Benzodiazepines get a bad wrap – addiction specialist explains when they can be useful and how to safely prescribe them to reduce the risk of dependence

Safely prescribing benzodiazepines in the first place is key to preventing inappropriate long-term use, says addiction medicine specialist Dr Adam Straub.

While benzos are no longer the most widely prescribed medication as they were in the 70s, they’re still frequently used. They accounted for about 4.9 million prescriptions in Australia from 2021-22, with diazepam making up almost half of those prescriptions. Recent decades have seen growing awareness of the risks of long term and problematic use of benzos, but there continues to be a mixed bag of practice, says Dr Straub.

In the short term, benzos can be useful for many mental health and physiological disorders and in certain circumstances they may be the only effective option.

Here’s what to keep in mind to safely prescribe them.

When are they useful?

Benzodiazepines can be useful for a broad range of conditions including:

• Insomnia
• Anxiety disorders
• Alcohol or other drug withdrawal syndromes
• Mania/hypomania
• Epilepsy
• Acute seizures
• Arousal/agitation in the in-patient setting
• Palliative care
• Musculoskeletal disorders

“They can act as a sedative, a hypnotic, they’re anxiolytics, anticonvulsants, muscle relaxants, amnestics, and if used appropriately, they can even cause dissociation. We can use these things for so many different health conditions,” explains Dr Straub.

“We’ve got so many choices with how they work too. They range from higher to lower potency, faster or slower onsets, and shorter or longer half-lives as well. We can titrate these and tailor them to what we want or need.”

Guidelines typically recommend durations of 1–4 weeks for benzodiazepine therapy, as long-term use is associated with decreased effect, dependence and cognitive impairment​.

However, with a third of people using benzodiazepines for longer than three months, it’s important to know the signs of problematic use and how to safely deprescribe.

There are also some circumstances where benzodiazepines may be the best long-term option—for example the anticonvulsant properties are particularly effective, but it’s still important to review with a neurologist to ensure it’s the best option, Dr Straub says.

Factors to consider in finding the right benzo:

• Potency
• Half-life
• Absorption
• Metabolism
• The patient, and how benzodiazepines will affect them as they age
• Have alternative treatments been tried?
• Staged supply of medication, particularly when there’s substance use disorder history

Consider alternatives as first-line

Dr Straub says benzodiazepines, particularly diazepam, are sometimes prescribed first-line, when they may be more appropriate as a second, third or fourth line treatment.

“Very rarely would I go benzo first. The only time that I use benzos as a primary thing is when I’m treating withdrawal, and that’s an intended short course. For all of the other health conditions, benzos should be a later, down-the-track idea, we’ve got a whole lot of better, no risk of dependence, medications for just about everything else,” says Dr Straub.

For insomnia, he recommends trialing antidepressants or antihistamines (doxylamine or promethazine​), as well as non-medication strategies such as sleep hygiene, sleep restriction and relaxation techniques.

Consider a brief course of temazepam as a second or third line treatment for insomnia when alternatives have not been effective.

“For short courses, the primary one that you would use for insomnia is temazepam, and you’d use that for a very brief course. It’s often used in hospitals because they are good at initiating sleep, but they don’t do much in the way of continuing sleep. It’s good for helping somebody get off to sleep because they’re in a new strange environment or something’s upsetting them and disturbing them. But it doesn’t help to maintain sleep,” explains Dr Straub.

Similarly, for anxiety, benzos are best suited as a third or fourth line treatment. “They’re for when the other stuff fails,” Dr Straub says.

For depression and anxiety, SSRIs (paroxetine and sertraline) and psychological treatment are first line.

“Panic disorder is relatively similar, but it’s where you have more leeway. You can do a little bit of a pill in the pocket kind of idea, where you have a couple of tablets around, not for regular use, but for when patients are in extremis. Where you’ve got it there, just as the absolute backup.”

They can be useful or muscle spasms after surgery or when there are no other alternatives. Aim for the lowest effective dose as infrequently as possibl​​e. Baclofen (as an alternative) can be effective, but needs to be used with caution and in consultation with a neurologist. While not dependence-forming, it can cause sedation, balance issues and carries some overdose-risk.

Lay out the timeline

In almost all cases, it’s important to have an ‘exit plan’ to wean off as the situation stabilises or their health condition changes.

Dr Straub says it’s important to be transparent with the patient about the timeframe from the beginning.

“When you’re starting benzodiazepines it’s, ‘This is something we’re planning on being a short, temporary thing, and we will look at winding them off in the near future, here are the alternative medications that we have already tried, or why we can’t use other medications’,” Dr Straub says.

“Looking at ‘why am I using it, what’s my timeframe for weaning and ceasing, and where’s my follow up? How am I regularly checking in with the patient to make sure we’re not overusing these.’”

Key points:

• Trial alternatives first
• Tailor the benzodiazepine to the patient, considering factors like half-life and potency
• Clearly outline the timeframe for use, weaning and follow up to the patient
• Be vigilant about the signs of problematic use