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 think this article very timely. Although I’m from the UK I have the perspective of a patient made dependent on prescribed benzodiazepines. I wish to underline that I simply followed the advice of my physician and never sought to misuse or abuse my medication in any way.

    In 1988, the UK Comittee on Safety of Medicines stipulated that benzodiazepines should be prescribed for no more than 2-4 weeks beacause of the grave risk these drugs pose for dependence. While we have an estimated 1,092,000 long-term prescribed benzo users in the UK the picture in the US is a little more worrying. Between 1996 and 2013 the number of benzo prescriptions for adults in the US rose by 67%, from 8.1 million to 13.5 million. Opioids and benzos are often prescribed simultaneouly leading to an explosion in overdose related deaths by more than 500% during that same period. Benzos are now involved in more than 30% of all overdose deaths.

    These drugs are incredibly hard to get off as I can personally attest. According to the American Psychiatric Association some 40 to 80% of patients report experiencing withdrawal symptoms, not an insignificant number. Indeed, emeritus Professor Malcolm Lader of King’s College London has opined that they are harder to get off than heroin. The support forum BenzoBuddies receives around 250,000 hits per month, it’s members mostly from the US. The vast majority are like myself unwitting victims of prescribed benzo dependence and withdrawal. Few of us have any real conception of what we are letting ourselves in for when we accept a presciption for a benzodiazepine. What compounds the problems is that too often prescribers are unknowledgeable about the safest way to get off these drugs leading to more unecessary harm and distress. Astonishingly few in the medical profession seem to be aware of Professor Heather Ashton’s invaluable protocol on withdrawing from benzodiazepines.

    I have suffered immensely from prescribed dependence and withdrawal from two sets of drugs, namely, antidepressants and benzodiazepines. Withdrawal symptoms for many of us last months and as in my own case, sometimes years. I can only wish this subject becomes a greater cause for concern as our numbers continue to increase.

  • We must get this straight. The sickness and injury caused by benzo prescriptions are caused by taking exactly as directed, and that injury has zero to do with addiction. Addiction is the compulsion to use a substance while knowing the harm in using it. Benzo patients are not abusers; their condition is not of their own making. Their overwhelming benzo-sickness is very clearly caused by following their doctors’ instructions.

    “Why don’t prescribers know the damage that they are causing?” is a persistent refrain ubiquitous on the many benzo-help internet sites. This problem is far from patient-caused. It is supported by the unearned admiration for physicians. That adoration has worn thin.

    After having been seriously harmed, these patients are warned always to taper from the drugs under the direction of the physician who has had no training it all in discontinuing this class of drug. Medical rumor replaces scientific method.

    What to do? Research peer reviewed articles with a critical mind and always ask: “Why should I believe this?” Benzo victims must stop dishonoring their own intelligence in favor of blindly followin medical hearsay. And mostly, benzo victims must reject the self-serving medical label, addict. It is a shameful reassignment of the medical perpetrators’ guilt.

    The benzo-problem is not similar to the opiate crisis in any way other than both are produced by modern medical practice. Some people, really crave opiates. No one actually craves a benzo. People whose bodies have been altered by a benzo prescription crave only relief from the pain caused by improper benzo prescribing

    Trust was misplaced, and now the victims must take charge. Yes, benzo withdrawal can be dangerous, and withdrawing under uneducated supervision also is dangerous. Benzo-sick people do not belong in care of people who misdiagnose the illness and ignore their own guilt.

  • Stop demonixing medications that have been used successfully to alleviate anxiety insomnia panic attacks ptsd etc.
    stop the false narratives and scare tactics. People are suffering needlessly due to the false opioid crisis . Now your starting this ??
    Taken as prescribed both benzodiazepines and opioids are vital
    Medications for many suffering debilitating pain anxiety etc
    Ssri’s are FAR more dangerous drugs
    alchol is involved in more overdoses than you people want to document . But hey …. prohibition worked real well huh ??
    You can stop the designer drugs by just not demonixing valuable medications
    Anna Lemke is the type of doctor we all must avoid if we value our lives something she clearly does not

  • Here we go again. Since the opiod “epidemic” has pretty well been taken care of by our caring government, throwing the baby out with the bath water and depriving countless chronic pain patients of their only relief, leading to despair and suicide, now the media needs to manufacture another crisis, the benzo crisis. A few people have a problem with a benzo and this is an “epidemic” that needs government attention, and the media has a new crisis. Forget about the millions of people who would be basket cases without benzos, inculding myself. and who have been on them for years with no problem. I hope this new sensationalism and gross misrepresentatation goes nowhere, but with the stupidity and authoritarian tendencies rampant in this country, God knows what will happen. People like myself can only hope common sense will prevail, but in a country I barely recognize anymore, maybe that is too much too ask for.

