From the Guidelines
Benzodiazepines are associated with increased all-cause mortality, particularly with long-term use, and may potentially reduce life expectancy. The evidence from studies, such as those published in the Annals of Internal Medicine 1, suggests that benzodiazepines can have serious adverse effects, including increased risk of falls, fractures, cognitive impairment, and respiratory depression. These risks are higher in older adults and those taking higher doses for extended periods.
Key Points to Consider
- Benzodiazepines should be used with caution and at the lowest effective dose for the shortest duration possible, typically not exceeding 2-4 weeks for anxiety or insomnia.
- Long-term use of benzodiazepines has been associated with increased mortality risk, as found in a retrospective cohort study using data from the United Kingdom General Practice Research Database 1.
- Non-pharmacological approaches like cognitive behavioral therapy should be considered as first-line treatments for anxiety and insomnia whenever possible.
- Patients should never abruptly stop taking benzodiazepines after long-term use; instead, a gradual, medically supervised taper is essential to minimize the risk of withdrawal.
Mechanisms of Potential Life-Shortening Effects
- Increased risk of falls and fractures
- Cognitive impairment leading to accidents
- Respiratory depression, especially when combined with opioids or alcohol
- Possible associations with pneumonia and other infections
- Worsening of existing respiratory conditions like sleep apnea or COPD
Given the potential risks associated with benzodiazepines, it is crucial to weigh the benefits against the risks and to consider alternative treatments. The FDA-recommended doses are often lower than those used in some studies, and most individuals at the end of a study continued to have global outcomes and sleep measures exceeding thresholds used for study enrollment, indicating that medications do not typically result in remission 1.
From the Research
Benzodiazepines and Life Expectancy
- The relationship between benzodiazepines (BZDs) and life expectancy is complex, with various studies investigating their long-term safety and potential risks 2, 3.
- A systematic review conducted in 2012 identified vulnerable populations, including those with renal disease, lung disease, and recent hospitalization, who may be at increased risk of harm from BZDs 2.
- Another study published in 2021 found that patterns of BZD use, including short-term, chronic, and discontinued use, were associated with an excess risk of all-cause mortality in the elderly 3.
- The study found that adjusted hazard ratios for all-cause mortality were higher for short-term use, chronic use-discontinued, and chronic use-ongoing, with higher risks observed for patients aged <80 years 3.
Long-term Use of Benzodiazepines
- Long-term use of BZDs is a concern due to the development of tolerance and risk of dependence, with numerous treatment guidelines recommending avoidance of long-term use 4.
- A systematic review of register-based studies found that the length of BZD use defined as "long-term" varied, with the most common definition being six months or longer during a year 4.
- The prevalence of long-term BZD use in the general population was estimated to be around 3%, with higher estimates found in studies focusing on the elderly 4.
Risks Associated with Benzodiazepines
- BZDs have been found to adversely affect the safety of older drivers, particularly at high doses and with long half-life compounds 5.
- The use of BZDs has also been associated with other risks, including psychomotor function impairment, crash involvement, and other types of injuries 5.
- These findings highlight the need for cautious prescribing of BZDs, including assessment of non-pharmacologic alternatives, use of the lowest possible dose for the shortest possible time, and avoidance of long half-life compounds 5.