by Loremaster Dopameanie
Disclaimer
A community member contributed this article as part of our open submission policy and does not represent the official views or opinions of the Lorehounds podcast or its hosts. The Lorehounds team members are not medical professionals, and this content is provided for informational and entertainment purposes only. It should not be construed as medical advice, diagnosis, or treatment recommendations. If you have questions about benzodiazepines, mental health, or any health-related concerns, please consult a qualified healthcare provider, such as a psychiatrist or physician, for personalized guidance.
Hey Lorehounds - Let’s talk about benzodiazepines! Specifically, Xanax (alprazolam), Valium (diazepam), Klonopin (clonazepam), and Ativan (lorazepam).
Quick Answer: Xanax, Valium, Klonopin, and Ativan are different benzodiazepines with distinct characteristics:
Xanax: Fast-acting, short duration—best for acute panic attacks
Valium: Slower onset, longer duration—used for anxiety, muscle relaxation, alcohol withdrawal
Klonopin: Long-acting—helps with severe anxiety and nervous system regulation
Ativan: Medium duration—commonly used in emergency and hospital settings
Questions about benzodiazepines were raised during episode 5 of It: Welcome to Derry. Is Xanax a newer, better version of Valium? Can someone use benzodiazepines long-term without running into issues of physical dependence, tolerance, and/or addiction?
While I’m familiar enough with this class of drugs to feel confident speaking on this topic, please do NOT take any of this as medical advice, and please, never use benzodiazepines without the guidance of a psychiatrist you trust enough to be honest with AND a therapist and/or appropriate doctor/specialist.
When it comes to modern benzodiazepine use, the exact nature of what is being treated is key. I do agree with John’s point from the podcast for episode 5 of It: Welcome to Derry that overprescribing “mother’s little helper” (Valium) to women in the 60s so a wife would be too drowsy to finish that blasted copy of The Feminine Mystique her “single friend” let her borrow and just get back to scrubbing pots with a smile already, was a real problem. (I may have put my own slight spin on John’s words here).
Understanding Different Benzodiazepines
Valium is still widely used. Xanax has not replaced it as an updated version of a benzodiazepine! However, they differ in onset and duration.
Xanax (Alprazolam): Fast-Acting for Acute Anxiety
Of the oral benzodiazepines, Xanax is one of the fastest-acting and has a shorter duration. This makes it very effective for panic attacks, but also more prone to addiction and abuse. However, minority cases of abuse should not override the potentially life-saving value it offers people who suffer from panic attacks and other forms of anxiety that can have an acute presentation, such as PTSD.
Prescribing Practices and Access Issues
Even though Xanax is likely the most commonly recognized brand-name benzodiazepine, psychiatrists are actually very reticent to prescribe it because of its abuse potential. It’s unlikely a patient would be offered a prescription for Xanax (especially if they ask for it directly) unless they have established a great rapport and mutual trust with a psychiatrist over time, who knows they are also seeing a therapist. I am aware of discrimination and bias in prescribing practices around Xanax in particular. Wealthy and otherwise very privileged people can usually get it for something as trivial as discomfort with flying, and men typically have an easier time getting it than women. The stage of the provider’s career matters too. Even if you’ve been prescribed Xanax in the past, say in another city, used it with no complications, and have a true need for it, if you see a resident psychiatrist, who has to explain and justify their treatment plan to the attending doctor on staff, they will be doubtful to prescribe any benzodiazepine, because it could lead to a lecture they have to endure on screening out potential “drug-seekers.”
