Georges Marcoux’s sleepless nights began with an ominous red phone. It was the 1980s, and after a decade living in Ottawa and Quebec City he had moved back to his home province of New Brunswick, to start a new job in a management position with the federal government. On his first day, he walked into his office to find a black phone on his desk and a red phone on the wall. “I asked my assistant, ‘What was that red phone for?’ And she said, ‘Well, this is [for] when the big boss calls,’” he tells me nearly forty years later.

The phone followed Marcoux into his dreams, taunting him with crimson foreboding. “Every night, I was thinking about that red phone and when that red phone was going to ring and why he [would be] calling me,” Marcoux recalls. He couldn’t sleep. After six months of fitful nights, his doctor put him on 30 milligrams of Oxazepam, a short-acting benzodiazepine used to treat anxiety and sleep issues.

Seven or eight months into the job, Marcoux finally ripped the red phone off the wall and threw it in the trash. “But what I didn’t do was throw my pills in the garbage,” he reflects. Marcoux continued taking the pills for decades. Nobody, not his doctor, pharmacist or himself, paused to ask if he still needed them. “For thirty-five years of my life, I needed those—what I call ‘candies’—without knowing what [they were] doing to my brain,” says the now-seventy-nine-year-old. 

Benzodiazepines, commonly known as benzos, are drugs prescribed for sleep disorders, anxiety and depression, as well as seizures and alcohol withdrawal. Their brand names—Valium, Xanax, Ativan—are part of a lexicon associated with the overworked and overmedicated; little pills procured from clutch purses and popped like candy, as Marcoux refers to them. In more recreational circles they’re referred to as downers, where they’re abused for their relaxing, anxiety-diminishing effects. Once they’re taken, typically either orally or absorbed under the tongue, benzos send signals to the brain prompting it to release a neurotransmitter called gamma-aminobutyric acid, which in turn inhibits nerve transmission within the central nervous system. You loosen up and slow down—but you can also become forgetful and disoriented. Alongside barbiturates and benzo-like sleeping pills known as Z-drugs, benzos are part of a class of drugs called sedative-hypnotics, because they do just that: sedate you.

Benzos have been around for over sixty years, and for the past few decades the healthcare industry has had a “love-hate relationship” with the pills, according to a 2013 paper published in the Consultant Pharmacist journal. The first benzo, Librium, was introduced to the market in 1960, at a time when the dependency and toxicity risks of the older barbiturates were coming to light. In 1963, Valium was born, eventually becoming one of the most notorious benzos due to its omnipresence. By the 1970s, Valium and its siblings were some of the most popular drugs in the world, often topping lists of the most frequently prescribed medications. They worked fast—and they were assumed to be safe. But by the 1980s attitudes had begun to shift, as “a Pandora’s box of potential risks” revealed itself, according to the Oxford University Press book The Benzodiazepines Crisis.

One of the risks with benzos is dependence. If you’re taking the drug regularly, your body gets used to it, resulting in tolerance, which can lead to increasing dosages. Once you’re dependent, you’re at risk of withdrawal if you suddenly stop taking your pills. Withdrawal symptoms vary from person to person, but can range from a slight headache to, in rare cases, seizures. The longer you’re on benzos, and the higher your dosage is, the harder it is to get off them—and the only way to safely do so is to wean yourself off by slowly decreasing your dosage over time, a process called deprescribing or tapering. Deprescribing can take many months, and should be done under the guidance of a health professional. 

For seniors like Marcoux, long-term benzo usage raises the risk of memory problems such as dementia and falls due to dizziness. As we age, we produce less of the sleep-inducing hormone melatonin, increasing the risk of insomnia. Lifestyle changes from retirement and illness also increase the chance of disturbed sleep. In Canada, adults aged sixty-five or older have the highest rates of sedative usage, at 13 percent. While benzo usage rates are dropping nationally, they remain overprescribed among seniors. In Ontario, for example, a 2018 study found prevalent benzo usage in just over 13 percent of older adults. In Quebec, 9.5 percent of seniors who are prescribed benzodiazepine receptor agonists (BZRAs)—which refer to both benzos and drugs that are benzo-like—meet the criteria for substance dependency, according to a 2010 study in the Canadian Journal on Aging. 

