Benzodiazepines
Home Up Benzodiazepines Panic Disder Social Anxiety Disorder Buspirone Hydroxyzine PTSD

 

This has been a very popular group of mild to moderately addictive medicines called tranquilizers or minor tranquilizers.  They are controlled substances in DEA Class IV, a less restrictive category than methylphenidate (Ritalin) which is Class III or powerfully addictive opiates like oxycontin in Class II.  Benzodiazepines includes such famous or infamous brand names as Valium, Xanax, and Halcion.  While benzodiazepines have been heavily promoted by pharmaceutical companies and heavily prescribed by physicians, in my opinion, they are best to avoid in almost all situations with the exception being long-acting ones are great for alcohol detoxification.  A few patients do benefit from them who are not helped out by other medicines.

That said, I wean a patient who was started on benzodiazepines by another physician off of them only very slowly so as to avoid withdrawal reactions.  Also, if a patient simply cannot get off of them, there may be no great harm staying on them long-term so long as the patient is careful not to let the dosage increase.  There is some evidence that suggested that long-term benzodiazepine usage might actually increase depression and anxiety, but this has not been proven.

I used to have dozens of studies documenting the harm, but that was in pre-computer days and I no longer have the notes.

Benzodiazepines

France: Benzodiazepine Usage by Elderly Very High and Chronic: 1265 elderly subjects (aged 60 to 70 years) interviewed in Epidemiology of Vascular Aging Study. Use of sedative or sleeping drugs was reported by 28.7% and benzodiazepines by 23%. Most of the benzodiazepines used (71%) had anxiolytic indications, 48% were long-acting compounds (elimination half-life>=20 h.). Among benzodiazepine users, 71% reported using benzodiazepines daily and 77% reported they had been taking benzodiazepines for at least 2 years. Nearly two third of the benzodiazepine users reported taking their medications as prescribed. When they were not compliant, they took benzodiazepines less often and/or at slighter doses than prescribed. Use of benzodiazepines was associated with symptoms of depression or anxiety (women: odds-ratio=2.6; men: odds-ratio=4.4) and with regular use of at least three non-psychotropic drugs. Benzodiazepine use in the elderly: the EVA Study. Lechevallier N, Fourrier A, Berr C. Rev Epidemiol Sante Publique. 2003 Jun;51(3):317-26

Elderly 50% Increase Auto Accidents on Long-Acting Benzos: Data analysis Quebec 5579 accident reports drivers 67-84yo and match controls. 7% accidents with long-acting vs 5% without. 14% accidents with short-acting vs. 15% controls. Calculated 30% increase with long-acting and 50% is rx written in past week. Amazingly, 20% of all elderly drivers were taking a benzo on any given day! Hemmelgarn B, et al: Benzodiazepine use and the risk of motor vehicle crash in the elderly. JAMA 97;278:27-31, McGill

Not Assoc with Falls: Brit Med J 3/31/01 matched control study in France found no association with hip fractures for long-acting and only with lorazepam or when two or more being taken at one time.

Melatonin for Benzo Withdrawal: 34 pt 12 weeks 40-90yo, on benzos at least 6 months. DB 6 weeks melatonin 2mg or placebo 2 hr bef sleep. Encouraged to taper and d/c benzos over 6 weeks. Those not succeeding, encouraged during single blind second 6 weeks all on melatonin. 14/18 d/c with melatonin in 6 weeks v 4/16 on placebo. 6 more in placebo group d/cd in second 6 weeks. Over next 6 months, 19 of 24 stayed off benzos while taking melatonin. Sleep much better after 6 months than when on benzos. Garfinkel, Arch Int Med 99;159:2456

Prior Benzo Reduces Buspirone Benefit: 735 pt with GAD 4 week DB buspirone,benzodiazepine, or placebo for FDA. Patients on benzos had them d/cd 1 week before study. Patients on recent benzos 42% stopped buspirone. Those continuing buspirone, 62% of those with no prior benzo rx had clinical response v 46% on recent benzos or 56% on benzos more than 1 month in past. Rickels, NEJM 86;314:719 & J Clin Psych 00;61:91,U Penn.

Zolpidem Dependence: 4 cases, 3 women 26-42yo given zolpidem 10/d as anxiolytic/hypnotic increased their dosageto 120-500/d. All had withdrawal symptoms. Int Clin Psychoph 00;15:181. Blocks benzodiazepine omega 1 receptor subtype causing marked hypnotic and supposedly lower abuse potnetial. Druggies say 40/d similar to diazepam 20/d. J Pharm Exp Therap 90;255:1246

Rebound Anxiety Up to 2 Years: Guy Chouinard, Montreal, reports up to benzodiazepine daily users suffer rebound anxiety when abruptly stopping meds. Worse with short-acting and higher dosages. Malcom Lader, U London, interviewed 100 patients off benzos. Perceptual problems reported in 20% for up to 2 years after stopping, including extreme sensitivity to light and sound. Martin Scharf, Cincinnati Sleep Disorders Center, found increased amnesia in benzo patients. Sci News 5/19/84.

Withdrawal Treated With Longer Acting: 12 having difficulty withdrawing from prescribed doses and reporting adverse med effects, switched to diazepam and slowly withdrawn. Symptoms increased about 5-7 days after d/c diazepam then improved. Anxiety, sweating insomnia, muscle aches, hallucinations, paranoia, feelings of unreality, agoraphobia, depression, and craving not uncommon. Most paitnets still not free of withdrawal symptoms 4-6 months after. None had hx alc or drug abuse. H. Ashton, Newcastle U, Brit Med J 84;288:1135-40.

Imipramine > Buspirone Helping Withdrawal in DB: 107 pt on diazepam, alprazolam or lorazepam for average 8.5 yr. kept on stable dose while started on 4 weeks imipramine (aver. 180/d), buspirone (aver 38/d) or placebo then had benzodiazepine gradually withdrawn over 4 weeks then placebo withdrawal of meds for 3 weeks. Average had 3 previous unsuccessful tapers. 83% succeeded with imipramine vs. 68% buspirone vs. 37% placebo. Imipramine and buspirone in treatment of patients with generalized anxiety disorder who are discontinuing long-term benzodiazepine therapy. Rickels K, DeMartinis N, Garcia-Espana F, Greenblatt DJ, Mandos LA, Rynn M. U Penn: Am J Psychiatry 2000 Dec;157(12):1973-9

Carbamazepine Helps Withdrawal in Elderly in DB: 35 pt 60yo+ DB PC. Fewer withdrawal effects, less anxiety. 3 of 18 c/o carbamazepine side-effects which disappeared at lower dosage. The prophylaxis of benzodiazepine withdrawal syndrome in the elderly: the effectiveness of carbamazepine. Double-blind study vs. placebo. Di Costanzo E, Rovea A. Minerva Psichiatr 1992 Oct-Dec;33(4):301-4; Similar findings in out-patient DB reducing benzodiazepines 25% per week. Carbamazepine treatment in patients discontinuing long-term benzodiazepine therapy. Effects on withdrawal severity and outcome. Schweizer E, Rickels K, Case WG, Greenblatt DJ. Arch Gen Psychiatry 1991 May;48(5):448-52