Are benzodiazepines (BZDs) used for long-term treatment?

From the Guidelines

Benzodiazepines are not recommended for long-term treatment due to their potential for physical dependence, cognitive impairment, and increased risk of falls and accidents. The most recent and highest quality study, published in 2020 in the Annals of Internal Medicine 1, advises against the use of benzodiazepines for treatment of chronic insomnia disorder, citing the widely known harms and adverse effects of benzodiazepines, including risk for dependency and diversion, falls and cognitive impairment in older patients, hypoventilation in patients with respiratory conditions, and neuromuscular diseases.

Key Points to Consider

• Benzodiazepines may improve sleep efficiency, sleep onset latency, sleep quality, total sleep time, and wake after sleep onset compared with placebo, but the benefits are outweighed by the risks of long-term use 1.
• The FDA has approved pharmacologic therapy for short-term use (4 to 5 weeks), and patients should not continue using the drugs for extended periods 1.
• Cognitive behavioral therapy for insomnia (CBT-I) is a more effective and safer alternative to pharmacologic treatments for chronic insomnia disorder, with fewer adverse effects and no risk of physical dependence 1.
• When benzodiazepines are needed, regular reassessment by a healthcare provider is essential, and the lowest effective dose should be used, with discontinuation always being gradual through tapering to minimize withdrawal symptoms 1.

Recommendations for Clinical Practice

• Use benzodiazepines for short-term treatment only (2-4 weeks), and always reassess the need for continued treatment after this period.
• Consider CBT-I as the first-line treatment for chronic insomnia disorder, due to its effectiveness and safety profile.
• Monitor patients closely for signs of physical dependence, cognitive impairment, and increased risk of falls and accidents when using benzodiazepines.
• Gradually taper benzodiazepines when discontinuing treatment to minimize withdrawal symptoms.

From the FDA Drug Label

DRUG ABUSE AND DEPENDENCE Physical and Psychological Dependence Withdrawal symptoms similar in character to those noted with sedative/hypnotics and alcohol have occurred following discontinuance of benzodiazepines, including alprazolam tablets WARNINGS Dependence and Withdrawal Reactions, Including Seizures Certain adverse clinical events, some life-threatening, are a direct consequence of physical dependence to alprazolam tablets. Spontaneous reporting system data suggest that the risk of dependence and its severity appear to be greater in patients treated with doses greater than 4 mg/day and for long periods (more than 12 weeks)

Benzodiazepines are not recommended for long-term treatment due to the risk of dependence and withdrawal reactions, which can be severe. The risk of dependence is greater with higher doses and longer treatment durations, typically more than 12 weeks 2 2.

From the Research

Benzodiazepines (BZDs) Use for Long-Term Treatment

• Benzodiazepines are generally not recommended for long-term treatment due to the risk of addiction, withdrawal symptoms, and potential side effects 3, 4, 5.
• However, long-term prescription is occasionally required for certain patients, and the definition of long-term use varies in different studies, ranging from one month to several years 3, 6.
• The most common definition of long-term BZD use is six months or longer during a year, and the prevalence of long-term BZD use in the general population is estimated to be about 3% 6.
• Long-term use of BZDs typically involves steady treatment with low doses, but in elderly patients, long-term BZD use and exceeding recommended doses is relatively common 6.
• Several characteristics are associated with long-term BZD use, including steady treatment with low doses, and uniform definitions for "long-term" use are needed to have more comparable results between studies 6.

Risks and Disadvantages of Long-Term BZD Use

• Long-term use of BZDs can lead to tolerance, dependence, and withdrawal effects, which can become major disadvantages 3, 4, 5.
• The risk of addiction and physical dependence is higher in patients with a history of alcohol or drug abuse, and dependent personalities pose a higher risk than other personality types 5.
• Adverse events, such as psychomotor impairment, especially in the elderly, and occasionally paradoxical excitement, can occur with long-term BZD use 3, 7.

Alternatives and Interventions for Long-Term BZD Use

• Cognitive Behavioral Therapies (CBT) and Acceptance and Commitment Therapy can increase abstinence success and address underlying conditions, such as insomnia and anxiety disorders 4.
• Pharmacological interventions, such as valproate, tricyclic antidepressants, and pregabalin, may facilitate BZD discontinuation, but the evidence is limited and of low quality 7.
• More research is needed to determine the effectiveness of these interventions and to develop uniform definitions for long-term BZD use 7, 6.