Limited Utility for Benzodiazepines in Chronic Pain Management: A Narrative Review

Abstract

Introduction: Controversy and uncertainty exist about the use of benzodiazepine receptor agonists (BZRAs) in pain management. This article curates available research to determine the appropriate role of BZRAs in the course of pain management, and how prescribers might address these challenges. Methods: A narrative review was performed to determine the appropriate role of BZRAs in pain management and to develop practice recommendations. Publications were identified by a search of PubMed, references of retrieved reports, guidelines, and the author's personal files. Results: BZRAs were found to have analgesic benefit for two pain conditions: burning mouth syndrome and stiff person syndrome. Absence of research, heterogeneity of trials, and small sample sizes precluded drawing conclusions about efficacy of BZRAs for the other 109 pain conditions explored. Data supports the use of BZRAs to treat co-occurring insomnia and anxiety disorders but only when alternatives are inadequate and only for short periods of time (2-4 weeks). The utility of BZRAs is limited by loss of efficacy that may be seen with continued use and adverse reactions including physiologic dependence which develops in 20-100% of those who take these agents for more than a month. Conclusions: BZRAs are often used inappropriately in pain management. Their initiation and duration of use should be limited to a narrow range of conditions. When prescribed for 4 weeks or more, patients should be encouraged to discontinue them through a supported, slow tapering process that may take 12-18 months or longer.

Association between chiropractic spinal manipulative therapy and benzodiazepine prescription in patients with radicular low back pain: a retrospective cohort study using real-world data from the USA

“…24 28 Although early research suggested BZDs had a direct analgesic effect related to central or peripheral receptormediated interactions, 24 29 there has not been conclusive evidence that BZDs produce an overall analgesic effect. 22 Accordingly, researchers have proposed that benefits related to pain management could result from BZDs alleviating pain-related anxiety and/or depression. 27 Adverse effects of BZDs include sedation, addiction 7 and increased risk of suicide.…”

Suvorexant and mirtazapine improve chronic pain-related changes in parameters of sleep and voluntary physical performance in mice with sciatic nerve ligation

“…Sleep disorders and pain cause a vicious spiral and should be treated simultaneously in clinical situations. Common sleep drugs, benzodiazepines, and nonbenzodiazepines (also referred to as Z-drugs) have a narrow role in managing secondary sleep disorders caused by other mental or physical conditions, including pain [13]. Furthermore, the indications for these drugs should be limited due to their harmful side effects, such as falling [14], cognitive impairment [15], dependence [16], and increased risk of death [17].…”

Systemic and intra-amygdala administrations of midazolam reverse anxiety-like behavior induced by cohabiting with a cagemate in chronic pain condition

“…In this context, although benzodiazepines are frequently indicated for clinical treatment of pain-induced anxiety, their clinical use with analgesic intent is still controversial [55,56]. Here, we found that systemic injection of midazolam brought back the anxiety behavior of CNC group to CS levels.…”