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Keywords:

  • Benzodiazepines;
  • clinical guidelines;
  • dependence;
  • prescription;
  • substitution

Dependence on benzodiazepines has been recognized as a significant clinical problem for 30 years [1–3] and yet, despite much effort into helping patients to stop taking these drugs and developing alternative forms of treatment, we are not much better off in practice than we were when the problem first attracted great media attention. A phenomenon that was described as worse than addiction to heroin in some quarters was appropriately penned as the ‘opium of the masses’[4], and those who prescribed these drugs thought of in the same terms as drug peddlers on the streets. This notion is, of course, nonsense, but it was held by many people at the time and led to a strong recommendation that these drugs should not be used or, if considered absolutely necessary, to be taken only for the ‘short-term relief’ (up to 4 weeks) of disabling anxiety [5]. As someone who was part of the working group that was consulted before this recommendation was made I thought it was both unrealistic and unwise, not least as we had evidence that when such a policy was implemented the outcome was worse after treatment and withdrawal of the benzodiazepine, diazepam, than when patients were given placebo tablets [6].

Liebrenz et al. [7] remind us of an uncomfortable truth; that despite all the good intentions and efforts to stop people taking benzodiazepines when they are dependent, they have failed and failed again, so that all that we can really recommend on the basis of good evidence is that benzodiazepines are reduced gradually [8]. Not only do people with high-dose dependence fail to withdraw successfully but those with low-dose dependence fail frequently too, and in personal studies we found attempts to persuade people not to take these drugs after they had been through the process of withdrawal successfully were thwarted; a majority returned to taking them in the longer term, not often regularly, but sufficiently to make a nonsense of the apparent triumph of stopping their drugs completely [9]. There is no evidence that this type of behaviour promotes dependence; it is more likely to reflect the well-known fact that many patients, particularly those with comorbid symptomatology, tend to relapse over time [10]. There are some who have claimed that benzodiazepines should never be prescribed for anxiety because it is an invitation to dependence, but long-term findings show that those who take medication have better health 10 years later than those with the same disorder who do not take medication [11].

Therefore, with this catalogue of failure of both pharmacological and psychological alternatives to benzodiazepines it is quite logical for Liebrenz et al. to suggest that controlled prescription of benzodiazepines, probably of the more long-acting and less potent variety in view of greater problems with the alternatives [12], might be a better therapeutic option. One of the most trenchant critics of the storm of opprobrium that followed the demonstration that benzodiazepines could create dependence was the Czech psychiatrist Frederick Kräupl Taylor, who anticipated Liebrenz et al. by 20 years, when he wrote:

Moreover, when patients have been fairly well adjusted on benzodiazepines for a long time but succumb, after a successful withdrawal procedure, almost immediately to a modified recurrence of their anxiety illness, the proof that there had been a continuing therapeutic activity of benzodiazepines could hardly be stronger. Of course, it then also follows that the patients are in need of further medication and perhaps even of further prescriptions for benzodiazepines [13] (p. 703).

Who should take regular benzodiazepines?

  1. Top of page
  2. Who should take regular benzodiazepines?
  3. Declaration of interests
  4. References

It is difficult to decide who should be the population who should be chosen, or allowed, to take benzodiazepines long-term. Liebrenz et al. do not address this subject, except by their implied benefit–risk calculation for each patient being considered. Particularly with high-dose dependence there are clear risks attached to regular consumption, but these may be substantially less than the dangers of refusal. Whatever is decided, the period of prescription should not be open-ended, but set for a fixed period and then reviewed. We are now in a position of equipoise whereby randomized controlled trials of such procedures would be fully justified and both the advantages and disadvantages of a substitution policy exposed for all to view.

References

  1. Top of page
  2. Who should take regular benzodiazepines?
  3. Declaration of interests
  4. References