Assessing the Risks and Benefits of Benzodiazepines for Anxiety Disorders in Patients with a History of Substance Abuse or Dependence

Abstract

In this article, the authors reevaluate the traditional position that benzodiazepines should be avoided in anxiety disorder patients with a history of substance abuse or dependence. The efficacy of benzodiazepines in each of the anxiety disorders is reviewed, as are their side effects and toxicity. The definitions of benzodiazepine abuse and dependence are discussed, and relevant animal, experimental, and clinical data are reviewed and analyzed. A manual and computerized (MEDLINE) search was performed from 1966 to the present to examine the English-language literature published on benzodiazepines, substance abuse, and each of the anxiety disorders listed in DSM-IV. The authors found that benzodiazepines have demonstrated efficacy in generalized anxiety disorder, panic disorder, and agoraphobia; they are promising agents in the treatment of social phobia and alcohol-induced anxiety disorders. They are generally well tolerated. There is much ambiguity over appropriate definitions for benzodiazepine abuse and dependence: although most benzodiazepine abusers concurrently abuse other substances, there is little evidence to indicate that a history of substance abuse is a major risk factor for future benzodiazepine abuse or dependence. Furthermore, benzodiazepines do not appear to induce relapse of substance abuse in these patients. The authors conclude that the position that benzodiazepines are contraindicated in former substance abusers appears to lack empirical justification. Benzodiazepines may be indicated in certain patients with anxiety disorders and a history of substance abuse or dependence.

Substance Use Disorders and Anxiety: A Treatment Challenge for Social Workers

“…It has been suggested that the empirical evidence regarding these concerns is lacking, and benzodiazepines may be safely used to treat anxiety disorders in some patients with a SUD (Posternak & Mueller, 2001), but this approach remains controversial. Buspirone, an anxiolytic with low abuse potential, has been shown to be efficacious in some studies in individuals with alcohol use problems and who are anxious (Kranzler et al, 1994; Malec, Malec, Gagne, & Dongier, 1996; McKeehan & Martin, 2002), but the results are mixed (Malcolm et al, 1992; Tollefson, Montague-Clouse, & Tollefson, 1992), and more evidence is needed.…”

Cognitive Control Network Function in Alcohol Use Disorder Before and During Treatment With Lorazepam

“…Benzodiazepines were recently explored (in combination with disulfiram) for the treatment of AUD in individuals with co-occurring anxiety in a 16-week open-label trial, at the end of which the benzodiazepine was tapered off (clinicaltrials.gov identifier: NCT00721526; manuscript under preparation). Benzodiazepines are commonly used to lower anxiety levels during treatment of alcohol withdrawal, and they may decrease craving, but there are few studies of their longterm effects on alcohol consumption (Mayo-Smith, 1997; Posternak & Mueller, 2001). The rationales for combining a benzodiazepine with disulfiram in this clinical trial were that the benzodiazepine could serve as a positive reinforcer for taking the disulfiram, and could decrease anxiety and insomnia symptoms (possible relapse triggers) (Brower, 2003; Posternak & Mueller, 2001).…”

“…Benzodiazepines are commonly used to lower anxiety levels during treatment of alcohol withdrawal, and they may decrease craving, but there are few studies of their longterm effects on alcohol consumption (Mayo-Smith, 1997; Posternak & Mueller, 2001). The rationales for combining a benzodiazepine with disulfiram in this clinical trial were that the benzodiazepine could serve as a positive reinforcer for taking the disulfiram, and could decrease anxiety and insomnia symptoms (possible relapse triggers) (Brower, 2003; Posternak & Mueller, 2001). Moreover, in addition to preventing drinking via its usual mechanism (expectation of the alcohol-disulfiram reaction), disulfiram could minimize one of the primary risks of benzodiazepines (sedation in combination with other sedating drugs) by discouraging concurrent heavy drinking.…”

Beliefs about the consequences of using benzodiazepines among persons with opioid use disorder

“…Although persons with opioid use disorders use BZDs for intended anxiolytic reasons (Fatseas, Lavie, Denis, & Auriacombe, 2009) and as a sleep aid (Gelkopf, Bleich, Hayward, Bodner, & Adelson, 1999; Posternak & Mueller, 2001; Vogel et al, 2013), BZDs are commonly used in conjunction with opioids to enhance their rewarding effects or “high” (Chen et al, 2011; Fatseas et al, 2009; for review see Jones, Mogali, & Comer, 2012) or to decrease the effects of opiate withdrawal (Stein et al, 2016). Not surprisingly, BZD use among opioid dependent persons is associated with heightened risk.…”