Because of the risks, benzos are typically not meant to be used long-term—defined as anything longer than four weeks—and yet, seniors often stay on these drugs for decades. Partially because of a lack of comprehensive discussions with doctors burdened by our strained healthcare system, not all seniors even know they’re on medications they shouldn’t be on, or about the risks of dependence. But cutting back the rates of overprescription, making sure seniors are well-informed and getting them off long-term benzo use is still only half a solution. We need to address the sleep issues that bring older adults to the pills in the first place.

In 2021, Marcoux came across a newspaper ad for a sleeping pill study conducted by researchers at Dalhousie University. “I had been thinking about stopping, but I didn’t know how,” he says. Having lost five siblings to Alzheimer’s, he knew intimately the signs of cognitive decline, and had a feeling the drugs were impacting his cognitive functioning in some way; he experienced dizzy mornings if he took a pill the previous night. Marcoux felt that something finally needed to change. 

After participating in the study, everything did change. The randomized trial, called “Your Answers When Needing Sleep in New Brunswick,” or YAWNS NB for short, provided participants with educational resources about benzo tapering with the intention of helping them reduce their BZRA usage. One of the study’s lead investigators was David Gardner, a professor of psychiatry at Dalhousie and the co-lead developer of Sleepwell, a non-profit initiative looking to help older adults get off sleep medications by using cognitive behavioural therapy for insomnia (CBTi). CBTi is a psychotherapy approach that attempts to help us sleep better by changing our thought and behavioural patterns. This can mean things like improving our sleep hygiene, a term that refers to our bedtime routines: keeping a sleep diary, leaving bed when we’re not sleepy or doing boring activities before bed. Most medical experts who are against long-term benzo use for sleep are proponents of non-pharmacological alternatives like CBTi. 

The aptly named YAWNS NB study was a wake-up call for Marcoux about the risks associated with long-term benzo usage. After thirty-five years, he decided it was time to wean himself off. His pharmacist and doctor—not the one who had first prescribed him the pills—agreed. By that point, the red phone that had haunted Marcoux was a distant memory, but his sleep remained rocky. Using Sleepwell’s online resources, including tapering schedules and CBTi program guides, Marcoux began the arduous process of getting off benzos and changing the way he slept. 

It took a year. At three months, he cut his dose down to three-quarters of a pill. He started keeping a sleep diary and analyzing how he slept. After about five months, he felt the fog around his mind lifting. At six months, he cut his dose again, so he was only taking half of what he had originally been prescribed. Weaning himself off wasn’t exactly a straight path; some weeks he had worse sleep than others, but he still kept to his goals. “That’s the most important thing. If you’re not committed, you’re not gonna stop,” he says. The journey is capricious and unpredictable; you need to ignore the yearnings of a body accustomed to the comforts of a nightly pill. 

Today, Marcoux is completely benzo-free. He wakes up with better energy, his brain is clearer and he feels less grumpy. Despite the difficult process, the benefits were clear to him. But not everyone on benzos is interested in quitting. Marcoux’s wife, who had also been taking 30 milligrams of Oxazepam for twenty years, initially had no interest in following his lead. “She was saying to me, ‘Well, nobody’s going to get rid of my sleeping pills.’ And I said, ‘Well, that’s your prerogative.’ But every time I had the occasion, I would slide to her an article and I said, ‘Just think about it,’” he says. 

Dependence, it should be noted, is not the same as addiction. Drug dependence is a physical sensation defined by experiencing withdrawal if you stop suddenly. Addiction, meanwhile, is neurological, emotional and defined by a compulsion to seek the drug out. You can be dependent on a drug and not even know it. In an interview with Maisonneuve, Gardner says that for some people, a psychological relationship to benzos exists alongside their physical dependence—which could be why so many have tried and failed to get off of benzos on their own, or not tried at all. “For a lot of people, it’s not that you believe that you’re getting a good night’s sleep with your sleeping pill, it’s that your sleep is not very good, and without your sleeping pill, it only gets worse,” Gardner says. The pill is not the problem, you tell yourself; it’s the solution.

