The diagnosis and management of benzodiazepine dependence
Purpose of review
Despite repeated recommendations to limit
benzodiazepines to short-term use (2–4 weeks), doctors
worldwide are still prescribing them for months or years.
This over-prescribing has resulted in large populations of
long-term users who have become dependent on
benzodiazepines and has also led to leakage of
benzodiazepines into the illicit drug market. This review
outlines the risks of long-term benzodiazepine use, gives
guidelines on the management of benzodiazepine
withdrawal and suggests ways in which dependence can
Recent literature shows that benzodiazepines have all the
characteristics of drugs of dependence and that they are
inappropriately prescribed for many patients, including
those with physical and psychiatric problems, elderly
residents of care homes and those with comorbid alcohol
and substance abuse. Many trials have investigated
methods of benzodiazepine withdrawal, of which the
keystones are gradual dosage tapering and psychological
support when necessary. Several studies have shown that
mental and physical health and cognitive performance
improve after withdrawal, especially in elderly patients
taking benzodiazepine hypnotics, who comprise a large
proportion of the dependent population.
Benzodiazepine dependence could be prevented by
adherence to recommendations for short-term prescribing
(2–4 weeks only when possible). Withdrawal of
benzodiazepines from dependent patients is feasible and
need not be traumatic if judiciously, and often individually,
benzodiazepine dependence, benzodiazepine withdrawal,
prevention of dependence
Curr Opin Psychiatry 18:249–255.#2005 Lippincott Williams & Wilkins.
Department of Psychiatry, University of Newcastle upon Tyne, Royal Victoria
Infirmary, Newcastle upon Tyne, UK
Correspondence to Professor C.H. Ashton, Department of Psychiatry, University of
Newcastle upon Tyne, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
Tel: +44 191 2226000 ext 6978; fax: +44 191 2226162;
Current Opinion in Psychiatry 2005, 18:249–255
#2005 Lippincott Williams & Wilkins
Since their introduction in the 1950s, benzodiazepines
appear to have passed their zenith of medical popularity.
However, they are still prescribed excessively and often
inappropriately. With their reputation perhaps approach-
ing a nadir, at least as prescribed medications for
long-term use, it is timely to review approaches to the
diagnosis and management of dependence on these
The benzodiazepine bonanza
In the late 1970s benzodiazepines became the most
commonly prescribed of all drugs in the world. Their
range of actions – sedative/hypnotic, anxiolytic, anti-
convulsant and muscle relaxant – combined with low
to make them ideal medications for many common con-
ditions (Table 1). The drugs were prescribed long term,
often for many years, for complaints such as anxiety,
depression, insomnia and ordinary life stresses. Benzo-
diazepines were undoubtedly efficacious at first for these
conditions, and apparently harmless – but there was a
sting in the tail.
By the early 1980s long-term prescribed users themselves
had realized that the drugs tended to lose their efficacy
over time and instead became associated with adverse
effects. In particular, patients found it difficult to stop
taking benzodiazepines because of withdrawal reactions
and many complained that they had become ‘addicted’
[1??]. Controlled clinical trials among such patients [2–4]
demonstrated beyond doubt that withdrawal symptoms,
even from regular ‘therapeutic’ doses of benzodiazepines,
Changing definitions of dependence
That benzodiazepines could cause physical dependence
withdrawal syndrome occurred on cessation of regular
use, and doctors were advised to reserve them for
short-term use in minimal dosage [5,6]. However, defini-
tions of drug dependence changed in the 1990s.
Previously, dependence had been defined in terms of
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The diagnosis and management of benzodiazepine dependence Ashton255