Uhlenhuth E H, Balter M B, Ban T A, Yang K
Department of Psychiatry, University of New Mexico School of Medicine, Albuquerque 87131, USA.
J Clin Psychopharmacol. 1999 Dec;19(6 Suppl 2):23S-29S. doi: 10.1097/00004714-199912002-00005.
Despite decades of relevant basic and clinical research, active debate continues about the appropriate extent and duration of benzodiazepine use in the treatment of anxiety and related disorders. The primary basis of the controversy seems to be concern among clinicians, regulators, and the public about the dependence potential and the abuse liability of benzodiazepines. This article reports systematically elicited judgments on these issues by a representative panel of 73 internationally recognized experts in the pharmacotherapy of anxiety and depressive disorders, a panel which was constituted by a multistage process of peer nomination. The criterion for inclusion at each stage was the nomination by at least two peers as one of the "professionally most respected physicians of the world with extensive experience and knowledge in the pharmacotherapy of anxiety and depressive disorders." Sixty-six respondents (90%) completed a comprehensive questionnaire covering a wide range of topics relevant to the therapeutic use of benzodiazepines and other medications that might be used for the same purposes. Overall, the expert panel judged that benzodiazepines pose a higher risk of dependence and abuse than most potential substitutes but a lower risk than older sedatives and recognized drugs of abuse. There was little consensus about the relative risk of dependence and abuse among the benzodiazepines. Differences between benzodiazepines with shorter and longer half-lives in inducing withdrawal symptoms are much less clear during tapered than during abrupt discontinuation. There was little agreement about the most important factors contributing to withdrawal symptoms and failure to discontinue benzodiazepines. The pharmacologic properties of the medication may be the most important contributors to withdrawal symptoms. In contrast, the clinical characteristics of the patient may be the most important contributors to failure to discontinue medication. The experts' judgment seems to support the widespread use of benzodiazepines for the treatment of bona fide anxiety disorders, even over long periods. The experts generally viewed dependence and abuse liability as clinical issues amenable to appropriate management, as for other adverse events related to therapy. However, more definitive clinical research on the remaining controversial issues is urgently needed to promote optimal patient care.
尽管进行了数十年相关的基础和临床研究，但关于苯二氮䓬类药物在治疗焦虑症及相关疾病时的适当使用范围和时长，仍存在激烈的争论。争议的主要根源似乎是临床医生、监管机构和公众对苯二氮䓬类药物的成瘾可能性和滥用倾向的担忧。本文报告了一个由73位国际公认的焦虑症和抑郁症药物治疗专家组成的代表性小组对这些问题的系统性判断，该小组是通过多阶段同行提名程序组建的。每个阶段的入选标准是至少有两位同行提名其为“世界上在焦虑症和抑郁症药物治疗方面拥有丰富经验和知识的最受专业尊重的医生”之一。66名受访者（90%）完成了一份全面的问卷，涵盖了与苯二氮䓬类药物及其他可能用于相同目的药物的治疗使用相关的广泛主题。总体而言，专家小组判断，与大多数潜在替代品相比，苯二氮䓬类药物具有更高的成瘾和滥用风险，但比旧的镇静剂和公认的滥用药物风险更低。对于苯二氮䓬类药物之间成瘾和滥用的相对风险，几乎没有达成共识。半衰期较短和较长的苯二氮䓬类药物在逐渐减量过程中引发戒断症状的差异，远不如突然停药时那么明显。对于导致戒断症状和未能停用苯二氮䓬类药物的最重要因素，几乎没有达成一致意见。药物的药理特性可能是导致戒断症状的最重要因素。相比之下，患者的临床特征可能是未能停用药物的最重要因素。专家的判断似乎支持苯二氮䓬类药物广泛用于治疗真正的焦虑症，即使是长期使用。专家们普遍认为成瘾和滥用倾向是可通过适当管理解决的临床问题，就如同其他与治疗相关的不良事件一样。然而，迫切需要对其余有争议的问题进行更明确的临床研究，以促进为患者提供最佳护理。
