n my humble opinion, benzodiazepines are not evil. Nor are they magical. They’re just drugs—with the potential to do good or ill, depending on dose, administration, the patient, etc., etc. They do many things well, help many people, and when prescribed by a knowledgeable physician and taken by a responsible patient, they can alleviate suffering. When the New York Times Magazine lambasted “Valiumania” decades ago, I thought that unfair.
But the triazolobenzodiazepines triazolam (Halcion and others) and alprazolam (Xanax and others) have always given me pause. Patients, friends, and colleagues have forgotten whole mornings’ activities after a bedtime dose of triazolam due to its powerful anterograde amnesia. It was withdrawn from the market in several countries because of these cognitive disturbances.
All benzodiazepines can, of course, be abused. But alprazolam gives more of a “buzz” than I’ve seen with other benzos. Its withdrawal effects are intense and dangerous. Patients taking maintenance doses of alprazolam watch the clock, eagerly awaiting their next dose. And boy, is it hard to get many patients to stop that medicine.
Some of the properties of triazolam and alprazolam may be due to their pharmacodynamic properties and receptor effects. Others likely reflect their pharmacokinetics—namely, their brief half-lives. I try to avoid prescribing them, favoring other members of the class when a benzo makes sense.
Given these opinions, I was dismayed to read in November’s Psychiatric Times that, of more than 250 million prescriptions for psychiatric drugs written in the U.S., alprazolam was far and away #1! Almost 50 million prescriptions were written last year for brand-name Xanax or generic forms.
I suspect most of the prescriptions are written by primary care practitioners, rather than psychiatrists. It’s a disappointing pattern.
- Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry