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

288 IV. SPECIAL POPULATIONSdiagnosed population, well-designed controlled trials are needed to establishsafety, tolerability, and efficacy in this population.Anxiety DisordersThe use of benzodiazepines in populations with SUDs and co-occurring psychiatricdisorders is controversial. This issue has been explored almost exclusivelyin populations with anxiety and alcohol use disorders. The prevalence of benzodiazepineuse among patients with alcohol use disorders is greater than in thegeneral population but comparable to psychiatric disorder populations (Ciraulo,Sands, & Shader, 1988). Clinicians are often understandably concerned thatprescribing benzodiazepines to these patients may lead to either a worsening ofthe alcohol use disorder, the development of a benzodiazepine use disorder, orpotentiation of the benzodiazepine effect when combined with alcohol. Preliminaryevidence from case reports (Adinoff, 1992) and a prospective naturalisticstudy (Mueller, Goldenberg, Gordon, Keller, & Warshaw, 1996) suggests thatthere may be a carefully selected subpopulation of patients with co-occurringalcohol use and anxiety disorders for whom long-term prescription of benzodiazepinemay not affect sobriety or result in benzodiazepine misuse. However,it may not improve outcomes either. For example, a retrospective naturalisticstudy of veterans with PTSD and SUD found that physicians were less likely toprescribe benzodiazepines for those with SUD (Kosten, Fontana, Sernyak, &Rosenheck, 2000). While those with prescribed benzodiazepines did not haveworse outcomes, chronic benzodiazepine treatment (independent of a cooccurringSUD) did not improve anxiety or social functioning in these patientseither. Similarly, Brunette, Noordsey, Xie, and Drake (2003) followed SPMIpatients with SUDs annually for 6 years and found that the rate of benzodiazepineprescribing was high (up to 63%) but not associated with differences insubstance use remission, hospitalization, or, interestingly, reductions in anxietyor depression. Also, unsurprisingly, patients prescribed benzodiazepines weremore likely to abuse them than those who were not. While controlled trials areneeded to explore these issues more fully, the findings from these reports addfurther to concerns that the long-term use of benzodiazepines in these populationsperhaps offers the risk of abuse or dependence without great potential forclinical benefit.Another pharmacological alternative in this population is buspirone,which does not have abuse potential. Thus far, there have been three doubleblind,placebo-controlled studies of buspirone in patients with alcohol dependenceand anxiety—generalized anxiety disorder (GAD) (Tollefson, Montague-Clouse, & Tollefson, 1992), GAD and “other nonpanic anxiety” (Malcolm etal., 1992), or “anxious alcoholics” (Kranzler et al., 1994). Two of the studiesfound buspirone to be associated with improvements in anxiety and alcohol useoutcomes (Kranzler et al., 1994; Tollefson et al., 1992). Although there have