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Editorial |

Why Are Benzodiazepines Not Yet Controlled Substances?

Nicholas Moore, MD, PhD1; Antoine Pariente, MD, PhD1; Bernard Bégaud, MD, PhD1
[+] Author Affiliations
1Department of Pharmacology, University of Bordeaux, Bordeaux, France
JAMA Psychiatry. 2015;72(2):110-111. doi:10.1001/jamapsychiatry.2014.2190.
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In this issue of JAMA Psychiatry, Olfson et al1 report a very comprehensive study of the use of benzodiazepines in the United States. This study confirmed what has been found in several other countries, that benzodiazepines are used predominantly in elderly persons, mostly women, and for long periods of time.2,3 The older the patient, the longer the drug is used. This would not be a major issue if benzodiazepines were truly useful (preferably life-saving) and reasonably risk-free. They have saved many lives by being used to attempt suicide instead of barbiturates that are much more toxic4; however, for their main indications of insomnia and anxiety, benzodiazepines fare little better than placebos after a few weeks of treatment. After an initial improvement, the effect wears off and tends to disappear. At that point, what happens when patients try to stop taking benzodiazepines is that they experience withdrawal insomnia and anxiety. The usual conclusion is “you see, they work. When I stop them, I get worse.” Initially, patients get better before returning to the pretreatment state and then get worse than before treatment began when they attempt to stop taking benzodiazepines. After a few weeks of treatment, patients are actually worse off than before they started (or at least not better) and cannot stop taking the drug.

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Submit a Comment
Why Are Benzodiazepines Not Yet Controlled Substances: It is the Wrong Solution
Posted on March 25, 2015
Mark Hyman Rapaport, MD
Brain Health Ctr, Emory School of Medicine, Department of Psychiatry/Behavioral Sciences
Conflict of Interest: None Declared

I am concerned by the Editorial by Moore and colleagues entitled “Why are Benzodiazepines Not Yet Controlled Substances” for several reasons(1). First, these authors clearly do not understand that in the United States neither State medical boards nor the controlled substance/regulated chemical registration certificate of the Drug Enforcement Administration restricts prescriptions of approved medication by medical specialty. Second, as is evident by the widespread prescription of both stimulants and narcotics, designating a class of medications “a controlled substance” does little to limit or control their prescription. There is no ideal solution to curb the inappropriate prescription of benzodiazepines or other potentially dangerous substances, but I would suggest that a concerted, multi-pronged educational program that is directed both at practitioners and the lay public would be more effective. For the practitioner, such efforts require the development and promulgation of guidelines, performance in practice measures, and Joint Commission quality improvement standards similar to those developed for hand washing and “time-outs” before interventional procedures. As we have observed over time in the United States, public health campaigns that inform the public about the risk of an activity, smoking tobacco for example, can have a profound effect on use. Third, although no one minimizes concerns about the potential adverse consequences of unnecessary or inappropriate medication use; it is important to remember that many of the studies describing these legitimate concerns are larger scale epidemiologic association studies(2,3). One must always be cautious to continually acknowledge the difference between an association or correlation and causality.

  1. Moore N, Pariente A, Begaud B.  Why are benzodiazepines not yet controlled substances?  JAMA Psychiatry 2015 72(2) 110-11.
  2. Olfson M, King M, Schoenbaumm. Benzodiazepine use in the United States. JAMA Psychiatry 2015 72(2) 136-141.
  3. Billiofi de Gage S, Begaud B, Bazin F et al. Benzodiazepine use and risk of dementia: prospective population –based study.  BMH 2012 345:e 6231.

Benzodiazepine Withdrawal Protocols
Posted on April 9, 2015
Jocelyn Pedersen
Brigham Young University, BWSG
Conflict of Interest: None Declared

This article does a good job of addressing half of the problem with prescribing benzodiazepines on a daily basis. What about withdrawal protocols? According to several studies (Ashton, 1984; Ashton, 2002; Lader, 2014) effects of cold turkey and or rapid withdrawals can last for years if not done properly. Lader emphasizes the need for a slow taper rate. According to Current Psychiatry (2013), before starting a tapering plan, it is essential to inform the patient about the risks of withdrawal. Abrupt reductions from high-dose benzodiazepines can result in seizures, psychotic reactions, and agitation. Ashton (2002) states that it cannot be too strongly stressed that withdrawal symptoms can be minimized and largely avoided by slow tapering. It has been estimated that perhaps 10-15 percent of long-term benzodiazepine users develop a "post-withdrawal syndrome.” The lack of recognition of post acute withdrawal syndrome leads the misdiagnosis and unnecessary treatment of additional psychiatric symptoms. Gabbard (2007) notes that the withdrawal reaction or protracted withdrawal may exacerbate or resemble serious psychiatric and medical conditions, such as mania, schizophrenia, agitated depression, panic disorder generalised anxiety disorder, and complex partial seizures and, especially at high doses, seizure disorders. For those patients who have already been harmed by benzodiazepine use, there needs to be a standardized method of withdrawal like the 10% diazepam reduction taper method recommended by Ashton and Current Psychiatry.


References:


Ashton, H. Benzodiazepine withdrawal: an unfinished story. British Medical Journal (Clinical research ed). 1984;288(6424):1135-1140.


Ashton, H. (2002). Benzodiazepines: how they work and how to withdraw (aka The Ashton Manual).


Gabbard, Glen O. (2007). Gabbard's Treatments of Psychiatric Disorders, Fourth Edition (Treatments of Psychiatric Disorders). American Psychiatric Publishing. pp. 209–211.


Lader, M. (2014). Benzodiazepine harm: how can it be reduced?. British Journal of Clinical Pharmacology, 77: 295–301. doi: 10.1111/j.1365-2125.2012.04418.x.4. Current Psychiatry (2013 September);12(9):55-56.


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