Valium (Diazepam) Has No Established Role in Chronic Pain Management and Should Be Avoided
Diazepam is not indicated for chronic pain and should not be used for this purpose. The FDA-approved indications for diazepam include anxiety disorders, acute alcohol withdrawal, and skeletal muscle spasm due to acute reflex spasm or upper motor neuron disorders—but not chronic pain 1. Current evidence demonstrates that benzodiazepines like diazepam lack meaningful analgesic properties and carry significant risks that outweigh any potential benefits in chronic pain management 2.
Why Benzodiazepines Should Be Avoided in Chronic Pain
Lack of Analgesic Efficacy
Benzodiazepines do not possess independent analgesic properties. Any reduction in pain complaints appears to be an indirect effect related to anxiolysis rather than true analgesia 3.
Clinical trial data shows no benefit. In patients with rheumatoid arthritis, diazepam failed to demonstrate any beneficial effect on pain intensity, function, or quality of life compared to placebo at 24 hours, 1 week, or 2 weeks 4.
The evidence base is insufficient. There is inadequate data to support the contention that benzodiazepines have meaningful analgesic properties in most clinical circumstances 3.
Significant Safety Concerns
High rate of adverse events. Patients receiving muscle relaxants including diazepam experienced significantly more adverse events compared to placebo (Number Needed to Harm = 3), predominantly central nervous system effects including dizziness and drowsiness 4.
Increased overdose risk when combined with opioids. Benzodiazepines and other sedative-hypnotics contribute to the risk of opioid analgesic overdose and cause anterograde amnesia 2.
Cognitive impairment and dementia risk. Long-term benzodiazepine use has been associated with cognitive impairment and dementia in the general population, which may negatively impact evidence-based pain treatments such as cognitive behavioral therapy 2.
Rapid development of tolerance and dependence. Benzodiazepines carry risks of physical and psychological dependence, worsening depression, and potential for overdose 3.
Guideline-Recommended Alternatives for Chronic Pain
First-Line Treatments by Pain Type
For Neuropathic Pain:
- Antidepressants (tricyclics, SNRIs like duloxetine and venlafaxine) 2
- Anticonvulsants (gabapentin and pregabalin have the strongest evidence) 2
- Topical lidocaine 2
For Fibromyalgia:
- Pregabalin, duloxetine, and milnacipran (all FDA-approved) 2
- The muscle relaxant cyclobenzaprine (note: this is NOT a benzodiazepine) 2
For Low Back Pain and Osteoarthritis:
Second-Line Considerations
- Opioids may be considered as second-line treatments for certain neuropathic pain conditions, though they have limited effectiveness in chronic noncancer pain overall 2
- Tramadol for fibromyalgia 2
The Only Potential Exception: Acute Muscle Spasm
Diazepam is FDA-approved as an adjunct for skeletal muscle spasm due to acute reflex spasm to local pathology (such as inflammation or trauma), not chronic conditions 1.
One case report suggested diazepam had an opioid-sparing effect for severe back pain with muscle spasm from vertebral metastases 5, but this represents acute cancer-related pain with muscle spasm, not chronic noncancer pain.
Even for acute muscle spasm, the FDA label notes that "the effectiveness of diazepam in long-term use, that is, more than 4 months, has not been assessed by systematic clinical studies" 1.
Clinical Pitfalls to Avoid
Do not prescribe benzodiazepines for chronic pain management under the guise of treating "muscle spasm" when the actual goal is pain relief 3, 4.
Exercise particular caution in patients on opioids. The combination significantly increases overdose risk 2.
Recognize that any perceived benefit is likely placebo effect or anxiolysis, not true analgesia, and does not justify the substantial risks 3.
If a patient is already on chronic benzodiazepines for pain, consider a judicious taper and transition to evidence-based alternatives 2.