COMMENTARY
Should Patients With Substance Use Disorders Be
Prescribed Benzodiazepines? No
Robert L. DuPont, MD
Patients with substance use disorders (SUDs) should not use benzo-
diazepines to treat anxiety, insomnia, or anything else, for the same
reasons that they should not drink any alcohol or use other drugs,
regardless of their primary drug used. Once the addiction switch is
thrown on, it never again goes off. This question has additional
relevance today because in 2016, the US Food and Drug Adminis-
tration put black box warnings on all benzodiazepines and opioid
analgesics about the serious risks associated with their concomitant
use. Anxiety is not a benzodiazepine-deficiency disease. It is possible
to treat anxiety and insomnia without medicines of any kind, and it is
possible to use medicines other than benzodiazepines for these
common and serious mental disorders. Although many patients with
SUDs are eager to use benzodiazepines, using alternatives is often
effective and it does not put the patients recovery in jeopardy. The
standard I propose here is based on the experience of many people
with SUDs who have tried and failed to use benzodiazepines for
anxiety.
Key Words: anxiety, benzodiazepines, substance use disorders
(J Addict Med 2017;11: 8486)
P atients with substance use disorders (SUDs) should not
use benzodiazepines to treat anxiety, insomnia, or any-
thing else, for the same reasons that they should not drink any
alcohol or use other drugs, regardless of their primary drug
used. This question has additional relevance today, because in
2016, the US Food and Drug Administration (FDA, 2016) put
black box warnings that the benzodiazepines not be pre-
scribed to patients also using opioids because of risk of
overdose death among other serious interactions. Data from
opioid overdose deaths show the high prevalence of the
specific combination of opioids and benzodiazepines: nearly
one-third (30.1%) of all opioid overdose deaths in 2010
From the Institute for Behavior and Health, Inc., Rockville, MD (RLD);
Georgetown University Medical School, Georgetown, Washington, DC
(RLD).
Received for publication November 18, 2016; accepted December 19, 2016.
Disclosure: No funding was received for this work.
The authors report no conflicts of interest.
Send correspondence and reprint requests to Robert L. DuPont, MD, Institute
for Behavior and Health, Inc., 6191 Executive Boulevard, Rockville, MD
20852. E-mail: contactus@ibhinc.org
Copyright 2017 American Society of Addiction Medicine
ISSN: 1932-0620/17/1102-0084
DOI: 10.1097/ADM.0000000000000291
84
Copyright 2017 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
involved benzodiazepines and 77.2% of benzodiazepine over-
dose deaths involved opioids (Jones et al., 2013).
I came to my strong opinion about the simple standard
that physicians should not prescribe benzodiazepines to
patients with SUDs based on a combination of decades of
clinical experience and research.
In 1968, I made a fateful personal decision, when, at the
age of 32, I completed my medical training. In my residency, I
had worked 1 day a week at the Norfolk Prison in Massachu-
setts, where I was not only fascinated by the stories of the men
with whom I worked, but I wanted to use my training at the
Harvard Medical School and the National Institutes of Health to
help people in the criminal justice system. I chose to work full
time for the District of Columbia Department of Corrections
(DCDC). At that time, the District of Columbia was suffering
from a crime epidemic which had started about 5 years earlier.
The intense public concern about crime in the city led President
Lyndon Johnson in 1965 to establish the District of Columbia
Crime Commission (Johnson, 1965). In 1968, Richard Nixon
labeled the city the crime capital of the nation. Into this
vortex I asked a question: Is heroin a major driver of the rising
rate of crime? I collected urine from everyone coming into DC
jail in August of 1969. Using the primitive thin layer chroma-
tography tests then available, I discovered that 45% were
current heroin users (Kozel et al., 1972). The year of first
heroin use tracked the rise of crime (DuPont, 1971). Next up:
What to do about heroin addiction? I turned to Drs Vincent
Dole and Marie Nyswander in New York who pioneered
methadone maintenance treatment. On February 18, 1970, I
started one of the largest drug treatment programs in the
countrythe Narcotics Treatment Administration (NTA). As
an employee of DCDC, I launched my nearly 50-year career in
addiction medicine (DuPont and Greene, 1973). Our success
with methadone in the District of Columbia was largely
responsible for the US FDA approval of methadone mainten-
ance treatment in 1973 (it had previously been available only
for use as an Investigational New Drug [IND]). That same year,
I became the first Director of the newly created National
Institute on Drug Abuse (NIDA) (Drug Abuse Office and
Treatment Act of 1973, 2016).
Throughout my career, in addiction medicine, I had
seen that the benzodiazepines were booze in a pill. I had no
sympathy for these pills, seeing them as equivalent to the
barbiturates which then were well-established as addictive
drugs. I saw how patients with SUDs used benzodiazepines.
Rather than using them at stable low does, these patients used
high doses of benzodiazepines and usually combined them
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with other drugs including alcohol, cocaine, and heroin. I
seldom saw a patient with a SUD who used only benzo-
diazepines. Patients said they were boosting the effects of
alcohol and opioids with their use of benzodiazepines, or they
were treating the adverse effects of using other drugs, like side
effects of cocaine, or opioid withdrawal.
