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

234 III. SUBSTANCES OF ABUSEtheir doctors, and because many family members are concerned about longtermbenzodiazepine use, we generally ask that a family member come to theoffice at least once with the patient who is taking a benzodiazepine for a prolongedperiod. This gives us an opportunity to confirm with the family member,while the patient is present, that benzodiazepine use produces a therapeuticbenefit without problems. If there is a problem of toxic behavior or abuse ofother drugs, we are more likely to identify it when we speak with the patient’sfamily members; if not, we have an opportunity to educate and reassure boththe patient and family members when they are seen together.Most patients without a history of addiction produce four “yes” answers tothese four questions. Even a single “no” answer deserves careful review and maysignal the desirability of discontinuation of the benzodiazepine. After completionof the Benzodiazepine Checklist, if there is clear evidence that long-termbenzodiazepine use is producing significant benefits and no problems, and if thepatient wants to continue using the benzodiazepine (which is, in our experience,a common set of circumstances for chronically anxious patients), then wehave no hesitancy in continuing to prescribe a benzodiazepine, even for thepatient’s lifetime.On the other hand, many anxious patients, even when they have goodresponses without problems, want to stop using benzodiazepines. Other patientsdo not want to stop using a benzodiazepine, but they do show signs of poor clinicalresponse or trouble with the use of a benzodiazepine. In either case, discontinuationis in order, and it is an achievable goal.Some critics of benzodiazepines, including Stefan Borg and Curtis Carlsonof St. Goran’s Hospital in Stockholm, Sweden (Allgulander, Borg, & Vikander,1984), have expressed concerns about the possibility that benzodiazepine usemay lead to alcohol problems in patients without a prior history of alcoholabuse, especially in women. The simple advice to a long-term medical user of abenzodiazepine is not to use alcohol, or to use alcohol only occasionally andnever more than one or two drinks in 24 hours. Most anxious patients who donot have a prior history of addiction either do not use alcohol at all or use itonly in small amounts. The Benzodiazepine Checklist helps the physician, thepatient, and the patient’s family identify any problems (including alcoholabuse) at early stages, thus facilitating constructive interventions.LONG-TERM DOSE AND ABUSEOne clinical observation helps the physician identify people who have addictionproblems among anxious benzodiazepine users. Most anxious medical usersof benzodiazepines have used these medicines at low and stable doses over time,often for many years, with good clinical responses. Dose is a critical and distin-