Are they the next big drug crisis?
The opioid epidemic has been in the news for the past several years and as a result of the coronavirus pandemic, it’s starting to ramp up again. This definitely needs to be addressed, but so does another drug crisis that no one is talking about…benzodiazepines. Many people are addicted to and overdosing on these drugs, but it isn’t being covered in the same way. Why should they be? How harmful are they?
Anxiety is your body’s response to warn you of any potential danger. In this sense, it’s very helpful. However, when it’s severe and misdirected, it’s miserable and disabling. While it’s been around for centuries, it’s particularly prevalent in today’s society with over 40 million American adults having it according to the Substance Abuse and Mental Health Services Administration (SAMHSA), which makes it the most common mental illness in the United States. No one is immune to anxiety and many people develop it in their early 20s. Our societal environment is ripe for precipitating it. Part of that is due to the increase in connectivity, which has created an elevated expectation of productivity and pushed the capacity of our attention span to its limit. Also, we have social media, on which we create curated versions of ourselves and compare it to our peers. Correspondingly, we have an economic system that is very uncertain, especially for those just starting out who have student loan debt and face stagnant wages. On top of these burdens, people are juggling work and family responsibilities. In addition, a warming climate has now changed weather patterns in a way that takes concerns about it from the hypothetical to a very real fear that our planet won’t be the same in our lifetimes or our children’s lifetimes. With all of this going on, it’s no wonder that more people are anxious now.
Symptoms of anxiety disorder include racing/catastrophic thoughts, difficulty breathing, muscle tension, fatigue and restlessness. It creates a vicious cycle where the symptoms feed into each other. Panic attacks, which usually involve shortness of breath, feelings of dread and a racing heart, occur in the most severe cases. These attacks can last anywhere from several minutes to several hours. When these feelings/episodes negatively impact one or more areas of your life and limit functionality, it becomes a disorder. If given the option, wouldn’t you want to not feel like this? Through the centuries, people have tried a variety of solutions to get rid of anxiety. One of the first, and powerful, drugs used were barbiturates, but they presented many challenges, including strong side effects, difficulty gauging the right dose and changes in brain chemistry that led to tolerance, withdrawal and loss of control over use. This means that they were highly addictive. In 1955, a new class of drugs came to market—benzodiazepines (benzos). They work by binding to receptors in the brain, GABA, which bring a sense of calm and drowsiness. This makes them sedatives and some examples are Valium, Librium, Rohypnol and Xanax (their close cousins are Ambien and Lunesta). Doctors found that patients responded immediately to medications, so they were quick to prescribe them. Most commonly they’re used to treat anxiety and mood disorders, like depression and insomnia. They can also treat seizures. Most people benefit from short-term use for a temporary problem or while waiting for another medication, like a selective-serotonin reuptake inhibitor (SSRI), to work.
When used correctly and a person is monitored by trained medical professionals, benzos can be very effective. However, they do come with some risks. Besides their sedative properties, they also affect the brain’s reward pathway by increasing dopamine release, which helps you to feel better and reinforces the desire for them. Unfortunately, this makes them addictive. The more you use them increases your tolerance to it, so to achieve the same feeling, you need to take higher doses and makes the person develop a dependence on the drug. If a person doesn’t take it, they find that their anxiety is worse, so they think they need to take more, but, in many instances, they’re actually medicating the withdrawal from their last dose. It turns into this vicious cycle. This addictive quality is why, according to a study published in the Journal of the American Medical Association (JAMA) Internal Medicine, they “are intended to be used for less than 14 days,” but “chronic use—over 120 days—is common.” As stated in a 2018 article in the Journal of Clinical Medicine, you shouldn’t take them for longer than two to four weeks because dependence is widespread even if you take it as prescribed. Most experts say that if you use them longer than that, you should only take them two to three times a week. A report in JAMA states that between 2005 and 2015, the number of people using them for six or more months increased by 50%.
Not surprisingly, people who’ve been on benzos for a long time find it hard to stop taking them because of withdrawal symptoms, like increased tension/anxiety, panic attacks, hand tremors, insomnia, elevated heart rate, gastrointestinal problems, dizziness, depression, irritability or muscle jerks. Some individuals describe having “benzo rage,” which is like have a temper tantrum but as an adult. In severe cases, seizures can occur. Some studies have found that long-term use can even cause lasting neurological damage. If you abruptly stop taking the medication, it can cause withdrawal symptoms so severe you might need to be hospitalized. Since they work on the same receptor as alcohol, the process is very similar to those trying to detox from it. It’s estimated that about 10-15% of users will develop an addiction and a larger proportion of people will develop a physiological dependence. Shorter-acting benzos, like Xanax, are more likely to cause severe withdrawal symptoms; whereas, longer-acting ones, such as Librium and Valium, might result in some that are less severe. This is why anyone wanting to stop taking these medications should do so under medical supervision.