Rural Access and Alternative Treatments
Today, antihistamines like hydroxyzine are frequently offered to patients in place of benzodiazepines. This keeps more patients being seen at clinics by nurses who do not have a DEA license to prescribe controlled substances. This is an issue in rural places, like where I am from, where doctors (especially psychiatrists and other specialists) are few and far between; you may only have one in a fifty-mile radius and be stuck with him, no matter how he treats you. Patients in need often wind up self-medicating, usually with alcohol (which we will return to shortly). While marijuana works for some, don’t forget that in states like where I live, mere possession or cultivation for personal use can still get a person locked in a cage. Additionally, for many experiencing physiological issues that benzodiazepines can help regulate, marijuana can actually cause acute anxiety episodes, especially if there are co-morbid chronic illnesses and anxiety disorders. In the U.S., benzodiazepines are Schedule IV controlled substances; marijuana remains federally controlled (historically on Schedule I but in the process of being moved toward Schedule III), and alcohol is legal but regulated outside the Controlled Substances Act.
Valium (Diazepam): Long-Duration with Multiple Medical Uses
Valium and Klonopin have a slower onset and a longer duration, making them much better options for people who need a benzodiazepine for longer-term use, whether for anxiety or to help mitigate a different issue, chronic or acute. Valium, for example, is a go-to medication for people detoxing from alcohol, which really should be medically managed if at all possible if someone is truly physically addicted to alcohol, as this is among the most dangerous types of withdrawal and can be fatal without medical care; withdrawal from benzodiazepines and some other sedatives can also be life-threatening and should be medically supervised (yet alcohol is legal with only age restrictions here in the US).
Valium, while an older benzodiazepine, is still widely used for anxiety and has other uses people are likely not aware of. It’s a potent muscle relaxer and can be made into a compounded suppository form for women with severe pelvic floor pain, which could arise after childbirth or be caused by the constant tension one experiences if living with an untreated, painful condition like adenomyosis or endometriosis. There can be fewer systemic psychoactive effects when used this way, though some may still occur. Valium is also used in some cases to treat seizures, and Klonopin can be helpful with severe nausea (though these are both off-label ways of using the drugs and neither would be a first-line treatment for these conditions).
Klonopin (Clonazepam): Nervous System Regulation
Klonopin is recognized for helping people whose nervous systems have become severely dysregulated due to dysautonomia that can arise with some chronic illnesses, especially the invisible, forever-debilitating kind. For example, some people with dysautonomia can experience prolonged disturbances in heart rate and blood pressure that Klonopin can help regulate, sometimes along with beta blockers. These physiological disturbances cannot be prevented by or cured with yoga, meditation, therapy, or exercise, so yes, there are cases when long-term benzodiazepine use is called for. Further, it is possible to find a dose, even a high dose, that works long-term without ever needing a dose increase or an increased frequency of use.
Ativan (Lorazepam): Medium Onset and Duration
Ativan is somewhere in the middle between Xanax and Valium, regarding speed of onset and length of duration. It seems to be the most common benzodiazepine given in an ED setting if needed. It’s also commonly used in inpatient psychiatric hospitals, like Juniper Hill, if a patient has, for example, become violent and needs a combo of several fast-acting medications in intramuscular shots to quickly sedate and thus protect the patient, other patients, and staff from potential injury.
A Note About Mental Health Facilities
Finally, speaking of Juniper Hill, I’d like to close with a little PSA. Many patients in public mental health facilities do not have access to appropriately sized clothes, and they can be in such facilities for a very long time, even years, if there is nowhere else for them to get care. If you want an easy, fast way to do good that makes an immediate impact and will cost you nothing but time, consider donating the next time you clean out your closet of old clothing, still in great condition, to a public psychiatric inpatient hospital. These are usually state-run, although they may be part of a larger hospital system in your area. Though I’m sure it varies state to state, hospitals generally don’t provide patients with clothing beyond what is donated. We all deserve basic dignity, and finding a clean, comfy hoodie to slip into, or pants that actually fit rather than digging in or falling off, during one of the most traumatic times of one’s life can make a larger impact than dropping them off at a resale site or bin.
Thanks for giving me some time. This is one of my favorite podcasts ever on the channel, so thank y’all so much for your great content.
Dopameanie
