The subject of Long Term Benzo Use, or long-term benzodiazepine treatment, is marked by a significant and often undiscussed paradox within published research. This paradox arises from two distinctly different perspectives. One perspective is heavily influenced by the experiences of patients attempting to discontinue long-term benzodiazepine use. These accounts frequently highlight the considerable challenges in stopping and maintaining abstinence from these medications, with studies showing that, on average, about one-third of individuals are unable to successfully cease usage. Originating from the work of experts like Ashton, numerous patient reports detail the adverse effects associated with benzodiazepines, not only during withdrawal but also with continued long term benzo use. These narratives often paint a concerning picture, describing a range of distressing symptoms during both ongoing use and withdrawal, including somatic complaints, emotional disturbances like uncontrollable crying or anger, eating disorders, anxiety, agoraphobia, and even hallucinations. Some patients describe a profound decline in overall functionality, with one individual stating, “I lost my corporate job after 20 years…due to low-dose benzodiazepines. This drug destroyed my entire health, personality, and quality of life.”
This viewpoint suggests that a substantial portion of long-term benzodiazepine users experience minimal therapeutic benefit, or may even be harmed by their continued medication use. The primary reason for ongoing use in these cases is often attributed to the difficulties of benzodiazepine withdrawal. This perspective is central to the concept of patient “dependence” and is a key factor behind treatment guidelines that advocate for benzodiazepines’ safe and effective use only for short-term periods. Supporting this view, studies on acute withdrawal have shown that individuals engaged in long term benzo use often exhibit high levels of pre-existing anxiety and depression, which paradoxically decrease after successful benzodiazepine tapering. However, it’s important to note that systematic research into chronic, persistent withdrawal syndromes or severe, long-term adverse effects directly linked to long term benzo use remains limited.
Conversely, a sharply contrasting perspective emerges from studies focusing on benzodiazepine efficacy and tolerability in long-term management. These investigations portray long-term maintenance treatment as generally stable and without major complications. Patients with anxiety disorders who initially respond well to benzodiazepines have been monitored for up to three years in both naturalistic and controlled double-blind studies. Notably, these studies have not observed dose escalation or a reduction in therapeutic effectiveness over time. While concerns about increased risks of cognitive and coordination impairments are valid, especially with aging populations continuing long term benzo use into geriatric stages, the long-term treatment efficacy literature does not typically report the severe adverse reactions highlighted in withdrawal-focused studies. Recent reviews even suggest that benzodiazepine withdrawal symptoms are comparable to, and not more severe than, those associated with antidepressant discontinuation. Furthermore, when used for anxiety disorders, benzodiazepines are often considered to have better tolerability profiles than antidepressants.
It’s also crucial to acknowledge a third, distinct group of benzodiazepine users: polysubstance abusers. These individuals use benzodiazepines alongside other substances, such as opioids or cocaine, to amplify the effects of other drugs or to mitigate undesirable side effects. Although often grouped with prescription benzodiazepine users, this population differs significantly in their motivations, patterns of use, and the resulting consequences.
While there is widespread agreement on the short-term effectiveness of benzodiazepines in treating anxiety, critical questions remain regarding long term benzo use. Specifically, we need better methods to identify individuals at higher risk of negative long-term outcomes and to gain a deeper understanding of the nature of these outcomes. Despite the limitations due to a lack of comprehensive systematic studies, existing research offers valuable insights. Discrepancies between the populations and treatment histories examined in withdrawal studies versus clinical efficacy trials may help explain the contrasting depictions of long term benzo use. However, these crucial differences have largely been overlooked in published discussions.
Treatment guidelines often involve study participants who are carefully selected based on well-defined anxiety disorder criteria and are managed by psychiatrists following specific protocols. In contrast, participants in benzodiazepine discontinuation studies are often described more vaguely, with many, if not most, having been treated by primary care physicians. Reasons for extended benzodiazepine prescriptions in these groups frequently include less clearly defined indications such as depression, insomnia, situational anxiety, psychosis, or somatic symptoms. Withdrawal study groups also commonly include patients without a specific diagnosis or clear medical need for long term benzo use. Furthermore, these studies often lack detailed information regarding participants’ previous treatment histories and responses. Predictive risk factors for adverse outcomes of long term benzo use are largely undefined and unexplored. The motivations behind patients’ desires to stop benzodiazepines also vary; some may have been advised to discontinue simply due to the duration of their use, while others might have experienced prior unsuccessful withdrawal attempts. In some studies, the aspect of patient motivation is not addressed at all.
