I advocate what helped me. In 2016 I stopped all medications on the advice of someone who believed Psychiatry was evil.I ended up in a rock bottom place.I will be eternally grateful to mental health professiionals that got me out of the place where I could see no point in living.
— Valerie Walsh (@valeriewalsh19) September 2, 2018
Psychiatry and psychiatric medicines probably saved my life. Saved my parents from burying their child. Thats why I am so selfish. Now lets end this pointless conversation and not distract from @valeriewalsh19 post any longer please!
— #HelloMyNameIsRachel (@LubyrLuby) September 2, 2018
This brief editorial is a statement to introduce a new working group on benzodiazepines, the International Task Force on Benzodiazepines, which comprises independent scientists, clinical researchers, and clinical psychopharmacologists. No references are included here as it would be beyond the scope and goal of this introduction, but a full review on benzodiazepines will be the topic of a number of papers and presentations in the near future.
Benzodiazepines have been with us since the dawn of modern psychopharmacology. Chlordiazepoxide, the first benzodiazepine, was discovered by Leo Sternbach in the late 1950s and was approved for use in the USA in 1960. Sternbach, a genial chemist, also discovered several other benzodiazepines, such as clonazepam, diazepam, flurazepam, flunitrazepam, and nitrazepam.
Benzodiazepines quickly became popular and widely used due to their versatility, tolerability, and ease of use. As they have anxiolytic, anticonvulsant, hypnotic, muscle relaxant, and sedative properties, they have been used widely and remain the most widely prescribed psychotropic medications among all medical specialties. Psychiatrists have been using benzodiazepines for the treatment of anxiety disorders, insomnia, alcohol withdrawal, and as adjunct therapy for many other indications since their discovery. The anxiolytic properties of benzodiazepines are still unsurpassed by other psychotropic medications, such as antidepressants and antipsychotics that are used in the treatment of anxiety disorders and anxiety symptoms in other mental disorders. Their adverse effect profile is relatively benign, with sedation and possible cognitive impairment being noted most frequently.
In spite of the unquestionable benefits of benzodiazepines and their popularity among physicians of various disciplines, we have witnessed a fairly negative campaign against benzodiazepines, which are often described as being readily abused (although their abuse liability is low and, if abuse occurs, it is in the context of other substance abuse). Interestingly, this campaign has intensified since the advent of selective serotonin reuptake inhibitors (SSRIs) in the mid-1990s. The SSRIs, originally approved for the treatment of depressive disorders, were quickly approved for various anxiety disorders despite the lack of sufficient evidence (i.e., comparison to the existing efficacious anxiolytic drugs, benzodiazepines), and they are now promoted as the first-line treatment for these disorders. In addition, the scientific literature has gradually and surreptitiously been flooded with more and more articles on “negative” properties of benzodiazepines. While many of these publications have either not been based on good science or been frankly biased, they easily achieved a common goal that negative propaganda frequently reaches: they aroused suspicion of benzodiazepines and suggested difficulties in using them, while overlooking their benefits. An “illusion of truth” effect then occurred as frequently repeated negative information and half-truths gradually became the truth as benzodiazepines were given a “bad” name and their reputation was damaged, especially in some scientific circles. Even prescribing these drugs has become a cumbersome procedure around the world.
The International Task Force on Benzodiazepines, as a group of investigators and clinical psychopharmacologists with long-standing clinical and scientific expertise, has been concerned about this excessively negative trend. We feel that benzodiazepines have not been given proper attention during the last 2–3 decades, they have not been adequately compared to other psychotropic medications in various indications, and their risks and side effects have been overemphasized. Some of us feel that benzodiazepines have been the subject of an unspoken “commercial war.”
This Task Force will be working on presenting various psychiatric and medical audiences with information about benzodiazepines which is evidence based, balanced, unbiased, and clinically relevant and useful. We believe that our colleagues deserve such information as it will encourage our common goal of treating our patients effectively, properly, and safely. We hope to preserve benzodiazepines as a valuable part of our armamentarium.
The chilling effects of the “addictive” label
But the main point is that in the U.S. and Britain this drug class became demonized as addictive. In 1975 the US Department of Justice placed Librium and Valium on schedule IV of its list of controlled substances. Being listed as potential drugs of abuse had a chilling effect on prescribing. In New York State a further drop in use followed the 1989 imposition of restrictive triplicate prescription regulations which mandated state monitoring. A 1991 study reported in JAMA that these regulations led to a 44% decrease in benzodiazepine prescribing between 1987 and 1990 – but also an increase in the use of “less acceptable medications” (barbiturates and other traditional tranquilizers) – as well as the emerging, “more expensive” antidepressants buspirone and Prozac.
