Psychiatric Annals

EDITORIAL 

Benzomania or Benzophobia and the Risk-Benefit Equation

Jan Fawcett, MD

Abstract

The use of benzodiazepines in psychiatry and medicine is presently a topic of strong and differing opinions fueled by misunderstandings, at times misinformation, and even the incursion of social, economic, and political considerations. Their clinical efficacy in treating the prevalent and varying symptoms of anxiety combined with their low toxicity has resulted in a degree of use that has brought them to the attention of government agencies concerned with their overuse and abuse. Benzodiazepines' capacity to cause neuroadaptation symptoms upon withdrawal has often been confused with a potential for addiction. This potential is enhanced by the chronic and recurring anxiety symptoms that they are used to treat, which resemble withdrawal symptoms.

Benzodiazepines' risks, in terms of short-term memory effects, potential abuse in the common condition of alcohol dependency, and high rate of illicit use as a secondary drug of abuse by narcotic addicts, have raised concerns among many clinicians who deal with these populations.

Because anxiety cannot be characterized as one disorder or a simple syndrome, but is seen across human experience and suffering in varying manifestations, it is difficult to balance the risk of not treating these symptoms against the risk of treatment with benzodiazepines except on a case-by-case basis. There are honest disagreements about this, and very strongly held differing opinions remain unresolved to some extent because of multiple perspectives from which the varying opinions are based.

This was illustrated in the efforts of our peer reviewers. This issue's reviewers differed quite sharply in their critiques of the various articles. One reviewer felt that the risks of benzodiazepines were not adequately spelled out in some of the articles, while another reviewer felt that risks were overemphasized in some articles. Both their opinions were valid and were reached through their clinical experience and knowledge of the literature. As a compromise, certain changes were requested in these articles before publication to minimize these differences, but I am sure that differences still exist. The same differences of opinion reflected in reviews of this set of papers seem to be reflected among practicing clinicians and government agencies, and in society.

This issue of Psychiatric Annals, guest edited by Ronald L. Martin, MD, and Sheldon H. Preskorn, MD, deals with the topic of "special and innovative uses of benzodiazepines." As stated in their introduction, the articles focus on the uses of benzodiazepines aside from well-known applications in healthy adults.

In his article, "Benzodiazepine Use at the Medicine/Psychiatry Interface," James G. Peden, Jr., MD, addresses the benefits and risks concerned with the use of benzodiazepines as adjunctive treatment in peptic ulcer disease and dyspepsia, ulcerative colitis, hypertension, neurodermatitis, rheumatoid arthritis, hyperthyroidism, as well as their use in substance abuse, coronary artery disease, chronic obstructive pulmonary disease, and other medical disorders. While discussing the significant or meager benefits to be expected in each case, Dr. Peden reminds us of the risks that are situation specific.

William A. Hewlett, MD, PhD, discusses the use of benzodiazepines in obsessive compulsive disorder and Tourettes syndrome, pointing out both the generally limited results and the increased efficacy of individual benzodiazepines (in this case, clonazepam) in these disorders.

W Dale Horst, PhD, and Sheldon Preskorn, MD, then consider the role of benzodiazepines in the treatment of psychotic disorders. This paper provides a comprehensive review of the experience utilizing various benzodiazepines as adjuncts in the treatment of both psychoses and acute mania.

This set of papers is accompanied by two articles reviewing clinical experience in the use of benzodiazepines at the two ends of the life cycle. Barbara J. Coffey, MD, brings us "Review and Update: Benzodiazepines in Childhood and Adolescence."…

The use of benzodiazepines in psychiatry and medicine is presently a topic of strong and differing opinions fueled by misunderstandings, at times misinformation, and even the incursion of social, economic, and political considerations. Their clinical efficacy in treating the prevalent and varying symptoms of anxiety combined with their low toxicity has resulted in a degree of use that has brought them to the attention of government agencies concerned with their overuse and abuse. Benzodiazepines' capacity to cause neuroadaptation symptoms upon withdrawal has often been confused with a potential for addiction. This potential is enhanced by the chronic and recurring anxiety symptoms that they are used to treat, which resemble withdrawal symptoms.

Benzodiazepines' risks, in terms of short-term memory effects, potential abuse in the common condition of alcohol dependency, and high rate of illicit use as a secondary drug of abuse by narcotic addicts, have raised concerns among many clinicians who deal with these populations.

