One clinical observation helps the physician identify people who have addiction problems among anxious benzodiazepine users. Most anxious medical users of benzodiazepines have used these medicines at low and stable doses over time, often for many years, with good clinical responses. Dose is a critical and distin guishing variable in long-term benzodiazepine use. People who are addicted to alcohol and other drugs commonly abuse benzodiazepines in high and unstable doses; anxious patients who are not addicted do not. People with active addiction (e.g., who currently use illegal drugs and/or abuse alcohol) seldom report a good clinical response to low and stable doses of benzodiazepines.
We use a simple assessment of dose level: If the patient's typical benzo-diazepine dose level is stable at or below one-half the ordinary clinical maximum dose of the prescribed benzodiazepine as recommended in the Physicians' Desk Reference (PDR; Medical Economics Data Production, 2003) or in the package insert approved by the FDA for the prescribed benzodiazepine, we call this the "green light" benzodiazepine dose zone. Thus, patients whose daily benzodiazepine dose is stable at or less than 2 mg of alprazolam, 20 mg of diaze-pam, 5 mg of lorazepam, 4 mg of clonazepam, or 60 mg of oxazepam are in the relatively safe or green-light zone.
The "red light," or danger, zone is above the FDA-approved maximum daily dose (e.g., above 4 mg of alprazolam or 40 mg of diazepam). Except in the treatment of panic, when doses up to two or three times the FDA maximum for chronic anxiety are occasionally needed, it is unusual to see an anxious non-alcohol- or non-drug-abusing patient taking benzodiazepine doses that are this high. Most panic disorder patients, after a few months of treatment, are able to do well (with good panic suppression) in the green light zone, without the physician or the patient making any effort to limit or restrict the benzodiazepine dose level. If vigilance and control are required by the physician to limit the benzodiazepine dose to levels below the maximum recommended doses, this is a poor prognostic sign and a signal that addiction to alcohol and other drugs may be a confounding comorbid disorder.
One common clinical challenge is to see a patient, a family member, or sometimes a physician or therapist who is concerned about "tolerance" and "addiction," because the patient feels compelled to raise the dose of the benzo-diazepine over time. In our experience, such worries among patients who lack a personal history of addiction to alcohol or other nonmedical drugs are usually the result of underdosing with the benzodiazepine rather than evidence of addiction. Although some patients with such a presentation are more comfortable taking no medicine at all, most need education about the proper dose of the benzodiazepine. Once the benzodiazepine dose is raised to an ordinary therapeutic level (e.g., well within the green light zone), patients usually feel much better in terms of their symptoms of an anxiety disorder and have no inner pressure to raise the benzodiazepine dose further.
Within the addicted population, several patterns of benzodiazepine abuse have been identified. The most common pattern is the use of a benzodiazepine to reduce the adverse effects of the abuse of other, more preferred drugs. Typical is the suppression of a hangover and other withdrawal phenomena from alcohol use with a benzodiazepine. Patients waking up in the morning after an alcoholic binge may take 10-40 mg or more of diazepam, for example, "just to face the day."
Other common nonmedical patterns are to use benzodiazepines (often alprazolam or lorazepam) concomitantly with stimulants (often cocaine or methamphetamine) to reduce the unpleasant experiences of the stimulant use, and/or to use benzodiazepines (often triazolam [Halcion]) to treat the insomnia that accompanies stimulant abuse.
Benzodiazepines are occasionally used as primary drugs of abuse, in which case they are typically taken orally at high doses. Addicted patients report using doses of 20-100 mg or more of diazepam, or the equivalent doses of other benzodiazepines, for example, at one time. Such high-dose oral use is often repeated several times a day for long periods or on binges. Although, in our experience, such primary benzodiazepine abuse without simultaneous use of other drugs is unusual, it does occur.
Daily use of benzodiazepines, even when there is no dose escalation and no abuse of alcohol or other nonmedical drugs has led to controversy. Clinical experience has shown that even over long periods of daily use, benzodiazepines typically do not lose their efficacy and do not produce significant problems for most patients. An example of this experience was a study of 170 adult patients treated for a variety of sleep disorders continuously with a benzodiazepine for 6 months or longer over a 12-year period. The study found sustained efficacy, with low risk of dose escalation, adverse effects, or abuse (Schenck & Mahowald, 1996).
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