 individuals took the survey, resulting in 1,207 qualified respondents. The survey constituted 20 questions, including demographic inquires. Some of these questions had multiple sub-questions and/or allowed multiple answers.
The survey generated three published research papers in scientific journals (as noted below) between April 25, 2022 and June 29, 2023. The research team is still together working on new benzodiazepine-related research projects.
Special thanks to the Alliance for Benzodiazepine Best Practices for sponsoring and organizing this research.
Published Papers
PAPER 1 — April 25, 2022
Finlayson AJ, Macoubrie J, Huff C, Foster DE, Martin PR. Experiences with benzodiazepine use, tapering, and discontinuation: an Internet survey. Therapeutic Advances in Psychopharmacology. 2022;12. doi:10.1177/20451253221082386. https://journals.sagepub.com/doi/full/10.1177/20451253221082386.
PAPER 2 — February 6, 2023
Huff C, Finlayson AJR, Foster DE, Martin PR. Enduring neurological sequelae of benzodiazepine use: an Internet survey. Therapeutic Advances in Psychopharmacology. 2023;13. doi:10.1177/20451253221145561. https://journals.sagepub.com/doi/10.1177/20451253221145561.
PAPER 3 — June 29, 2023
Ritvo AD, Foster DE, Huff C, Finlayson AJR, Silvernail B, Martin PR. (2023) Long-term consequences of benzodiazepine-induced neurological dysfunction: A survey. PLOS ONE 18(6): e0285584. https://doi.org/10.1371/journal.pone.0285584.
Research Team
Research Team / Authors (alphabetical)
A. J. Reid Finlayson, MD, MMHC — Vanderbilt University Medical Center
D E Foster — Benzodiazepine Action Work Group
Christy Huff, MD — Benzodiazepine Information Coalition
Peter R. Martin, MD, MSc — Vanderbilt University Medical Center
Alexis Ritvo, MD, MPH — University of Colorado Anschutz Medical Campus
Bernard Silvernail — The Alliance for Benzodiazepine Best Practices
Acknowledgements
The Alliance for Benzodiazepine Best Practices — Sponsoring Organization
Jane Macoubrie, Ph.D. — Survey originator
Jo Ann LeQuang — Medical Writer
Limitations
This study has several limitations.
The study reported on ‘suicidal thoughts’, which can range from fleeting notions of self-harm to passive desperation, preparatory planning, and disinhibition. Suicidal thoughts may be underreported, even in an anonymous online survey, as respondents might hesitate or be embarrassed to report self-destructive thoughts.
There was no control group. Much of the survey dealt with symptoms presented in multiple-choice lists, and it is possible that patients may have been suggestible to the list presented, may not have correctly remembered past symptoms, or may incorrectly attribute certain symptoms or feelings to benzodiazepines.
We did not account for a nocebo effect.
The large number of write-in comments suggests that many respondents felt the survey did not allow them to fully describe the extent of their experiences and emotions.
Another limitation of our survey is that it recruited respondents from social media and online sources that deal with benzodiazepine use and withdrawal. Respondents were self-selected, forming a convenience sample that may not represent the population of benzodiazepine users as a whole because visitors may have sought sites such as these specifically because they have experienced problems. Moreover, those who use the Internet for health information tend to be younger, and those who join online support groups for medical conditions tend to be in generally worse health. Our results thus may not be generalizable to the population of all people taking benzodiazepines.
Data Analysis
A medical statistician produced the initial results of this survey utilizing SAS Software. Subsequent data analysis was performed in greater detail by an experienced data scientist who imported the survey data into a custom SQL Server data model.
Customized queries were employed to obtain correlations among the data. In particular, this analysis examined conditions for which benzodiazepines were prescribed and compared them to symptoms and adverse life effects reported by patients who were tapering or had discontinued benzodiazepine use.
All analyses were delivered via a structured reporting process and validated against the original SAS reports. The survey was made available online through websites and internet benzodiazepine support groups and general health and wellness groups.
The data scientist mentioned above is D E Foster, who is also the author of this blog series and the founder of Easing Anxiety. D has been a member of the Benzodiazepine Survey Research Team since 2019, providing general benzodiazepine knowledge and lived-experience in addition to formal data analysis and reporting. Prior to his withdrawal from benzodiazepines, D worked as a database developer and data scientist for over 25 years.
For Informational Purposes Only
All information presented on Easing Anxiety is for informational purposes only, and should never be considered medical or health advice. Withdrawal, tapering, or any change in dosage of benzodiazepines or any other prescription drugs should only be done under the direct supervision of a licensed physician.
This article was written by a living, breathing, human person.
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