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January 8, 2021

Balancing the Risks and Benefits of Benzodiazepines

Author Affiliations
  • 1Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
  • 2Department of Psychiatry, College of Physicians and Surgeons, Columbia University and the New York State Psychiatric Institute, New York, New York
  • 3Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, New York
  • 4Department of Medicine, Indiana University School of Medicine, Indianapolis
  • 5Regenstrief Institute Inc, Indianapolis, Indiana
JAMA. 2021;325(4):347-348. doi:10.1001/jama.2020.22106

In September 2020, the US Food and Drug Administration (FDA) announced an anticipated update to the boxed warning on all benzodiazepines to explicitly “address the serious risks of abuse, addiction, physical dependence, and withdrawal reactions” among this class of medications.1 The current boxed warning for benzodiazepines (eg, alprazolam, lorazepam, clonazepam, diazepam) highlights only the risks of coadministration of opioids and benzodiazepines. Benzodiazepines are prescribed for multiple indications, most notably generalized anxiety disorder, panic, social phobia, insomnia, and seizure prophylaxis and rescue.

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    3 Comments for this article
    Difficult Weaning
    CJ Hinke | Thammasat University
    Benzodiazepines are inexpensive. CBT is not. Therein lies the rub!

    The trouble with the drugs is not abuse, it's dependence.

    Heather Ashton wrote the manual (1). But still it's devilishly hard for our patients to wean, even with the most attentive medical support.

    Most patients, let's face it, give up and we write another script.


    1. https://www.benzo.org.uk/manual/ 
    Medicare/Insurance places bars on lower doses
    Christine Doyle |
    It's not just the number of prescriptions, it's the dose that's ordered.

    My nonagenerian mother takes temazepam to help her sleep. But Medicare will not pay for the 7.5mg capsules, only the 15mg capsules. So she can opt to pay $200 for a 30 day supply, or $16 for a 30 day supply.

    They're capsules, so we can't cut them. And she's been taking something for over 50 years, we won't ever be able to wean her.

    The one time we gave her the 15mg, she managed to fall. That led
    to a trip to the ER and admission, so definitely cost Medicare more than the correct dose of the drug did.

    How can we address this?
    Carolyn Quadrio, MD, PhD | School of Psychiatry, University of New South Wales, Australia
    The problem with avoiding benzodiazepines is that the trend is to prescribe antipsychotics such as quetiapine and olanzepine, the side effects of which are just as troubling. In my experience, this usually involves patients who are anxious and/or depressed and not sleeping; very few have a psychotic disorder. In particular, serious weight gain is a problem and all the risks to health that this entails. I have seen several young women with weight increases of between 30 and 60 kilos (66-132 pounds).