The Enduring Impact of Ghostwriting on the Treatment of Alcohol Withdrawal

Guidelines recommend chlordiazepoxide or diazepam over lorazepam for alcohol withdrawal due to lorazepam's increased risk of breakthrough symptoms and rebound phenomena, including seizures and delirium. Additionally, diazepam has a shorter time to peak effect than lorazepam, enabling more rapid symptom control and accurate titration to avoid over-sedation. The efficacy of chlordiazepoxide and diazepam for alcohol withdrawal was well established by the mid-1970s, while lorazepam was not approved in the USA until 1977. Despite its inferiority and later approval, lorazepam is the most widely used benzodiazepine for Emergency Department and inpatient alcohol withdrawal management. Therefore, it is notable that the first three studies comparing lorazepam to chlordiazepoxide and diazepam, published in 1983 and 1984, all concluded lorazepam is the "drug of choice." This conclusion is anomalous, as some lorazepam-treated patients developed seizures or delirium tremens, complications not observed with chlordiazepoxide or diazepam. These adverse outcomes were not disclosed in abstracts or discussions but seemingly intentionally concealed within the text. Evidence reveals these studies were ghostwritten by Wyeth, the pharmaceutical company that originally marketed lorazepam. Wyeth sales representatives likely distributed reprint copies of these deceptive "drug of choice" papers to physicians and physicians-in-training, thereby initiating the widespread reiterative intergenerational use of lorazepam for alcohol withdrawal.