Benzodiazepines are Back

Vol 10 #6

Over the past three or four decades strong cautions have attached to the prescription of benzodiazepines by family physicians and psychiatrists. Principal concerns have been about potential for dependence and abuse.

Treatment guidelines have stressed that this class of medications should only be prescribed for short-term use.

Nevertheless in clinical practice benzodiazepines continue to be used for cases of intractable anxiety disorder. Concerns centred more on direct side effects than on the potential for drug dependency in patients with anxiety disorders.

These side effects include impact on cognitive functioning, on memory recall and retention of new information, impaired driving, impaired balance. These side effects also occur with many other classes of psychiatric medications that often have more significant potential medical side effects. In fact benzodiazepines can be medically safer than SSRIs for many patients.

Now in article in the March edition of the British Journal of psychiatry indicates that present views about benzodiazepines are not supported by an extensive review of the evidence[1].

The authors question a number of fallacies regarding benzodiazepine use and come to the following conclusions:

1. Benzodiazepines are unlikely to be abused by patients with anxiety disorders.
2. Patients with anxiety disorders who deviate from the prescribed dose in order to reduce symptoms are unlikely to proceed to abuse or addiction. Conversely patients with established substance abuse may also misuse benzodiazepines.
3. Long-term benzodiazepine treatment is not associated with dose escalation. Tolerance does develop to the sedating and psychomotor effects but not to the therapeutic effects.
4. Benzodiazepines are among the safest psychotropic medications in overdose. However taken in conjunction with alcohol or opioids there is an enhanced lethality risk.
5. Benzodiazepines are associated with physiological withdrawal symptoms but not with psychological dependence.

Comment

Benzodiazepine withdrawal might be better compared to that seen with SSRIs. The  term “discontinuation syndrome” may be a misnomer as this is in fact a physiological withdrawal syndrome. For some benzodiazepines may be preferable to SSRIs in the treatment of panic disorder [2,3].

References

1. Silberman E, Balon R, Starcevic V et al. Benzodiazepines: it’s time to return to the evidence. Br J Psychiatry. 2021 Mar;218(3):125-127. doi: 10.1192/bjp.2020.164.
2. Nardi AE, Cosci F, Balon R et al. International Task Force on

Benzodiazepines. The Prescription of Benzodiazepines for Panic Disorder: Time

for an Evidence-Based Educational Approach. J Clin Psychopharmacol. 2018

Aug;38(4):283-285. doi: 10.1097/JCP.0000000000000908.

3. Balon R, Silberman EK, Starcevic et al. Benzodiazepines, antidepressants and addiction: A plea for conceptual rigor and consistency. J Psychopharmacol. 2019 Nov;33(11):1467-1470. doi:10.1177/0269881119878171