The matter gets more complicated, says Gardner, because insomnia is a common symptom of benzo withdrawal. You stop your sleeping pills cold turkey and your sleep gets instantly worse, which can certainly be enough to convince you that you need the pills. Gardner calls it “the vicious cycle,” and it’s why tapering off sleeping pills slowly is essential. A 2010–2012 randomized trial titled EMPOWER, published in the JAMA Internal Medicine journal, found that more patients successfully tapered off benzos when they were directly educated and aided by a pharmacist. The difficulty of quitting is what motivated Gardner to set up Sleepwell—to spread the word about tapering off benzos, and to encourage as many seniors as possible to incorporate CBTi practices instead. 

In the absence of proper education on the risks of long-term benzo usage, patients end up requesting sleeping pills. Donna Manca, a professor of family medicine at the University of Alberta and researcher at SPIDER Deprescribing, a national initiative studying safer prescribing methods for seniors, often gets pushback when she tells her patients she wants to avoid benzo prescriptions. Manca notes how as we age, our bodies can no longer metabolize drugs as effectively. Consequently, medications reach higher concentrations in our bodies, since they aren’t being cleared out as efficiently as they once were. “So, with older adults, you need to use a lower dose [because] the impact of the drug is bigger,” she says. Seniors also tend to be on many medications at once, and adding sedative-hypnotics like benzos to the mix can complicate drug interactions, according to the College of Physicians and Surgeons of Manitoba. SPIDER Deprecribing’s core research focus is identifying common medications overprescribed to seniors, such as benzos, and empowering both patients and practitioners to better analyze whether those drugs are needed. 

Benzos do have their uses; they can be prescribed as short-term solutions for mentally painful situations or emergency sleep issues. Manca might prescribe a limited amount to a patient who has just lost a spouse; but she would also make the dependency risks clear. Benzos’ powerful and typically fast-acting nature can provide immediate relief when used sparingly and conscientiously in emergency situations. The problem is that for some patients, chronic sleep issues turn every night into an emergency situation. 

Faye Latour was sometimes going up to two days without sleep before her doctor put her on 15 milligrams of Temazepam, a benzodiazepine used to treat insomnia. That was over thirty years ago; and even then, her doctor warned her that the drug was addictive and it was possible she’d be on the pills for the rest of her life. “I said, ‘Well, I don’t want to take them if they’re addictive,’” the seventy-one-year-old retiree tells me from her home on Prince Edward Island. “[My doctor] said, ‘You need your sleep, so it’s better to take something that you’re addicted to to help you sleep than it is to not get any sleep.’ So, I believed her.”

After about three months the drug’s effects began to wane, so her doctor upped her dosage. The same thing happened after another three months. Eventually, Latour’s dosage reached 45 milligrams—or three pills a night—a routine she kept for the next three decades. According to Mayo Clinic, a typical starting dose of the drug for older adults is 7.5 milligrams. Despite Latour’s high dosage, the drugs didn’t exactly fix the issue. She was still only sleeping about two or three hours a night; but for an insomniac, it was better than nothing. “I was working a full-time job and I kept thinking, if I don’t take them, I won’t get any sleep, and I need whatever sleep I could get,” she recalls. 

Over the years, strange things began to happen. Her memory started to fail her; she’d arrive at work in the morning and completely forget how she got there. “I’d think, ‘Oh my god, I don’t even remember driving,’” she says. She was always tired, and she started having balance problems.

Two years ago, a few friends brought Latour to Age Friendly PEI, a seniors conference on PEI where Gardner happened to be doing a virtual talk on CBTi. When it was time to open the floor to questions, Latour stood up. “I’ve been on three of these [pills] for so many years, and I only get two or three hours of sleep with them. What can I do?” she asked. Gardner had a straight answer: the pills weren’t working.

It was the kick that Latour needed. She sorted out a deprescribing schedule with her pharmacist and started working with Gardner to incorporate CBTi techniques into her life. It only took six months to completely wean herself off the benzo. Now, she’s sleeping between five or six hours a night, without any pills. She has more energy, is more talkative and wakes up in a good mood. There are still some lingering memory problems, which she admits could be age-related but blames on the pills. “I don’t think sleeping pills do anything,” she says, looking back at her experience. “It’s harmful, not helpful.”

