What can be used to manage anxiety in a patient with a history of benzodiazepine (Benzodiazepines) and alcohol abuse?

Managing Anxiety in Patients with History of Benzodiazepine and Alcohol Abuse

Avoid benzodiazepines entirely in this patient and use buspirone or SSRIs as first-line pharmacotherapy, combined with cognitive behavioral therapy. 1, 2

Why Benzodiazepines Are Contraindicated

• The American Academy of Family Physicians explicitly recommends avoiding benzodiazepine refills in patients with history of alcohol or substance abuse due to significantly higher risk for dependence. 1
• Patients with substance use disorders require specialist management rather than benzodiazepine treatment. 1
• Benzodiazepines carry potential for abuse, and patients with alcohol use disorder are at documented higher risk for misusing these medications. 3
• While one study found no significant difference in benzodiazepine use patterns between anxiety patients with and without alcohol history over 12 months, this does not negate the fundamental safety concern that drives guideline recommendations against their use in this population. 4

First-Line Pharmacotherapy: Buspirone

Buspirone is the optimal choice for this patient because it has no abuse potential and does not exhibit cross-tolerance with benzodiazepines or alcohol. 2, 5

Key Advantages of Buspirone:

• The FDA label explicitly states buspirone "is not a controlled substance" and "has shown no potential for abuse or diversion" with "no evidence that it causes tolerance, or either physical or psychological dependence." 2
• Buspirone does not block withdrawal syndrome from benzodiazepines or other sedative/hypnotic drugs, making it safe to use during or after withdrawal from these substances. 2
• Studies in volunteers with history of recreational drug or alcohol use showed subjects could not distinguish buspirone from placebo, whereas they showed significant preference for benzodiazepines. 2
• Buspirone was found effective in comorbid anxiety disorder and alcohol use disorder patients. 5

Buspirone Prescribing Details:

• Take consistently either always with or always without food. 2
• Avoid large amounts of grapefruit juice during treatment. 2
• Does not cause significant functional impairment or sedation compared to other anxiolytics. 2
• Efficacy demonstrated in generalized anxiety disorder with treatment duration of 3-4 weeks in controlled trials, though 264 patients were treated for 1 year without ill effect. 2

Second-Line Option: SSRIs

SSRIs, particularly paroxetine and sertraline, represent alternative first-line agents but require caution regarding active alcohol use. 5, 3

SSRI Considerations:

• Paroxetine was found effective in social anxiety patients with alcohol dependence. 5
• Sertraline showed effective results in PTSD and comorbid anxiety-alcohol use disorder. 5
• Critical caveat: SSRIs should be used with caution when patients are actively drinking because they may increase alcohol consumption. 5
• In Japan, fluvoxamine, paroxetine, and escitalopram are approved for social anxiety disorder treatment. 3
• SSRIs are now considered first-line drugs for most anxiety disorder subtypes and have no dependency risk. 6

Alternative Pharmacological Options

Gabapentin and Pregabalin:

• Both gabapentin and pregabalin were found effective in comorbid anxiety disorder and alcohol use disorder. 5
• Gabapentin can be started at 100-300 mg and helps with withdrawal symptoms if the patient is discontinuing benzodiazepines. 1
• Pregabalin has shown benefit in facilitating benzodiazepine discontinuation. 1

Essential Psychotherapy Component

Cognitive behavioral therapy (CBT) should be provided concurrently with pharmacotherapy, as it is evidence-based treatment for anxiety disorders and can be delivered by physicians or in collaboration with nurses. 3

• CBT is available as insured psychotherapy treatment in many healthcare systems. 3
• Third-generation CBT approaches including mindfulness-based cognitive therapy and acceptance and commitment therapy are also options. 3

Critical Management Pitfalls to Avoid

Do Not Use Benzodiazepines Even Temporarily:

• The guideline for alcohol withdrawal syndrome recommends benzodiazepines for AWS treatment 3, but this is a distinct clinical scenario from ongoing anxiety management in a patient with abuse history.
• Long-acting benzodiazepines (chlordiazepoxide, diazepam) are recommended for AWS prevention of seizures 3, but once AWS is resolved, continuation for anxiety is contraindicated in this population. 1

Monitor for Substance Use:

• Screen for concurrent substance use disorders and psychiatric comorbidities before initiating any anxiolytic. 1
• Women with anxiety disorders are more vulnerable to maintaining alcohol consumption levels and suffer higher stress levels. 5

Avoid Polypharmacy Risks:

• Do not combine with opioids due to respiratory depression risk. 1
• Check for concurrent CNS depressants. 1

Treatment Initiation Strategy

1. Start buspirone as first-line agent given its complete lack of abuse potential and safety in substance use disorder populations. 2, 5

2. If buspirone is ineffective after adequate trial, switch to SSRI (paroxetine or sertraline), but only if patient is abstinent or has minimal alcohol use. 5

3. Consider gabapentin or pregabalin if both buspirone and SSRIs fail or are not tolerated. 5

4. Initiate CBT concurrently with any pharmacotherapy choice. 3

5. Refer to addiction psychiatry specialist if anxiety remains refractory, as patients with co-occurring substance use disorders require specialist management. 1