Guidelines for the rational use of benzodiazepines

Recreational users should limit use of benzodiazepines to once a week or less to minimize problems. Every day use is discouraged because addiction and tolerance can become an issue (editor).

The main actions of benzodiazepines (hypnotic, anxiolytic, anticonvulsant, myorelaxant and amnesic) confer a therapeutic value in a wide range of conditions.

Rational use requires consideration of the large differences in potency and elimination rates between different benzodiazepines, as well as the requirements of individual patients.

As hypnotics, benzodiazepines are mainly indicated for transient or short term insomnia, for which prescriptions should if possible be limited to a few days, occasional or intermittent use, or courses not exceeding 2 weeks.

Temazepam, loprazolam and lormetazepam, which have a medium duration of action are suitable. Diazepam is also effective in single or intermittent dosage. Potent, short-acting benzodiazepines such as triazolam appear to carry greater risks of adverse effects.

As anxiolytics, benzodiazepines should generally be used in conjunction with other measures (psychological treatments, antidepressants, other drugs) although such measures have a slower onset of action.

Indications for benzodiazepines include acute stress reactions, episodic anxiety, fluctuations in generalized anxiety, and as initial treatment for severe panic and agoraphobia.

Diazepam is usually the drug of choice, given in single doses, very short (1 to 7 days) or short (2 to 4 weeks) courses, and only rarely for longer term treatment.

Alprazolam has been widely used, particularly in the US, but is not recommended in the UK, especially for long term use.

Benzodiazepines also have uses in epilepsy (diazepam, clonazepam, clobazam), anaesthesia (midazolam), some motor disorders and occasionally in acute psychoses.

The major clinical advantages of benzodiazepines are high efficacy, rapid onset of action and low toxicity. Adverse effects include psychomotor impairment, especially in the elderly, and occasionally paradoxical excitement.

Long term use, tolerance, dependence and withdrawal effects can become major disadvantages. Unwanted effects can largely be prevented by keeping dosages minimal and courses short (ideally 4 weeks maximum), and by careful patient selection. Long term prescription is occasionally required for certain patients.

The benzodiazepine family of depressants are used therapeutically to produce sedation, induce sleep, relieve anxiety and muscle spasms, and to prevent seizures.

In general, benzodiazepines act as hypnotics in high doses, as anxiolytics in moderate doses, and as sedatives in low doses. Of the drugs marketed in the United States that affect CNS function, benzodiazepines are among the most widely prescribed medications and, unfortunately, are frequently abused.

Fifteen members of this group are presently marketed in the United States and an additional 20 are marketed in other countries.

Barbiturates and benzodiazepines differ from one another in how fast they take effect and how long the effects last. Shorter-acting benzodiazepines, used to manage insomnia, include estazolam (ProSom), flurazepam (Dalmane), quazepam (Doral), temazepam (Restoril) and triazolam (Halcion).

Benzodiazepines with longer durations of action include alprazolam (Xanax), chlordiazepoxide (Librium), clorazepate (Tranxene), diazepam (Valium), halazepam (Paxipam), lorazepam (Ativan), oxazepam (Serax) and prazepam (Centrax).

These longer acting drugs are primarily used for the treatment of general anxiety. Midazolam (Versed) is available in the United States only in an injectable form for an adjunct to anesthesia. Clonazepam (Klonopin) is recommended for use in the treatment of seizure disorders.

Flunitrazepam (Rohypnol), which produces diazepam-like effects, is becoming increasingly popular among young people as a drug of abuse. The drug is not marketed legally in the United States, but is smuggled in by traffickers.

Benzodiazepines are classified in the CSA as Schedule IV depressants. Repeated use of large doses or, in some cases, daily use of therapeutic doses of benzodiazepines is associated with physical dependence.

Withdrawal syndrome is similar to that of alcohol withdrawal and is generally more unpleasant and longer lasting than narcotic withdrawal and frequently requires hospitalization. Abrupt cessation of benzodiazepines is not recommended, and tapering-down the dose eliminates many of the unpleasant symptoms.

Given the number of people who are prescribed benzodiapines, relatively few patients increase their dosage or engage in drug-seeking behavior.

However, those individuals who do abuse benzodiazepines often maintain their drug supply by getting prescriptions from several doctors, forging prescriptions or buying diverted pharmaceutical products on the illicit market.

Abuse is frequently associated with adolescents and young adults who take benzodiazepines to obtain a high. This intoxicated state results in reduced inhibition and impaired judgement. Concurrent use of alcohol or other depressants with benzodiazepines can be life-threatening.

Abuse of benzodiazepines is particularly high among heroin and cocaine abusers. Approximately 50 percent of people entering treatment for narcotic or cocaine addiction also report abusing benzodiazepines.