What characteristics of these patient groups might elevate the risk of severe adverse experiences during both long term benzo use and subsequent withdrawal? A small, though undetermined, proportion of individuals may possess an exceptional physiological sensitivity to benzodiazepines and withdrawal, leading them to seek specialized withdrawal programs. A potentially larger group comprises diagnostically ambiguous individuals who may have been using benzodiazepines to alleviate general dysphoria related to life stressors—a purpose for which these medications are not well-suited. Such patients often exhibit maladaptive personality traits, which have been linked to more severe withdrawal experiences in short-term studies. Treatment settings where patients are not clearly informed about target symptoms, medication limitations, or are not thoroughly assessed for treatment response are also problematic. Lack of referral to non-pharmacological therapies for coping strategies in such cases can increase the risk of patients developing medication dependence and attributing a wide range of physical and psychological effects to the medication, beyond its inherent pharmacological actions. The powerful influence of patient expectations has been well documented, even in short-term withdrawal studies, where some patients who believed they were undergoing tapering but were still receiving their maintenance benzodiazepine dose reported experiencing subjective withdrawal symptoms.
The field of psychiatry has historically lacked robust, evidence-based guidelines for benzodiazepine prescribing. Following their introduction, benzodiazepines were sometimes prescribed liberally for anxiety-related complaints, often without clear indications, contraindications, or discontinuation plans. As the potential drawbacks of benzodiazepines became more apparent, the notion that they should never be considered as first-line treatments or for long term benzo use gained traction. However, this restrictive view may not fully align with the extensive evidence base concerning benzodiazepine safety, efficacy, and tolerability when used appropriately.
Our understanding of the long-term adverse effects of benzodiazepines remains limited by a lack of systematic research. There is a consensus that elderly patients engaging in long term benzo use face heightened risks of sedation, cognitive impairment, and falls, necessitating cautious use and close monitoring in this population. However, concerns that benzodiazepines might increase the risk of dementia have not been substantiated. Future research should prioritize patients in primary care settings who are prescribed benzodiazepines for managing distress related to life stressors. Conversely, we have substantial evidence supporting well-monitored benzodiazepine treatment for patients with diagnosed anxiety disorders. Ignoring the risks of inappropriate prescribing is as detrimental as overlooking the evidence supporting appropriate therapeutic applications. As suggested by recent research on long term benzo use, revising current prescribing guidelines may be timely. Adopting evidence-based working guidelines would be a prudent step and ultimately serve the best interests of our patients. We propose the following guidelines:
- Benzodiazepines can be appropriate for both short-term and long-term maintenance treatment of well-defined DSM anxiety disorders, particularly panic disorder, social anxiety disorder, generalized anxiety disorder, and disorders with mixed anxiety and depressive features.
- Long term benzo use should only continue when there is clear and sustained benefit from the medication, maintained at stable doses.
- Patients should receive comprehensive education from the outset regarding the specific symptoms being targeted, the limitations and goals of benzodiazepine therapy, and the potential need for psychotherapy to address cognitive distortions and avoidant behaviors associated with anxiety. Prescribers must be prepared to provide or refer patients for such treatments if symptoms or functional impairments persist despite medication.
- A realistic goal for medication in treating generalized anxiety disorder is to reduce anxiety to a manageable level, enabling the patient to effectively utilize non-pharmacological strategies, including cognitive and behavioral techniques, to enhance their coping abilities.
- Benzodiazepine prescriptions for anxiety or insomnia related to life stressors should be carefully monitored. Patients experiencing ongoing difficulties or perceived medication needs beyond a few weeks should undergo reassessment by a psychiatrist.
- Tapering off benzodiazepines should be undertaken for reasons specific to the individual patient and mutually agreed upon. Withdrawal processes should be flexible, collaborative, and supportive.
