Benzodiazepines are often co-ingested, or used simultaneously, with other substances in a range of heterogenous samples (see Supplementary Materials)13. Qualitative and descriptive results indicate that coingesting benzodiazepines with alcohol increases the intoxicating effects of both substances (Calhoun et al., 1996; Dåderman and Lidberg, 1999; Perera et al., 1987). Interestingly, one study among individuals in OUD treatment found that nearly 90% of participants who mixed benzodiazepines with other drugs did so to “improve emotional states” (Gelkopf et al., 1999).
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Some studies showed an increase in the consumption of benzodiazepine while others demonstrated a decrease in the prescription refills of benzodiazepine, which may be a result of gaps in mental health care. At this time, we can conclude that the current trend with benzodiazepine use is fluctuating and mental health professionals must continue to exercise caution before prescribing benzodiazepines. Future research is also warranted to be aware of the changing patterns and to avoid misuse and/or abuse at an epidemic level. We evaluated 104 cases from the FDA Adverse Event Reporting System (FAERS) database of abuse, dependence, or withdrawal involving a benzodiazepine as a single drug substance reported by patients or health care professionals directly to FDA from January 1, 1968, through June 30, 2019. While this is a small subset of FAERS cases received for benzodiazepines as a whole, we selected a focused case series to identify the most descriptive reports of dependence or withdrawal.
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Clinicians should recognize their role as a source of misused benzodiazepines, either through medication they prescribed but was used other than as instructed, or as the source of prescribed medication given for misuse to a friend or relative. In addition to being mindful of their role as a potential source for misuse, clinicians have an important role in understanding the reason for their patients’ misuse to determine the appropriate intervention. If patients are consuming prescribed medication faster than expected, why is this the case? Some misuse may be for symptoms appropriately treated by a benzodiazepine, but clinicians should be mindful of other potential reasons for misuse. An uninsured young relative may use their older relative’s prescribed benzodiazepine for insomnia relieved by a benzodiazepine rather than to get high, but this certainly was not the intention of the prescribing clinician.
3. Correlates and Risk Factors for Benzodiazepine Misuse
Although benzodiazepines are invaluable in the treatment of anxiety disorders, they have some potential for abuse and may cause dependence or addiction. It is important to distinguish between addiction to and normal physical dependence on benzodiazepines. Benzodiazepines are usually a secondary drug of abuse-used mainly to augment the high received from another drug or to offset the adverse effects of other drugs. Pharmacologic dependence, a predictable and natural adaptation of a body system long accustomed to the presence of a drug, may occur in patients taking therapeutic doses of benzodiazepines.
With long-acting benzodiazepines, it might take up to 3 weeks to notice withdrawal symptoms. Some people who are prescribed benzodiazepines become dependent on them and end up misusing them. Doctors recommend waiting until all benzodiazepines pass out of your system before you drink alcohol. That could take up to 20 hours for shorter-acting drugs like alprazolam (Xanax) and lorazepam (Ativan, Loreev).
People with SUDs in the U.S. have rates of benzodiazepine misuse 3.5 to 24 times higher than the general population (Votaw et al., 2019), and the misuse of other substances is the most consistent and robust correlate of benzodiazepine misuse. In fact, it is unclear how frequently benzodiazepine misuse occurs in isolation, rather than as part of a pattern of polysubstance use. Answering this question will help identify factors influencing the development of benzodiazepine misuse and populations who might benefit from interventions to reduce benzodiazepine misuse. Based on the present review, it is likely that the misuse of benzodiazepines for multiple reasons partially explains the high prevalence of misuse among those with SUDs. Future studies evaluating motives for benzodiazepine misuse among other vulnerable populations, including those with psychiatric disorders and benzodiazepine prescriptions, are needed to understand the relationship between motives and benzodiazepine misuse incidence and severity. In the same study referenced above conducted in the Ubon Ratchathani Province region of Thailand, 0.6% of respondents met criteria for DSM-IV benzodiazepine abuse and 0.2% of respondents met criteria for dependence (Puangkot et al., 2010).
Withdrawal symptoms usually show up anywhere from 3-4 days to 2 weeks after you last use the drug. The abuse of benzodiazepines is related to both the effects they produce and to their widespread availability. They can be chronically misused or, as seen more commonly in hospital emergency departments, intentionally or accidentally taken in overdose. When combining all benzodiazepines—free, bought, or stolen—a friend or relative was the source for nearly 70% of respondents reporting misuse.
- COVID-19 has been a global pandemic that has spiked the rates of anxiety and insomnia.
- Researchers in this study also cautioned, however, that these drugs are known to cause delirium, falls, and other adverse events in the elderly, so when possible, prescribers should either abstain from prescribing BZD to elderly patients or deprescribe them when possible [74].
The same rate of current benzodiazepine misuse was found in a 2008–2009 household survey of 2,280 individuals ages 15 and older residing in the Ubon Ratchathani Province region of Thailand (Puangkot et al., 2010). Yet, a nationwide survey of 26,633 general population respondents across Thailand (ages 12–65) found a slightly lower prevalence of misuse, with approximately 1% reporting the misuse of anxiolytic severe benzodiazepine withdrawal syndrome and hypnotics in the previous year (Assanangkornchai et al., 2010). Similar rates of past-year misuse (approximately 1–2%) have been reported in general population samples in Brazil (Galduróz et al., 2005) and Australia (Hall et al., 1999). Although tranquilizers are among the most commonly misused drug types, tranquilizer use disorder was only the fifth most common illicit drug use disorder.
- The proportion of people with an opioid analgesic prescription who were also prescribed a benzodiazepine increased 41% from 2002 to 2014 (Hwang et al., 2016), despite evidence that concomitant opioid and benzodiazepine prescriptions increase risk of overdose (Sun et al., 2017).
- Studies that reported the use of benzodiazepine since the beginning of the pandemic were included.
- Another study that tested a different standardized education protocol showed more promising results [73].
- Indeed, studies of people with AUD in treatment demonstrate even higher rates, with estimates of recent benzodiazepine misuse (self-reported past-month use or urine drug screen results) ranging from 19–40% (McHugh et al., 2018; Morel et al., 2016; Ogborne and Kapur, 1987; Ross, 1993).
- Synthetic benzodiazepines, sometimes called «street,» «designer,» or «novel» benzos, are classified as schedule I.
Prescribing benzodiazepines has been controversial due to the recognized deleterious effects of long-term treatment with these drugs. Benzodiazepine use in COVID-19 patients has been shown to exacerbate delirium and suppress respiratory drive in patients with respiratory suppression [41]. Caution has been exercised in the use of benzodiazepines, especially palliative care. Some drugs such as midazolam and triazolam are contraindicated with the use of lopinavir/ritonavir because of the risk of increasing the level of some benzodiazepines due to CYP450 inhibition [41]. With the emerging coronavirus pandemic, most countries have updated their drug prescription policies [1]. In the USA, Prescription Drug Monitoring Program (PDMP) is an electronic way to monitor the dispensing of controlled substances used in most states [42].
