Dependence as a limiting factor in the clinical use of minor tranquillizers

The recognition that all minor tranquillizers carry the risk of dependence has had a significant impact in their prescription over the years. But it has only recently had the same impact on the prescribing of benzodiazepines because their dependence risks were not recognized until late. Approximately one third of all patients prescribed a benzodiazepine regularly for six weeks or longer will experience withdrawal symptoms if the drug is withdrawn suddenly after this time. Even if the drug is withdrawn gradually withdrawal symptoms may still lead to demands for further prescription. The major change in prescribing has been towards shorter and intermittent treatment so that tolerance is reduced and withdrawal symptoms avoided. This is appropriate for acute anxiety reactions but more difficult for longer term anxious and depressive neurotic disorders, which have a much longer natural history. Continuing evidence that other drugs not specifically marketed for the relief of anxiety, particularly the antidepressants, are effective in relieving this anxiety has led to increased prescription of antidepressants. Some patients may also be helped by treatment with beta-blocking drugs and new agents such as buspirone which have no significant dependence potential. There has also been a move away from drug treatment to psychological treatments for anxiety as a consequence of concern over dependence. For some conditions, particularly medical ones such as spasticity and epilepsy, benzodiazepines may be considered for long-term treatment. They may also be regarded as necessary for more severe psychiatric disorders, usually as an adjunct to other therapy. In such instances the dependence risk is acknowledged but the benefits of treatment are considered to outweigh them. There may also be patients who are dependent on benzodiazepines but the alternative of withdrawing the drug may lead to dependence on a more dangerous drug such as alcohol. In such cases it is reasonable to regard continued prescription of the benzodiazepine as the least dangerous course of action. It is important to maintain a perspective of dependence on minor tranquillizers, particularly as attitudes are in danger of being distorted by excessive media attention. To date there is no evidence that dependence on benzodiazepines leads to any dangerous long term sequelae although there is concern over their effects on higher cognitive function. Nevertheless, the dangers of barbiturates, alcohol and nicotine are so much greater that it would be unfortunate if public concern led to excessive restrictions on the use of benzodiazepines.(ABSTRACT TRUNCATED AT 400 WORDS)