While America wrestles with its opioid crisis, another closely linked epidemic remains largely under the radar. It involves benzodiazepines (known as benzos), a class of tranquilizing pharmaceuticals, including Xanax, Valium and Klonopin, which depress the central nervous system to treat anxiety, insomnia and certain types of seizures and convulsions. These drugs decrease brain activity to reduce feelings of anxiety or induce sleep. They are designed to help patients overcome everything from panic disorders and public speaking nerves, to severe insomnia and fear of flying.

The drug was first made available around 1960. By the late '70s, benzos were the most prescribed medications in the world. During the late '80s and early '90s concerns around dependency began to arise, leading to lawsuits in the U.K. against the makers of Ativan. Despite these concerns prescriptions in the U.S. continued to rise throughout the '90s. As primary care physicians embraced these drugs for their efficiency in treating certain conditions, the U.S. saw a 67 percent increase in individuals prescribed them between 1999 and 2013, all while quantity prescribed per individual also increased. On a parallel track, deaths involving benzos rose at an alarming pace, with the U.S. seeing an 830 percent increase in overdose mortality rates among women between the ages of 30 and 64 between 1996 and 2017, from below one death per 100,000 to over 5 deaths per 100,000.

Benzodiazepines are also used in treatment for other addictions, such as alcohol or opioid dependency. If an individual relapses while continuing to use benzos, the combination of these depressants can often be lethal, with 23 percent of all opioid overdoses in 2015 also involving benzos.

Widespread abuse

While these drugs serve many valid medical purposes, they can also be abused recreationally, leading to a black market for the drugs. There has been an increase in deaths linked to illicitly obtained benzos as counterfeit versions of the drug hit the streets, cut with other substances, similar to what we've seen with opioids. Use of benzos have also been glamorized in pop music references and on social media that raise these drugs' profile—modern day echoes of the Rolling Stones' Mother's Little Helper, a song about valium use.

The benzodiazepine problem is not confined to the U.S. Benzos appear to be more widely abused than opioids outside of the U.S.—so much so that Australia had to drastically tighten its restrictions around the drug in 2014, and Xanax is no longer available from the U.K.'s National Health Service. In Northern Ireland, the Public Health Agency has issued warnings concerning the drugs after an increase in related deaths and rising fears about the circulation of counterfeit benzos. A study in Sweden uncovered benzos as the most commonly forged drug prescription in the country.

Benzos can cause physical dependence, and those stopping use can experience sudden and serious withdrawal symptoms, including psychosis, delirium tremens and seizures. Without careful management, seizures can be progressive, difficult to control, even fatal. Quitting cold turkey can cause a rebound effect, intensifying the condition treated by the drug.

Assessing the risk

There are some key differences between the opioid and benzos problems, and they do not bode well for controlling benzos abuse. While opioid prescriptions plateaued and have begun to decline, prescriptions for benzos continue to increase. Unlike opioids, which are often associated with Appalachia and other parts of rural America, benzodiazepines have no identifiable hotspots geographically.

Benzos work well when used as prescribed for patients in need—and there is no safer, comparable pharmaceutical alternative for many of its users. (While "Z-drugs," such as Ambien and Lunesta, can be used to treat insomnia in place of benzos, there are not effective treatments available for other conditions.) In fact, benzos were introduced as the safer alternative and replacement for barbiturates, which were linked to many deaths in the '50s and '60s.

Where is the benzos problem going? While the U.S. is just now seeing a cascade of litigation around opioids, another epidemic involving benzodiazepines appears to be brewing. While the future is uncertain, it is clear that all those in the business of healthcare risk management must monitor developments closely. Moreover, every healthcare entity—from pharmacies and distributors to practitioners and manufacturers—must actively manage the risks around benzos, just as they now do for opioid-related exposures.

Trouble on the medical malpractice side is starting to rear its head with an increase in overdoses and cases of unrecognized and untreated withdrawal symptoms in clinical and correctional settings. While monitoring how benzos are prescribed, marketed, and dispensed should be a priority moving forward, recognizing and treating the signs of overdose and withdrawal should also become standard training for organizations that could face this exposure.

Chris Dunlavy is a health care underwriter at Beazley. He focuses on a wide range of risks including allied health, social services and telemedicine. He has 10 years' experience of underwriting misc-med risks, and has been at Beazley since 2015 when he joined to help expand the firm's presence in the US southeast region.

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The epidemic no one is talking about

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