Benzodiazepines: The Considerable Risk of Abuse & How to Taper

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CONFERENCE REPORTER

Benzodiazepines, a controversial treatment widely prescribed for anxiety and insomnia, carry a considerable risk of abuse.

The poster, “Mood over Matter: literature review on benzodiazepine tapering, current practices and updates on adjunct mood stabilizers,” presented at the 2024 American Psychiatric Association Annual Meeting, summarized a literature review of current benzodiazepine tapering practices, outpatient detoxification challenges, and potential barriers to discontinuation.¹ The presenters also prioritized reviewing literature that highlighted mood stabilizer adjunct use.

Here is some of the research the presenters featured:

-A recent study reveals that between 2014 and 2016, an estimated 25.3 million US adults (10.4%) reported using benzodiazepines, and approximately 17.2% of these individuals admitted to misuse.²

-The National Institute on Drug Abuse documented that benzodiazepines were implicated in over 14% of opioid overdose deaths in 2021.³

-A report from the Centers for Disease Control and Prevention pinpointed benzodiazepines as a factor in nearly 7000 overdose deaths across 23 states from January 2019 to June 2020, constituting 17% of all drug overdose deaths. This timeframe saw a staggering 520% surge in deaths related to illicit benzodiazepines, while fatalities from prescribed benzodiazepines rose by 22%.⁴

Challenges to tapering patients with chronic benzodiazepine use include:
-Difficulty tolerating intense withdrawal symptoms

-Heightened anxiety

-Mood shifts

-Disrupted sleep

-Tremors

The presenters believe psychiatric and addiction-focused clinicians play an integral role in preventing benzodiazepine misuse, abuse, and addiction. In order to help patients taper benzodiazepines to discontinuation, clinicians must be up to date on practices; if clinicians mismanage tapering, sudden withdrawal can prove fatal.

As to tapering strategies, the presenters suggested adjunct mood stabilizers such as carbamazepine and oxcarbazepine. Carbamazepine, used as an adjunct or prophylactically, can help reduce intense withdrawal symptoms and thus keep patients on track for discontinuation. However, carbamazepine has received criticism regarding its efficacy, and is well documented to have a series of concerning adverse effects such as skin reactions, agranulocytosis, leukopenia, and significant drug-drug interactions by nature of its metabolism. This makes some clinicians wonder: are the risks are worth the benefit? Oxcarbazepine has also been proposed as an alternative. Some small-scale clinical trials noted moderate efficacy for oxcarbazepine in helping patients with detoxification and it has fewer adverse effect concerns. The presenters suggested that other mood stabilizers, particularly those with anti-epileptic effects, require further research for their potential help with benzodiazepine addiction.

“Through a more current literature review, we hope to increase the tools available to psychiatrists for more success in discontinuation and maintaining sobriety for patients,” wrote the presenters.

However, others—like Psychiatric Times columnist Daniel Morehead, MD—suggest that while benzodiazepines certainly carries risks, those risks are exaggerated by government officials, critics, and the public at large.⁵ Steve Adelman, MD, suggests 8 universal precautions adapted from Gourlay et al for use by psychiatrists who must decide whether to initiate or continue pharmacotherapy with benzodiazepines.⁶

What are your thoughts on benzodiazepines? Let us know at PTEditor@MMHGroup.com!

References

1. Vo PB, Qazi Z, Rashid K, Rafano CM. Mood over Matter: literature review on benzodiazepine tapering, current practices and updates on adjunct mood stabilizers. Poster presented at: 2024 APA Annual Meeting; May 4-8, 2024; New York, NY. Accessed April 25, 2024. https://s7.goeshow.com/apa/annual/2024/poster_search.cfm?session_key=8E8BB444-90B1-1C06-DFD2-2FB028E89C7E&session_date=Saturday,%20May%2004,%202024

2. Maust DT, Lin LA, Blow FC. Benzodiazepine use and misuse among adults in the United States. Psychiatr Serv. 2019;70(2):97-106.

3. Drug overdose death rates. National Institute on Drug Abuse. Accessed May 1, 2024. https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates

4. A day to remember: International Overdose Awareness Day. Centers for Disease Control and Prevention. Accessed May 1, 2024. https://www.cdc.gov/drugoverdose/featured-topics/ioad-benzo-overdose.html

5. Morehead D. Benzodiazepines: fellow psychiatrists, we still have work to do. Psychiatric Times. April 23, 2024. https://www.psychiatrictimes.com/view/benzodiazepines-fellow-psychiatrists-we-still-have-work-to-do

6. Adelman S. Benzodiazepines: it’s time to prescribe caution. Psychiatric Times. November 10, 2021. https://www.psychiatrictimes.com/view/benzodiazepines-it-s-time-to-prescribe-caution