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Anxiety

Best Practices for Prescribing Benzodiazepines

Understanding how to safely prescribe this class of medication.

Anxiety disorders are the most common mental health affliction, affecting 40 million Americans each year. Benzodiazepines are a fast-acting treatment option that can be used as needed to reduce panic, generalized anxiety, and phobias. While these drugs are highly effective, they also carry a risk of abuse. Patients who need these drugs should not have to wait for them or take doses that are unlikely to work just because they are potentially addictive. Nevertheless, physicians must carefully assess their patients for abuse risk factors and continually monitor patient outcomes.

To maximize value and reduce side effects, follow these prescription guidelines:

Get the Right Diagnosis First

The fact that a patient reports anxiety or insomnia does not necessarily mean that this is the correct diagnosis, nor that benzodiazepines are the appropriate treatment. Get a complete patient history, including a list of all symptoms and previous diagnoses. Then used evidence-based diagnostic criteria to arrive at the correct diagnosis.

Assess the Patient for Addiction and Abuse Risk Factors

Patients with a history of substance abuse, and especially of prescription drug abuse, should generally not take benzodiazepines. Proceed with caution if the patient has other risk factors, including:

  • a history of chronic pain
  • a family history of substance abuse
  • behavioral addictions

Advise Patients About Adverse Reactions

Don’t assume that patients know about benzo-alcohol interactions, or that your patient will read the drug insert. Tell patients explicitly that drinking alcohol and mixing other drugs with benzodiazepines is dangerous.

Consider Alternative Treatments

The most common use for benzodiazepines is in the treatment of anxiety-related conditions, including anxiety-related insomnia. A number of other medications may be more appropriate. Discuss these options with the patient first. If a patient has serious contraindications for benzodiazepines, such as ongoing alcohol abuse or a high risk of benzo abuse, prescribe another drug. Some alternative options include:

  • over-the-counter sleep aids
  • serotonergic medications for anxiety
  • antidepressants, especially SSRIs
  • anticonvulsant medications for restless leg syndrome

Discuss Lifestyle

Lifestyle changes alone are rarely sufficient to treat anxiety. They can, however, reduce the need for medication. Encourage patients to limit caffeine, cultivate mindfulness, get plenty of exercise, and adopt other healthy lifestyle strategies to manage anxiety. If a patient seeks benzodiazepines to deal with insomnia, discuss the importance of healthy sleep hygiene, including:

  • not lying awake in bed for long periods of time
  • using the bed only for sleep or sex
  • maintaining a cool, dark room
  • going to bed at the same time each night
  • waking at the same time each day
  • not exercising or consuming caffeine right before bed

Be Circumspect About Long-Term Benzo Use

Patients and clinicians should be clear about the specific purpose and use of the medication. For example, will the patient take the drug as-needed to prevent panic attacks or manage a specific phobia? Or is the patient using the drug on a continual short-term basis to manage severe anxiety? Be explicit with the patient about the length of time for which it is safe to use the drugs. Then work with the patient to build a treatment plan to manage and treat anxiety over the long-term.

IWhen patients use these drugs for long-term treatment, they absolutely must pursue other treatments as well, including therapy and lifestyle changes. Otherwise, the risk of abuse and drug-seeking greatly increases.

Continue to Monitor Patients

Physicians should continue to monitor patients for the duration of their benzodiazepine use. Even if a patient has used the drug for many months with no adverse effects, regular appointments to discuss side effects and symptoms are key. It’s equally important to continue asking patients if they have new symptoms or are taking any new medications. Not all patients realize that they need to convey this information to their providers.

Start Low and Go Slow

As with other potentially addictive drugs, the safest course of action is to start with the lowest dose that is likely to still be efficacious. Then steadily increase the dosage only if the patient tolerates the drug well and shows no signs of abuse. It’s appropriate to have more regular appointments during the initial weeks of benzodiazepine treatment.

Encourage Therapy

Many patients spend years living with anxiety, insomnia, or both before seeking treatment. So it should come as no surprise that they want fast relief. Many hope that medication will offer this fast relief, and are reluctant to try longer-term strategies such as therapy and lifestyle changes. However, therapy is highly effective in the treatment of anxiety and insomnia. Research consistently shows that cognitive-behavioral therapy (CBT) in particular can help patients make lasting sustainable changes.

Encourage patients to pursue therapy as part of their treatment plan. Encourage them to see medication as a way to get relief as they work through therapy, rather than as a permanent strategy. Remind them that benzodiazepines are not designed to be taken long-term and that therapy may offer the lasting relief they seek.

References

Benzodiazepine and z-drug safety guideline [PDF]. (n.d.). Kaiser Permanente.

Benzodiazepines, when to prescribe. (n.d.). Retrieved from https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health…

Facts & statistics. (n.d.). Retrieved from https://adaa.org/about-adaa/press-room/facts-statistics

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