Alcohol Use and Anxiety

To The Editor: The Treatment in Psychiatry case study by Kathleen T. Brady, M.D., Ph.D., et al. (1), published in the February 2007 issue of the Journal, is a beautifully written clinical summary that utilized the presentation of a patient with commonly observed comorbid symptoms to review the most recent literature on the treatment of alcohol use disorders, anxiety spectrum disorders, and the overlap between the two. However, I cannot help but to notice that the authors chose not to address the controversial issue concerning the use of benzodiazepines with a patient such as “Ms. M.” Although those of us who work in the field of addiction psychiatry are generally in agreement that benzodiazepines are contraindicated in managing symptoms other than alcohol withdrawal in individuals with alcohol use disorders who are actively drinking, many of my psychiatric colleagues would have prescribed either a benzodiazepine or a nonbenzodiazepine GABA-BZ receptor agonist hypnotic, such as zolpidem or eszopiclone, to treat the patient’s insomnia. I feel that it is important to stress the risks of prescribing such treatment. These risks include 1) complicating the substance use picture with a cross-tolerant agent, thereby delaying diagnosis and treatment of potential alcohol dependence; 2) drug-drug interactions between sedatives and alcohol that can further impair motor function, resulting in a variety of untoward incidents, e.g., motor vehicle crashes, accidents in the home; 3) increasing rather than decreasing patients’ craving for alcohol, making it less likely that he or she will be able to establish abstinence; and 4) worsening of depressive symptoms with possible suicide via a combination of sedatives and alcohol.