There's no understating the extent of America's opioid crisis. In 2017, the same year it became a public health emergency, an estimated 1.7 million people in the US had substance abuse disorders related to prescription opioids. And this year, the National Safety Council found that the odds of dying from an accidental opioid overdose are greater than those of dying in a car crash.
But there's another prescription drug concern that experts say has grown in the shadow of the opioid epidemic: the rise in use of benzodiazepines.
Benzodiazepines, or "benzos," are a class of medication commonly prescribed to treat conditions such as anxiety and insomnia. Even if you don't recognize the term, chances are you're familiar with the brand names that fall within this category drugs such as Xanax, Ativan, Valium and Klonopin.
"It's really not 'the opioid overdose epidemic' but the 'opioid and ...' overdose epidemic," said Dr. Chinazo O. Cunningham, an internist and a professor of family and social medicine at the Albert Einstein College of Medicine.
"It's not just one substance, here. The focus has been on opioids but we need to expand the way that we're thinking about it," she said. "I think many of us feel that if we don't turn our attention to benzodiazepines, if we ignore this pattern that we're beginning to see, we may very well find ourselves in the same position that we have with opioids."
In 2016, Cunningham and a team of co-authors published research that showed the number of adults filling a benzodiazepine prescription in the US increased 67% between 1996 and 2013, rising from 8 to nearly 14 million. The amount of benzodiazepine medicine in a prescription also doubled over this time period.
And along with the increase in prescriptions has come an increase in overdoses.
According to the National Institute on Drug Abuse, overdose deaths involving benzodiazepines rose from 1,135 in 1999 to more than 11,537 in 2017, driven by the combination of a benzo with an opioid -- something so dangerous the FDA has begun issuing black-box warnings against mixing the two drugs.
This class of drugs is by no means new, but today "there's increased availability and increased access, not just through prescriptions but through illicit sources," said Dr. Anna Lembke, a psychiatrist, professor and medical director of addiction medicine at Stanford University. "You've got this popularization of Xanax in culture and in music, and the availability (of benzodiazepines) on the dark web -- all of that is part of the growing problem."
Why we're using them
A drug like Ativan or Valium works on the calming neurotransmitter in our brain, which allows us to relax, Dr. Lembke explained.
"They also work on the brain's reward pathway and increase dopamine release, which means they're inherently reinforcing, even separate from their sedative properties," she continued. "So people take them and feel improved in all kinds of different ways. It doesn't have to be like a high -- they just feel better."
In the short-term, benzodiazepines can be a useful tool -- especially in very severe or emergency situations.
"The problem is in the long term, they lead to more problems than they solve," Dr. Lembke said. "People develop a tolerance, and they need more and more to get the same effect. They develop a dependence, finding when they don't take them their anxiety is worse. And they think, 'Oh, I need it because I have an anxiety disorder,' but in many instances they're actually medicating withdrawal from the last dose, so you can get into this vicious cycle. If they worked long term there would be nothing wrong with it, but they don't and then they cause all kinds of harm."
Dr. Sumit Agarwal, an internist and instructor at Brigham and Women's Hospital in Boston, also found a substantial increase in benzodiazepine prescriptions when he and his co-author examined outpatient visits between 2003 and 2015.
The study, released earlier this year, found that the rate for benzodiazepine visits doubled during those 12 years and that more kinds of doctors were prescribing them, from primary care physicians to surgeons. The study also found that benzos were increasingly given as treatment for conditions other than insomnia and anxiety, such as back and chronic pain.
"I think most of our attention has been on the opioid epidemic and for good reason, but I think benzodiazepines have flown under the radar," Agarwal said.
Because the drugs work so well and so quickly, Agarwal believes both patients and prescribers have developed "an over-appreciation of the benefits of these drugs and an underappreciation of their risks," he said. "This is very similar to what we saw with opioids; the risks were very downplayed. Just overall, benzodiazepines are very easy to start but very hard to stop."
Not just 'mother's little helper'
As for what could be behind the steady uptick in prescriptions, experts don't know for sure; there could be a few factors at play. For one, there's the increased prevalence of anxiety in the US -- although there are other effective treatments that don't involve prescribing a controlled substance, Cunningham said.
Another may be the influence of a culture that values the fastest solution, she added.
"Our health-care system has changed, doctors are under a lot of pressure in terms of time, and our society has changed -- people are much more interested in getting a quick fix, like a pill," she said. "All of that together is what we see as a result."
Another part of the problem with benzodiazepines is a lack of awareness in the medical community, too.
"There just aren't good guidelines to help us decide when, and when not, to use it," Agarwal said. "Benzodiazepines are one item in our toolkit for treating anxiety and treating pain, even if the evidence isn't that great, especially if there's not great access to any alternatives. For example, with anxiety, cognitive behavioral therapy has really good evidence behind it but access to it is not so great. Same with pain: Physical therapy has a very good effect for chronic back pain, but access to it isn't as great either. And so we turn to medications when we don't have access to alternatives."
Lembke agrees, and points out that medical students get little training on mental health issues and psychiatry, and even less on addiction.
"There's very little understanding or appreciation among healthcare providers for how addiction develops, for how these medications themselves are addictive -- even a patient's personal predilection for the problem of addiction," she said.
"There's a lot of ignorance. When patients are started on these medicines they have no idea that they're addictive and habit-forming, and that's because doctors don't know either," she continued. "People think of it as 'mother's little helper.' I think people think of it as something benign."
What patients should know
If patients are prescribed a benzodiazepine, Agarwal advises that they should "take care to use it sparingly," he said. "If it is being used chronically, don't stop cold turkey. Talk to your physician about starting a slow taper."
Abruptly stopping the medication can cause withdrawal symptoms so severe they could require hospitalization, Agarwal said. "I see patients in the hospital withdrawing from the medication. It's very similar to people who have formed a habit to alcohol, because they actually act on the same receptor. If you stop alcohol cold turkey after developing a dependence to it, you'll end up in the hospital, sometimes in the ICU."
Agarwal believes that, as with opioids, the medical community and patients should pay more attention to how and why benzodiazepines are prescribed.
"I think we've begun to see the pendulum swing in how we prescribe opioids. In the same vein, we need to be cautious about how we prescribe benzodiazepines," he said. "We just have to be careful that if we do see a drop in benzodiazepines that we're not replacing it with something that's more dangerous."