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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.

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).

  • Wow. So Many comments by people that misused thier medicine or took it with other medications. If indeed it was prescribed and you misused it you are the .011% of patients that messed it up for the patients that take thier legitimate prescriptions as directed. Of the 40 million that suffer from for ever chronic pain 40k of the legit prescriptions were talen by addicts that like one woman said took her whole bottle in 10 days. I just want to that all of you from all of us for making our lives a living hell. Because of you and the heroin junkies, every person that needs these medications have become bedridden or close to it.
    Mixing pain relievers with xannex or xannex with even weed or alcohol can kill you unless you’ve built up a super high tolerance. Any of these medications on thier own are harmless when taken as directed.

  • If I read this article correctly the patient who overdosed got the Benzos online with no prescription and not at a pharmacy (online or otherwise). Thus it seems to miss several points to suggest that prescription monitoring will help. Good treatment for people suffering addiction will help. Addiction is the public health crisis that needs to be addressed.

  • I agree, @Don, that opiates can be a slippery slope, and now it’s such a hassle to get them. So I did let my doc talk me into trying the CBD oil. I had to keep getting increases coz it did not ease my pain at all. I just got more tired and hungry. It does help people, for sure, but after years of trying alternatives, most people finally know what works for them. Everyone is different.

  • Has anyone looked in to Marijuana Therapy to replace The Benzo’s? I’m a Skeptic about Marj, but the more I read from Clinical testing and Patient Comments, I think Marijuana could Stop the Opiod & Benzo Epidemic. I wear a Fentanyl 100mcg Patch Every day of my life & would look very hard at Marijuana if it could replace the Opioids.
    Opioids suck the life out of a person, even when taking them as prescribed.
    I wish all of you good Luck with your fight to get away from these Meds.

  • I have taken valium for PTSD & anxiety for about 20 years, it has been increased once during that time. At one point, I had to visit a different Dr., he cut me off Valium cold-turkey & prescribe a high dose of Xanax which I took the entire bottle in less than 10 days because I had no-one to monitor me or realize I was way messed up. Then that same Dr. refused to give me more to wean off of or valium which I’d never had a problem with.

  • That’s just great. Make it practically like pulling teeth to get the pain meds that I need to tie my own shoes, and now go after the only meds that work for my debilitating anxiety, because of irresponsible fools. Sure, punish the people who use the meds AS PRESCRIBED. I agree with @Liz brown. I know more than one person who has turned to the streets because they are not longer able to turn to their doctors for help. So cue up thousands more addicts. Whoever thinks that doesn’t happen is not in touch with today’s reality. I’m lucky that my doctor isn’t completely afraid to prescribe the meds that I need, because if he didn’t, in essence destroying my quality of life, I might have to treat myself.

  • If someone been on benzos for over 3o years, what in the hell can you give them? Anything else won’t do! I’m talking from experience..so the only way to go is to a website or on the street ! Dumbass Doctor’s so keep giving your patient the benozs. Otherwise there will be many death! And that’s fucking life talk

    • Liz Brown, Your comments sure aren’t helping the cause. I wouldn’t even know where to purchase illegal drugs if I wanted to. If you want to get off of benzodiazepines, you should do a slow taper with your doctors help. If you really need them and aren’t abusing them you should be able to find a doctor who will legally prescribe them for you. You won’t die if you do a slow taper. Buying drugs illegally is NEVER the answer. You will do a really quick withdrawal in prison. They won’t care how uncomfortable you are either.

    • Looks as if the 30 years of use has affected your cognition due to that grammar. Just as the article states! I’m flushing mine now. Thank you! Consider being a spokesperson for anti-benzos. You’re liable to single handedly stop this epidemic from even taking off.

    • I agree, @Don, that opiates can be a slippery slope, and now it’s such a hassle to get them. So I did let my doc talk me into trying the CBD oil. I had to keep getting increases coz it did not ease my pain at all. I just got more tired and hungry. It does help people, for sure, but after years of trying alternatives, most people finally know what works for them. Everyone is different.

    • I agree, @Don, that opiates can be a slippery slope, and now it’s such a hassle to get them. So I did let my doc talk me into trying the CBD oil. I had to keep getting increases coz it did not ease my pain at all. I just got more tired and hungry. It does help people, for sure, but after years of trying alternatives, most people finally know what works for them. Everyone is different.

    • Not tapering your benzos will give you symptoms similar to delirium tremens. That’s what happens to alcoholics who are suddenly withdrawn from alcohol. It includes visual and auditory hallucinations, shaking, high heart rate and blood pressure, and worst of all seizures. The seizures can be fatal. All benzodiazepines are horrible to get off of. It sometimes takes years. I think it’s actually worse than withdrawal from opiates. If I had to do it all over again with what I know now, I would never have started taking them. It’s like a ball and chain around your leg. I hate having to take them to just feel normal.

  • I have used diazepam for years for muscle spasms. The doctors don’t know what causes the spasms, and have given me muscle relaxants in the past which left me so over-medicated that I was unable to function. I have taken 5mg of diazepam every 12 hours, and it has not stopped working in over 10 years. If I miss a dose, by the time I’m due for the next dose, my hands, ankles, and abdomen are experiencing painful spams. I have heard how bad a drug it is and how it becomes ineffective quickly due to developing a tolerance, but that had not been my experience. I have been taking the same 5mg all this time. The only time I potentially had a problem was when my Primary Doctor sent me to a Rheumatologist who gave me a RX for clonazepam, which is basically the same drug as diazepam. I didn’t fill the prescription and reported the incident to my primary MD.

    • I agree with alot of what is said, my Dr has me on colazapam, 1 tablet.50 mg a day that’s 30 a month I know if I over take I will be out before my next visit, so I only take them if I have bad anexity, sometimes only take a half of a tablet which is.25 mg. I had to learn the hard way. So all of you out there taking meds for anxiety, or benzos, please be smart and only take them as prescribed. Thank you and have a Blessed Day…,

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