Latour and Marcoux were both first prescribed their pills decades ago. Since then, healthcare has caught on to the risks of long-term benzo usage. Perhaps the two seniors’ experiences were the outcomes of a legacy of looser prescribing methods. Yet both were able to refill their prescriptions well into recent years; no clinician stopped to question whether they still needed the pills. In workshops for SPIDER Deprescribing, Manca and other physicians discuss how most of their patients who ask to stay on a benzo have already been on one for decades. How are so many seniors having these drugs prescribed or their prescriptions continually refilled?

The immediate effectiveness of benzos is part of what enables their wide prescription. “They do help calm people down and do help with sleep,” says Frances Carr, a geriatric physician at the University of Alberta. “Despite more of an awareness about some of the problems that they can cause, especially in older adults, they are effective, and I think that’s why they’re prescribed … They’re well-established medications as opposed to some of the more new, complicated medications on the market, so people are more familiar with them.”

The caveat is that benzos work well as short-term solutions. Because of this, they’re often prescribed to seniors who are hospitalized after a fall or medical emergency that might require a sedative, explains Barbara Farrell, a pharmacist and deprescribing researcher at the Bruyère Research Institute in Ottawa. When these seniors leave the hospital, they “get a prescription for the sedative and maybe vague instructions not to use it too long—but then it gets renewed,” Farrell explains. Once they are discharged, there is no concrete discontinuation plan—the prescriptions are continually refilled, so patients just continue using the medications. “Quite often, prescriptions will be renewed because the physician doing the renewing was not the person who started the medication. They may not be totally aware of why the medication was being used or [for] how long,” Farrell says. She describes how when a medication is first prescribed, the physician doesn’t need to document why the medication is needed or for how long the medication is intended for—a gap she connects to seniors staying on benzos for longer than they need to.

The lack of transparency between physicians and patients, or between medical professionals, is compounded by the fact that Canada’s healthcare system has been strained to its limits. An estimated 6.5 million Canadians don’t have a family doctor, according to a 2024 national survey by OurCare, a research initiative looking for solutions to Canada’s primary care crisis. Those who do are competing for their doctor’s already stretched-thin time, and medication reviews are not always at the top of the list during appointments. James Wright, professor emeritus in the faculty of medicine at the University of British Columbia (UBC), says that this can also be complicated by the fact that some doctors genuinely believe that benzos are appropriate medications for long-term use, although this perspective is in the minority. 

In February, Radio-Canada’s Enquête, a French news program, released an investigation on the overprescription of benzodiazepines and Z-drugs in Canada, finding that health professionals often prescribed the drugs without informing patients about the adverse effects. As a result, Quebec’s College of Physicians, an organizational body that regulates the province’s medical community, said it will more closely monitor physicians who heavily prescribe benzos. Each province has its own regulatory college that sets standards when it comes to prescription practices; both Manitoba and Saskatchewan’s colleges, for example, limit benzo prescriptions to a maximum of three months before needing to be re-prescribed, and state that they should be prescribed for the shortest possible duration at the lowest possible dose. In practice, these limits and regulations don’t quite translate to real changes—according to Wright, requiring constant returns to have prescriptions re-prescribed can be an inconvenience, but isn’t enough to actually prevent unnecessary benzo usage. Quebec’s College of Physicians’ new intention to monitor prescriptions may not amount to much of a change. It wouldn’t be the first time that efforts to curb benzo usage have fallen flat.

By the late eighties, benzos were suffering from a bad rep amid growing concerns of the potential for dependency and withdrawal effects. A large class-action lawsuit against drug manufacturers was brewing in the United Kingdom, with claimants blaming manufacturers for advertising the drugs despite knowing the risks. Then, in the early nineties, a new class of drug entered the scene: nonbenzodiazepines, better known as Z-drugs. These included Zolpidem, under the brand name Ambien, and Zopiclone, under the brand name Imovane. “I often refer to [Zopiclone] as Canada’s favourite sleeping pill,” says Gardner. Z-drugs send the same sleepy signals to the brain as benzos do, but were thought to not have the same long-term sedation effects due to the former’s shorter half-lives. Because of this, researchers initially believed they posed less of a risk than benzos. History was repeating itself: Z-drugs stepped in as alternatives to benzos, the same way benzos had for barbiturates decades earlier.

