Benzodiazepines, or benzos for short, marched onto the treatment scene like stormtroopers some 60 years ago when Librium became available for managing anxiety. But this new class of anxiolytics really began making waves when Valium was released 3 years later. Often referred to as “vitamin V” by the corporate jet set and immortalized in a Rolling Stones tune as “Mother’s Little Helper,” Valium went on to become the number 1 selling drug in America for years on end.
As for the viability question, benzos are still widely used, but sparsely studied, primarily as a result of their age. They’re also much maligned, so I’ll address that first. “Benzodiazepines are very addictive, right?” is a common concern among patients, and the most often asked question when I discuss this drug class in seminars and workshops that I teach. So, are they or aren’t they? The best research I can find, shows that the vast majority of those abusing benzos are also abusing other substances like opioids at the same time, as a way to enhance the opioid “high;” while the number of people actually abusing benzodiazepines alone is rather small. And although it’s true that long-term benzo use, particularly at high dose, can lead to physical dependency and associated withdrawal symptoms, this is not the same thing as a true substance use disorder. If it were, then the antidepressants Paxil, Effexor and Cymbalta would need to be considered “addictive” medications as well, as they are notorious for their withdrawal syndromes. What’s important is that benzos and these antidepressants need to be tapered very slowly.
All benzodiazepines work the same way – they enhance the actions of the neurotransmitter GABA, which has direct anti-anxiety effects. The main differences among the benzos are their onset of action and duration of action. Here’s a quick rule of thumb: The faster they work, the quicker they wear off; the slower they work, the longer they last.
Benzos for specific anxiety disorders
Panic disorder
The rapid onset of doom, accompanied by symptoms of chest pain, trembling and feeling frozen, can be debilitating for those prone to panic, who of course, want immediate relief. The best choices here are Xanax or clonazepam wafers because of their rapid onset of action. I’ve found that for many people, just knowing they have these agents on hand and thus available to them on a moment’s notice, can go a long way toward minimizing future attacks.
Generalized anxiety disorder
Because those with GAD have trouble distinguishing what is a problem from what might be a problem and are quite prone to replacing resolved worries with new ones, benzodiazepines are not a good medication choice because they’d need to be taken long-term to obtain consistent relief. Cognitive-behavioral therapies aimed at “worry reduction” work best.
Obsessive-compulsive disorder
OCD is a disorder of excessive carefulness accompanied by an exaggeration of possible danger. Because it is now widely believed that OCD is neurologically-based and not an anxiety disorder per se, benzos have never demonstrated usefulness for OCD’s core symptoms, in spite of the high anxiety levels OCD patients can feel. The CBT technique exposure and response prevention remains the gold standard treatment intervention.
Social anxiety disorder
SAD can range from benign to incapacitating, and it can also be limited to certain situations such as public speaking, dating or meeting new people for the first time. SAD can trigger real-life repercussions ranging from limited social development to severely curtailed career advancement. Thus quality of life can markedly suffer, particularly if the disorder is generalized to multiple scenarios, in which case, CBT combined with a quieting SSRI are the best initial treatment options. In more predictable circumstances, such as those mentioned above, someone with SAD could benefit from a benzo taken 30 minutes to one hour preceding the anxiety-triggering event. This can work very well in helping someone get into the flow of delivering a talk, relaxing on a date or feeling more at ease when making new acquaintances.
Insomnia
Insomnia is not an anxiety disorder, but in those who are routinely sleep-deprived, it can certainly feel like one; because the absence of proper sleep produces agitation, irritability and exhaustion – all of which promote anxiety. The first step for those with unremitting insomnia is to become educated about good sleep hygiene habits. However, in some instances when the insomnia is related to an acute, time-limited stressor such as a tight work deadline or difficulty coping with the sudden and unexpected loss of a loved one, benzodiazepines are the best choice. Valium (diazepam) is often ideal because of its rapid onset and long-acting effects. Also, benzo side effects tend to be minimal, with little next day lethargy or grogginess.
Benzodiazepines have a well-established track record for treating anxiety and insomnia. When used sparingly with a clearly identified purpose in mind, they can provide much-welcomed relief from stress-laden events or psychosocial stressors. And make it clear to patients, or if you’re using or contemplating the use of a benzo yourself, that abuse and dependency issues are much exaggerated.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.