Benzodiazepines are a class of medications often prescribed for anxiety and insomnia. However, the long-term use of these drugs presents a complex and often contradictory picture when we examine existing research. On one hand, patient experiences and withdrawal studies highlight significant challenges in discontinuing benzodiazepines and persistent adverse effects even with continued use. On the other hand, studies focusing on efficacy and tolerability often portray long-term maintenance treatment as stable and generally well-managed. This article delves into this paradox, aiming to clarify the factors contributing to these differing perspectives and explore the concept of safer long-term benzodiazepine use within evidence-based guidelines.
Reports from individuals attempting to stop long-term benzodiazepine use frequently underscore the difficulties encountered. Discontinuation programs often report a considerable proportion of participants struggling to successfully wean off and remain off these medications. Alongside these challenges, anecdotal accounts, particularly stemming from the work of Dr. Ashton and others, describe a range of distressing experiences associated with both benzodiazepine withdrawal and continued long-term use. These include a wide array of physical symptoms, intense emotional disturbances like uncontrollable crying or anger, eating disorders, heightened fear and agoraphobia, and even hallucinations. Some patients describe a profound decline in overall functioning, with devastating impacts on their careers, health, and overall life quality, even from low doses. This perspective fuels the view that a significant number of long-term benzodiazepine users may derive minimal therapeutic benefit or even experience harm, continuing medication primarily due to withdrawal difficulties. This aligns with treatment guidelines generally advocating for short-term benzodiazepine use only, emphasizing the risk of dependence with prolonged treatment. Supporting this, studies on acute withdrawal have indicated that long-term users often exhibit elevated anxiety and depression levels at the start of withdrawal, which subsequently improve with successful tapering. Despite these observations, systematic investigations into chronic withdrawal syndromes or severe long-term adverse effects remain limited.
In contrast, research examining benzodiazepine efficacy and tolerability presents a different scenario. These studies often depict maintenance therapy as stable and relatively uncomplicated. Long-term follow-ups, extending up to three years in both naturalistic and controlled settings, involving anxiety disorder patients who initially responded well to benzodiazepines, have not observed dose escalation or loss of therapeutic effectiveness over time. While concerns about potential cognitive and motor skill impairments in older adults remain valid, the long-term treatment literature does not typically report the severe adverse reactions highlighted in withdrawal-focused studies. Recent reviews have even suggested that benzodiazepine withdrawal symptoms are comparable to, and not more severe than, those associated with antidepressant discontinuation. Furthermore, benzodiazepines, when used for anxiety disorders, have been reported to have better tolerability profiles than antidepressants in some studies.
It’s important to acknowledge a third, distinct group of benzodiazepine users: those who misuse these medications in conjunction with other substances, such as opioids or cocaine, to amplify desired effects or mitigate unwanted side effects. Although often grouped with prescription benzodiazepine users, their motivations, patterns of use, and consequences differ significantly.
While the short-term effectiveness of benzodiazepines in treating anxiety is widely accepted, crucial questions remain. We need to better understand how to identify individuals at greater risk of negative long-term outcomes and gain a deeper understanding of the nature of these outcomes. Despite the scarcity of systematic research, existing literature provides valuable clues. Discrepancies between the populations and treatment histories in withdrawal studies versus clinical trials may shed light on the contrasting views of long-term benzodiazepine treatment. However, these differences are rarely discussed in detail.
Treatment-focused studies typically involve participants carefully screened for specific anxiety disorders and managed by psychiatrists following established protocols. In contrast, participants in discontinuation studies are often less clearly defined, and many have been treated by primary care physicians. Reasons for extended benzodiazepine prescriptions in these groups often include less well-established indications such as depression, insomnia, situational anxiety, psychosis, or somatic complaints. Withdrawal cohorts frequently include individuals without a clear diagnosis or specific indication for benzodiazepine use. Furthermore, information on prior treatment courses and responses is often lacking in these studies. Predictive factors for adverse outcomes remain largely undefined. The motivations behind patients’ desire to discontinue benzodiazepines are also varied and often unclear, ranging from advice to discontinue due to long-term use itself, previous unsuccessful withdrawal attempts, to unaddressed motivational factors in some studies.
