Discuss long-term benzodiazepine with doctor

DEAR DR. ROACH: Last week there was an article in your column on the fact that you don’t recommend alprazolam as a long-term sleep aid. It has been recommended to me. What are the consequences of long-term use? — A.T.

ANSWER: Alprazolam (Xanax) is a relatively short-acting benzodiazepine drug, in the same class as diazepam (Valium). These are pretty powerful sedatives, and are used extensively in people with anxiety disorders, such as panic disorder, agoraphobia (fear of open spaces) and generalized anxiety disorders.

I very seldom prescribe benzodiazepine drugs for long-term use (I often use them while other therapies, such as cognitive-behavioral therapy or SSRI medications are first administered, until they have a chance to become effective). The reason is that they all can cause confusion or trouble thinking, and contribute to potential motor vehicle accidents and falls with fractures, which I have seen too often lead to a progressive decline, ending in death. As an internist, I have respect for the downsides of these medications. They are particularly likely to cause problems in people older than 65.

However, they sometimes still are the best treatment for a given individual. I have patients who have done well with chronic use of these medications, when prescribed and carefully monitored by a psychiatrist. I think too many people are probably taking them unnecessarily, but my general advice can in no way be considered to have more applicability to you than that from your own doctor or other provider, who knows your individual medical details.

I do hope that my advice leads to a more productive conversation between my readers and their doctors.

DEAR DR. ROACH: Can you fix real gynecomastia without surgery or liposuction? — R.A.

ANSWER: Gynecomastia is a benign condition of breast enlargement in men. It is common and has many possible causes. Gynecomastia can cause tenderness in the breast and may cause significant embarrassment.

The most common cause is pubertal gynecomastia. It is routine for adolescents to have some breast tissue develop at about age 13-14, but this regresses and goes away 90 percent of the time. Other causes include medications. The list is long, but the most common prescription drug I see causing gynecomastia is spironolactone. Marijuana use is another common cause. Both of these interrupt synthesis of androgens (male hormones), and a relative excess of female hormones to male is the underlying cause of most cases of gynecomastia.

If a drug is the cause, the problem usually goes away upon stopping the drug. If it isn’t medication-related, then, depending on the underlying cause (if known), medications sometimes are used. Anti-estrogens, such as tamoxifen, often are used for this purpose, although the Food and Drug Administration has not approved it (or other anti-androgens, such as aromatase inhibitors, usually used for breast cancer) for this cause. Testosterone is used only in the case of testosterone deficiency. The earlier medication treatment is begun, the more likely it is to be successful.

If the gynecomastia is large, then medication treatment alone is unlikely to be effective at completely resolving the breast tissue, in which case liposuction or surgery is best for good cosmetic results.