Prescribing benzodiazepines in general practice

Benzodiazepines are very widely prescribed in general practice. They have very effective anti-anxiety, sedative, anticonvulsant, and muscle-relaxant properties. Enormous divergence exists between best-practice guidance,1,2 which generally recommends short-term use at the lowest possible dose for severe anxiety or insomnia, and the reality of general practice, where very large numbers of patients are known to be prescribed these drugs on a long-term basis, at high dosages, and for less than ‘severe’ indications.3,4 The recommendation to limit the use of benzodiazepines to the short term (for example, <2–4 weeks) is largely based on the issues of tolerance and dependence. Tolerance is a physiological response whereby, with continued use, a higher dose than that originally prescribed is required in order to achieve the identical original clinical effect. Thus, use beyond the short term often leads to dose escalation just to maintain the same effect originally brought about at a lower initial dose. The rate of development of tolerance is variable from one person to the next, but certainly can occur after just 3–4 weeks of use. Dependence can be considered in physiological and psychological terms. Physiological dependence refers to the experience of withdrawal symptoms on stopping the drug. Symptoms range from relatively minor (for example, headache, tremor, or sweating) to very serious and potentially life threatening (for example, seizures, psychosis, or delirium tremens). With psychological dependence, patients increasingly require their drug in order to cope with life events. Other negative effects resulting from long-term use include memory impairment in older patients, diminished sleep quality, daytime drowsiness, decreased reaction time, …