The Religion of Benzodiazepines

Man is tormented by no greater anxiety than to find someone quickly to whom he can hand over that great gift of freedom with which the ill-fated creature is born.
-Fyodor Dostoevsky, The Brothers Karamazov

Several months ago, a new psychiatrist came from a prestigious university in the Northeast to work in the VA hospital out West where I practice. During one of our initial conversations, he expressed the emphatic view that "benzodiazepines are only useful for acute alcohol withdrawal or psychiatric emergencies and other than that they have no place in pharmacology." I juxtaposed this position with that of several of our older clinicians, who are equally strong advocates of the generous use of benzodiazepines for a variety of psychiatric symptoms.

I mentioned this marked difference of opinion among our service to a wise mentor who responded, "benzodiazepines are a religion and this new fellow is an atheist while the others are true believers." While I am sure he meant the statement somewhat ironically, it started me thinking about the subject of science and faith in pharmacology and how this particular class of medications arouses passionate, even sectarian, divisions reminiscent of religious debates. This was not an entirely novel line of thought for me, since I can recall as a resident being struck by the wide and intense spectrum of theory and protocol among the attendings regarding benzodiazepines, especially for patients with a history of substance abuse. I once drew the diagram below to illustrate the polemic and have since employed it with my own residents to illustrate the divergence of faculty perspectives (Figure).

The science of benzodiazepines is not nearly as controversial as the faith.I was fortunate enough to have trained under Dr E. H. Uhlenhuth, one of the world's foremost experts on benzodiazepines. In a series of rigorous reviews and elegant clinical studies,^1-3 he has defended these much-maligned medications, as in the following abstract:

"Despite a sharp decline in the prescription of benzodiazepines during the past decade, reservations about their use have continued to escalate. . . . Data from . . . diverse sources . . . suggest that (1) the risks of overuse, dependence, and addiction with benzodiazepines are low in relation to the massive exposure in our society; (2) benzodiazepine addiction can occur when doses within the clinical range are taken regularly over about 6 months; (3) many patients continue to derive benefit from long-term treatment with benzodiazepines; and (4) attitudes strongly against the use of these drugs may be depriving many anxious patients of appropriate treatment."⁴

The last statement of this passage returns to our theme that it is more likely that provider perspectives, rather than cold clinical facts, underlie the immense light and heat surrounding these agents. In an excellent review of the history of attitudes toward benzodiazepines, Rosenbaum⁵ points out that despite the beneficial aspects of these nearly 4-decade-old drugs, there have been persistent concerns that benzodiazepines were being overprescribed and abused and that the risks of physical dependence and withdrawal were being underplayed. In contrast, proponents of the agents have argued that these objections diminish and dismiss the suffering and severity of anxiety disorders and insomnia.

In an essay in 1972, Klerman⁶ had characterized these 2 opposing perspectives toward the use of medications that relieve distress with the quasi-theological or moral terms, "pharmacological Calvinism" and "psychotropic hedonism." Kramer,⁷ in the best-selling Listening to Prozac, revisited this contrast with reference to the mood-brightening properties of fluoxetine. In a footnote in this book, Kramer mentions that, "In the 1980s Klerman told me he wished he had instead used the phrase 'pharmacological puritanism,' as more expressive of the judgmental and prohibitive quality of the objection to medication." For readers for whom it has been a few years since they took a philosophy or religion class, I would like to briefly review the historical schools of puritanism and hedonism to see what, in fact, they have to say about this contemporary issue in modern psychiatry.

Puritanism and hedonism
Contrary to its use in popular parlance, hedonism was an ethical theory that advocated not indulgence and excess but the good life worth living, of which pleasure was an important condition. Epicurus, one of the chief exponents of the theory, taught that humans should seek to attain a state of ataraxia, free from fear, trouble, pain, and anxiety-not unlike what contemporary clinicians endeavor to bring about through the use of anxiolytics.⁸ Puritanism is both a religious movement and a worldview; the latter can be traced back to ancient rivals of the Epicureans, the Stoics. Puritanism emphasized daily self-examination; hard work; and a demanding, austere moral code for individual, social, and economic life.⁹

Implications for prescribing
When these 2 fundamentally different and, I might venture, fundamental responses toward pain and peace in the human condition are applied to the prescribing of benzodiazepines, parallel sets of presuppositions and habits emerge. Clinicians who are on the conservative end of the prescribing spectrum weigh more heavily their own responsibility for causing psychomotor impairment and falls in the elderly and triggering or exacerbating abuse and dependence in those with an uncertain diathesis to addiction. This is in part a medical but also a moral, or in some frames of reference, a theological judgment, that anxiety, while not trivial, may be a lesser evil for which there are effective treatments-antidepressants and cognitive-behavioral therapy-with more benign side effects.¹⁰ Those on the more liberal end of the continuum of prescribing seem to place the locus of accountability more on patients-accepting their prima faciedescription of their anguish and their ability to maturely manage a controlled substance. While not discounting the real adverse possibilities of benzodiazepines, these physicians view the burden of worry, terror, or sleeplessness in anxious patients as far greater and more tangible.¹¹

A series of fascinating studies done with general practitioners in Norway regarding their prescribing of benzodiazepines supports this somewhat simplistic schema. High prescribers were more likely to attribute responsibility to the previous physician who started the drug initially, to the age of patients "too old to change," to the comorbid conditions of the patients causing them suffering, and to the autonomy of the patient.^12,13 Together, this constellation of factors expresses a hedonistic rather than a puritanical attitude toward benzodiazepines and indeed toward the theology of pharmacology.

However, the pervasive regulatory climate caused even the high end prescribers to have a sense of doing something immoral or illegal despite following the rules and acting within the standard of care. To manage this internal dissonance, the physicians justified their decisions in terms of humanism and compassion in accordance with hedonism. Those with lower volumes of benzodiazepine prescriptions were more comfortable with setting limits on patient demands, were more suspicious of patient motives, and were not afraid of making patients angry or running them off-approaches more consonant with puritanism.

These observations are not of merely academic interest when one realizes that in 1989, New York State instituted a triplicate prescription program for benzodiazepines, which most experts agree led to decreased use of the target drugs but increased use of older, more problematic medications such as barbiturates for the same eternal sedative-hypnotic indications.¹⁴ Note that both government qualms about abuse and diversion and clinician fears regarding punishment (legal action) of prescribers stand squarely in the line of puritanism.

Finding a balance
What is important to realize is that each time we write a prescription for alprazolam (Xanax) for a young woman with panic disorder or refuse to give an anxious elderly man diazepam (Valium), our choices may not be nearly as grounded in dispassionate research as we might think. Being aware of one's personal beliefs regarding benzodiazepines and the social and philosophical forces acting on the fulcrum of prescribing can help all of us find a balanced position in accordance with the 1990 task force report on benzodiazepines of the American Psychiatric Association (APA).¹⁵ Benzodiazepines, the APA said (and most good clinicians know), are not so much drugs of abuse as drugs that can be abused. As I tell my residents, in the end it is still the doctor who controls the prescription and so we should err on the side of succor whenever reasonable and resume the reins if the pleasure so overwhelms the patient that it causes pain.