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Anxiolytics: Misuse, Dependence, and Withdrawal Syndromes

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NeuroPsychopharmacotherapy

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The use of anxiolytic medications requires a careful assessment of the risk for misuse, dependence, and withdrawal. Clinicians should be aware of the range of presentations for misuse and dependence, which includes non-medical use, diversion, self-medication, inappropriate prescription, and behavioral and psychological syndromes of addictive disorders. In comparison to other anxiolytics, benzodiazepines pose the greatest risks for misuse, dependence, and withdrawal. A strong association between benzodiazepine misuse with other sedating drugs such as opioids has been reported and is associated with increased overdose deaths. Careful monitoring is needed for benzodiazepine withdrawal, which can be severe, and gradual tapers with psychological support should be offered. Cognitive behavioral therapy has evidence for efficacy through the stages of benzodiazepine discontinuation and relapse prevention. Although reports of gabapentinoid misuse, dependence, and withdrawal have been increasing in the literature over the years, the numbers involved are small relative to the large number of individuals who have been exposed to the drugs, and true population-based prevalence rates remain poorly characterized. However, randomized controlled trials involving discontinuation in people with anxiety disorders do not show evidence for any significant withdrawal potential. Azapirone anxiolytics including buspirone and tandospirone likely have negligible pharmacological potential for misuse, dependence, and withdrawal. While there may be a gradient of risk for misuse and dependence from benzodiazepines, having the highest, through gabapentinoids to azapirones, having the least, the greatest risk factor by far with all anxiolytic drug classes is the presence of other substance use disorders. This suggests that the pre-existing characteristics of individuals using a medication may contribute as much if not more than the pharmacology of specific drugs in determining the likelihood of misuse and dependence.

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  1. Centre for Addiction and Mental Health, Toronto, ON, Canada

    Victor M. Tang & Simon J. C. Davies

  2. Department of Psychiatry, University of Toronto, Toronto, ON, Canada

    Victor M. Tang & Simon J. C. Davies

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    Peter Riederer

  2. Institute of Psychological Medicine (IPM), Soyen, Germany

    Gerd Laux

  3. Centre for Research Promotion and Support, Fujita Health University, Toyoake, Aichi, Japan

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  4. Center Translational Res Neurol Diseases, Dalian Med Uni Shanghai Inst Health Sc Center Translational Res Neurol Diseases, Dalian, China

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Tang, V.M., Davies, S.J.C. (2022). Anxiolytics: Misuse, Dependence, and Withdrawal Syndromes. In: Riederer, P., Laux, G., Nagatsu, T., Le, W., Riederer, C. (eds) NeuroPsychopharmacotherapy. Springer, Cham. https://doi.org/10.1007/978-3-030-62059-2_405

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