Benzodiazepines, removing the stain

Lady Macbeth wanting to purge a stain

Benzodiazepines are a class of medicines that are as widely used as they are frequently criticized. As a class they have become stained largely as a result of the decades-long opiate crisis and the association of benzodiazepines with addiction.

For the purpose of discussion, I regard a stain as a blemish, something that is not essential to the inherent properties of the thing that is stained. Stains are ugly, properties are interesting.

As physicians we are at our best when we regard medicines objectively. All widely prescribed medicines have benefits and liabilities. The decision to use a particular drug should be based on the simple analysis that the benefits of the drug outweigh the liabilities to such a degree that, in a particular patient, there is no better choice of drug. The decision to maintain the use of a drug should be based on observing an improvement in functioning to the degree that the drug's liabilities are worth the benefit.

First, let's look at some benefits of benzodiazepines. Valium the prototype of its class was synthesized in the late 50s and first marketed in 1963. Valium was welcomed with great enthusiasm as it was replacing a class of meds, the barbiturates, that were hundreds of times more lethal in overdose. Valium and allied drugs became choice medicines to treat sleep difficulties, anxiety, and in the modern era, agitation. In our practice we frequently use benzodiazepines as mood stabilizers, helping patients contend with irritability and concomitant sleep problems, both of which are often in the bipolar spectrum. These patients often do poorly on antidepressants, and competing mood stabilizers such as Lithium, Depakote, Lamictal, or the second generation antipsychotics. All of these competing medicines have challenging issues and can have a side effect burden that exceeds drugs in the Valium class.

Negative attributes of benzodiazepines are that they can be problematic with people with addictions. They also can lead to physical dependence, ie, getting off of them requires a taper to avoid unpleasant and potentially hazardous withdrawal symptoms. Though the phenomenon of dependence is not the same as addiction, it nevertheless presents challenges. In all patients there is the potential for sedation if this class of drugs is not dosed properly. And finally, a problem with benzodiazepines is that they can make people feel good at the expense of helping a patient develop strength. We will have more to say about this in a bit.

Then there is the problem of the stain. Where do stains come from? Stains tend to evolve when a thing seems to be at odds with social trends. For example, psychedelics were popular and an object of fascination in the 60s both amongst scientists and the public. They then became associated with hippies, the antiwar movement, and were thought by the generation in power to be contributing to the disorder of society as a whole. Hence they were banished, regulated as schedule1 narcotics, ie, were designated as having no evidence of therapeutic benefit. With the ban, years of scientific research came to a halt.

We now are in an era in which society is loosening its grip on recreational drugs. Along with this, research is picking up from where it left off in the 60s. The perceived side effects of many drugs, from THC to LSD and Psilocybin are being more realistically weighed relative to the therapeutic promise of many of these drugs.

With regard to benzodiazepines, though their inherent properties have not changed an iota over the decades, the social tide has shifted negative regarding their acceptability. So what are physicians to do?

I would suggest that we stick to basics. First, make sure that in prescribing a benzo, as in deciding about any medicine, there is no better choice. Second, always pay close attention to functioning. If a drug is earning its keep, the benefit of the drug should be clear. Our patients on benzodiazepines should be energetic and alert. Drugs in psychiatry should contribute to a patient's strength. Feeling better should not be a shortcut to being better. Rather, if a medicine works well it should contribute of having the positive energy and strength to actively shape life in directions that work for us. We don't want our medicines to enable passivity.

Ultimately, it's up to doctors to see through the stain on benzodiazepines and be aware of their inherent properties both good and bad. It is up to us physicians to devote ourselves to the welfare of our patients rather be irrationally biased by social pressures. At times, that can take a bit of courage.