Benzodiazepine Abuse: A Look at Another Prescription Drug Problem
A paper in the Perspectives section of the New England Journal of Medicine (Feb 22 issue, 2018) discussed the problem of benzodiazepine abuse, examining both the inappropriate prescribing of these DEA-scheduled drugs and the lack of effort to address it.
The authors believe that efforts to reduce overprescribing of opioids and to educate the prescribers and public about their risks should be expanded to include benzodiazepines.
Titled “Our other prescription drug problem,” the paper is written by Anna Lembke, Jennifer Papac, and Keith Humphreys from Stanford University School of Medicine and Veterans Affairs, Palo Alto Health Care System, California. (Access: NEJM 378; 8:693-695.) According to the authors, benzodiazepines effectively treat anxiety when used intermittently and for less than a month at a time. When used daily and for long periods, effectiveness decreases and risks associated with their use increases. They can be addictive, and when taken daily, can cause anxiety. In addition, the risks of long-term use include cognitive decline, accidental injuries and falls, and increased rates of emergency department visits.
The authors discuss inappropriate prescribing of benzodiazepines such as alprazolam, clonazepam, diazepam and lorazepam. They cite data from the National Institute on Drug Abuse showing that overdose deaths involving benzodiazepines increased from 1,135 in 1999 to 8,791 in 2015.
In addition, highly potent new forms of benzodiazepines are increasingly showing up on the streets. These illicit chemicals are potentially as deadly as the synthetic opioid analog fentanyl. Clonazolam, an analog of clonazepam, is so potent that it needs to be dosed at the microgram level to prevent lethal overdose.
As part of their discussion, the authors also cite a 2017 study by Mateu-Gelabert, et al, that provides a snapshot of the nonmedicinal use/abuse of benzodiazepines among opioid users in New York City. Those study results revealed a high prevalence of nonmedical benzodiazepine use among young adult opioid users. It incorporated both qualitative and quantitative investigations which found that benzodiazepine use is very common and often concurrent with nonmedical prescription opioid and heroin use.
This qualitative portion of the 2017 investigation included data from 46 participants who were interviewed for about 90 minutes each. Participants were asked about their initiation into drug use, including their age at initiation of each major class or form of drug and the context in which it occurred. Questions were open-ended, allowing participants to introduce and elaborate upon issues relevant to their opioid use and their use of prescription drugs, including benzodiazepines.
Participants often used “Xanax” as a common street name to refer to any benzodiazepine. There was no information to determine when “Xanax” was used to refer to the specific drug alprazolam or when it was used as reference to the other benzodiazepines, i.e., diazepam, lorazepam, clonazepam, triazolam.
In the interviews:
- Many participants described first using prescription opioids nonmedically during teenage years in gatherings with friends and in combination with other drugs including benzodiazepines. Benzodiazepines were often first provided by friends.
- As their drug use developed over time, participants described a process in which they moved from casual use in gatherings to regular polysubstance use. Many participants described regularly using opioids in combination with benzodiazepines. One said that every time she does an opiate, she takes a benzodiazepine to increase the high. Another described his daily use as involving Xanax and Percocet: two Xanax in the morning and Percocet at night. Some said they used benzodiazepines to help them through opioid withdrawal.
- Those who used benzodiazepines said they did so because the drugs were easy to obtain and relatively inexpensive. One participant said she was able to get “benzos” prescribed from various doctors. Also benzos were “cheap” in comparison to prescription opioids and sometimes given out for free.
- There was a wide variety of motivations for using benzos nonmedically, usually in conjunction with other drugs:
- Enhancing the high of opioids
- Supplementing the opioid high when users did not have enough opioids
- Helping the user to “come down” from other drugs such as cocaine
- Allowing the user to self-manage mental health problems, such as anxiety
- Helping users through withdrawal from opioids and to cope with the withdrawal symptoms
- One user described using buprenorphine and naloxone (Suboxone) in combination with Xanax to help him “kick” his opioid dependence
- Many participants reported having overdosed when using benzodiazepines in combination with other drugs, particularly opioids. They also witnessed other people overdose from this combination or knew people who died as a result. Some of the users overdosed multiple times as a result of mixing benzodiazepines with opioids.
- Despite their awareness of the risks associated with the misuse and abuse of benzodiazepines, such as blacking out, overdosing, and dependence, participants continued to use them for their perceived benefits.
There were 464 participants in this quantitative portion of the 2017 study. They were recruited using a form of chain-referral sampling designed to engage hard-to-reach populations. The participants were recruited by means of their personal network connections. Initially, 20 opioid users were recruited to serve as “seeds.” From this group, the participants were invited to refer up to three eligible peers from their opioid-using contacts. The process was then repeated until the number of participants were fulfilled.
Interviews lasted between 90 and 120 minutes and included questions on drug use, history and current use, overdose, drug treatment, and mental health. Participants were asked about nonmedical use of prescription drugs defined as the use of prescription drugs for the experience or feeling they caused.
- Majority of participants were male with a mean age of 24.5 years
- Majority of 72% reported being white/Caucasian, with 27% reporting as Latino
- Most participants completed secondary education (80%) and a substantial number (40%) had attended some college
- The majority reported growing up in families with incomes of $51,000 or higher and 21% reported household incomes above $100,000
- 60% reported having experienced homelessness at some point in their lives
- The mean age at first nonmedical use of prescription opioids was 16.7 years; the mean age at first heroin use was 19.4 years; 80% initiated use of prescription opioids either prior to heroin initiation or within the same year
- 93% reported lifetime nonmedical use of benzodiazepines, with a mean age at first use of 17.8 years
- A third of the participants reported being medically prescribed benzodiazepines, and 44% reported encouraging fellow drug users to use benzodiazepines as a way to cope with opioid withdrawal
- White participants were significantly more likely to engage in regular use of benzodiazepines, while Latinos were less likely to do so. Also, participants from higher income households (> $50,000 annual income) were more likely to regularly use benzodiazepines
- Those who used heroin, cocaine, or prescription stimulants were more likely to report regular use of benzodiazepines. Binging on drugs in the past 30 days and having ever experienced an overdose increased the odds of having regularly used benzodiazepines by 2.57 times and 2.32 times, respectively
- Those who reported encouraging fellow drug users to use benzodiazepines as a way to cope with “dope sickness” were 3.23 times as likely to have used benzodiazepines regularly
These reports address concerns about the benzodiazepine abuse problem and describe “street-level” information about benzodiazepine abuse in concert with opioid addiction.
This New York City study revealed a high prevalence of nonmedical benzodiazepine use among young adult opioid users. The study found benzodiazepines use to be very common and often concurrent with nonmedical prescription opioid and heroin use.
The findings from the New York City study could be reflective of benzodiazepine abuse on a national level. The authors of the New England Journal of Medicine report believe that efforts to reduce overprescribing of opioids and to educate the prescribers and public about their risks should be expanded to include benzodiazepines to prevent this additional problem from reaching “epidemic” proportions.
Richard L. Wynn, BS Pharm, PhD, is professor of pharmacology at the Baltimore College of Dental Surgery, Dental School, University of Maryland Baltimore.
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