Quality & Science

Editorial Comment 1/07/2020: Management of Benzodiazepine (BZ) Use Disorder

by William Haning, MD, DFAPA, DFASAM | January 6, 2020

The New York Times (NYT)  Science section of 03 January carried this eulogy, by Knvul Sheikh*: “Dr. Heather Ashton, 90, Dies; Helped People Quit Anxiety Drugs

An excerpt from this review of Dr. Ashton’s professional life underscores how it is not merely opioids which have led to our dereliction of better judgment, in the prescribing of addiction-activating drugs:

“Heather was a remarkable person,” Nicol Ferrier, an emeritus professor of psychiatry at Newcastle University who worked closely with Dr. Ashton, said in an interview. “She was very upset by this problem of benzodiazepine dependence that was essentially caused by doctors overprescribing the medications, and she took it upon herself to help patients struggling to withdraw from them.”

While the disease of addiction is not reliant uniquely upon certain drugs, and its treatment has commonalities across the different drug use disorders, there are unique requirements assignable to each drug for a successful recovery. Rationalizing responses to the use of the respective substances appear pretty early in treatment: for the opioids, it is generally the complaint of pain; and if pain is not a component of the initiation of use, certainly it comes up at the end. If the substance is alcohol, at least one of the rocks upon which the treatment ship capsizes is the insistence that one’s friends drink and that alcohol is an essential component of a balanced social life.  And with sedative-hypnotics, certainly with the anti-anxiety agents of the benzodiazepine family, there is legitimacy to the complaint of stress and anxiety upon termination.

The imagination with which the person with addiction defends his use of BZs is pretty daunting, for the doctor who would undertake to manage this problem. It partly explains why so few can do it well, and why not all addiction specialists are even inclined to address that drug class.  In the past week I have encountered two colleagues who, well-meaning in their effort to manage an alcohol use disorder and an opioid use disorder, have continued benzodiazepines with no plan for discontinuation.  Dr. Ashton’s singular contribution was in emphasizing the role of the physician qua teacher, pursuing the problem slowly and methodically over months and longer, maintaining trust.  Several foci within the article deserve additional emphasis, apart from Dr. Ashton’s role in addressing BZ use: her policy regarding risk of conflict of interest, her overriding concern for patient welfare, her singling-out physicians as the causative link in BZ access and addiction, and her efforts to transmit the needed knowledge directly to the patient – her textbook on BZ withdrawal and recovery was written to a lay understanding – all justify her being singled-out in this NYT encomium. 

- Editor-in-Chief: William Haning, MD, DFAPA, DFASAM

*noted by ASAM CEO/EVP, Penny Mills