Abuse of Benzodiazepines: The Problems and the Solutions

Abstract

Benzodiazepines are medications used to treat many of the most frequent and disturbing symptoms seen in medical practice, including anxiety, insomnia, muscle spasms, some forms of epilepsy, and other illnesses. The World Health Organization (WHO) has determined benzodiazepines to be “essential drugs” that should be available in all countries for medical purposes. As benzodiazepines were recognized as generally safe and effective drugs, their medical use increased but so did problems of abuse outside medical practice.

This report focuses specifically on the nonmedical use, or abuse, of benzodiazepines. Abuse includes purely illegal use as well as use of prescribed benzodiazepines for purposes, durations, or at dosage levels not intended by the prescribing physician or in ways outside medical guidelines.

The principal contribution of this report to the resolution of the controversy about the use of benzodiazepines is to draw a sharp distinction between the medical use of these drugs and their nonmedical use, which this report labels “abuse.” Problems which exist with the medical use of benzodiazepines, such as their use by patients who are better treated with other medications (or without medication) and the problems of withdrawal symptoms on discontinuation of medically prescribed benzodiazepines, are not addressed because these are problems of routine, legitimate medical practice.

On the other hand, aspects of medical practice which affect nonmedical use of benzodiazepines are extensively dealt with in this report including the diversion of legitimately prescribed benzodiazepines into the illicit drug market and the prescribing of benzodiazepines for drug abusers.

Extensive animal and human research has shown that benzodiazepines are “reinforcing” drugs in the sense that animals and humans will maintain behavior on which delivery of the drug is dependent. Animal studies of self-administration of potentially abused drugs show that benzodiazepines are less powerful reinforcers than intermediate half-life barbiturates (such as secobarbital) and psychomotor stimulants (such as amphetamine and cocaine).

A substantial body of human research has shown that benzodiazepines are moderately “liked” for their reinforcing effects by drug abusers and alcoholic subjects but that both anxious people and normal (non-drug abusing, non-anxious) human subjects prefer placebo to benzodiazepines, demonstrating that these substances are usually not liked by people who are not drug abusers or alcoholics. Among drug abusers, benzodiazepines are preferred less than either intermediate half-life barbiturates or stimulants. This difference between the response of substance abusers and normal and anxious research subjects supports the fundamental distinction made in this report between medical use of benzodiazepines and nonmedical use [1,2].

Survey research and other data demonstrate that abuse of benzodiazepines often is associated with abuse of drugs generally (including alcohol and illegal drugs such as marijuana, cocaine, and heroin) and abuse of other prescription drugs specifically. Within both contexts, benzodiazepine abuse occurs at modest levels relative to their widespread medical use. It is uncommon for drug abusers to seek out benzodiazepines as either initial or preferred drugs of abuse. Rather, benzodiazepines, when abused, are typically selected only after another drug has been used nonmedically.

Approximately 6.5 million Americans used a benzodiazepine nonmedically in 1985. Over half of all people reporting nonmedical benzodiazepine use reported total lifetime use as 10 times or less while an estimated 850,000 people used a benzodiazepine nonmedically more than 100 times in their lives. Sixty-one percent of nonmedical users were male and 74% were under the age of 35 years. Most of the nonmedical users reported substantial nonmedical use of other drugs. For example, 72% had used marijuana and 49% had used cocaine.

Approximately 11% of the drugs associated with surveyed emergency room drug abuse problems were benzodiazepines. Seven of the top 50 drugs of abuse seen in emergency rooms were benzodiazepines. In nearly 70% of surveyed emergency room (ER) visits involving benzodiazepines, use was in conjunction with at least one other drug. In more than half of the ER drug episodes involving benzodiazepines, the patient had attempted suicide. Because of the pharmacology of benzodiazepines, only a small percentage of those suicide attempts caused death unless the benzodiazepines were used in combination with other drugs having more lethal pharmacological properties.

Trend data show that the medical use of benzodiazepines peaked in 1976, declined significantly until 1982, and increased slightly in recent years. Current levels of medical use of benzodiazepines as tranquilizers are about 25% below the 1976 peak. Abuse of benzodiazepines also declined in recent years. Emergency room drug problems associated with benzodiazepines in 24 surveyed metropolitan areas decreased 41% between 1976 and 1985. Nevertheless, the problem of abuse of benzodiazepines remains serious.

Problems of benzodiazepine abuse exist among patients being treated for both alcoholism and drug abuse. A particularly high rate of abuse exists in some cities among heroin addicts receiving methadone maintenance treatment. Although some nonmedical use of benzodiazepines may be low-dose “self- medication” by addicts, most abuse appears to be for the “high” produced by the high-dose combination of a benzodiazepine with methadone.

Extensive clinical experience shows that only a very small percentage of patients who are not drug abusers or alcoholics and who are prescribed benzodiazepines for medical indications escalate their dose above commonly accepted treatment levels or go on to abuse other drugs or alcohol. In fact, the opposite pattern usually is seen in clinical practice, and survey research data confirms that most patients' medical use of benzodiazepines is brief or moderate or both.

Medical users of benzodiazepines, especially long-term users, in contrast to typical nonmedical benzodiazepine users, tend to be female and over 50 years old.

Several approaches show promise for reducing the abuse of benzodiazepines:

1. Education of physicians, pharmacists, patients, and the media about the safe use of benzodiazepines and methods of detecting and preventing their abuse. Physicians need reliable information on the prescribing indications and cautions for the benzodiazepines. Physicians must keep track of their patients' medical and nonmedical use of all drugs, including nonmedical drugs such as nonprescription sleeping aids and alcohol, in order to insure that problems (including abuse) do not develop. Patients and their families need to know the warning signs that indicate benzodiazepine abuse and they must safeguard the supply of these drugs in order to prevent someone other than the patient from taking them. Pharmacists need guidelines to identify physicians and patients whose use of benzodiazepines appears unwise. The media need accurate information in order to bring the abuse of benzodiazepines into perspective.

2. Working with drug and alcohol treatment programs to reduce the risk of abuse of benzodiazepines by patients. People with drug and alcohol abuse problems are at a high risk for benzodiazepine abuse. Their unique needs and the understanding of their special vulnerability require far greater attention than they have received in the past.

3. Developing nonintrusive means to identify the sources of benzodiazepines diverted to nontherapeutic uses. Several states and professional societies have effectively reduced the abuse of other prescription drugs. However, a small number of physicians and pharmacists in some areas are recklessly and, in some cases, criminally prescribing and dispensing abusable drugs, including benzodiazepines. Such physicians and pharmacists, as well as “patients” who deceive prescribing physicians, constitute a major source of diversion. All of these practices need to be identified and stopped by professional sanctions, regulatory agencies, and law enforcement.

Efforts to reduce benzodiazepine abuse must be governed by two considerations. The first is the large number of people for whom benzodiazepines are legitimately prescribed. The second is that benzodiazepines are not unique among prescription drugs in terms of actual or potential abuse. Nevertheless, benzodiazepine abuse has become a significant problem that must be addressed through cooperative efforts of industry, professional associations, treatment programs, and regulatory/law enforcement authorities. There is a need for additional research to define the nature, extent, and consequences of the abuse of benzodiazepines and to evaluate various solutions to the problem.