Professor Jim Lucey discusses the use of benzodiazepines and warns against those purchased on the black market.
Benzodiazepines are sedative drugs. They can provide rapid symptomatic relief from acute anxiety states. They form useful parts of the treatment of epileptic seizures and they are exceptionally valuable within anesthesia. However, their use in the treatment of an anxiety disorder has become very problematic.
All the best prescribing guidelines confirm that this group of drugs should only be used to treat anxiety that is severe, disabling and subjecting the individual to extreme distress. The Maudsley Guidelines in Psychiatry are perhaps the most authoritative and practical guide to the use of medications in mental health and this is a guide to which most psychiatrists would refer regularly. A recent edition of the Maudsley Guidelines says that, “because of their potential to cause physical dependence and withdrawal symptoms, benzodiazepine drugs should be used at the lowest effective dose for the shortest period of time (maximum four weeks) while medium and long-term treatment strategies are put in place and only with caution in patients who also have substance misuse”.
The majority of patients take sensible recommendations from their doctor and adhere to these carefully. There is no need to panic about benzodiazepines. Indeed, a very small number of patients with severely disabling anxiety may benefit from longer-term treatment under the supervision of their doctor.
However, it is known that benzodiazepines have been over-prescribed in the long-term for the treatment of anxiety, depression, panic disorder and post-traumatic stress disorder. There are more appropriate treatments for all these conditions and they should be used.
So what are benzodiazepines? These drugs were first described in the late 1960s. They have the capacity to increase the potential of a brain transmitter called GABA; GABA is an inhibitory brain transmitter. A similar effect is brought about by the use of alcohol and by barbiturates. The short-term effects are mainly those of sedation.
Longer-term use of benzodiazepines is associated with accumulation of the drug, particularly in the case of drugs like Diazepam (Valium). After long-term administration of these drugs, a tolerance develops. This can happen over weeks and months. Most patients rapidly become tolerant to the sedative effects of the drugs and some elderly patients experience excessive sedation with poor memory, poor concentration and poor coordination, leading to weakness. Like all sedatives, benzodiazepines interact with alcohol and therefore these should not be used in combination with alcohol.
In addition to the development of tolerance that occurs over weeks and months, there is also the development of dependency. Dependence is defined as a situation occurring as a consequence of the compensatory changes in the brain that arise from chronic administration of the drug. Physical dependence is associated with the experience of withdrawal symptoms that arise once the medication is discontinued.
There are also rebound effects that are defined as an increase in the severity in the initial symptoms, beyond that occurring in the patient before the treatment started. In other words, the person taking long-term benzodiazepines may experience more anxiety than they did in the first place. This is associated with conditions like rebound insomnia following abrupt discontinuation of benzodiazepine hypnotics or most sleeping tablets. Rebound anxiety occurs not uncommonly in patients in whom the benzodiazepine has been suddenly terminated (ended). The best advice involves slowly tapering the dose of benzodiazepine over a prolonged period of days or weeks and this largely overcomes the problem of rebound effects.
It is not a good idea to suddenly withdraw from high chronic doses of benzodiazepines. Sudden withdrawal of this kind has been associated with seizures and even paranoid behaviours in extreme cases. Withdrawal symptoms include psychological changes such as anxiety, irritability, insomnia and even dysphoria; as well as common bodily symptoms, such as palpitations, tremor, vertigo, sweating, hypersensitivity to light, sound, pain and even depersonalisation.
It has been estimated that between 15 and 30% of patients on benzodiazepines longer than one year will encounter problems or difficulties in trying to discontinue their medication. Measures to improve benzodiazepine and hypnotic prescribing in acute mental health centres have been published, and the strategies involved include better assessment of patients and clearer prescribing guidelines for clinicians. Significant changes in clinical practice can be achieved over time.
Unfortunately, the volume of the community taking benzodiazepines on a chronic basis is still very high. There is a need to promote better sleep practice in the community and to move away from a dependence on sleeping tablets.
All of this is ample reason to be concerned about the illegal use and purchase of benzodiazepines. Like any drug of abuse, there is a black market in these substances and people would be well advised to avoid engaging in this kind of drug use. Health services should provide better information for patients and service users on withdrawal schedules for hypnotic and anxiety agents, and we should all move towards a more mindful solution for the challenge of anxiety in our world.
The evidence is that practical measures such as greater exercise, withdrawal from the abuse of caffeine, and a willingness to experience what Jon Kabat-Zinn calls “full catastrophic reality” as part of a mindfulness regime are all better ways to deal with the anxiety in our lives.
This time has been called by some “the age of anxiety”. Dependence on benzodiazepines is no solution. A more mindful, exercised and engaged lifestyle is probably within our grasp. We can improve our response to anxiety by emphasizing the importance of mental health, by encouraging each other to take exercise, eat well and be mindful of ourselves and each other.
Useful references in regard to this can be found at the “Journal of Clinical Audits – Improving Benzodiazepine and Hypnotic Prescribing in an Acute Mental Health Hospital (C Ni Dhubhlaing et al)”or by accessing our information booklet on “Withdrawal schedules for hypnotic and anxiolytic agents”.
Information in relation to prescribing guidelines was obtained from the “Maudsley Prescribing Guidelines in Psychiatry”, 12th Edition, David Taylor et al, published by Wiley-Blackwell. Also referenced ‘Fundamentals of Psychopharmacology’ by Brian Leonard, published by John Wiley and Sons.
