Chronic Benzodiazepine Use and Coping Skills

Jenifer is a 47-year-old woman who reports significant jobrelated stress and anxiety. In her late 20s, Jenifer’s primary care physician prescribed her Clonazepam after she reported examrelated anxiety. Today, Jenifer is taking Clonazepam for sleep, and as needed for anxiety attacks. Recently, her psychiatrist introduced the idea of tapering off the clonazepam and considering alternative methods for addressing her anxiety. This is particularly pertinent because Jenifer began to run out of her medication before the next prescription was due. Additionally, Jenifer reports regular alcohol use but insists that she is not using Clonazepam when she drinks alcohol, she makes sure that “there are at least a couple of hours” between when she consumes alcohol and takes her medication. Her psychiatrist noticed that she presents well at the beginning of the session and when the topic of Clonazepam taper is approached, she immediately reports poor sleep, anxiety, panic attacks, and low mood. This prompts the psychiatrist to postpone the discussion until the next appointment in a month as it becomes inappropriate to talk about taking away the anxiety relief in times of crisis. For the subsequent 6 months, the psychiatrist reports, it seems like an on-off switch, if Clonazepam taper is not the topic, then things are going well and vice versa.

Psychiatrists do prescribe medications for various psychiatric illnesses. Conflict arises when the psychiatrist and the patient are not in agreement on what medications to be used. Sometimes the patient refuses to take a certain medication (such as antipsychotics, mood stabilizers, and medications for addictive disorders), or the patient requests medication that is not particularly beneficial to their specific problem. The latter scenario almost always involves controlled substances such as benzodiazepines, stimulants, and hypnotics.

As per the FDA label, benzodiazepines are indicated for shortterm treatment of anxiety and related symptoms, they are not intended to be used for years or decades. Although this is the recommended standard for benzodiazepine use, Clinical practice often looks different. According to a study published at JAMA in 2020 “Incidence of and Characteristics Associated with Long-term Benzodiazepine Use in Finland”: In a cohort study of 129 732 new benzodiazepines users in Finland, 34% of working-aged persons and 55% of older persons developed long-term use.

Benzodiazepines are mostly prescribed for anxiety, insomnia, and seizures. The effectiveness of benzodiazepines is undeniable. They are fast-acting medications that provide immediate relief of symptoms with a decent tolerability profile. In comparison to SSRI class which is currently the first-line treatment for anxiety, they barely cause any Gastrointestinal or sexual side effects and do not require weeks of wait time to work. However, taking a benzodiazepine for an extended period can be harmful in a way that goes beyond the traditional cognitive decline. When individuals experience anxiety, their first instinct is to attempt to curb the symptoms via coping skills. When the experience of anxiety goes beyond what one’s coping skills can curtail, a disturbance in functioning starts to occur. This is the point when patients usually begin to seek help. Evidence-based management is psychotherapy combined with pharmacotherapy. Pharmacotherapy targets the brain neurotransmitters to provide steady and sustained adjustment while psychotherapy targets coping skills and cognitive distortions.

Benzodiazepine can be of help as a temporary solution to safely hand the lead to other meds.

The fast-acting nature of benzodiazepines and using them as needed can be of a significant negative psychological impact on the individual. The connection between taking them and relief of the anxiety symptoms can hinder the development and maturation of coping skills. When the brain couples this action with the external source of fast and reliable aid that attenuates or completely removes anxiety symptoms, then what is the need for coping skills? Imagine a machine helping you at the gym to lift heavy weights, well, weightlifting will indeed happen, but muscles won’t profit. The reliance on this external source of immediate anxiety relief can interrupt the much-needed daily exercises of coping skills and render them immature and atrophied. When an individual takes benzodiazepine for years and decades, they miss important milestones of building their coping skills arsenal to fight stressors. The fast-acting external relief becomes the first-tocome- to-mind coping skill rendering the natural skill rudimentary and underdeveloped. Hence, if a psychiatrist suggests taking away benzodiazepines, they are, in a way, threatening to take away patients’ “pharmaceutical” coping skills. Other pharmacological approaches to treating anxiety do not have this issue. As they provide a steadily rising level of comfort that works hand in hand with coping skills without replacing them. There is no classical conditioning between taking the pill and the immediate relief of symptoms.

Back to Jessica, when she switches to crisis mode it was not a conscious trick. She was legitimately expressing the already formed conditioning between benzos and stress. Her behaviour translates into “what shall I do when I am in distress, it is the only remedy I have got, do not take it away from me”. She does not necessarily meet the criteria for addiction, despite being at a higher risk of developing it.

In order to properly help Jessica and millions of other benzodiazepine-dependent individuals, we need to provide an alternative. 7-day benzo detox in an inpatient setting is a shortsighted and unreasonable approach that cares for physical withdrawals and ignores other aspects of benzodiazepines’ effects. The best approach is an outpatient extended taper with concurrent extensive psychotherapy to strengthen the natural coping skills. Gradually and very slowly taking away one element to re-construct and build another. At least 6 months, maybe a year or two is a reasonable time frame to fully and gradually replace benzodiazepines with coping skills. One should expect setbacks, struggles, and resistance which should be discussed in detail with the patient. Constantly provide support and reassurance, when successful results are magnificent and very rewarding to both patient and doctor.

None.

None of the authors have a conflict of interest.