Duke Health Referring Physicians

Practice Management

Prescribing Benzodiazepines: Weighing the Risks and Benefits

Consider these precautions to reduce the risks for dependence, adverse effects, and overdose

Spilled pill bottle on counter

Benzodiazepines (e.g., alprazolam, diazepam, clonazepam) are among the most commonly prescribed medications in the U.S. Used primarily to treat anxiety, insomnia, and seizures, these drugs offer benefits to patients in acute situations. But the risks—including dependency, addiction, increased accidents, and overdose—rise steeply with long-term use.

An increasing number of organizations and agencies urge caution when prescribing these medications. In response to a 10-fold increase in overdose-related deaths involving benzodiazepines in recent years, the FDA issued its highest warning in August 2019 for the concurrent prescription of benzodiazepines and opioids.

Christy Huff, MD, a cardiologist based in Texas and director of the Benzodiazepine Information Coalition, believes “there is a lack of education surrounding these drugs that needs to be remedied.” To reduce the risks for benzodiazepine dependence, adverse effects, and overdose, consider the following precautions.

Consider alternatives. Behavioral interventions—psychotherapy, cognitive behavioral therapy, and counseling—are “safer and better” in the long term for anxiety and insomnia from stress, says Robert McLean, MD, president of the American College of Physicians.

Check clinical history and occupation. Benzodiazepines pose extra risks to patients who have lung disease, sleep apnea, and other conditions. In addition, older people, shift workers, or people who drive or operate heavy machinery are at higher risk for accidents.

Consult guidelines. Several organizations and agencies have recently issued guidelines for benzodiazepines. The Alliance for Benzodiazepine Best Practices offers a list of guidelines at https://benzoreform.org/links.

Start low and go slow. McLean recommends starting with the lowest dose possible and not prescribing more than necessary to treat an acute response to trauma or social stressors.

Look for signs of dependence. The development of withdrawal symptoms (e.g., anxiety, sleep disturbances, tremors) between doses can indicate dependence, Huff says. She recommends looking for patterns: Do symptoms appear at certain times? Are symptoms relieved with the next dose?

Encourage safe disposal. Most people who take benzodiazepines without a prescription acquire them from a friend or relative. Reviewing safe disposal instructions and providing a list of local disposal options may reduce diversion of benzodiazepines.


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