Due to their ability to suppress the nervous system, benzos can easily lead to overdoses and result in death. Overdose deaths involving them rose more than sevenfold between 1999 and 2015. Data from the National Institute on Drug Abuse shows that there were 8,791 benzo overdose deaths in 2015, which is dramatically higher than the 1,135 benzo overdose deaths in 1999. Per a report in JAMA Network Open, women are twice as likely as men to have anxiety, so they’re twice as likely to be prescribed benzos. Also, the number of visits to get these prescriptions increases with age. Findings released by the Centers for Disease Control and Prevention (CDC), show the overdose mortality rate involving benzos for women between 30-64 expanded 830% between 1999 and 2017. Another factor that stood out is the number of elderly patients who are prescribed these drugs because they face the most danger since they’re more likely to fall, prone to confusion and could have cognitive impairment.
With the rise in anxiety levels, benzos are being prescribed at an alarming rate and often for conditions that don’t have anything to do with anxiety or mood disorders. They’re so popular that per reports from Zion Market Research the market for them is expected to reach $3.8 billion in the US at some point this year. Research done in 2016 showed the number of adults in the US filling a prescription for a benzo increased 67% between 1996 and 2013, jumping from 8 to nearly 14 million. The quantity prescribed per patient more than tripled during this period. Xanax is the number one prescribed psychiatric medication with over 50 million prescriptions written each year. The research showed that many of these prescriptions are coming from primary care providers and are being used for conditions like back pain because the access to traditional analgesics, like opiates, has become limited as a result of the opioid epidemic. A JAMA study discovered that the number of primary care visits that ended with a benzodiazepine prescription grew from 3.8% in 2003 to 7.4% in 2015.
Most people know about America’s opioid crisis and how bad it has been with an estimated 1.7 million people having an opioid substance abuse disorders in 2017, which is the same year that it was declared a national public health emergency and had 46,700 reported deaths according to the CDC. Last year, the National Safety Council found that the odds of dying from an accidental opioid overdose were greater than dying in a car crash. With the declaration as a national emergency and increased funding to resources to combat the problem, the opioid epidemic has received a significant amount of attention. One area that is being examined is how did it become such a problem. A major component was that new mandates to effectively manage pain were put into place in the 1980s and 1990s. These changes coupled with marketing from pharmaceutical companies, inaccurate assumptions about the drugs’ ability to treat chronic pain and lack of attention to the associated risks are the main contributors that resulted in the number of opioid prescriptions going from 670,000 to 6.2 million between 1997 and 2002. By the time 2017 rolled around, the CDC states there were almost 58 opioid prescriptions written for every 100 Americans, which adds up to almost 190 million prescriptions per year. The scary thing is that this matches the number of benzo prescriptions currently being written each year. Data from the Boston University School of Public Health illustrates that the prescription rates for benzos have followed a trajectory similar to that of opioids with rates nearly doubling from 2003 through 2015. This path will lead to a benzo epidemic parallel with the opioid crisis.
At least as of right now, benzo overdose deaths aren’t nearly at the same level of opioids. SAMHSA states that in 2016 there were 11,000 deaths related to them. However, they’re on the rise. The National Institute on Drug Abuse affirms that benzo overdose deaths went from 1,135 in 1999 to over 11,500 in 2017 with most of them being the result of an individual taking a benzo in combination with an opioid. This is because both affect the central nervous system, so when they’re used together, it exacerbates dangerous side effects, such as difficulty breathing. The National Institute on Drug Abuse says that over 30% of opioid overdose deaths include a benzo. The number of people prescribed both classes of medication simultaneously has increased sharply since 2000. Between 2014 and 2016, of the doctor visits during which benzos were prescribed, around one-third had an overlapping opioid prescription. A different set of data indicates that the prescription combination went from 0.5% in 2003 to 2% in 2015. The Food and Drug Administration (FDA) said the number of individuals who were prescribed both swelled 41%, or 2.5 million, between 2002 and 2014. A study done in 2018 found that when the two are combined, the risk of overdose quintuples in the first 90 days. This is why the FDA began issuing black-box warnings against mixing the two drugs.
