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Am Fam Physician. 2019;100(9):520

To the Editor: As a psychiatrist embedded within a family practice setting, I have found that many of my primary care colleagues view benzodiazepines as a medication to be avoided completely or used only as a last resort. However, when used properly, benzodiazepines are an essential tool that can mitigate pain and suffering in patients who present with anxiety symptoms.

Benzodiazepines present risks of addiction and overdose, particularly among patients who concurrently use opioids.1 Since 1996, overdose deaths involving benzodiazepines have increased fivefold, and the proportion of adults receiving and filling benzodiazepine prescriptions has also considerably increased.2

The underuse of benzodiazepines in patients who have untreated anxiety also has risks. I recall treating a patient in his mid-40s who struggled with severe periods of anxiety as part of his depression. The anxiety-fueled periods of physical and emotional distress included bouts of angina, diarrhea, and insomnia. He had been prescribed various antidepressants; they were not fully effective, and some produced intolerable adverse effects, including more anxiety. By adding a low-dose benzodiazepine along with an antidepressant to his treatment, my patient reached full stability. The benzodiazepine was then tapered but available for periods of exacerbation, which prevented him from relapsing into depression.

This example illustrates the complexity of managing anxiety as a chief symptom. Benzodiazepines have been found to be the fastest and most effective approach to controlling anxiety symptoms.3,4 In my experience, prescribing benzodiazepines requires low dosages that do not escalate (e.g., 1 mg or less per day, or 10 mg for diazepam [Valium]). If a patient requires escalating doses, this indicates that other problems need to be assessed, such as addictive behavior, iatrogenic causes, caffeine intake, or other undiagnosed medical problems. After anxiety symptoms are controlled, patients can be more successfully transitioned to alternative therapies.

Physicians always need to balance the risks associated with our tools of healing against the benefits. When used together with the right balance of other interventions (e.g., psychotherapy), benzodiazepines remain an essential treatment for patients with anxiety.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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