There are high reported rates of alcohol dependence among the homeless, and there are substantial reports of benzodiazepine abuse and dependence in this population also. Cross-tolerance between benzodiazepines and alcohol permits individuals who are alcohol dependent to tolerate high doses of benzodiazepines. Patients may be prescribed benzodiazepines to manage alcohol withdrawal, but injudicious prescribing that is not targeted towards the management of alcohol withdrawal symptoms may result in iatrogenic benzodiazepine dependence.
The extensive research on pharmacological interventions for management of alcohol withdrawal in alcohol-dependent patients has been examined in a meta-analysis by Mayo-Smith, who subsequently produced a systematic review with treatment guidelines. (17) This review supports the use of benzodiazepines as the treatment of choice for managing withdrawal symptoms for patients whose symptoms are of sufficient severity to warrant medication. Alternative agents used in withdrawal, such as chlormethiazole and the barbiturate phenobarbital, are less well-supported by controlled trials than benzodiazepines, and carry higher risks of adverse effects.
The potential for misuse of benzodiazepines must be considered in alcohol-dependent patients. However, this is not an adequate reason for avoiding the use of benzodiazepines in the management of withdrawal in view of their superiority in effectiveness, and possibly in potential for harmful misuse, over other treatments. Benzodiazepines with a slower onset of action, such as chlordiazepoxide, appear to have less potential for misuse. The prolonged use of benzodiazepines in withdrawal is rarely necessary or helpful, and evidence for benefits of 'substitute prescribing' of benzodiazepines for alcohol users in the longer term is lacking. Use of benzodiazepines to manage phobic and anxiety disorders associated with alcohol dependence should be strenuously avoided.
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