Are benzodiazepines appropriate to prescribe for survivors and others after an incidence of mass trauma?

Emergency physician, Houston

The use of benzodiazepines in psychiatry and general medicine is fraught with controversy because of the potential for abuse and dependence. In daily practice, clinicians vary widely in their comfort level with prescribing this class of medications, whether for short-term relief of panic or for long-term prophylaxis of generalized anxiety. The use of benzodiazepines in acutely traumatized persons is particularly controversial.

After mass trauma, survivors may present to emergency departments (EDs) or other urgent care settings in significant distress. Common symptoms may include intense anxiety, panic attacks, agitation, insomnia, irritability, anger, and tearfulness. Some persons may have more intensely dramatic responses and present with erratic behavior; acting out; or less frequently, frank psychosis.

Trauma victims, and often their family members and loved ones, may request that medical practitioners provide sedating medications to relieve the intense distress associated with acute trauma. In addition, clinicians may have their own emotional reactions to traumatic incidents and to the distress of their clients; this may be especially true after mass trauma, when clinicians also will more likely be affected by the trauma. At first, it might seem that reducing the suffering experienced by trauma survivors by giving them benzodiazepines would be a reasonable, humane thing for clinicians to do. Unfortunately, the literature is equivocal on the benefits of such treatment.

Few studies have examined benzodiazepine use in acute trauma victims. In a study of clonazepam and alprazolam given within the first week after trauma, more patients who received medication met diagnostic criteria for post-traumatic stress disorder (PTSD) at 6 months than did those who did not receive medication.¹ Temazepam, given at bedtime, improved sleep and decreased symptoms of PTSD in acute trauma survivors; however, there was no follow-up beyond 1 week post-treatment.²

The data on the usefulness of benzodiazepines in trauma survivors suggest little long-term benefit and a potential for negative outcomes. When trauma survivors pre-sent with complaints of intense distress, benzodiazepines are often prescribed as sole agents without patients receiving adequate information about the potential for abuse and dependence. As a result, trauma therapists and mental health professionals often have to intervene and educate clients in whom a problem with these drugs has developed. Drug dependence issues are especially relevant to trauma survivors, given the comorbidity of substance abuse with trauma and PTSD.

Benzodiazepines should be used only in managing very intense anxiety and panic--and even then with great caution. Ideally, the patient's symptoms should be managed in the ED or urgent care setting, until the most intense distress resolves and the patient can be discharged without benzodiazepines. If benzodiazepines are necessary, the drugs should be prescribed for as short a time as possible, and the initial treatment plan should include a discussion of risks and side effects, as well as a plan for discontinuation. In emergency settings, dispensing medication for only 4 or 5 days is recommended; this ensures that dependence will not develop before follow-up can occur and reduces the potential for suicide by overdose.

The clinician should discuss with the patient the advisability of a less addictive, more long-term medication for ongoing symptoms, such as a selective serotonin reuptake inhibitor (SSRI). Ideally, treatment with an SSRI would begin concomitantly with the benzodiazepine, with the benzodiazepine slowly tapered over the first 10 to 14 days of treatment. Close follow-up is essential. If sleep is the primary goal of treatment, a non-habit-forming, nonbenzodiazepine agent (such as trazodone, diphenhydramine, or amitriptyline) is preferable to a benzodiazepine. Scott and Briere³ provide more detailed information on the specific psychopharmacology of acute traumatic stress.

As with any medical intervention, the above medications should only be given after a full psychiatric examination has been performed, a medical history obtained, and information about allergies and contraindications noted.

Catherine Scott, MD

Assistant Professor of Clinical Psychiatry

Keck School of Medicine, University of Southern California

Medical Director, Psychological Trauma Program

Attending Psychiatrist, Psychiatric Emergency Services

LAC+USC Medical Center

Los Angeles

John Briere, PhD

Associate Professor of Psychiatry and Psychology

Keck School of Medicine, University of Southern California

Director, Psychological Trauma Program

LAC+USC Medical Center

Los Angeles

References:

REFERENCES

1. Gelpin E, Bonne O, Peri T, et al. Treatment of recent trauma survivors with benzodiazepines: a prospective study.

J Clin Psychiatry.

1996;57:390-394.2. Mellman TA, Byers PM, Augenstein JS. Pilot evaluation of hypnotic medication during acute traumatic stress response.

J Trauma Stress.

1998;11:563-569.3. Scott C, Briere J. Psychobiology and psychopharmacology of trauma. In: Briere J, Scott C.

Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment.

Thousand Oaks, Calif: Sage Publications. In press.