Editor’s Note: Dr. Robert DuPont is a physician who is uniquely qualified to address the complexities of both the benefits and the problems associated with the use of benzodiazepines, the most commonly used class of minor tranquilizers. He presents his arguments articulately and supports them with substantial facts. We usually agree on issues, but even when we do not, I always come away having learned something. The rise in problematic benzodiazepine use has been overshadowed by the focus on the “opioid epidemic,” but may now start to get the attention that it deserves. Dr. DuPont will deliver the keynote address on this topic at both the Annual Meeting of the Maryland Chapter of the American Society of Addiction Medicine and the Louis J. Kolodner Annual Memorial Lecture co-sponsored by Kolmac and MedChi, the Maryland Medical Society.
Benzodiazepines and Addiction: New Thinking about Old Drugs
By Dr. Robert DuPont
My medical career has been intertwined with the benzodiazepines since Valium was introduced in 1963, the year I graduated from medical school. My professional life has included serving as the first director of the National Institute on Drug Abuse (NIDA), the leading addiction research organization in the world, and serving as the founding president of the Anxiety Disorders Association of America, the leading advocacy group for the anxiety disorders.
In my private practice, from my start in 1969 to the present, the benzodiazepines have been front and center every day with my anxious and addicted patients as well as many patients who have both anxiety and substance use disorders, two of the most common mental disorders in the country. Many of my professional publications have focused on the benzodiazepines, including my work as one of eight principal investigators in the influential Cross-National Collaborative Panic Study. As a result of this study, alprazolam (Xanax) became the first medicine approved to treat agoraphobia and panic disorder.
Introduced in the early 1960s, the benzodiazepines rapidly became the world’s most widely prescribed class of pharmaceutical products. Off-patent since the 1980s, benzodiazepines are no longer promoted by the pharmaceutical industry, but today they remain among the most commonly prescribed drugs. The benzodiazepines have had many lives in the treatment of anxiety disorders and in addiction medicine. Today their common role in opioid overdoses has put benzodiazepines back in national headlines.
These drugs are commonly used to treat anxiety and insomnia as well as in the prevention of seizures. There are dramatic differences between common experiences with benzodiazepines when used by patients with and without substance use disorders, particularly the way in which the patient’s behavior with these medicines has major diagnostic significance. The similarity between the use of benzodiazepines and the use of alcohol in the general public is striking. The use of alcohol in non-intoxicating doses is common among normal adults but rare among those who have an alcohol use disorder. Similarly, the non-problem use of benzodiazepines by individuals with anxiety disorder but no substance use disorder is common, whereas the use patterns of benzodiazepines among patients with substance use disorders is problematic and often dangerous. However, as with alcohol, this behavioral distinction, while common and important, is not without endless exceptions and complications.
The use of benzodiazepines by patients in addiction treatment is controversial. Understanding where and when the prescribed and non-prescribed use of the benzodiazepines occurs is important, especially in the context of risk of overdose death. While a few tentative clinical guidelines are possible, all of the controversies and questions about the benzodiazepines will not be resolved when it comes to this endlessly fascinating, and hugely important, class of pharmaceuticals.
Robert L. DuPont, MD, a clinical professor of psychiatry at Georgetown University Medical School, is president of Institute for Behavior and Health Inc.