Dr. Grossi's Blog
For many years I have believed that the benzodiazepines (diazepam, lorazepam, alprozolam, clonazepam etc.) are a much maligned and poorly understood family of drugs. This misunderstanding includes doctors, patients, and the government. My conclusion is based on many contacts with other doctors, many articles in the medical literature, and the thinking behind federal government's decision to exclude them as a benefit under Part D of Medicare. That last has been changed and they are now included as a benefit of Part D.
The misunderstanding has been perpetuated by a recent article in JAMA Psychiatry by Moore and colleagues. They questioned their clinical usefullness, emphasized their addictive potential, and suggested much tighter control of their usage. They demonstrated complete tunnel vision because they failed to take into account the issues set out in the following paragraphs.
All benzodiazepines have four actions. Those are: anti-anxiety, antispasmotic, anticonvulsant, and soporific (sleeper). They are also useful in a variety of medical procedures and as a tool in alcohol withdrawal. The indication found in the PDR or in online sites reflects a marketing decision by the manufacturing drug company. The manufacturing company decides to study a drug for a particular purpose and if the studies confirm its effectiveness and safety in the eyes of the FDA, then the FDA allows the company to promote the drug to the medical community for that purpose. The drug can be used for other purposes but it cannot be promoted for those other purposes. A good example of this is the study of clonazepam as an anti-convulsant for which it received an approval. The vast majority of its usage however is as an anti-anxiety agent. The company did this because it already had diazepam (Valium) which was a massive product in the anti-anxiety space and it did not want to introduce a competing product.
Benzodiazepines are an effective pharmacological treatment for anxiety disorders. Offidani et.al. published a meta-analysis of studies comparing benzodiazepines and antidepressants in Psychotherapy and Psychosomatics. The benzodiazepines showed superior efficacy and a more benign side effect profile. Furthermore, the discontinuation rate is much higher with the antidepressants.
Moore et. al. and the majority of the medical community are over-focused on dependency, addiction, toxicity, abuse, tolerance, and withdrawal syndromes. I have found that the rate of abuse is relatively low provided that the drugs are not given to alcoholics or individuals without anxiety disorders. People with anxiety disorders do not get addicted if the drugs are used properly. Antidepressants sometimes have very prominent withdrawal syndromes which can last weeks and are very uncomfortable. With regard to tolerance, this can definitely become an issue especially if these agents are need for a long period. There are a variety of strategies to prolong their clinical effect without raising the dose beyond acceptable limits. Contrary to popular opinion, these agents can be used for long periods with proper management and caution.
Some other oft expressed concerns include falls in the elderly, auto accidents, dementia, confusion, memory problems. While there is some merit in these concerns, if we compare these possible adverse events with those of the antidepressants and antipsychotics, the benzodiazepines look relatively better and less problematic in the long run. On the positive side of the ledger, these drugs enable individuals to relax, reduce anxiety, facilitate sleep and thus provide a better environment to work on longer term solutions to underlying problems.