America’s Next Epidemic

While the American public has remained largely focused on the nation’s biggest drug crisis, the opioid epidemic, another pharmaceutical is quickly making strides towards that title. Benzodiazepines (BZDs) are a class of sedative medications used to treat anxiety and panic, seizures, alcohol withdrawal, and muscle tension. They increase the effects of an inhibitory neurotransmitter called GABA by allosterically binding to the GABA receptor, a ligand gated chloride channel, thereby causing an influx of chloride into the cell. This influx causes a membrane hyperpolarization, which makes it more difficult for subsequent action potentials to occur. Thus, you achieve the inhibitory/anxiolytic effects seen with benzodiazepines (Sankar, 2012).

Although BZDs are quite efficient, there is a growing body of research linking long term benzodiazepine use to cognitive impairments and dementia (Toombs et al., 2018). Similar to opioids, those taking BZDs are subject to increased dependence and withdrawal. Moreover, BZDs can cause fatal overdose when taken in abundance or in combination with other drugs. From 1996-2014, the rate of fatal overdoses involving benzodiazepines quadrupled (Bacchuber et al., 2016).

With this knowledge, why do we continue to prescribe them? The answer is easy, right? Just don’t do it. I would argue that it’s not always that easy. A study of 35 general practitioners investigated reasons why general practitioners decided to initiate benzodiazepine prescriptions. The study concluded that general practitioners tend to become overwhelmed by their patients’ psychosocial problems and perceive benzodiazepines as “the lesser evil” (Anthierens et al., 2007). One general practitioner stated, “I have to do a lot of “psycho”. Whether I want it or not but I haven't got the training for it. What do I do? I prescribe.…”.

From the outside looking in, it’s easy to make judgements, blaming this rising “epidemic” on physicians’ disregard of nonmaleficence. But consider what you would do in a similar situation—when a distressed patient is looking to you for answers. In the case of the practitioner just mentioned, this was likely an attempt to uphold beneficence, by giving a patient the relief he or she needed. Although there is evidence that BZDs are safe in short term, history shows us (i.e. our old pal the opioid crisis) that tapering/refusing to prescribe addictive medications is not particularly easy, especially when there is currently no better alternative. These are the difficult situations that we as future health providers will face.

References:

Anthierens, S., Habraken, H., Petrovic, M., & Christiaens, T. (2007). The lesser evil? Initiating a benzodiazepine prescription in general practice: A qualitative study on GPs’ perspectives. Scandinavian Journal of Primary Health Care, 25(4), 214–219. http://doi.org/10.1080/02813430701726335

Bachhuber, M. A., Hennessy, S., Cunningham, C. O., & Starrels, J. L. (2016). Increasing Benzodiazepine Prescriptions and Overdose Mortality in the United States, 1996–2013. American Journal of Public Health, 106(4), 686–688. http://doi.org/10.2105/AJPH.2016.303061

Sankar, R. (2012). GABAAreceptor physiology and its relationship to the mechanism of action of the 1,5-Benzodiazepine clobazam. CNS Drugs. https://doi.org/10.2165/11599020-000000000-00000

Toombs, A. R., Jung, J. Y., & White, N. D. (2018). Benzodiazepine Use and Cognition in the Elderly. American Journal of Lifestyle Medicine, 12(4), 295–297. https://doi.org/10.1177/1559827618767381