Puritanism and hedonism
Contrary to its use in popular parlance, hedonism was an ethical theory that advocated not indulgence and excess but the good life worth living, of which pleasure was an important condition. Epicurus, one of the chief exponents of the theory, taught that humans should seek to attain a state of ataraxia, free from fear, trouble, pain, and anxiety—not unlike what contemporary clinicians endeavor to bring about through the use of anxiolytics.8 Puritanism is both a religious movement and a worldview; the latter can be traced back to ancient rivals of the Epicureans, the Stoics. Puritanism emphasized daily self-examination; hard work; and a demanding, austere moral code for individual, social, and economic life.9
Implications for prescribing
When these 2 fundamentally different and, I might venture, fundamental responses toward pain and peace in the human condition are applied to the prescribing of benzodiazepines, parallel sets of presuppositions and habits emerge. Clinicians who are on the conservative end of the prescribing spectrum weigh more heavily their own responsibility for causing psychomotor impairment and falls in the elderly and triggering or exacerbating abuse and dependence in those with an uncertain diathesis to addiction. This is in part a medical but also a moral, or in some frames of reference, a theological judgment, that anxiety, while not trivial, may be a lesser evil for which there are effective treatments—antidepressants and cognitive-behavioral therapy—with more benign side effects.10 Those on the more liberal end of the continuum of prescribing seem to place the locus of accountability more on patients—accepting their prima faciedescription of their anguish and their ability to maturely manage a controlled substance. While not discounting the real adverse possibilities of benzodiazepines, these physicians view the burden of worry, terror, or sleeplessness in anxious patients as far greater and more tangible.11
A series of fascinating studies done with general practitioners in Norway regarding their prescribing of benzodiazepines supports this somewhat simplistic schema. High prescribers were more likely to attribute responsibility to the previous physician who started the drug initially, to the age of patients "too old to change," to the comorbid conditions of the patients causing them suffering, and to the autonomy of the patient.12,13 Together, this constellation of factors expresses a hedonistic rather than a puritanical attitude toward benzodiazepines and indeed toward the theology of pharmacology.
However, the pervasive regulatory climate caused even the high end prescribers to have a sense of doing something immoral or illegal despite following the rules and acting within the standard of care. To manage this internal dissonance, the physicians justified their decisions in terms of humanism and compassion in accordance with hedonism. Those with lower volumes of benzodiazepine prescriptions were more comfortable with setting limits on patient demands, were more suspicious of patient motives, and were not afraid of making patients angry or running them off—approaches more consonant with puritanism.
These observations are not of merely academic interest when one realizes that in 1989, New York State instituted a triplicate prescription program for benzodiazepines, which most experts agree led to decreased use of the target drugs but increased use of older, more problematic medications such as barbiturates for the same eternal sedative-hypnotic indications.14 Note that both government qualms about abuse and diversion and clinician fears regarding punishment (legal action) of prescribers stand squarely in the line of puritanism.
Finding a balance
What is important to realize is that each time we write a prescription for alprazolam(Drug information on alprazolam) (Xanax) for a young woman with panic disorder or refuse to give an anxious elderly man diazepam(Drug information on diazepam) (Valium), our choices may not be nearly as grounded in dispassionate research as we might think. Being aware of one's personal beliefs regarding benzodiazepines and the social and philosophical forces acting on the fulcrum of prescribing can help all of us find a balanced position in accordance with the 1990 task force report on benzodiazepines of the American Psychiatric Association (APA).15 Benzodiazepines, the APA said (and most good clinicians know), are not so much drugs of abuse as drugs that can be abused. As I tell my residents, in the end it is still the doctor who controls the prescription and so we should err on the side of succor whenever reasonable and resume the reins if the pleasure so overwhelms the patient that it causes pain.