Policy on Anxiety (benzodiazepine) and Sleep (Z-drug) Medications

This information was added in 2018, but remains quite relevant. I updated practice policies then:

Evolving research and heightened scrutiny of quality of care—along with law enforcement concerns of misuse and diversion—have intensified the concern and monitoring long term (and even short term) benzodiazepine use.

Because tranquilizers in the Z-class (Ambien, Sonata, Lunesta) and benzodiazepine class such as Xanax (alprazolam), Ativan (lorazepam) Klonopin (clonazepam), Valium (diazepam), Restoril (temazepam) and others are controlled substances subject to definite standards of clinical and ethical care — as well as laws— prescription policy for such in this practice bears reiteration. Their risks are well known, including—but not limited to — dependency, addiction, impaired alertness and coordination (i.e. people are more likely to fall when taking them), and illegal misuse and diversion. They can be especially problematic when combined with legitimate medications, and/or ill-advised medicines referred to below. Furthermore, because they are widespread and easy to find in the community, they may be diverted and frequently present in the mix of narcotic overdose. For some public health and law enforcement agencies, this approaches a public health hazard.

These tranquilizing medications, when used only as prescribed, are very effective agents for the immediate relief of acute anxiety. They are indicated for short term use in appropriate clinical situations, as long as there are no contraindications. Those contraindications would include—but not be limited to—past or current misuse of benzodiazepines and other dependency-producing substances such as alcohol, cannabis, narcotic pain meds, stimulants, barbiturates, and various street drugs. Also, any history of illegal activity (convicted or not) connected with use of such.

What we've learned is that the best treatment for anxiety is to learn coping skills to deal with the anxiety. Medications like benzodiazepines just cover it up, and in essence, become the coping strategy.  Plus, research has shown that tolerance develops over time with these medications, making them no longer effective at the accustomed dose. 

Many patients want to continue these long term for a variety of reasons:

• Withdrawal symptoms.
• Inadequate accepted treatment of ongoing biological anxiety disorder (such as General Anxiety Disorder (GAD), Social Anxiety Disorder (SAD), Obsessive Compulsive Disorder (OCD) and Panic Disorder (PD)
• Psychological craving, reliance, or looking for placebo response.

For those who have been taking benzodiazepines long term, abruptly stopping could quickly lead to un- comfortable and even dangerous withdrawal symptoms. Therefore, a gradual taper schedule is called for in order to achieve physiological freedom from the tranquilizer. The time required can be individualized, and, as many of us have already discussed, will occur over several months if not years.

If someone needs closer monitoring to help them discontinue, a formal outpatient detox program is in order. If this proves too limiting and/or challenging, inpatient detox might be necessary.

For those who have been incorporating benzodiazepines into their very coping, the “loss” of such medication can seem daunting. Getting other professionals, like counselors, involved is often necessary.  Additionally, I am committed to learning new research in functional/integrative treatment such as nutritional and supplement interventions.

For most people in this practice, benzodiazepine use (problematic or not) is only a relatively minor aspect of their medication protocol. Their more important medications pertain to mood, anxiety, adjustment and attention disorders. Getting off the “benzo” (and any other uncalled-for substance) will only enhance the treatment of all conditions and improve quality of life.

Thank you for reading this reminder—and update. I look forward to reviewing your protocol with you so that we can answer questions and make any required changes.  If you would like to see the research on the topic, I will direct you to this link:https://wa.kaiserpermanente.org/static/pdf/public/guidelines/benzo-zdrug.pdf. The Kaiser Permanente group put together a very well written summary for healthcare professionals with a detailed bibliography.