Distinguishing Medical And Nonmedical Use Of Benzodiazepines

A series of national surveys tracking the medical use of the benzodiazepines showed that their use peaked in 1976 and by the late 1980s had fallen about 25% off that peak rate (DuPont, 1988). A 1979 survey of medical use of the benzodiazepines (near the peak of benzodiazepine use in the United States), showed that 89% of Americans ages 18 years and older had not used a benzodiazepine within the previous 12 months. Of those who had used a benzodiazepine, most (9.5% of all adults) had used the benzodiazepine either less than every day or for less than 12 months, or both, whereas a minority (1.6% of the adult population) had used a benzodiazepine on a daily basis for 12 months or longer. This long-term user group was two-thirds female; 71% were age 50 or older, and most had chronic medical problems, as well as anxiety (DuPont, 1988).

Of those with anxiety disorders in a large community sample, three-fourths were receiving no treatment at all, including not using a benzodiazepine. The 1.6% of the population who are chronic benzodiazepine users can be compared to the 17% of the population suffering from anxiety disorders at any 12-month period. This statistic led many observers to conclude that not only are benzo-diazepines not overprescribed but they also may actually be underprescribed, because of the reluctance of both physician and patients to use these medicines (Mellinger & Balter, 1981).

To understand the place of the benzodiazepines in contemporary medical practice, it is important to separate appropriate medical use from inappropriate, nonmedical use. Five characteristics distinguish medical from nonmedical use of all controlled substances, including the benzodiazepines.

1. Intent. Is the substance used to treat a diagnosed medical problem, such as anxiety or insomnia, or is it used to get high (or to treat the complications of nonmedical use of other drugs)? Typical medical use of a benzodiazepine or other controlled substance occurs without the use of multiple nonmedical drugs, whereas nonmedical use of the benzodiazepines is usually polydrug abuse. Although alcoholics and drug addicts sometimes use the language of medicine to describe their reasons for using controlled substances nonmedically, "self-administration" or "self-medication" of an intoxicating substance outside the ordinary practice boundaries of medical care is a hallmark of drug abuse (DuPont, 1998).

2. Effect. What is the effect of the controlled substance use on the user's life? The only acceptable standard for medical use is that it helps the user live a better life. Typical nonmedical drug use is associated with deterioration in the user's life, even though continued use and denial of the negative consequences of this use are nearly universal.

3. Control. Is the substance use controlled only by the user, or does a fully knowledgeable physician share the control of the drug use? Medical drug use is controlled by the physician, as well as the patient, whereas typical nonmedical use is solely controlled by the user.

4. Legality. Is the use legal or illegal? Medical use of a controlled substance is legal. Nonmedical drug use of controlled substances, including benzo-diazepines, is illegal.

5. Pattern. What is the pattern of the controlled substance use? Typical medical use of controlled substances is similar to the use of penicillin or aspirin, in that it occurs in a medically reasonable pattern to treat an easily recognized health problem other than addiction. Typical use of nonmedical drugs (e.g., alcohol, marijuana, or cocaine), in contrast, takes place at parties or in other social settings. Medical substance use is stable and at a moderate dose level. Nonmedical use of a controlled substance is usually polydrug abuse at high and/ or unstable doses (Juergens & Cowley, 2003).

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