From the Guidelines
Benzodiazepines should not be used chronically for generalized anxiety disorder, panic disorder, mood disorders, or as muscle relaxants for refractory lower back pain due to their significant risks and unfavorable long-term outcomes. The use of benzodiazepines for these conditions is associated with physical dependence, tolerance, cognitive impairment, and an increased risk of falls and accidents 1. For patients with generalized anxiety disorder, panic disorder, or mood disorders, first-line treatments include selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs), often combined with cognitive-behavioral therapy.
When considering treatment for chronic back pain, non-opioid analgesics, physical therapy, and non-benzodiazepine muscle relaxants like cyclobenzaprine or tizanidine are preferred for short courses. If benzodiazepines are prescribed, it should be at the lowest effective dose for the shortest duration possible, with regular reassessment and a tapering plan to minimize the risk of dependence and withdrawal symptoms. The evidence from the study published in the Annals of Internal Medicine in 2007 highlights the effectiveness of various medications for acute and chronic low back pain but also notes the limitations and potential harms associated with long-term use of certain medications, including benzodiazepines 1.
Key considerations for the management of these conditions include:
- Avoiding chronic benzodiazepine use due to its risks
- Utilizing first-line treatments for anxiety disorders and chronic back pain
- Implementing a cautious approach when benzodiazepines are necessary, with a focus on the shortest duration and lowest effective dose
- Regularly reassessing the need for medication and planning for tapering when appropriate. The primary goal is to prioritize the patient's morbidity, mortality, and quality of life, which is best achieved by avoiding the long-term use of benzodiazepines for these conditions.
From the Research
Chronic Benzodiazepine Use for Generalized Anxiety Disorder (GAD) and Other Conditions
- Patients with GAD can be treated with various classes of drugs, including benzodiazepines, but these should not be given over the long term due to the danger of addiction 2.
- Benzodiazepines may still be prescribed for a limited amount of time (i.e., 6 to 12 weeks) due to the fluctuating nature of generalized anxiety 3.
- The chronic evolution of GAD in most patients often justifies the long-term prescription of serotoninergic (5-HT) or dual-action (5HT-NA) antidepressants and sometimes of 5HT-la partial agonists like buspirone 3.
- Antidepressants, such as imipramine, venlafaxine, and paroxetine, have been found to be superior to placebo in treating GAD, with a calculated number needed to treat (NNT) of 5.15 4.
Chronic Benzodiazepine Use for Panic Disorder and Other Mood Disorders
- Benzodiazepines have been used effectively for panic disorder and generalized anxiety disorder, but their use should be limited due to the risk of addiction 5.
- Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are useful first-line agents for most anxiety disorders, including panic disorder and generalized anxiety disorder 5.
- Other antidepressants, such as tricyclic antidepressants or monoamine oxidase inhibitors, are generally reserved as second- and third-line strategies due to tolerability issues 5.
Chronic Benzodiazepine Use as Muscle Relaxants for Refractory Lower Back Pain
- There is no direct evidence in the provided studies to support the use of chronic benzodiazepines as muscle relaxants for refractory lower back pain.
- However, it is worth noting that benzodiazepines are sometimes used as muscle relaxants, but their use should be limited due to the risk of addiction and dependence 6, 2, 3, 5.