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Am Fam Physician. 2023;108(3):260-266

Published online August 11, 2023.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

In the United States, more than 30 million adults have reported taking a benzodiazepine within the past year. Misuse—use of a drug in a way that a doctor did not direct—accounts for 17.2% of all benzodiazepine use. Family physicians face challenges when balancing the patient's perceived benefits of benzodiazepines with known risks and lack of evidence supporting their use. Benzodiazepines cause significant central nervous system–related adverse effects including sedation, confusion, memory loss, depression, falls, fractures, and motor vehicle crashes. Factors that increase the risk of adverse effects and misuse are other substance use disorders, using concomitant central nervous system medications, and central nervous system or pulmonary diseases. Compared with intermittent use, chronic daily use in older adults is associated with a higher risk of falls, fractures, hospitalizations, and death. Withdrawal symptoms such as anxiety, sleep disturbances, and agitation are common and often prolonged. Adjunctive treatment with antiepileptics, antidepressants, and pregabalin has been shown to lessen withdrawal symptoms. Deprescribing benzodiazepines for patients who use them chronically should be individualized with slow tapering over weeks to months, or longer, to minimize the intensity of withdrawal symptoms. Incorporating behavioral interventions, such as cognitive behavior therapy, improves deprescribing outcomes.

In the United States between 2014 and 2016, nearly one-half (48%) of the estimated 65.9 million office visits per year where benzodiazepines were prescribed were primary care visits, and most were continued prescriptions.1 The rapid anxiolytic and sedative properties of benzodiazepines make them an attractive option for treating acute anxiety and insomnia, but data are lacking to support ongoing therapy for more than one month.2 Therefore, family physicians face challenges when balancing the patient's perceived benefits of benzodiazepines with known risks and lack of evidence supporting their use. Because of their potent agonistic activity on the gamma-aminobutyric acid receptors in the brain and periphery, benzodiazepines cause receptor downregulation within weeks of use.3 Tolerance to anxiolytic and hypnotic effects can develop soon after, with physiologic and psychological dependence. This dependence often leads to continued benzodiazepine use to abate withdrawal.4

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