Use, abuse, or misuse? Knowing when to stop benzodiazepines
Many patients who request a benzodiazepine dose increase need more medication to manage their anxiety or panic disorder. Some patients, however, are misusing or abusing the drug.
How can you tell when to stop a benzodiazepine prescription? Consider these cases:
Mr. A says a 1-week trial of diazepam, 5 mg tid, has alleviated his anxiety “a little” but adds that he has to “double-up” to get complete relief.
Is Mr. A being honest? Probably, because he is volunteering the information. Remember that diazepam, 10 mg every 4 hours, is within the agent’s therapeutic range for severe anxiety.
Recommendation: Increase diazepam to 10 mg tid and continue monitoring use. Expect that the patient may need additional doses during periods of greater stress.
Three days after his last visit, Mr. B says he lost his clonazepam or it was stolen.
Is Mr. B being honest? Possibly not. Patients who abuse their prescriptions often make this claim.
Recommendation: Admonish Mr. B that clonazepam is a controlled substance. Tell him you will terminate the prescription if he cannot keep it secure.
Schedule a follow-up appointment. At that visit, order a toxicology screen and remind the patient that he must manage his prescription.
Mr. C—who has been taking lorazepam, 5 mg tid to qid, for 1 year—mentions that he recently had a drink at a party. During his initial evaluation, he denied alcohol use. Upon further questioning, he admits that he drinks “socially” 4 to 6 times per year but never has more than a second drink on any occasion.
Is Mr. C being honest? Probably. Patients who drink minimally commonly deny alcohol use.
Recommendation: Explain the need to avoid alcohol when taking benzodiazepines but do not give the impression that an occasional drink will lead to serious harm or death.
Also find out how much and how often your patient drinks. Make sure “a drink now and then” is not in fact a few drinks 2 or 3 nights a week.
Ms. D says her diazepam use has escalated to 40 to 60 mg/d, depending on her anxiety level. One day she calls to reschedule her appointment; her speech sounds slightly slurred.
Is Ms. D being honest? Probably, but she may be misusing diazepam or abusing another substance.
Recommendation: See the patient ASAP. Order urine and serum toxicology and a breath alcohol test. Consider inpatient detoxification. Also consider switching anxiolytics, as benzodiazepine abusers often crave one agent but not another.
A new patient—Ms. E, age 70—says she has been taking diazepam, 5 mg qid, for 35 years.
Recommendation: Continue the prescription. Stopping diazepam for fear of long-term adverse effects could cause an upheaval for this patient.
Dr. Roth is attending psychiatrist, Department of Veterans Affairs Medical Center, North Chicago, IL.