Benzodiazepine consumption in Brazil: considerations regarding a population-specific scenarioAround the world, benzodiazepines constitute a broadly prescribed and consumed class of medication. In the United States, three benzodiazepines appear among the 60 most prescribed medications.1 While this class has been proven effective for treatment of anxiety, epileptic seizures, and sleep disorders,2 there is a sizable body of evidence highlighting a series of side effects that may appear due to their use, including motor impairment and cognitive deficits.2 Benzodiazepines are also known for their capacity to generate dependence and tolerance, leading users to consume increasing doses of medication and experience withdrawal symptoms when treatment is discontinued.3 In the event of a withdrawal syndrome, exacerbation of psychiatric conditions, such as anxiety, is expected.4 In more severe cases, suicidal ideation might also occur.5
While reports of these side effects and other risks from inadequate benzodiazepine use are common worldwide, comparatively little research has been performed in the Brazilian population. Benzodiazepines rank among the most widely prescribed medications in Brazil, and consumption of substances in this class has increased in the past decades, as suggested in a study published recently in the Brazilian Journal of Psychiatry.6
Considering the Brazilian scenario is essential for evaluation of the particular risks that may be related to widespread use of benzodiazepines in this society. A World Health Organization (WHO) report showed Brazil as the country with the highest prevalence of anxiety disorders in the world, as well as the fifth country with highest prevalence of depressive disorders.7 It must be remembered that there is increased risk of both anxiety and depressive symptoms to appear with benzodiazepine withdrawal.2 Furthermore, benzodiazepines are known to cause alterations in sleep architecture and worsen obstructive sleep apnea (OSA).8,9 As found in a previous study, the prevalence of OSA in the general population can surpass 32%.10 In this sense, worsening of OSA symptoms might be particularly common in patients that use benzodiazepines and must be assessed.
Benzodiazepines can be a useful treatment option when prescribed adequately and when proper follow-up is given to patients, both to evaluate progression of side effects and to ensure the medication is discontinued at the appropriate time. However, indiscriminate use of this class of medications has become widespread, and Brazil may be one of the leading markets. In this sense, the Brazilian physician community must raise awareness of the consequences of inappropriate benzodiazepine use and assess the presence of dependence and tolerance symptoms more closely. Given the prevalence of comorbidities that may be exacerbated by benzodiazepine use, a cautious evaluation of the intake of these drugs by the Brazilian population is a mandatory public health issue.
Acknowledgements
This work was supported by grants from Associação Fundo de Incentivo à Pesquisa (AFIP). ST and MLA received fellowships from Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).
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