The anti-benzo backlash was particularly strong in the U.K. Prescribing there peaked in 1979, with 31 million prescriptions, then began a steady decline in response to government warnings. In 1988, the Committee on Safety of Medicines warned of withdrawal symptoms and dependence “following therapeutic doses given for SHORT periods of time” (its emphasis) and recommended limiting their use for a maximum of 2-4 weeks for “disabling” anxiety or insomnia. These restrictions remain in effect, forcing British doctors to “write fraudulent prescriptions” in order to adequately treat catatonia patients. (Healy, 2013)
Diazepam is mainly used to treat anxiety, insomnia, panic attacks and symptoms of acute alcohol withdrawal. It is also used as a premedication for inducing sedation, anxiolysis, or amnesia before certain medical procedures (e.g., endoscopy). Diazepam is the drug of choice for treating benzodiazepine dependence with its long half-life allowing easier dose reduction. Benzodiazepines have a relatively low toxicity in overdose.
Diazepam has a number of uses including:
- Treatment of anxiety, panic attacks, and states of agitation
- Treatment of neurovegetative symptoms associated with vertigo
- Treatment of the symptoms of alcohol, opiate, and benzodiazepine withdrawal
- Short-term treatment of insomnia
- Treatment of tetanus, together with other measures of intensive treatment
- Adjunctive treatment of spastic muscular paresis (paraplegia/tetraplegia) caused by cerebral or spinal cord conditions such as stroke, multiple sclerosis, or spinal cord injury (long-term treatment is coupled with other rehabilitative measures)
- Palliative treatment of stiff person syndrome
- Pre- or postoperative sedation, anxiolysis and/or amnesia (e.g., before endoscopic or surgical procedures)
- Treatment of complications with a hallucinogen crisis and stimulant overdoses and psychosis, such as LSD, cocaine, or methamphetamine
- Preventative treatment of oxygen toxicity during hyperbaric oxygen therapy
Dosages should be determined on an individual basis, depending on the condition being treated, severity of symptoms, patient body weight, and any other conditions the person may have.
Intravenous diazepam or lorazepam are first-line treatments for status epilepticus. However, intravenous lorazepam has advantages over intravenous diazepam, including a higher rate of terminating seizures and a more prolonged anticonvulsant effect. Diazepam gel was better than placebo gel in reducing the risk of non-cessation of seizures. Diazepam is rarely used for the long-term treatment of epilepsy because tolerance to its anticonvulsant effects usually develops within six to 12 months of treatment, effectively rendering it useless for that purpose.
The anticonvulsant effects of diazepam can help in the treatment of seizures due to a drug overdose or chemical toxicity as a result of exposure to sarin, VX, or soman (or other organophosphatepoisons), lindane, chloroquine, physostigmine, or pyrethroids.
It is sometimes used intermittently for the prevention of febrile seizures that may occur in children under five years of age. This use, however, is not typically recommended as the benefits are small and side effects are common. Long-term use of diazepam for the management of epilepsy is not recommended; however, a subgroup of individuals with treatment-resistant epilepsy benefit from long-term benzodiazepines, and for such individuals, clorazepate has been recommended due to its slower onset of tolerance to the anticonvulsant effects.
Diazepam is used for the emergency treatment of eclampsia, when IV magnesium sulfate and blood-pressure control measures have failed. Benzodiazepines do not have any pain-relieving properties themselves, and are generally recommended to avoid in individuals with pain. However, benzodiazepines such as diazepam can be used for their muscle-relaxant properties to alleviate pain caused by muscle spasms and various dystonias, including blepharospasm. Tolerance often develops to the muscle relaxant effects of benzodiazepines such as diazepam.Baclofen or tizanidine is sometimes used as an alternative to diazepam.
The United States military employs a specialized diazepam preparation known as Convulsive Antidote, Nerve Agent (CANA), which contains diazepam. One CANA kit is typically issued to service members, along with three Mark I NAAK kits, when operating in circumstances where chemical weapons in the form of nerve agents are considered a potential hazard. Both of these kits deliver drugs using autoinjectors. They are intended for use in “buddy aid” or “self aid” administration of the drugs in the field prior to decontamination and delivery of the patient to definitive medical care.