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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  • Take a benzo as directed and become sick, and you are an addict. Refuse to take it, and you are a “non-compliant” patient. Choose your label.

  • Taking benzos as directed is not safe. Benzos were touted as extremely safe when they were first marketed. Here, benzo deaths were being compared to opiate deaths. Opiates killed faster, but what a mistake to call benzos “very safe”.

    The issues are confused. Dying from overdose may take longer, but dying from a Benzo C/T leaves the patient just as dead. One issue is being overlooked. It is the combination of a benzo taken with another CNS depressant that usually causes what is termed, overdose. Every prescribed benzo user needs to monitor interactions between benzos and other drugs because we can’t rely on physicians to do this.

  • We must stop using the Addict word to describe the violent illness that can follow discontinuation of a prescription drug. This inaccurate use of the word reassigns responsibility from prescriber to the patient who believed that a medical license meant competency.
    Related to this: assuming that the profession that allowed this horror knows how to correct the harm obviously is unfounded. We must vet any discontinuation plan ourselves and recognize that a plan that is better than C/T W/D is still inadequate to harmful. I say harmful because we see the former users of medical discontinuation plans enduring “persistent” neurological damage. Here, “persistent” means permanent.

    Although some physicians do avoid prescribing benzos at all, medical literature still trivializes the pain of real benzo-victims. Reading medical literature, I notice that much benzo-fact has no scientific source. It merely is assumed to be true when it is a guess. “How do you know?” and ” What is the evidence?” remain unanswered. We must question the need for any drug. We also must question the efficacy of any medical treatment for medically-caused ( iatrogenic) illness.

    I guess that we all know this but may not have not actually said it.
    J.Hill

  • My family was in a bad car accident. We were parked at a gas station, when a woman out of her mind/passed out crashed into us at a high speed. A man was smashed between my vehicle and his. He’s paralyzed now. The woman had a ridiculous amount of alcohol in her system and Klonopin.
    I found out she had admitted herself to alcohol rehab twice. What the hell is wrong with this world, that doctors think they can overcome one addiction with another. Stop prescribing this shit. Not only does it endanger the welfare of the addict, but it also endangers the welfare of anyone they may come in contact with.
    You can’t expect that an addict is going to take their medication as prescribed. That’s stupid.

  • My family was in a bad car accident. We were parked at a gas station, when a woman out of her mind/passed out crashed into us at a high speed. A man was smashed between my vehicle and his. He’s paralyzed now. The woman had a ridiculous amount of alcohol in her system and Klonopin.
    I found out she had admitted herself to alcohol rehab twice. What the hell is wrong with this world, that doctors think they can overcome one addiction with another. Stop prescribing this shit. Not only does it endanger the welfare of the addict, but it also endangers the welfare of anyone they may come in contact with.

  • It’s important in this discussion to disclose what dosage you are taking . When my wife passed our doctor prescribed 3 by 1 mg lorazepam daily. I took just one pill , and then found 1/2 of a pill was enough to get me to relax at bedtime. I took 1/2 a pill per night for several years and rarely had to increase it ( to 3/4 pill) temporarily. Recently I had a traumatic experience and the doctor at the clinic told me this was a terrible drug , a controlled substance, and if I was over 65 (I am) it would make me fall down. He gave me 30 by 1 mg pills only and said don’t come back. No sympathy when I could have used it.
    This is the only drug I have taken in my life , and I fear I might have to go some street drug to find relief if I need . The doctors are conflating older seniors who take 3 mg or more with fit healthy people . And lorazepam is cheap here , a generic brand . Maybe the doctors make more money selling opioids , which apparently they hand out like candy.

    • I agree with u ou! I have been on the generic Xanax for 30 years for anxiety and heart problem.I have never misused it.I take my dose exactly as ordered by my Doc.My Doc is also on Klonopin and he has told me that thry will ban these drugs in the .He told me to go to Canada or Mexico to live.I had an appt yesterday and I asked him when is this going to happen and he said “Soon”.That’s so wrong,we use the meds are prescribed and I never ever take over my dose.Good Luck to you.You are not alone in this.Might be on my way to Canada.

    • To Deborah L Zupa – I sympathize with your predicament. I have weaned myself off the .5mg lorazepam I was taking at bedtime . It wasn’t that difficult , I used some hemp oil and other herbal capsules and they helped with sleep , although my sleep is still irregular right now I can see better sailing when spring comes and I’m working a lot in my gardens.
      But, the ban is going on here in Canada . Doctor’s are retiring and new doctors are not willing to prescribe these. There has been a media campaign blaming benzos for everything even though negative incidents involved opioids and alcohol abuse , with benzos also in the system. In my opinion Big Pharma have decided they do not make enough money on the benzos ?? and want to replace them with something more expensive. I have a busy social schedule today and I needed a good night’s sleep ,a 1 mg lorazepam last night did the trick ..a one-off use.

  • I understand that the benzo and opioids are a problem and Drs and patients need to take care when prescribing and taking. But my question is why all these articles stopping at 2013? You never give data for 2014-2018? I think it’s because Drs are not prescribing these drugs as much or discontinuing Ppl who take them. And most ODs are caused by heroin. And the Ppl who really need one or the other to live a normal life are the ones who are being treated like drug addicts. Just ask anyone who has been on one of these medications and you will find out how hard it is to have a Dr prescribe them. Release new data already.

  • Please let’s stop demonizing medications that for decades have helped people . Same with opioids. When taken AS PRESCRIBED, benzodiazepines like opioids are beneficial to many sufferers.
    If you want to create a war on medications look to the SSRI’s drs prescribe like candy . Look to Lyrica and gabapentin . These drugs have far more dangers associated with them

  • I took Clonazepam for 25 years and was kicked off of them by my doctor. The withdrawal was horrible to say the least. It was a month of hell before I was over it. If I would have known before hand I would have taken a leave of absence from my job for that month. All I can say is that getting off of Benzodiazepines can be done but you will be tempted to go and get a prescription from another doctor. Don’t do it! Get off of them. I feel great now and you can too.

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