Benzodiazepines

Introduction

Benzodiazepines are indicated for

• Short-term relief (2-4 weeks only) of anxiety or insomnia that is severe, disabling or causing the patient unacceptable distress.
• Rapid tranquillisation
• Treatment of some forms of epilepsy and severe muscle spasm

Long-Term Use

In most developed countries, the use of benzodiazepines is restricted to a maximum of 2-4 weeks. Most guidelines recommend that people on long-term benzodiazepines should be advised to stop because

• Tolerance to these drugs (which can develop after 2-4 weeks) means that they are not effective for insomnia or anxiety over the long term, and
• Dependence is likely to develop, meaning that treatment is continued only to prevent withdrawal symptoms.

Long-term use of benzodiazepines is associated with several problems, which patients may be unaware and only appreciate after stopping.

Withdrawal Symptoms

Stopping these medications is often difficult. One study found that 90% of patients experience withdrawal symptoms on stopping, with 32% of people on long half-life benzodiazepines and 42% of people on short half-life benzodiazepines unable to cease their medication because of withdrawal symptoms. Short-acting drugs such as lorazepam are associated with more severe problems on withdrawal than longer-acting drugs such as diazepam.

To avoid or reduce the severity of these problems, good practice dictates that benzodiazepines should not be prescribed as hypnotics or anxiolytics for longer than 4 weeks. Intermittent use (i.e. not every day) at the lowest possible dose is also prudent.

Gradual reduction of benzodiazepine dose reduces the intensity of withdrawal symptoms by spreading them out over a longer time period (and giving time for neural adaptations to the drug to resolve).

NOTE: Patient should be warned not to stop benzodiazepines abruptly, because this can cause seizures and can be fatal, and may be the method most likely to give rise to severe and long-lasting withdrawal symptoms.

External Links

• The Maudsley Prescribing Guidelines in Psychiatry, 2021
• Long-term therapeutic use of benzodiazepines. II. Effects of gradual taper, 1990
  
• Pharmacological interventions for benzodiazepine mono-dependence management in outpatient settings, 2006
  
• Effectiveness of current treatment approaches for benzodiazepine discontinuation: a meta-analysis, 2009