Anxiety, Addiction, and Benzodiazepine Use

Speaking with Joseph F. Goldberg, MD, Carl Salzman, MD, recounted a talk he delivered years earlier at an American Psychiatric Association meeting. Using anonymous audience-responses, Salzman asked how many attendees had brought a benzodiazepine to the meeting, regardless of whether they intended to take it. Roughly a third of the audience reported bringing one, Salzman recalled.¹ Most respondents did not identify a specific reason for carrying the medication, though sleep disruption in an unfamiliar location and flight-related anxiety were commonly cited explanations. Salzman said of this indication, "I don't think it's bad because there's no evidence that this leads to further taking and drug addiction." He characterized the behavior as reflecting benzodiazepines' status as a preferred hypnotic rather than evidence of misuse, noting that even psychiatrists familiar with the drugs' pharmacology sometimes took them without a prescription on isolated occasions, such as before a flight.

Salzman also addressed physiologic dependence associated with benzodiazepines, sedative-hypnotics that act at the GABA-chloride ionophore, the chloride-channel complex through which these agents produce their anxiolytic and sedative effects. Regular use over a period of weeks, for example alprazolam 0.5 mg taken 2 to 3 times daily, produced sufficient receptor-level changes that abrupt discontinuation could trigger withdrawal symptoms.² Withdrawal severity tracked with dose and duration of use, according to Salzman: "The more you've taken, the worse the withdrawal symptoms are, but they're never or rarely very severe unless you've taken very large amounts over a long period of time." Salzman distinguished this typical clinical pattern, in which withdrawal after standard therapeutic dosing was rarely severe, from high-dose, long-term exposure, which he associated with more pronounced discontinuation effects. Taken together, Salzman's remarks framed occasional unprescribed benzodiazepine possession among physicians as a low-risk behavior distinct from the dose- and duration-dependent physiologic dependence that could accompany regular, prescribed use, a distinction Salzman suggested clinicians should keep in mind when counseling patients about long-term benzodiazepine therapy.

Dr Salzman is a professor of psychiatry at Harvard Medical School.

Dr Goldberg is a clinical professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York, NY, and the immediate-past president of the American Society of Clinical Psychopharmacology.

References

1. Maust DT, Lin LA, Blow FC. Benzodiazepine use and misuse among adults in the United States. Psychiatr Serv. 2019;70(2):97-106.

2. Gray SL, Dublin S, Yu O, et al. Benzodiazepine use and risk of incident dementia or cognitive decline: prospective population based study. BMJ. 2016;352:i90.