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.”

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“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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  • I took low-dose Ativan in ’05 for my temporary menopause state when undergoing chemo for cancer. I was on massive doses of opioids at the time too, but the Ativan was such a small dose, I never came remotely close to having an issue. I had ZERO side effects whatsoever, not even euphoria or sleepiness (no euphoria from opioids either due to tolerance), and was able to simply quit taking it after my 5 month chemo run was done. No withdrawal, again, a very low dose. The problem now is the stigma surrounding benzos makes doctors wary to prescribe them, even at low doses for patients that can irrefutably prove their conditions.

    I have been strongly urged to have my ovaries removed (I’m a BRCA1 positive, 3x breast cancer survivor), yet NO doctor I have seen in the past 10 years is willing to write an Ativan prescription should I have the anxiety and hot flashes I had previously, which I almost certainly would have again, which can be also permanent in some people. The doctors have all admitted that fact. I have untreated anxiety anyway and live in Phoenix (and I’m only 37!). I’m hot and anxious enough!

    I SUFFERED before Ativan. The fact that a doctor would rather give me antidepressants to control menopause symptoms because of STIGMA is absurd! The fact that they’d rather I take my 85%+ risk of ovarian cancer and take a hike than prescribe low-dose Ativan is unconscionable. My mother died from ovarian cancer and my younger sister died from the same type of cancer I had. Yes, I’d rather lose my life than suffer a horrible quality of life. I shouldn’t be forced to choose between the two though.

    With chronic back pain and fibromyalgia for 15+ years, I can barely work as it is. Antidepressants have considerably more side effects, as well as deadly ones (suicide ideation and seizures to name a couple), and are not effective for many people. I had a grand mal seizure after taking a first time dose of Cymbalta at night, prescribed for fibromyalgia. Thank God I took it at bedtime instead of before heading off to work or I likely would have died and maybe taken some people with me! I couldn’t sit myself up for over two days because of the total body muscle pain caused by the violent convulsions. Caused by Cymbalta, an SSRI antidepressant.

    Yes, some people manipulate their doctors to increase recommended doses and end up abusing their meds, some people buy fake pills on the street or internet and die (I’m pretty sure it is near impossible to OD on benzos alone), but some people consider these drugs a miracle and necessary to live a quality life. It’s not right to punish that last group because of the actions of the first two. I’m sorry your patient almost died from overdose, but please realize you were not in the wrong. He deceived you and did it to himself. As long as you made notes in his chart regarding your hesitancy to prescribe what he was previously getting and warned him of potential bad outcomes, you are in the clear, no? Doctors are not lie detectors. I had a doctor who would go over the risks of opioids every single month with me. He knew I was already aware, but he made sure to cover his @ss every single time. He ultimately decided to stop prescribing opioids (and probably also benzos) altogether because of celebrity deaths and Trump’s speech last year. I’s a shame, I really liked being his patient.

    I’m not one to obtain drugs illegally no matter what, but I can understand why many people turn to that option. I have friends who have been weaned way too quickly or cut off completely. One of them did turn to illegally purchasing the meds that were needed to stay sane and not have seizures from withdrawal, the other suffered, lost a good job and is now homeless.

    I think some legislation needs to be reformed. Doctors need to have confidence they will not get into trouble should a patient be harmed or die from prescription(s) as long as they do their due diligence in preventing such an event.

  • It angers me that my doctor let me stay on a dose of 0.05 of klolopin for over 30 Years. Just recently a new doctor I’m seeing took me off of benzo cold turkey. I feel I’m through the horrible withdrawals but now depression has set in. I’m looking for a new doctor. I don’t want to be on benzo anymore. But I must say I see a pain doctor. She prescribes me the maximum dose for my pain. Starting next month we are going to look at other options for dealing with my pain.

  • 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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