Benzodiazepine Backlash

In the July/August, 2009 issue of the Bulletin of the King County (Washington) Medical Society psychiatrist August Piper, MD asks, “Has the Time Come to Cease Thinking of Benzodiazepines as Routinely Addictive Drugs?” My response appears in the September/October issue and below with minor modification:

Regardless of the answer to Dr. Piper's question I would like to present some arguments against prescribing benzodiazepines routinely.

Benzodiazepines are not bad drugs and have many indications. Many patients do take them without becoming addicted to them. We use them for anesthesia and to manage withdrawal from alcohol, opiates, and other central nervous system depressants, including benzodiazepines. We use them to treat epilepsy and to manage status epilepticus. They are safer than the drugs they replaced: acetylcarbromal, chloral hydrate, chlormethiazole, Doriden, ethchlorvynol, ethinamate, Equanil, glutethimide, meprobamate, methaqualone, methyprylon, Miltown, Noctec, Noludar, paraldehyde, Paxarel, Placidyl, Quaalude, Sopor, thalidomide, Thalomid, Valmid, mostly names we do not hear any more, and others.

The risk of addiction to benzodiazepines is very real. Patients addicted to them and other drugs seek them from physicians and will lie to obtain them. Use of benzodiazepines can produce a “high” or euphoric effect. Other risks include dangerous interactions with drugs like buprenorphine, alcohol, and other central nervous system depressants. Use of these drugs can lead to disinhibition, impaired judgment, and amnesia. Impairment of motor coordination may not be accompanied by awareness of impairment.

Benzodiazepines can help build a thriving practice. Most patients like to take them and do not like to skip a dose. What I do not like about this is that eventually I am unable to determine whether the patient continues to take them because they really need them or because they like them.

For treatment of insomnia and anxiety many other classes of drug offer substantial advantages, but both conditions often respond to behavioral intervention alone. Most antidepressants effectively treat anxiety and gabapentin and pregabalin may offer advantages as well.

Grand mal seizures can result from abrupt discontinuation of benzodiazepines. Dr. Piper argues that abrupt discontinuation of other “drugs” not usually considered addictive can produce symptoms, but none of these drugs or classes is typically used to get high or can be purchased on the street (except that the class “anticonvulsant” includes barbiturates and benzodiazepines), and in my experience patients almost always find discontinuation of benzodiazepines more unpleasant. To say discontinuation of insulin can lead to symptoms is like saying discontinuation of oxygen can lead to symptoms.

Whether we should consider benzodiazepines “routinely addictive” (whatever that means) or not, Dr. Piper has failed to convince me to prescribe them for anxiety or insomnia.