Appropriate Use of Benzodiazepines 5/24/2018

Millions of prescriptions are written every year for benzodiazepines which can be important therapeutic agents. In a large percentage of these cases, the provider is uncomfortable with the prescription. For this reason and many others, it is important to have a good understanding of when it might be appropriate to prescribe a benzodiazepine for a patient. This is also becoming particularly important in light of the many protocols being developed for the prescribing for this class of medication, including the upcoming California requirement for checking with the CURES system before and during ongoing treatment—this to become effective in October 2018.

While the intention behind prescribing a benzodiazepine for a patient is to help alleviate emotional or physical pain for the patient, there is a risk that the use of the medication may get out of hand. Generally, benzodiazepines, which work to enhance GABA, are helpful in treating anxiety, insomnia, agitation, seizures, muscle spasms, alcohol withdrawal and as a premedication for medical or dental procedures.

Here we will focus on its uses for anxiety disorders. Benzodiazepines can be useful in the short-term for 1-3 months for a variety of anxiety disorders, like Generalized Anxiety Disorder, Social Anxiety Disorder and Panic Disorder, while waiting for the SSRI or other antidepressant/anti-anxiety medication to “kick in” and take full effect, which can take 1-2 months. Benzodiazepines may also be offered for use as PRN “rescue medications” for patients with episodic panic attacks, without prescribing an ongoing course of daily administration. It is important to know that benzodiazepines are not particularly helpful for depressive disorders or Obsessive-Compulsive Disorder.

When considering starting a benzodiazepine, it is important to inform the patient that the prescription is a short-term intervention, noting the need to avoid long-term side effects, like tolerance, cognitive effects, and physiological and psychological dependence. When choosing a benzodiazepine, it is important to try to avoid short-acting medications like alprazolam whenever possible, because patients can develop a quick dependence to it because they can experience a “high”, and it has a short half-life, which can lead to rebound anxiety which then can make it very difficult to taper off the medication. Also alprazolam is not a good medication for insomnia because of its short half-life. Patients may report they are able to fall asleep better with the medication but complain that they are waking up in the middle of the night. Alternative benzodiazepines to consider on a short-term basis for sleep include: clonazepam and temazepam.

If a patient is requiring adjunctive medication on a long-term basis for anxiety, consider non-benzodiazepine alternatives like diphenhydramine, hydroxyzine, propranolol, or buspirone. The first three of these medications can also be offered for PRN “rescue” intervention for panic disorder incidents. In the rare case when a long-term daily benzodiazepine is indicated, for example with Generalized Anxiety Disorder which responds well to a combination of SSRI + benzodiazepine, consider clonazepam. If a patient has infrequent panic attacks and a daily SSRI is not indicated, one could consider lorazepam on a prn basis. Lorazepam works well as a prn medication for acute anxiety and panic attacks, because it works relatively quickly but does not build up in the bloodstream. If one is prescribing benzodiazepines to be used on a long-term basis, it is important to make sure the use is not slowly escalating, because that is a sign of tolerance and dependence. Monitoring through the CURES system will be helpful in avoiding doctor shopping and diversion scenarios.

When helping a patient taper off a medication after he has been on it for some time, it is important to conduct a slow taper to avoid serious withdrawal symptoms, and to provide an alternative to treat the ongoing anxiety symptoms. Guidelines for appropriately tapering off benzodiazepines have been discussed in other e-Weekly’s. Patients with anxiety may also benefit from concurrent supportive and cognitive behavioral psychotherapy, yoga, mindfulness training, and other non-pharmacologic interventions.

The goal of this article is to help the primary care provider be more informed about the decision to prescribe a benzodiazepine to a patient in a safe and helpful way, because this class of medication has a role in treatment for anxiety disorders and can be helpful when used appropriately.

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