    • Agreed! I’ve been on them since I was 17, never abused them, came off of them for awhile, lost my grandmother (the person who raised me and had a miscarriage same year). So I asked my doctor to put me back on them I was told that I can get 7 a week no refills as long as I pick up an overdose nose spray in addition to it because I am on a medicine for my brain condition called IIH and they can mix badly, but that since a new law May 1, 2018 was passed 30 day supplies can no longer be given. So here is my complaint America!! Your pharmaceutical companys pushed these as the go to drug from the early 90’s into 2014 so everyone who got placed on them that DIDN’T abuse them and they helped (like me and others) you want to risk throwing into withdrawals now, which are DEADLIER then the drug you now claim is dangerous!! You want to blame the public for misusing these drugs and getting them from drug deals when our own GOVERNMENT has been the biggest dealer of all. Don’t make me laugh. Now I am having the fight of my life trying to get back on a medicine I know helps my panic attacks and doesn’t give me extreme side effects like psychosis or makes me suicidal. It simply helps slow my heart rate and breathing and allows me to sleep when I have insomnia. Now I have to fill it weekly.. Which makes me look like an addict when I never have been!! Like I stated before I came off of them by choice for two years prior to my grandmother passing away and my miscarriage and still tried to deal for 4 years without anything, I tried to deal with the night terrors and the PTSD and I just can’t anymore now a new law is going to tell me what I can and can’t do as far as a Schedule 4 drug goes its a 4 for Christ sales you can’t even OD on them unless you mix it with another drug like pain killers. So its Americas fault now they want to say it is our fault. Yeah okay. There is no epidemic with benzos they just need something else to scare everyone with to push their next big drug which in time will do this too…

  • Hello and good luck to all the people having problems with benzodiazepines . I will give you some insight of problems that i am stilling having and suffering every day with . This is my story which started by me going to my primary care doctor and being diagnosed as depressed , he then put me on Effezxor XR 75 mg morning and 75 mg evening became a zombie for a couple years and told him i wanted off could not function or work . I was weaned off in the next three months 37.5 at a time . During the next few months i started having severe panic and anxiety attacks went to ER over the weekend thought i was having a heart attack , all tests showed i was fine and that i was to follow up with PM doctor with my paper work from hospital . I then made an appointment . He then put me on a drug called Ativan (Lorazepam) 1 mg to take as needed script of 30 pills . Over the next 8 to 10 years they were constantly increased because they were not working anymore . Now mind you i was never once told that i would become addicted . In April of 2017 called in my prescription for 90 pills to be take every 8 hours , Pharmacist called me and told me that doctors office was not putting the request thru . I then called doctors office and got the run arround that it was sent in . Still a problem. Called doctors office an requested to see him asap. Two days later went to see him and he told me that the government was coming down on doctors for Benzodizepines and i have to go off them , fills only half of the prescription when i go to drug store .Then the pharmacist tells me i cannot taper or detox that fast and the way he wanted me too , 1 mg every Friday. So i call doctor back and tell him that i would need a 6 month taper and cut down .25 every two weeks and went along with it . This doctor of 17 years did not no how to detox me . I stopped taking the Lorazepam on June 15 , 2017 and it has been a little over a year and still suffer horrible withdrawals everyday , no quality of life , cannot work changed doctor and does not want to no anything about Benzos and recommends i see a Shrink they are the ones dealing with physic medications in which i did and she recommended that i go back on a longer lasting Benzo for two years and i told her she needed to see a Quack doctor and left. The only other medication i take is a 5 mg blood pressure pill and a baby aspirin once a day .Do not drink alcohol nor smoke , try to eat right , limited to exersize . Surf the internet everyday for help and see how many thousands of other people suffering , I think the government should help or compensate us after all they regulated it and now take it away , something has to be done . FDA needs to be looked at as well as big Pharma . There was not one time i went in doctors office any time of day that there was at least two to three Pharma reps what does that tell you . There is so much more to my story , All i want to say is good luck to all of you suffering and maybe someday there will be help . My days are numbered .

  • I have been talking Klonipin for 8 years 1 mg ,2 times a day. I was just informed by my psychiatrist today June 21,2018 that the state of Maryland has passed a law that he can no longer prescribe any benoziazepines after July 1, 2018. This is total insanity I have to be weaned off them in 3 weeks. Personally in my life right now I am dealing with chronic anxiety this medication along with others has helped me cope. I get panicky at work and I have to work to pay my bills. Additionally I am trying to cope with my father dying from cancer. Please if you have any suggestions I would be more than happy to recieve them

  • 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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