Benzos and Other Drugs

I rarely prescribe benzodiazepines, a chemical class of central nervous system depressants like alprazolam (Xanax), diazepam (Valium) and clonazepam (Klonopin) for purely psychiatric indications at all, and when I do I discontinue them as soon as possible. Physicians often compare benzos to other chronic prescribing in arguing against stopping them, but I believe those comparisons suffer from numerous flaws.

The key arguments against chronic benzo use:

  • Safer alternative treatments exist, including psychotherapy.
  • We cannot tell the patient still benefits from them without stopping the drug.
  • Discontinuation causes a reprise of the discomfort that led to the first prescription creating the illusion that the patient needs to continue.

Risks of benzos:

  • Impaired driving and other motor skills.
  • Falls.
  • Impaired judgement.
  • Disinhibition.
  • Interaction with alcohol and other drugs.
  • Somnolence.
  • Mood depression.
  • Overdose potential.

Let me compare and contrast with drugs that may warrant long term use. Parameters to consider:

  • Therapeutic effect
  • Abstinence syndrome
  • Time to loss of therapeutic effect
  • Symptoms treated
  • Availability of alternative treatments.

Buprenorphine (Suboxone)

  • No effective alternative for treating opiate addiction may exist.
  • Pain management led to the first use of opiates. Discontinuation of an opiate does not produce pain. It produces an entirely different syndrome.

Serotonin Reuptake Inhibitors

  • It may take weeks for return of the original target symptom.
  • The discontinuation syndrome bears no resemblance to the target symptoms/illness.
  • Risks of long term use pale by comparison to those of benzos.

Insulin

  • Diabetes does not resolve spontaneously.
  • Symptoms of diabetes recur almost immediately after discontinuation.
  • Insulin has no separate abstinence syndrome.

Oral contraceptives

  • They have no abstinence syndrome.
  • Discontinuation in itself does not lead to pregnancy.
  • You do not discontinue them just because you have not gotten pregnant (yet).

I have yet to find a valid comparison that might support chronic use of benzos.

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