Appropriate Use of Benzodiazepines

Millions of prescriptions are written every year for benzodiazepines. 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.

While the intention behind prescribing a benzodiazepine for a patient is to help alleviate emotional or physical pain for the patient, many times the use of the medication gets 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”. Benzodiazepines are not particularly helpful for depressive disorders or Obsessive-Compulsive Disorder. When starting a benzodiazepine, it is important to inform the patient that it is a short-term intervention, explaining the reason is 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 if possible, because patients can develop a quick dependence to it because they can experience a “high” with it, and it has a short half-life, which can lead to rebound anxiety and 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 complain of being able to fall asleep okay but then 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. 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 long-term benzodiazepines, it is important to make sure the use is not slowly escalating, because that is a sign of tolerance and dependence.  Also, 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 are discussed in another e-Weekly.

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. It is therefore useful to look at some guidelines for appropriate prescribing practices for this class of medications.

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