Victoria Ratliff, the wealthy financier’s wife on season 3 of HBO’s “The White Lotus,” has a problem: She keeps popping pills.
And her drug of choice, the anti-anxiety medication lorazepam, has left her a little loopy.
In the show, which follows guests vacationing at a fictional resort, Victoria pairs her medication with wine, which leads her to nod off at the dinner table. Sometimes she slurs her words.
When she notices that her pill supply is mysteriously dwindling, she asks her children if they’re stealing them.
“You don’t have enough lorazepam to get through one week at a wellness spa?” her daughter, Piper, asks.
“The White Lotus” is not the only show to recently feature these drugs. The new Max series “The Pitt,” which takes place in an emergency department, includes a story line about a benzodiazepine called Librium.
This isn’t a case of Hollywood taking dramatic liberties. Benzodiazepines such as lorazepam and chlordiazepoxide are notorious for having the potential to be highly addictive. They may also come with difficult — sometimes fatal — withdrawal symptoms.
The characters’ misuse of benzodiazepine drugs is not uncommon, said Dr. Ian C. Neel, a geriatrician at UC San Diego Health. “We definitely see that a lot in real life as well.”
And in recent years, he added, studies have shown that it’s a bigger problem than doctors initially realized.
A Widely Misused Collection of Drugs
The drugs, which are often called benzos or downers, are commonly used to treat anxiety, panic attacks and sleep disorders like restless leg syndrome. But they can also be used for other reasons, such as to help people manage alcohol withdrawal.
Other common benzodiazepines include diazepam (Valium), clonazepam (Klonopin) and alprazolam (Xanax).
Unlike antidepressants, which can take weeks to start working, most benzodiazepines can provide relief within minutes — which can comfort nervous fliers and others who need quick anxiety relief for a specific situation. But if taken for longer periods, patients can develop a tolerance within weeks of starting the drug, even when using it as prescribed, said Dr. Ludmila De Faria, chair of the American Psychiatric Association’s council on women’s mental health.
“That’s where people get into trouble,” she added, and start to take more of the medication. “The same dose will no longer get rid of the symptoms.”
In addition, drugs like clonazepam and diazepam last longer in the body than short-acting drugs such as alprazolam. “People don’t realize that,” she said. “So they take multiple doses and it accumulates,” which can result in people “walking around like they have a couple of drinks in them.”
All of these factors combined have led to the drugs being widely misused. In 2019, the most recent data available, pharmacies dispensed an estimated 92 million benzodiazepine prescriptions, according to the U.S. Food and Drug Administration. Research suggests that the drugs are prescribed most frequently to adults between the ages of 50 and 64.
Delirium, Falls and Other Risks
In 2020, the F.D.A. updated the information given to prescribers and patients for all benzodiazepines to warn about the risks of physical dependence, withdrawal reactions, misuse, abuse and addiction.
Ideally, these dangers are explained to a patient before they take their first pill. But that doesn’t always happen. And even if a patient does receive proper counseling, “it’s one thing to say it and then another thing to experience it,” Dr. Neel said.
He said he often sees patients who are already taking a cocktail of other medicines and don’t understand the dangers of combining benzodiazepines, which are depressants, with other drugs that also have sedating effects, like sleep medicine or Benadryl.
And if you’re going to drink alcohol or use cannabis, it’s best not to have any benzodiazepine in your system. When people combine substances that have a depressant effect, it can even interfere with their breathing.
The geriatric population that Dr. Neel treats is especially vulnerable because benzodiazepines are metabolized differently as we age, he added, lingering in the body for a longer period of time. As a result, older people who take them may be more prone to falls or car accidents. The drugs can also cause delirium in patients who have dementia.
But the medications can be risky for people of any age, which is why they are typically prescribed for a short period of time — usually four weeks or less — and they are considered a last resort to treat a chronic condition, Dr. Neel said.
A Delicate Withdrawal Process
A 2019 study found that nearly 20 percent of people who take benzodiazepines misuse them. If someone develops a dependence, quitting can be difficult, in part because of the intense withdrawal symptoms.
Those symptoms can include sleep disturbances, irritability, sweating, heart palpitations, elevated blood pressure and stomach problems like dry heaving.
Tapering off the drug needs to be done in a gentle way, ideally under the supervision of a doctor.
It’s “almost like landing an airplane, where there’s a gradual descent,” said Dr. John Torous, a psychiatrist at Beth Israel Deaconess Medical Center in Boston.
While this is happening, he added, the patient can try different methods to get more sleep and talk to a therapist about strategies to help manage anxiety.
In addition, there are other medications like clonidine, which can be used to treat the anxiety and also help with any withdrawal symptoms.
In the end, it’s always more effective to try to identify and address the root cause of the anxiety, Dr. Torous added. “The benzos are giving you rapid relief in the brain but then one day wear off — that rapid relief is gone.”