got the call every addiction doctor dreads: A patient of mine nearly overdosed. He had a long history of addiction, starting with opioid pain pills in his teens after a sports injury and progressing to heroin by his early 20s. He had been in recovery for six months.

“Was it heroin?” I asked the doctor, who was calling from the emergency department.

“Not opioids,” said the doctor. “Benzos.”


“Benzos” is shorthand for benzodiazepines, a class of drugs often used to treat anxiety and insomnia. The dozen or so different types include Ativan, Klonopin, Valium, and Xanax. Most people have heard of them. More people than you might think are taking them (three benzodiazepines are in the top 10 most commonly prescribed psychotropic medications in the United States). Yet few people realize how many people get addicted to and die from them.

As my colleagues, Jennifer Papac and Keith Humphreys, and I write in this week’s New England Journal of Medicine, we need to pay more attention to America’s other prescription drug problem — the hidden epidemic of benzodiazepine use and abuse.


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Between 1996 and 2013, the number of adults who filled a benzodiazepine prescription increased by 67 percent, from 8.1 million to 13.5 million. Unlike opioid prescribing, which peaked in 2012 and has decreased nearly 20 percent since then, benzodiazepine prescribing continues to rise. The risk of overdose death goes up nearly fourfold when benzodiazepines are combined with opioids, yet rates of co-prescribing benzodiazepines and opioids nearly doubled between 2001 and 2013. Overdose deaths involving benzodiazepines increased more than sevenfold between 1999 and 2015.

I spoke with my patient by phone a few days later. He was doing better — happy to be alive. I specifically asked him what he had taken and how he had gotten it. I knew he wasn’t getting benzodiazepines from a doctor’s prescription. I check the prescription drug monitoring database regularly, and he didn’t have a benzodiazepine prescription on record. Did he purchase Z-bars — a 2-milligram bar of prescription Xanax popular among teens and young adults — on the street?

His response was surprising, and scary.

He obtained clonazolam, the benzodiazepine that nearly killed him, from a website. The name is a mashup of clonazepam and alprazolam, the generic names for Klonopin and Xanax. Clonazolam is a highly potent benzodiazepine manufactured in laboratories in the United States and elsewhere. Sold as a “research chemical,” it can be shipped virtually anywhere. It is so potent that it needs to be dosed at the microgram level — millionths of a gram — using a high-precision scale.

My patient knew that clonazolam is potent, but didn’t realize just how powerful it is. He lacked a precision scale, and instead figured he was safe by measuring out just the smallest amount.

“The amount I took,” he told me, “wasn’t enough to cover a fourth of my pinkie fingernail. I thought I was safe.” Yet hours later he woke up in the hospital, lucky to be alive.


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Highly potent drugs like these designer benzodiazepines are a growing trend among those seeking a new high, fueled in part by doctors overprescribing benzodiazepines without appreciating their addictive potential. Just as overprescribing opioids contributed to the use of heroin and illicit fentanyl and related deaths, overprescribing benzodiazepines may herald the dawn of a new era of illicit and deadly benzodiazepines.

Benzodiazepines work well to ease anxiety or insomnia when used intermittently and for less than a month at a time. When taken daily for an extended period of time, they stop working and can make anxiety and insomnia worse. Most doctors don’t realize how addictive benzodiazepines can be for some people and, because they don’t know better, prescribe them long term and without safety monitoring, like checking the prescription drug monitoring database. In addition to addiction and death, long-term use of benzodiazepines can also contribute to cognitive decline, accidental injuries, and falls.

There are safer treatments than benzodiazepines for anxiety and insomnia. These include behavioral interventions and long-term medications like selective serotonin reuptake inhibitors.

Part of this public health crisis can be solved by physicians adopting wiser prescribing practices. But the public can help, too. If you are struggling with anxiety or insomnia and go to see your doctor, be wary of accepting a prescription for a benzodiazepine — including Ambien, a close cousin of benzodiazepines that is also addictive and potentially deadly.

If you take a benzodiazepine every day, ask your doctor about helping you taper off of it. It’s important to go slowly, because abruptly stopping a benzodiazepine can precipitate life-threatening withdrawal. If you’re a parent and you notice a precision laboratory scale in your child’s bedroom or mysterious packages arriving from FedEx, get worried fast.

Anna Lembke, M.D., is associate professor of psychiatry and behavioral sciences at the Stanford University School of Medicine, chief of the Stanford Addiction Medicine Dual Diagnosis Clinic, and author of “Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop” (Johns Hopkins University Press, 2016).

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  • Actually, although some people do abuse benzo’s (and they certainly can be mixed dangerously with other drugs of abuse), in people who are not abusing other drugs this problem has been grossly exaggerated by Big Pharma – because when properly used benzo’s have far fewer side effects than most of the drugs being pushed today and they are generic, cheap and effective. This, while companies push more widely-abused and far more dangerous drugs like Adderall (Schedule II as opposed to Schedule IV BTW and almost identical to methamphetamine) for phony disorders like “Adult ADHD,” while very few articles like this one seem to appear in the press.

    I wonder why.

    I know if I had to choose between being “addicted” to a drug that causes no intoxication and few side effects and being housebound with severe panic disorder and agoraphobia, I can tell you what I would chose.

    For patients who have panic disorder, long acting benzodiazepines are far more effective than antidepressants or CBT in controlling symptoms, and hardly any doctors even ask patients about panic disorder. Every study ever done on it say long term treatment is usually necessary.

  • I believe the author is grossly oversimplifying, at least for patients with chronic insomnia. There is no drug approved by the FDA (that is not addictive) that successfully treats chronic insomnia. It is a massive problem, and I think insomnia is the ailment that leads many to try these dangerous drugs.

    There is a decades-old drug, Trazodone, that works extremely well on insomnia but most GPs haven’t heard of it because the approved use is for depression. It is not addictive and with proper dosage the patient is bright and alert the following day. Patients will not find that they need to take more and more over time to get to sleep, a key problem with addictive drugs. Psychiatrists know all about it; if a GP is uncomfortable prescribing it they should refer the patient to a psychiatrist for treatment, even if the patient is not depressed.

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