Around the world, Z-drugs were marketed as safer alternatives than benzos to treat sleep disorders; a 1994 paper published in the journal Drugs & Aging found that Zopiclone worked in similar ways to benzos, but that it had a low risk of dependency and was safer. Z-drugs soared in popularity in Canada, but they didn’t quite succeed in replacing benzos. A 2014 study published in the journal CMAJ Open found that while Z-drug usage rose significantly in Manitoba between 1996 and 2012, benzo usage rates remained stable. Another study, published in the Journal of Population Therapeutics and Clinical Pharmacology in 2019, found the same trend between 2001 and 2016 on a national scale.

But benzos and Z-drugs are not that different, says Gardner. In the thirty years since their debut, multiple studies have found that Z-drugs impair cognitive performance and can lead to dependency, just like benzos. And just like benzos, they’re now only recommended for short-term use. In Gardner’s clinical perspective, Z-drugs and benzos come with the same risks. 

Evelyn Held would tell you the same thing. The sixty-seven-year-old was first prescribed a Z-drug seven years ago to sort out her sleep problems. She started on Zopiclone, but didn’t like the way the pills tasted under her tongue, so she switched to Zolpidem. Held began to take the pills nightly. “I just couldn’t go to sleep without them,” she says. About two months before we spoke in March, she found out her new insurance plan didn’t cover her sleeping pills and quit cold turkey. Her withdrawal was mild—headaches and difficulty sleeping—but she says she knows she was hooked. “I almost looked forward to the time at night that I could take them. They went under the tongue ... and it’s really funny now, I actually miss that more than I think I miss the drug. It’s the ritual,” she says. “So now I just put a small candy under my tongue.” Her sleep issues are back, but she attributes them to her hip problems. After she undergoes hip surgery, she plans on incorporating CBTi techniques to improve her sleep. 

Held’s biggest concern is that no pharmacist ever cautioned her to be careful with the pills when she went to refill her prescription—which she did frequently. She was prescribed three months of medication at a time, with three refills. After the third refill, her pharmacist would call her doctor “who would just go ahead and re-prescribe,” she says, rather than review if she still needed to be on them. 

Held, like Marcoux and Latour, stayed on a medication for far too long because she slipped through the cracks of a strained healthcare system. Benzos and Z-drugs are band-aid solutions that were never meant to be long-term. Tackling the sleep issues that older adults face at their roots means promoting non-pharmacological options like CBTi as frontline solutions, rather than relying on medication. It means doctors and pharmacists regularly reviewing their patients’ sleeping medication and helping patients figure out alternative options if the pills are unnecessary. 

To understand the best way to address the benzo problem, we need to take our cues from the people working in the sky. In the late 1980s, researchers in the aviation industry discovered that a majority of plane crashes occurred because of failed team dynamics, such as poor communication and a lack of collaborative decision-making. The researchers began to look into how better teamwork could improve work performance. Their results led to an aviation training system that involved teaching the pilot, co-pilot and flight engineer to coordinate and cooperate with flight attendants, air traffic controllers and other support staff during crisis management. The training was effective, and is now a standard part of the aviation industry. This concept of efficiently interconnected teamwork has been recognized by other industries, too; including in primary healthcare, where the idea has evolved into what we now know as interprofessional health teams. 

In Canada, provinces have different names for interprofessional health teams. In Quebec, they’re called Family Medicine Groups. In Alberta and BC, they’re known as Primary Care Networks, while Ontario calls them Family Health Teams. No matter what they’re known as, these models have the same premise: an interprofessional group of healthcare providers working together, that can include family doctors, nurse practitioners, wellness and mental health professionals, geriatric physicians and clinical pharmacists. Doctors on health teams share patients, a cost-effective practice which can reduce workload on the individual physicians while providing more comprehensive care. The team-based approach is also well-suited for patients with complex needs or chronic diseases, since multiple clinicians can pool their interdisciplinary expertise. Team-based care reduces walk-in clinic use because health teams are able to see patients more quickly. 

Canada began implementing health teams across the country in 2000. Those who had access to health teams were “more likely to receive health promotion and disease prevention [services],” according to a 2008 Statistics Canada report. Some provinces have dedicated more funding to establishing health teams than others. There are 187 teams in Ontario, for example, while BC only has seventy-seven, although the latter is in the process of creating more. 

