Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

10. Sedatives/Hypnotics and Benzodiazepines 231cated. A number of alternative treatments for anxiety are available, includingnonpharmacological treatments, antidepressants, and buspirone (Buspar), anonsedating antianxiety medicine with no abuse potential. As a general principle,the use of psychotropic medicines, whether controlled (e.g., benzodiazepines)or noncontrolled substances (e.g., antidepressants or antipsychotics), isunlikely to produce a therapeutic benefit for the actively using addicted patient.Stable abstinence is required for these antianxiety medicines to produce therapeuticresults.For patients who have been stable in recovery (including recovering alcoholics)and need treatment for anxiety, it is advisable not to use benzodiazepines,unless the physician can be sure that the patient uses the benzodiazepineonly as prescribed and in the absence of any nonmedical drug use,including alcohol use. For many recovering people, successful use of benzodiazepinesin the treatment of their anxiety disorders has not threatened theirsobriety. We have seen many more patients in recovery who do not want to useany controlled substance and have done well with their anxiety problems, withoutusing a benzodiazepine (Ciraulo et al., 1996; Sattar & Bhatia, 2003).If a benzodiazepine is to be administered to a recovering person, it may beprudent to use one of the slow-onset medicines (e.g., oxazepam, clorazepate, orprazepam) and to include a family member, as well as the sponsor from a 12-step fellowship in the therapeutic alliance, to help ensure that there is no abuseof the benzodiazepine or any other drug, including alcohol.WithdrawalAll of the medicines that influence the GABA system show cross-tolerance andsimilar withdrawal patterns. Because of cross-tolerance within this class of sedativesand hypnotics, an alcoholic or barbiturate addict can be withdrawn undermedical supervision using a benzodiazepine. For the same reason, phenobarbitalcan be used to manage benzodiazepine withdrawal (Wesson, Smith, & Ling,2003). Compared to other benzodiazepines, however, alprazolam withdrawalmay be inadequately covered by substitution. Alprazolam detoxification shouldinclude an estimation of daily use and a slow withdrawal over a period of weeks.Clonazepam has been found to be helpful in this condition.The sedatives/hypnotics withdrawal syndrome, including the potential forwithdrawal seizures on abrupt discontinuation, is also a phenomenon of thisclass of medicines, which argues against abrupt discontinuation of any of thesemedicines after daily use for more than a few weeks. Cessation of use of thebenzodiazepines, along with the other sedatives and hypnotics, can cause withdrawalseizures, because they are potent antiepilepsy drugs that raise the seizurethreshold. Medicines that raise the seizure threshold, when abruptly discontinued,produce a rebound drop in the seizure threshold that may cause seizures,even in people who have not previously had an epileptic seizure.