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COMMITTEE ON SAFETY OF MEDICINES
UK Government Bulletin to Prescribing Doctors
1988; Number 21: 1-2
Document on MHRA website
There has been concern for many years regarding benzodiazepine dependence (Br.Med.J,1980:280, 910-912)*. Such dependence is becoming increasingly worrying.
Withdrawal symptoms include anxiety, tremor, confusion, insomnia, perceptual disorders, fits, depression, gastrointestinal and other somatic symptoms. These may sometimes be difficult to distinguish from the symptoms of the original illness.
It is important to note that withdrawal symptoms can occur with benzodiazepines following therapeutic doses given for SHORT periods of time.
Withdrawal effects usually appear shortly after stopping a benzodiazepine with a short half life, or up to several days after stopping one with a long half life. Symptoms may continue for weeks or months. No epidemiological evidence is available to suggest that one benzodiazepine is more responsible for the development of dependency or withdrawal symptoms than another.
The Committee on Safety of Medicines recommends that the use of benzodiazepines should be limited in the following ways:
Benzodiazepines are indicated for the short-term relief (two to four weeks only) of anxiety that is severe, disabling or subjecting the individual to unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic or psychotic illness.
The use of benzodiazepines to treat short-term 'mild' anxiety is inappropriate and unsuitable.
Benzodiazepines should be used to treat insomnia only when it is severe, disabling, or subjecting the individual to extreme distress.
The lowest dose which can control the symptoms should be used. It should not be continued beyond four weeks.
Long-term chronic use is not recommended.
Treatment should always be tapered off gradually.
Patients who have taken benzodiazepines for a long time may require a longer period during which doses are reduced.
When a benzodiazepine is used as a hypnotic, treatment should, if possible, be intermittent.
Benzodiazepines should not be used alone to treat depression or anxiety associated with depression. Suicide may be precipitated in such patients.
They should not be used for phobic or obsessional states.
They should not be used for the treatment of chronic psychosis.
In cases of loss or bereavement, psychological adjustment may be inhibited by benzodiazepines.
Disinhibiting effects may be manifested in various ways. Suicide may be precipitated in patients who are depressed, and aggressive behaviour towards self and others may be precipitated. Extreme caution should therefore be used in prescribing benzodiazepines in patients with personality disorders.
* from Committee on the Review on Medicines quoted in The British Medical Journal, 29 March, 1980:
"The committee further noted that there was little convincing evidence that benzodiazepines were efficacious in the treatment of anxiety after four months' continuous treatment. It considered that an appropriate warning regarding long-term efficacy be included in the recommendations, particularly in view of the high proportion of patients receiving repeated prescriptions for extended periods of time.
"It further suggested that patients receiving benzodiazepine therapy be carefully selected and monitored and that prescriptions be limited to short-term use."
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