When it comes to seniors’ complex medical needs, interprofessional health teams can be particularly effective. Michelle Greiver, a researcher at SPIDER Deprescribing, is also a physician on a Family Health Team in North York, Ontario. She says her clinic is equipped with the tools to help seniors deprescribe from benzos and adopt healthy sleep habits, such as CBTi resources and a deprescribing program run by clinical pharmacists. The clinical pharmacists in her team frequently call up deprescribing patients to check in and adapt tapering schedules according to their needs. In this way, a team-based approach can be more thorough—a whole group works together to evaluate your condition and treatment.

Camille Gagnon, a pharmacist and the assistant director of the Canadian Medication Appropriateness and Deprescribing Network, would add one more element to the team-based approach: community pharmacists. These are the pharmacists who work at your local drugstore, as opposed to clinical pharmacists, who work with doctors to create treatment plans. Community pharmacists generally aren’t included in health teams because they operate in separate environments. Like family doctors, community pharmacists can sometimes be overwhelmed and fail to take the extra time to discuss medications with patients. But these discussions can be key tools in catching unnecessary prescriptions: a 2015 study in Italy that monitored community pharmacists’ interviews with patients about their benzo usage found that these conversations identified inappropriate benzo prescriptions. Like Held, who wished her pharmacist had cautioned her about her sleeping pills, Gagnon believes community pharmacists should be involved in the team approach—and compensated for the extra time they put into discussing medications. “Their time is worth a lot and we want them to spend it on high-value care. High-value care is not renewing a benzodiazepine prescription every time without asking questions,” says Gagnon. 

An interprofessional team can also help with difficult cases of withdrawal, according to UBC professor emeritus James Wright. In his experience, benzo withdrawal can get quite bad for a small percentage of patients. “For some people, it really becomes a damaging drug, and they start to have horrendous symptoms of anxiety and neurological effects,” he says. There’s no way to predict how your body will react to withdrawal—your age or health status don’t seem to matter, according to both Wright and Gagnon. “You don’t know if you’re going to be one of these people whose lives are destroyed,” says Wright. That’s why deprescribing slowly, with the assistance of professionals, is essential. A health team “would be able to take the time to help these people,” Wright says about those going through the lengthy withdrawal process.

There aren’t enough healthcare teams for everyone—and advocates in the medical community, including the Canadian Medical Association, are calling on provincial governments for more funding to establish more. In the meantime, Gagnon advises seniors to prioritize medication reviews during doctor appointments, instead of leaving them until the end of the session.

For Sleepwell co-leader David Gardner, the problem is more so that primary healthcare hasn’t yet figured out how to handle insomnia behaviourally. He believes the solution is quite simple. “To really make a change, we need something that’s an initiative or a program that anybody can access at any time and doesn’t require working directly with a healthcare provider,” he says. The plan for insomnia treatment that he established with colleagues at Queen’s University works according to a stepped care model, in which patients start at the most general level of healthcare and are moved up to specialists as needed. The lowest step in Gardner’s model is self-education—he believes that we don’t need to see a doctor right away for insomnia, if we can first try to address it on our own using CBTi techniques. Though the following steps include accessing healthcare teams, Gardner believes that most people can find success by themselves if they’re given the right tools and education. This is where he hopes Sleepwell, with its abundant resources on CBTi, can come in. Gagnon agrees that CBTi doesn’t always need to be done with a therapist—you can try it out on your own. That’s exactly what Marcoux did. 

Marcoux’s life has changed so significantly, he now volunteers with Sleepwell, coaching other seniors on weaning themselves off benzos. “If I can help one person every month improve their sleep and get out of sleeping pills, it will be a success,” he says. His determination, it seems, is infectious. Seven months ago, his wife approached him with a surprise. She had started reducing her pill dosage on her own. “I want to stop,” she told him. She needed his help to get to the finish line; now, she’s made it down to half her original dosage. Marcoux says that by fall, if all goes well, his wife will be completely through with the pills. It’s another success for the retiree, who sleeps easy now. There’s no red phone or little pill in sight. ⁂

Ayesha Habib is a writer and photographer in Vancouver. Find her byline in the Globe and Mail, Chatelaine, Montecristo, Capital Daily and the Narwhal. She lives with her exceptionally loud cat.