Benzodiazepines and stimulants for patients with substance use disorders

Although benzodiazepines and stimulants have well-documented efficacy for numerous psychiatric disorders, psychiatrists hesitate to prescribe these medications to patients with substance use disorders (SUDs)—even to those with a comorbid condition that likely would respond to a benzodiazepine or stimulant—because of risk of abuse or dependence. Conventional practice typically has focused on treating active substance use first rather than using simultaneous treatments. Prejudice, fear, and misinformation can influence this decision.

We believe these cases lie on a continuum. At one extreme, ignoring a past or present SUD may lead a remitted patient toward relapse, or further delay recovery for an active user. At the other end, psychiatrists who overreact to a remote history of substance use may deprive patients of legitimate pharmacologic symptom relief. Most cases lie somewhere in the middle.

A literature review does not support the assertion that the use of these medications leads to future substance use or worsens active use, especially for stimulants. In fact, stepwise—as opposed to concurrent—treatment for both conditions actually may delay recovery and increase patients’ risk for morbidity.

We outline issues involved in these complex clinical situations, point out controversies, review relevant research data, and offer guidelines for treatment.

CASE 1 Panic disorder in sobriety

Since he was a teen, Mr. A, age 51, drank heavily, which cost him jobs and relationships. After being convicted for driving under the influence, he was court-ordered to attend a rehabilitation facility, where, as he describes it, he “finally turned [his] life around.” He followed up residential treatment with regular attendance at Alcoholics Anonymous meetings.

After 1 year of sobriety, Mr. A develops increasingly frequent episodes of intense anxiety with sweating, nausea, chest pain, and hyperventilation and is diagnosed with panic disorder. His internist prescribes alprazolam, 0.5 mg 3 times a day, which provides some symptom relief, and refers him for follow-up psychiatric care. At his first visit, Mr. A confides to his psychiatrist that he is taking much more than the prescribed dosage of alprazolam, even when he is not experiencing anxiety, and is contemplating “buying it on the street” if his dosage is not raised to “at least 3 mg 3 times a day.”

CASE 2 Anxiety in controlled psychosis

Ms. B, age 40, had her first psychotic break at age 18 and was diagnosed with schizophrenia. Since then, she has had multiple psychiatric hospitalizations, usually presenting with auditory hallucinations and a recurring delusion that the person who calls herself Ms. B’s mother is really an actress “playing” her mother. At times this delusion has led Ms. B to attack her “imposter” mother. Over several years Ms. B began to drink heavily, but recently achieved a few months of sobriety by attending dual-diagnosis groups at her local community mental health center and individual psychotherapy sessions with her case manager. Fortunately, Ms. B’s psychosis has been stabilized with risperidone long-acting injection, 25 mg every 2 weeks, which she tolerates well.

When her beloved calico cat passes away, Ms. B experiences intense anxiety. Ms. B’s friend tells her she “needs some Valium,” but her psychiatrist, case manager, and the other patients in her dual-diagnosis group are not sure this is a good idea.

Benzodiazepines

Pros. There are multiple legitimate uses of benzodiazepines in general medicine and psychiatric practice, based upon their considerable sedative/hypnotic, anxiolytic, anticonvulsant, and muscle-relaxant properties (Table 1).¹

Recommendations regarding benzodiazepine use for anxious patients with a history of SUD are not clear-cut. First, it often is difficult to determine whether the patient truly has an anxiety disorder or is suffering anxiety symptoms secondary to substance use and/or withdrawal. In addition, even if a diagnosis of a separate anxiety disorder is established, psychiatrists debate how to treat such patients. Some clinicians maintain that benzodiazepines should be used only for acute detoxification, and that ongoing benzodiazepine use will lead to relapse or benzodiazepine dependence. However, in a prospective study of 545 alcohol use disorder (AUD) patients receiving benzodiazepines for anxiety disorders, Mueller et al² found no association—at 12 months or at 12 years—between benzodiazepine use and AUD recurrence. Furthermore, there was no difference in benzodiazepine usage when comparing patients with and without an AUD.³

Table 1

Clinical uses of benzodiazepines