Victoria Ratliff, the ultra-wealthy financier’s wife played by Parker Posey on season 3 of HBO’s The White Lotus, has a problem. Her bottle of the prescription anti-anxiety medication lorazepam has gone missing.
“You don’t have enough lorazepam to get through one week at a wellness spa?” her daughter Piper asks, with no small amount of judgment.
Um, that’s a hard no, or as Victoria herself might drawl, “Noooooooooooo.”
The Southern matriarch is shown taking lorazepam, a type of benzodiazepine (or benzo), to ease her social anxiety, induce sleep, and even relax before a massage — often with a white wine chaser. The combination leaves her loopy, and she slurs her words and even falls asleep during a family dinner. When her husband, Tim, starts taking the medication to ease his own stress, he quickly seems to become dependent, taking several a day while also drinking heavily.
While the portrayal of benzos on the show is sometimes used for comic effect, the reality is more complicated — and more dangerous. What is lorazepam? Is it really as addictive as the show portrays? And what are the risks of taking it with alcohol?
How Benzos Work
Benzodiazepines are depressants that cause sedation, and doctors usually prescribe them to treat conditions like anxiety, panic disorders, and insomnia. Besides lorazepam, which is marketed under the brand name Ativan, other common benzodiazepines include Valium (diazepam), Klonopin (clonazepam), and Xanax (alprazolam).
In The White Lotus, characters use the drug as a way to temporarily escape their current unpleasant reality or to relieve social anxiety.
“Benzos are genuinely effective for anxiety,” says Stephen Holt, MD, an associate professor at Yale School of Medicine and the director of the addiction recovery clinic at Yale Medicine in New Haven, Connecticut.
“They help people to get through their lives without having racing thoughts. They’re particularly useful for situational anxiety, like for people who get stressed out by flying on planes, getting an MRI, or public speaking,” says Dr. Holt.
Benzos are also commonly used for anesthesia as well. “Somebody gets a colonoscopy or something, they’re going to get a little bit of a short-acting benzo, just to kind of knock them out,” he says.
“These drugs have value when used appropriately on a short-term, as-needed basis,” says Holt.
Daily Use of Benzos Can Be Habit Forming
While the calming effect of benzos can be beneficial in the short term, it’s also what makes them so dangerous when used over an extended period.
“When somebody’s taking a benzo on a daily basis, around the clock for months or years — some say as soon as four weeks — the brain has already started to adapt. It changes the population of those GABA receptors in the brain, such that without benzodiazepines, you don’t feel right. You start to feel anxious, more anxious than when you started the benzos in the first place,” says Holt.
The body becomes more reliant on the medication to maintain a sense of calm. This leads to tolerance (needing more of the drug to achieve the same effect) and dependence (experiencing withdrawal symptoms when you stop the drug).
Benzos Are Not Recommended for Chronic Anxiety
For anyone who has generalized anxiety disorder as a chronic condition, “benzodiazepines are not the solution,” Holt says. “They are not recommended by psychiatrists or any other professional medical organization for that.”
The first-line treatment for anxiety is selective serotonin reuptake inhibitors (SSRIs), he says.
Benzos Often End Up Causing Anxiety
Plot twist — benzodiazepines can end up causing anxiety, says Holt.
“For decades, we’ve seen the addiction and dependence related to benzodiazepines. The irony is that this medication given to help people with anxiety, in the end, causes anxiety for patients,” he says.
For many people, after they’ve been weaned off their benzos, they find they are less anxious than when they were on the drug, says Holt. “They find that they’re actually much more comfortable in their own skin.”
Benzodiazepines and Alcohol Don’t Mix
The fictional Ratliffs are often popping lorazepam while drinking wine or even straight liquor. In real life, the dangers of benzodiazepines are significantly magnified when they are combined with other substances, such as alcohol or opioid pain medications such as oxycodone or hydrocodone.
“Benzodiazepines act on the same neurotransmitter system in the brain, GABA. You’re just basically accentuating the effects. When you combine the two, you have more potential for loss of coordination, more potential for disinhibition, more potential for basically just passing out — completely losing consciousness,” says Holt.
An important distinction between benzos and alcohol is that alcohol not only impacts the GABA system, but it also leads directly to the release of endorphins, your body’s natural feel-good hormone, he explains.
“So when people drink alcohol, they get buzzed, which is typically a pleasurable sensation. They’re not just feeling disinhibited, impaired in terms of coordination, a little bit sleepy — they also are experiencing pleasure. Benzos don’t actually do that. They cause you to be relaxed, but they don’t cause pleasure,” says Holt.
But there is an exception to this rule, and that’s in chronically anxious people, he says. “Benzos still aren’t actually leading to an endorphin release, but for a person who’s chronically anxious and chronically experiences how unpleasant it is to be anxious, they feel better. Not because you’re giving them pleasure, but because you’re taking away a negative sensation.”
Going Off Benzos Can Be Dangerous
Victoria Ratliff may be highly annoyed once her lorazepam goes missing, but she doesn’t seem to experience any side effects beyond that — which may not be accurate for someone who regularly takes these drugs.
If a person takes a short-acting benzo such as lorazepam or Xanax at a significant dose every day for an extended period of time, and then suddenly stops, they can experience a serious or even fatal withdrawal.
“Depending on the dose, a person completely stopping a short-acting benzo could experience significant withdrawal symptoms. Not just feeling agitated and revved up and anxious, but also hallucinating, delirium, and seizures, which is the most significant concern,” says Holt. While rare, death can occur from withdrawal seizures or suicide.
“In general, depending upon how much benzodiazepine somebody is taking, it’s preferred that a clinician be involved in tapering them off,” he says.