Evidence-Based Reviews

Benzodiazepines for substance abusers

Current Psychiatry. 2003 May;2(5):25-34

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If anxiety does not improve with an adequate trial of first-line agents, consider adding long-acting benzodiazepines at sufficient dosages, such as clonazepam, 0.5 to 1 mg bid to tid. Prescribe scheduled doses, rather than “as needed.” Continue the first-line antianxiety agent, and reiterate to the patient that benzodiazepine therapy will be short-term.

Observe prescribing precautions (see Algorithm), and screen patients’ urine randomly every 1 to 3 months to monitor their adherence to substance abuse treatment.

Keep patient records current, with attention to dates of visits and prescriptions and quantity of benzodiazepines prescribed. To ensure proper continued use of benzodiazepines, consider consulting with physicians who have expertise in treating similar patients. Watch for possible signs of benzodiazepine dependence and abuse, such as requests for dose increases or early refills.

NONDRUG TREATMENTS

Nondrug treatments have been shown to reduce substance use and control anxiety in some studies. These include cognitive-behavioral therapy, motivational enhancement therapy, interpersonal therapy, and brief dynamic therapy, among others. Their use requires specific training or referral to more experienced colleagues. For information on these treatments, consult the Web sites of the National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism (Related resources).

Group and self-help therapies such as Alcoholics Anonymous or Narcotics Anonymous also have been shown to reduce substance use.

Related resources

Parran TV. Prescription drug abuse. A question of balance. Med Clin North Am 1997;81:967-78.
Lader M, Russell J. Guidelines for the prevention and treatment of benzodiazepine dependence: summary of a report from the Mental Health Foundation. Addiction 1993;88(12):1707-8.
National Institute on Drug Abuse. www.nida.nih.gov
National Institute on Alcohol Abuse and Addiction. www.niaaa.nih.gov

Drug brand names

Alprazolam • Xanax
Buspirone • BuSpar
Chlordiazepoxide • Librium
Clonazepam • Klonopin
Clorazepate • Tranxene
Diazepam • Valium
Flurazepam • Dalmane
Gabapentin • Neurontin
Lorazepam • Ativan
Mirtazapine • Remeron
Oxazepam • Serax
Temazepam • Restoril
Triazolam • Halcion
Venlafaxine • Effexor

Disclosure

This work was supported by the Attorney General’s Office, Commonwealth of Massachusetts and the United States Department of Veterans Affairs.

Dr. Sattar has received grant funding from Abbott Laboratories and is a speaker for AstraZeneca and Eli Lilly and Co.

Dr. Bhatia is a speaker for AstraZeneca, Eli Lilly and Co., Janssen Pharmaceutica, and Bristol-Myers Squibb Co.

Acknowledgment

The authors wish to thank Jennifer Hong, second-year medical student, Creighton University School of Medicine, Omaha, NE, for her assistance in preparing this article for publication.