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The use of benzodiazepines presents a unique set of clinical, ethical, and legal dilemmas. Benzodiazepines are invaluable therapeutic agents that (in varying degrees) may produce physiological dependence; moreover, their use may complicate or be complicated by the abuse of other substances. In prescribing these controlled substances, more than with other medications, physicians may be perceived to be acting as agents of the state as well as of the patient, with the potential for ethical conflict that this dual role entails.1
In some circumstances it may be unethical to prescribe benzodiazepines; in other circumstances it may be unethical to withhold them, even if prescribing involves risks for the clinician. Benzodiazepines suffer from guilt by association, in that the clinician who treats streetdrug users will often see benzodiazepines used to self-medicate the consequences of that abuse. Conversely, the clinician who treats a more heterogeneous population may see diazepam misuse, but will not see true addiction, insofar as there is no dose escalation or compulsive use in spite of adverse consequences. As with insulin and digitalis, drugs needed for long-term therapeutic use may produce dependence, but that is not the same as addiction. The closest that benzodiazepine abuse comes to addiction is as part of a pattern of multi-drug abuse, sometimes with the rationalization that other chemical addictions require, in compensation, increasing dosages of benzodiazepines.
Long-term therapeutic use of benzodiazepines occurs primarily in three groups of patients. The largest group is those with chronic, serious medical illnesses (eg, cardiovascular). It would be cruel to deny to these patients, often well advanced in age, the degree of relief offered by benzodiazepines. The second group is those with panic disorder. Whether benzodiazepines are more appropriate for such individuals than selective serotonin reuptake inhibitors (SSRIs) or other antidepressants must be decided by weighing therapeutic versus side effects on a case-by-case basis. However, there is no evidence of benzodiazepine abuse in this population, and chronic use tends to result in gradual dose reduction over time. The third group consists of individuals with chronic psychiatric disorders or repeated instances of acute stress. Here, too, except for those with personality disorders, much chronic benzodiazepine use and pharmacologic dependence occur in the context of legitimate treatment.
TYPICAL DILEMMAS
Disagreements between clinicians concerned mainly with overuse...