I 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.
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.
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).
This article addressed the illegal acquisition of less than common drugs still classed as benzos and then addressed this as it it were the same isssue as the crisis caused by medical providers prescribing extremely inappropropriately while assuring that taking as directd never will cause illness.
Was this deception intentional? Illegal use is one thing, but the crisis is caused by the medical profession, itself. I have dealt with those iatrogenic disasters for 14 years now, and every case but one was caused by patients’ own doctors.
How do patients become so benzo-sick? They become so damaged by taking exactly as directed.
Cases of unlawful use are vigorously diaplayed while the massive iatrogenic holocaust is ignored. Why is that?
Dear Dr. Lembke,
Once again you emphasize the negatives of “Benzos”. Why don’t you discuss the positive aspects of these meds. Has it ever occurred to you that as you state above, the 3 of this class of meds are in the top 10 meds that are prescribed nationwide as to why they are so widely prescribed? I will tell why, it is because they give wonderful relief to so many afflicted with anxiety! Is there problems with the bentos, of course, and they are certainly not for everybody. How come you don’t discuss all the alcohol related deaths that are probably over 10 times as worse. You would not make it for 2 days in a family practice environment so stay in your ivory tower were you belong IMO.
Wail they give relief to many. They also disable about 40% of the patients. I was hit hard. Akathisia neuropathy agoraphobia tinnitus neurotoxicity. I was given this for sleep. I mg at night. For 8 months. The effects have completely destroyed me. So yes we want to warn you. The odds of this causing you physical damage is huge. I have just spent the last 4 years of life being tortured in ways I never could have imagined. The pain alone it’s barbaric. Sooo. Enjoy your meds wail you can. They do have an evil bite. No human. Horrible injury.
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