Since the abuse of benzos is so prevalent and the risks are incredibly real, why don’t we hear more about it? Some experts think it’s because attention has been so focused on the opioid crisis. In addition, people who are addicted to benzos tend to be older and less violent, so it’s not an addiction that gets noticed as much as those who are addicted to other substances. Also, with them being mentioned in lyrics of popular music, the use of benzos is becoming normalized, which is why the rate of addiction among teenagers has already overtaken rates of opioid addiction. The rise in availability of them on the dark web is also contributing. On top of that, you have combination benzos, like clonazolam (a mashup of clonazepam and alprazolam), which are much more potent and are finding their way to market. In fact, clonazolam is so potent that it needs to be dosed at the microgram level using a high-precision scale. Parents need to be aware that these powerful benzos can easily be bought online. This is why it’s important to talk to teens about the dangers and be on the lookout for mysterious packages and precision scales.
The other part of the issue surrounding the benzo crisis is that both patients and doctors don’t understand the risks associated with them. In some cases, they’re not even aware of it. Many patients have been harmed by these medications just by taking them as prescribed. The responsibility of a doctor is to educate patients on the risks of a medication before prescribing it. However, medical students get little training on mental health issues, psychiatry and addiction. This means that most primary care doctors don’t have enough knowledge on how to prescribe benzos safely. They don’t know to inform the patient that they’re addictive and habit-forming. Unfortunately, due to the difficulty with trying to access specialized care, many people who need mental health help are seeking it from their primary care doctors. This means that a lot of doctors are trying to manage symptoms they aren’t adequately prepared to. This factor is why Yale Medicine experts believe that educating primary care doctors is the cornerstone of preventing benzos from becoming the next opioid crisis.
There are other medications, like antidepressants (Prozac, Zoloft and Paxil), that work on anxiety and aren’t habit-forming, but don’t work as quickly. There are also nonmedication alternatives that have been proven to be effective. Cognitive behavior therapy (CBT) is one of these methods. It usually involves 12 to 16 sessions and helps patients learn to recognize and challenge thoughts and behaviors that could be contributing to the anxiety. Most people report some level of improvement within four to six sessions. Therapy that focuses on teaching mindfulness is helpful because it encourages people to stay in the moment and rediscover their values, meaning and purpose. The challenge is patients want a quick, easy solution to their problems and most are unwilling to put forth the effort into other techniques that work but take longer to get to the result. Besides patients not wanting to wait or put forth the effort, often access to these treatments isn’t always readily available as a result of insurance limitations. On top of that, our healthcare model only allows doctors to spend about 10 minutes with each patient, which means that there isn’t enough time to go over everything in one visit, so doctors often write prescriptions to appease their patients because, in our consumer-driven healthcare market, doctors can’t afford to have patient’s write bad reviews since this could affect compensation and ability to gain new patients.
Benzo addiction is extremely difficult to overcome. For some, quitting opioids was easier. To help prevent people from becoming addicted, the Benzodiazepine Information Coalition’s mission is to educate both doctors and patients about the dangers associated with these medicines. They recommend before taking them to ask your doctor what the risks are and if there are other treatment options you can try. They also point out that benzos should be used as short-term and intermittent treatments. Due to the possibility of withdrawal symptoms, never stop taking a benzo suddenly. Instead, talk to your doctor about a plan to taper over time. It’s also vital to tell your doctor about any other medications you’re taking and ask about the impacts they’ll have on your body if you take a benzo too. Many mental health professionals also point out that we need to teach people that having feelings of anxiety throughout life is normal and ways to cope with it rather than turning to medications to eliminate their discomfort. Another aspect to address is our healthcare model. We need to create better guidelines for doctors to assist them in deciding when, and when not, to use benzos. In addition, we need to help specialized mental healthcare become better integrated with primary healthcare. This would allow mental health professionals to work in primary care settings to provide support and expertise to patients and doctors. Thankfully, this model is already gaining ground in patient-centered medical homes and academic medical centers.
Benzos haven’t gotten the attention they deserve, which is why they’ve become a hidden killer. There needs to be more attention on the problem and awareness raised among doctors. It’s going to take time because as we can see with the opioid crisis, even when legal prescriptions have declined, illegal versions remain at epidemic levels. However, to prevent it from becoming worse, we must start raising awareness now!