Because anxiety cannot be characterized as one disorder or a simple syndrome, but is seen across human experience and suffering in varying manifestations, it is difficult to balance the risk of not treating these symptoms against the risk of treatment with benzodiazepines except on a case-by-case basis. There are honest disagreements about this, and very strongly held differing opinions remain unresolved to some extent because of multiple perspectives from which the varying opinions are based.

This was illustrated in the efforts of our peer reviewers. This issue's reviewers differed quite sharply in their critiques of the various articles. One reviewer felt that the risks of benzodiazepines were not adequately spelled out in some of the articles, while another reviewer felt that risks were overemphasized in some articles. Both their opinions were valid and were reached through their clinical experience and knowledge of the literature. As a compromise, certain changes were requested in these articles before publication to minimize these differences, but I am sure that differences still exist. The same differences of opinion reflected in reviews of this set of papers seem to be reflected among practicing clinicians and government agencies, and in society.

This issue of Psychiatric Annals, guest edited by Ronald L. Martin, MD, and Sheldon H. Preskorn, MD, deals with the topic of "special and innovative uses of benzodiazepines." As stated in their introduction, the articles focus on the uses of benzodiazepines aside from well-known applications in healthy adults.

In his article, "Benzodiazepine Use at the Medicine/Psychiatry Interface," James G. Peden, Jr., MD, addresses the benefits and risks concerned with the use of benzodiazepines as adjunctive treatment in peptic ulcer disease and dyspepsia, ulcerative colitis, hypertension, neurodermatitis, rheumatoid arthritis, hyperthyroidism, as well as their use in substance abuse, coronary artery disease, chronic obstructive pulmonary disease, and other medical disorders. While discussing the significant or meager benefits to be expected in each case, Dr. Peden reminds us of the risks that are situation specific.

William A. Hewlett, MD, PhD, discusses the use of benzodiazepines in obsessive compulsive disorder and Tourettes syndrome, pointing out both the generally limited results and the increased efficacy of individual benzodiazepines (in this case, clonazepam) in these disorders.

W Dale Horst, PhD, and Sheldon Preskorn, MD, then consider the role of benzodiazepines in the treatment of psychotic disorders. This paper provides a comprehensive review of the experience utilizing various benzodiazepines as adjuncts in the treatment of both psychoses and acute mania.

This set of papers is accompanied by two articles reviewing clinical experience in the use of benzodiazepines at the two ends of the life cycle. Barbara J. Coffey, MD, brings us "Review and Update: Benzodiazepines in Childhood and Adolescence." She presents a comprehensive discussion of the experience using benzodiazepines in a wide range of childhood and adolescent disorders while considering the risks and benefits involved. Steven P. Wengel, MD, and associates review the "Use of Benzodiazepines in the Elderly." This article clearly emphasizes the importance of attention to risk factors involved in using benzodiazepines in elderly patients, while at the same time reviewing studies showing that there is a significant rate of utilization of these substances in elderly individuals. Taken together, these articles present a balanced picture of both varying degrees of benefits and varying risks in the more innovative uses of benzodiazepines in individual clinical situations.

Benzodiazepines represent a class of medications that show effectiveness in a wide range of anxiety disorders and symptoms encountered in psychiatry and medicine. Because of this and their relatively good safety profile with respect to toxicity, they are very widely used all over the world. The prevalence of benzodiazepine use, misunderstandings concerning the neuronal adaptation changes that can lead to withdrawal on abrupt or too rapid discontinuation, the risk of their being abused or leading to a relapse in potentially alcohol-dependent individuals, and their use by narcotic addicts add to the overall social risks of these compounds.

At least one state (New York) has elevated benzodiazepines to Schedule II, requiring triplicate prescriptions and placing them on a par with narcotic substances. However, there is question as to whether this level of control over-restricts their use, leading to the use of more dangerous anxiolytic medications including alcohol as self-medication. Since alcohol is quite freely available without prescription and is demonstrably more toxic and dangerous than benzodiazepines, it would be more logically compatible to have its availability at least as controlled as that of benzodiazepines. One does not see legislators rushing ahead with fervor in this direction based on the outcome of previous efforts. Perhaps the problem is that benzodiazepines are one of a very few chemicals that can come close to being successfully regulated, even if it is the least significant in the drug abuse epidemic.

The bottom line may be that benzodiazepines are useful medications for a large number of people, maybe even lifesaving for a few. Like any other medication, there are risks to be balanced against the benefits, and both vary from patient to patient. We hope this series of articles provides a constructive step toward evaluating the benefits and risks of these medications in regard to the individual patient, the diagnosis, and the specific benzodiazepine involved.

10.3928/0048-5713-19930601-04

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