Benzodiazepines: good or bad medicine?

Roger Ladouceur

This month Canadian Family Physician presents the results of a survey of Belgian family physicians, which was designed to elicit their attitudes toward prescribing benzodiazepines (BZDs) and the barriers they perceived to nonpharmacologic methods as alternative ways to manage stress, anxiety, and insomnia (page e398). Anthierens and colleagues1 remind us how widespread the use of BZDs has become: in Belgium, 1 patient in 3 takes BZDs daily and in a habitual way; in Europe, a survey revealed that almost 10% of the population are taking BZDs over long periods; and in Canada, the rate of BZD use over long periods is about 3.4%. The authors also remind us how difficult it is to stop taking these medications once you have started.

Among the 948 family physicians surveyed, almost half (46%) did not see any problem with prescribing BZDs; approximately one-quarter considered habitual use of BZDs to be justified if patients felt better and were not experiencing secondary effects; and 71% believed that it was correct to prescribe BZDs for a week. It was the older physicians who mostly considered the use of BZDs as being justified.

In the opinion of the authors, such revelations were troubling, particularly in consideration of the risks associated with prescription of these medications: “The benefits associated with sedative use are marginal and are outweighed by the risks, particularly in people older than 60 years of age .... Long-term use, even at therapeutic dosages, has been associated with tolerance, dependence, and withdrawal effects.”1

In light of such statements, we would be right to ask why these medications have not simply been taken off the market if they are so pernicious. Moreover, for years we have been reminded that BZDs have been abused and that using them is risky. As Anthierens et al state, “It is now widely accepted that BZD prescribing has many risks, including tolerance, dependence and misuse, as well as BZD-induced depression, cognitive impairment, and psychomotor impairment.”1

Contradictory advice

Contrary to these affirmations and the beliefs set forth, the literature is not as adamant regarding the deleterious effects of BZDs. Other published articles have stated the following:

Chronic use of BZDs at a stable dose to manage anxiety and panic disorders is not associated with neuropsychologic impairment and does not cause problems in most patients.2
Clinical experience has shown that even over long periods of daily use, BZDs typically do not lose their efficacy and do not produce substantial problems for most patients.3
Serious concerns unrelated to addiction have been expressed, including the possibility of cerebral atrophy and personality change4; however, despite the widespread, long-term use of these agents to date, no evidence has emerged to suggest that any of these concerns are clinically relevant.5
Individuals with anxiety disorders who are taking BZDs sometimes complain of subjective loss of memory. Careful examination of the effects of long-term use of BZDs in panic disorder revealed meaningful nonclinical evidence of neuropsychologic impairment.6,7

If we analyze the evidence-based data with regard to the affirmations of Anthierens et al when they emphasize the deleterious effects of BZDs, we have to admit that the levels of evidence are somewhat low and open to discussion. In fact, the statement “It is now widely accepted that [use of BZDs is associated with] tolerance, dependence, and misuse, [and that BZDs] induce depression, cognitive impairment, and psychomotor impairment” is based on references that in some cases are at least 20 years old, and in other cases are not really relevant.

Who is right?

Is it those who propose that BZDs should be forbidden or those who suggest that their adverse effects have been exaggerated?

One thing is sure: it is reasonable to think that BZDs should be prescribed circumspectly and prudently. But to go beyond that and say that their use should be forbidden and that only nonpharmacologic methods should be used to treat stress, anxiety, or insomnia is going a bit too far. Benzodiazepines certainly have their place in the therapeutic arsenal. The Belgian physicians surveyed understood this well and expressed it strongly.

Footnotes

Cet article se trouve aussi en français à la page 1099.
Competing interests

None declared

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