Will US Drug Policymakers Blow It Again—This Time With Benzodiazepines?

In a recent column, Maia Szalavitz reports on the rise in overdose deaths related to benzodiazepines (a class of tranquilizers including Xanax, Valium, and Ativan). According to a recent study in JAMA, the number benzodiazepine prescriptions doubled in the US  from 2003 to 2015. And benzodiazepines are found in the bloodstream of almost a third of all opioid overdose victims—a nearly ten-fold increase since the beginning of this century. Szalavitz reminds us that the US is not the only developed country with an overdose problem from the nonmedical use of prescription drugs: Scotland has been contending with this problem for years, and the city of Dundee has been dubbed the “drug death capital of Europe.” 

Unlike the US, where fentanyl was found in 40 percent of overdose deaths in 2017, the main ingredients of Scotland’s overdoses are benzodiazepines, involved in more than half the drug deaths in Scotland. Like the US, most of Scotland’s overdose deaths involve multiple drugs, including heroin, cocaine, fentanyl, and alcohol.

US policy focused on decreasing opioid prescribing (high dose opioid prescriptions are down 58 percent in the US since 2008). Likewise, Scottish policy emphasized and succeeded in reducing benzodiazepine prescribing. In both cases, the goal was to reduce the amount of the drug available for diversion to the black market for nonmedical users. And in both cases, the efficient black market filled the vacuum with illicit and more dangerous substitutes.

Illicit benzodiazepines like phenazepam (originally developed in the USSR in the 1970s) and etizolam are much more potent and dangerous. Many are made in local clandestine labs and pressed into counterfeit Xanax or Valium pills.

Benzodiazepine overdoses are manifested by the victims growing stuporous, lapsing into a coma, hypoventilating from respiratory depression, developing bluish fingernails from decreased oxygenation and, ultimately, dying. Benzodiazepine withdrawal can last much longer than opioid withdrawal, sometimes taking months or years, often featuring seizures, and is much more likely to result in death. The potentially lethal consequences of acute withdrawal make Medication Assisted Treatment of benzodiazepine dependency or addiction essential.

It seems the Scots sowed the same (failed) supply-side policies towards benzodiazepine overdoses that the US did towards opioid overdoses. And they reaped the same results. Szalavitz explains:

“People who once had access to drugs that were of known dosage and purity suddenly did not. Drug dealers stepped in to meet the demand, and the global supply chain of illegally-manufactured pharmaceuticals provided the products users wanted.”wareness of the growing role of benzodiazepines in the US overdose crisis, US policymakers should learn from Scotland’s mistakes in addressing nonmedical benzodiazepine use so as not to repeat them. But that requires them to recognize that Scotland was merely emulating US policy towards opioids.

The growing role played by benzodiazepines in US drug overdose deaths is gaining more attention. US policymakers should learn from and avoid the mistakes Scotland made in dealing with nonmedical benzodiazepine use. That means recognizing that Scotland was emulating US policy toward nonmedical opioid use. 

(Maia Szalavitz will be a featured speaker at the Cato Institute day-long conference on harm reduction on March 21.)