When I left NIDA in 1978, I devoted myself to an
entirely different medical problem starting in my own small
clinical practice with a young woman with what I slowly came
to label agoraphobia. I became fascinated by the anxiety
disorders (ADs) and their treatment, especially cognitive
behavioral therapy (CBT), and exposure and response pre-
vention (ERP) therapy. In short order, not wanting to keep my
new passion to myself, I founded the Anxiety Disorders
Association of America, known today as the Anxiety and
Depression Association of America (ADAA), and what was
then called the Phobia Society of America (PSA) (DuPont,
1982). At the center of the ADs were the benzodiazepines. I
became 1 of 8 principal investigators on the Cross-National
Collaborative Panic Study funded by the Upjohn Company,
maker of alprazolam (Xanax). This landmark study estab-
lished the template for subsequent studies of the use of
medications to treat ADs (Ballenger et al., 1988; Lesser
et al., 1988; Noyes et al., 1988; Lesser et al., 1989). Alpra-
zolam was the first medicine of any kind to be approved to
treat agoraphobia and panic disorder. My own clinical practice
was filled with anxious patients, many of whom used benzo-
diazepines. I could not believe my eyes; here I had patients
lots of patientswho used benzodiazepines at low and stable
doses over the course of many years.
Of course, not all of my patients fit the diagnosis of
either an AD or SUD. There was a group of patients who had
both ADs and SUDs. Unsurprisingly, they mostly handled the
benzodiazepines like SUD patients, not like AD patients. My
patients with ADs who did not have SUDs seldom used any
drugs nonmedically. Most either did not drink alcohol or they
drank moderately with no episodes of excessive drinking.
These patients, whether prescribed benzodiazepines or not,
mostly did not have problems with their drinking. How do I
explain these striking observations about how these 2 groups
of patients commonly handled the benzodiazepines?
Once the addiction switch is thrown on, it never
again goes off. This is true of smokers. A former smoker
cannot smoke an occasional cigarette without risking reignit-
ing active nicotine addiction. This lifetime on position for
the addiction switch applies also to alcohol and other drugs.
That is the wisdom of Alcoholic Anonymous (AA), the real
experts on recovery. They have no ambiguity on this point: to
be in recovery from addiction to alcohol, opioids or any other
substance requires being abstinent from all drugs including
alcohol. The DSM-5 identifies SUDs as substance-specific;
not AA and NA. This clarity within AA and NA is the result of
the experiences of millions of people with SUDs over the past
81 years in countries all over the globe.
A confirmed long-time social drinker can develop a
severe alcohol use disorder. It is also true that some people
with histories of severe SUDs can stably and in safe moderation
use alcohol or marijuana with no problems. Those are uncom-
mon exceptions which prove the rule. Betting on a long-time
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SUDs and BZs Debate
stable drinker developing alcohol use disorder and betting on a
person in recovery becoming a controlled, safe drinker, or drug
user without suffering problems from that use is beyond hazard-
ous (DuPont, 2000). Not every physician who treats patients
with SUDs thinks it is a bad idea for them to drink alcohol
socially. The view that this is unwise and dangerous is, however,
widespread among clinicians, and this view has been increas-
ing. Why not apply the same standard commonly used for
drinking alcohol among persons in recovery to using benzo-
diazepines in this high-risk population? Benzodiazepine use by
individuals in recovery is playing Russian roulette. Some
survive the gamble at least for a while and many do not. Prudent
and experienced physicians are most likely to help their patients
suffering from SUDs deal with anxiety, insomnia, and other
conditions that are commonly treated with benzodiazepines
without using these widely misused medications.
Recall that I cut my teeth in treating ADs using CBT and
ERP. Anxiety is not a benzodiazepine-deficiency disease. It is
possible to treat anxiety and insomnia successfully without
medicines of any kind, and it is possible to use medicines
other than benzodiazepines for these common and serious
mental disorders (DuPont et al., 1998; Spencer et al., 2003). In
addition, there are many effective strategies to successfully
manage clinically significant anxiety. The alternatives to the
benzodiazepines for clinically significant anxiety take more
work for the physician than writing a prescription for a
benzodiazepine. Although many patients with SUDs are eager
to use benzodiazepines, using alternatives is often effective
and it does not put the patients recovery in jeopardy (DuPont,
1990a, 1990b, 1990c, 1995). The standard I propose here is
not based on religion. It is experience, and not only my own
experience. It is the experience of many people with SUDs
who have tried and failed to use benzodiazepines for anxiety.
What if physicians choose to prescribe benzodiazepines
to patients with SUDs? I suggest that they do so with caution
keeping their patients best interests rather than their wishes in
mind. Educate these SUD patients about the risks of using
benzodiazepines including both the risk of relapse to addic-
tion and the risk overdose death. Involve the patients families
in the decision. Watch these patients carefully and be prepared
for trouble. When it comes to prescribing benzodiazepines
to patients with SUDs: generally the juice aint worth the
squeeze.
Robert L. DuPont, MD, served as the first Director of
the National Institute on Drug Abuse (NIDA) from 1973 to
1978. He has been President of Institute for Behavior and
Health, Inc. since 1978 and Clinical Professor of Psychiatry at
Georgetown University Medical School since 1980. Special-
izing in addiction and anxiety, he has maintained a private
practice of psychiatry in Rockville, MD, since 1969.
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