Valium (Diazepam) for Long-Term Treatment of Alcohol Use Disorder
No, Valium (diazepam) should not be used for long-term treatment of alcohol use disorder—it is indicated only for short-term management of acute alcohol withdrawal symptoms and must be discontinued within 10-14 days due to significant abuse potential and lack of evidence for maintaining abstinence. 1, 2, 3
FDA-Approved Indication and Duration Limits
The FDA label explicitly states that diazepam "may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis" in acute alcohol withdrawal, but emphasizes that "the effectiveness of diazepam in long-term use, that is, more than 4 months, has not been assessed by systematic clinical studies." 2
Benzodiazepines including diazepam should not be continued beyond 10-14 days due to abuse potential, and after stabilization of acute withdrawal, psychiatric consultation is mandatory for long-term abstinence planning using evidence-based medications. 4
Why Diazepam Fails as Long-Term Treatment
Controlled studies demonstrate that benzodiazepine treatment does not improve abstinence rates in alcohol use disorder, and most reviews conclude that routine long-term use of benzodiazepines is not indicated. 3
Long-term benzodiazepine use in patients with alcohol dependence carries substantial risks including addiction, physical dependence, memory impairment, confusion, and delirium—particularly problematic given that patients with a history of alcohol abuse pose a higher risk for developing benzodiazepine dependence. 3, 5
Patients with dependent personalities and those with a history of alcohol or drug abuse should not receive long-term benzodiazepines, as they carry significantly higher risk of developing dependence than other personality types. 5
Evidence-Based Long-Term Treatment Options
After acute withdrawal is managed with benzodiazepines, transition to these FDA-approved or guideline-supported medications for maintaining abstinence:
First-Line Options for Abstinence Maintenance
Acamprosate reduces withdrawal effects and craving for alcohol, with treatment initiated 3-7 days after the last drink at 1,998 mg/day for patients ≥60 kg (reduced by one-third for <60 kg) for 3-6 months total duration. 1
Naltrexone decreases dopamine concentration and dampens the reward pathway, reducing excessive drinking and recurrence rates, dosed at 25 mg for 1-3 days then increased to 50 mg for 3-12 months—however, it is contraindicated in patients with alcoholic liver disease due to hepatotoxicity risk. 1, 4
Baclofen (a GABAB receptor agonist) has demonstrated efficacy in maintaining abstinence by reducing alcohol craving specifically in patients with liver cirrhosis over a 12-week course, making it particularly valuable for patients with alcoholic liver disease where naltrexone is contraindicated. 1
Critical Transition Protocol
Begin planning for long-term abstinence medications during the acute withdrawal phase (days 3-5), as psychiatric consultation is mandatory after stabilization for evaluation, ongoing treatment planning, and long-term abstinence strategies. 4
Start tapering benzodiazepines by 96 hours (4 days) after the last drink, as patients should be showing symptom improvement and nearing resolution of acute withdrawal by this time. 4
Common Pitfalls to Avoid
Never continue benzodiazepines "as needed" for anxiety or insomnia after acute withdrawal, even though many alcoholics in clinical practice continue to receive them for these indications—this practice lacks evidence for improving abstinence and increases dependence risk. 3
Do not prescribe diazepam prophylactically—over 70% of cirrhotic patients may not require benzodiazepines at all, and treatment should only be given based on actual withdrawal symptoms, not preventively. 4
Avoid the trap of treating post-acute withdrawal anxiety with continued benzodiazepines—instead, use evidence-based abstinence medications combined with psychosocial interventions including cognitive behavioral therapy, individual psychotherapy, and group therapy such as Alcoholics Anonymous. 1
The Correct Role of Diazepam in Alcohol Use Disorder
Diazepam is the preferred benzodiazepine for acute alcohol withdrawal (not long-term treatment) because:
It has the shortest time to peak effect when given intravenously (10 mg initially, then 5-10 mg every 3-4 hours), facilitating rapid symptom control and accurate titration. 4, 6
Its long elimination half-life provides self-tapering with gradual level decrease, resulting in smoother withdrawal with lower incidence of breakthrough symptoms and rebound phenomena including decreased seizure risk. 6
Long-acting benzodiazepines like diazepam provide superior protection against seizures and delirium tremens compared to shorter-acting agents during the acute withdrawal period. 1, 4
The treatment duration should be limited to the acute withdrawal period only (typically 5-10 days maximum), followed by transition to evidence-based long-term abstinence medications and mandatory psychiatric consultation for ongoing care. 1, 4, 2