Benzodiazepine abuse and dependence: misconceptions and facts

Journal of Family Practice, Oct, 1990 by Michael G. Farnsworth

Benzodiazepines can be prescribed for a number of medical conditions. Many physicians are reluctant to prescribe berizodiazepines out of fear of producing dependence in patients and incurring the disapproval of their peers. Studies of psychotropic drug use and abuse demonstrate that individuals using benzodiazepines for treatment of a medical illness rarely demonstrate tolerance to the therapeutic action of the medication or escalate dose. Eighty percent of benzodiazepines are prescribed for 6 months or less, and elderly women are the most common long-term users of low-dose benzodiazepines. In contrast recreational use of benzodiazepines is associated with polysubstance abuse, lack of medical supervision, rapid tolerance to the euphoric or sedating side effect, and escalation of dose. Most recreational users of benzodiazepines are young men. Documentation of indication for use, collection of drug-abuse history, close monitoring, and drug holidays can improve the management of this class of medication.

Benzodiazepines, as a class of psychotherapeutic medications, have enjoyed widespread use since their US introduction in the early 1960s. These medications are used to treat some of the most prevalent emotional and physical disorders seen in medical practice, which include anxiety, insomnia, seizure disorders, muscle spasms, and alcohol withdrawal. Benzodiazepines are also used as preanesthetics. The World Health Organization (WHO) has identified benzodiazepines as "essential drugs" that should be available in all countries for medical use.[1]

Because of their safety and efficacy, the benzodiazepines have largely replaced their anxiolytic predecessors. The oldest and most widely used drug for anxiety was alcohol. Its protean adverse effects, however, encouraged the search for better treatments. In the late 19th century, chloral hydrate and paraldehyde, with characteristics similar to alcohol, were introduced into medical practice as sedatives. Bromide salts and barbiturates were added to the pharmacopoeia in the early 20th century. By the 1950s most of these drugs had fallen out of favor. The barbiturates and meprobamate, introduced in 1955, remained as dominant anxiolytic drugs. Physicians, however, were concerned with the propensity of barbiturates to induce tolerance, physical dependence, drug interactions, and potential for a lethal withdrawal syndrome. Accordingly, chlordiazepoxide was synthesized and marketed in the United States in 1961. Since that time, a total of 12 different benzodiazepines have been marketed in the United States for several Food and Drug Administration-approved indications (Table 1). Whereas the drugs vary in rate of absorption, duration of action, relative potency, and metabolism, little evidence exists to support real differences in therapeutic action at equipotent doses.[2]

Despite the success of benzodiazepines as anxiolytics, many physicians have been reluctant to prescribe this class of medication because of concern for the potential misuse and abuse of these agents by their patients.

This concern had its origin with the negative media scrutiny and public perception of the overuse of diazepam in the late 1960s and early 1970s - as portrayed in books and film.[3] The unfortunate consequence of this overemphasis on the potential abuse of the benzodiazepines may be impairment in the delivery of effective treatment for legitimate medical illnesses.

In this article three case examples will illustrate the common misconceptions regarding the use and abuse of benzodiazepines. The actual abuse risk of these medications will be contrasted with other abused psychoactive drugs. Guidelines for the safe use of benzodiazepines by the primary care physician will be discussed.

TABLE 1. FOOD AND DRUG ADMINISTRATION APPROVED
BENZODIAZEPINES
  Indication                Drug
  Insomnia                  Flurazepam
                            Temazepam
                            Triazolam
  Epilepsy                  Clonazepam
                            Clorazepate
                            Diazepam
  Alcohol withdrawal        Clonazepam
                            Clorazepate
                            Diazepam
  Alcohol withdrawal        Chlordiazepoxide
                            Chlorazepate
                            Diazepam
                            Oxazepam
  Anxiety associated with   Alprazolam
    depression              Oxazepam
  Muscle spasm              Diazepam
  Anxiety                   Alprazolam
                            Chlordiazepoxide
                            Chlorazepate
                            Diazepam
                            Halazepam
                            Lorazepam
                            Oxazepam
                            Prazepam
  Preoperative medication   Midazolam
                            Chlordiazepoxide

BENZODIAZEPINE USE IN THE UNITED

STATES AND EUROPE

The ideal anxiolytic drug is as yet unavailable to medicine. The properties of in ideal antianxietal agent include effective relief of anxiety symptoms without significant side effects such as sedation, freedom from tolerance to the anxiety-relieving properties, oral administration, rapid onset of action and moderate elimination that does not require multiple daily dosing that could jeopardize compliance, no active metabolites, no drug interactions, and no potential for abuse or dependence.