What characteristics of these patient groups might increase the risk of negative experiences during both long-term use and withdrawal? A small, unknown proportion may be inherently more susceptible to benzodiazepines and withdrawal effects due to physiological sensitivities, leading them to seek specialized withdrawal programs. A larger group likely consists of diagnostically ambiguous individuals attempting to alleviate general distress related to life challenges – a purpose for which benzodiazepines are not well-suited. These individuals often exhibit maladaptive personality traits, which have been linked to more severe withdrawal experiences in shorter-term studies. Treatment settings where patients are not adequately informed about the target symptoms and limitations of benzodiazepines, not carefully assessed for treatment response, and not offered non-pharmacological coping strategies when needed, are more likely to foster medication dependence and the attribution of non-pharmacological effects to the medication. The significant influence of patient expectations has been well documented, even in short-term withdrawal studies, where some individuals who believed they were being tapered off benzodiazepines (but were actually maintained on their dose) reported subjective withdrawal symptoms.
The field of psychiatry has historically lacked robust, evidence-based guidelines for benzodiazepine prescribing. Following their introduction, benzodiazepines were often broadly prescribed for anxiety-related complaints, sometimes without clear indications, contraindications, or discontinuation plans. As the potential downsides of benzodiazepines became more apparent, the notion that they should never be first-line treatments or used long-term gained prominence. However, this restrictive approach may not fully align with the substantial body of evidence supporting the safety, efficacy, and tolerability of benzodiazepines when used appropriately.
Systematic studies on the long-term adverse effects of benzodiazepines are still needed. It’s well-established that older adults using benzodiazepines face an increased risk of sedation, cognitive impairment, and falls, necessitating cautious use and close monitoring in this population. However, concerns about benzodiazepines causing 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. Nevertheless, we possess considerable evidence regarding well-monitored benzodiazepine treatment for patients with diagnosed anxiety disorders. Ignoring the risks of inappropriate prescribing is as detrimental as disregarding the evidence supporting appropriate therapeutic use. As suggested by recent research on long-term benzodiazepine treatment, revising current prescribing guidelines may be warranted. Adopting practical guidelines grounded in existing evidence would be a prudent step and in the best interest of patient care. Based on the evidence, the following working guidelines are proposed:
- Benzodiazepines can be appropriate for both short-term and long-term 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 treatment should only continue if there is clear and ongoing benefit from the medication at a stable dose.
- Patients should receive comprehensive education at the outset regarding the targets, limitations, and goals of benzodiazepine therapy, as well as the potential need for psychotherapy to address maladaptive thought patterns and avoidance behaviors associated with anxiety. Prescribers should be prepared to provide or refer patients for such therapies if symptoms or functional impairments persist despite medication.
- A reasonable aim of medication in treating generalized anxiety disorder is to reduce anxiety to a manageable level that allows the patient to effectively utilize non-pharmacological strategies, including cognitive and behavioral techniques, to improve coping skills.
- Benzodiazepines prescribed for anxiety or insomnia related to life stressors require careful monitoring. Patients experiencing ongoing difficulties or a perceived need for medication beyond a few weeks should be reassessed by a psychiatrist.
- Discontinuation of benzodiazepines should be considered for specific, patient-centered reasons, with mutual agreement between patient and prescriber. Tapering should be individualized, collaborative, and supportive.
In conclusion, navigating long-term benzodiazepine use requires a nuanced approach. While concerns about dependence and withdrawal are valid, evidence suggests that when used judiciously, with careful patient selection, monitoring, and within a framework of evidence-based guidelines, benzodiazepines can be a valuable tool in managing chronic anxiety disorders. Focusing on appropriate prescribing practices, patient education, and integrated treatment approaches is crucial to maximizing benefit and minimizing potential risks associated with long-term benzodiazepine therapy, moving towards a safer and more effective approach for patients in need.
