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COVID-19 and Benzodiazepines: Out of the Frying Pan... Into the Fire

The coronavirus pandemic has confronted millions of Americans with issues such as unemployment, homelessness, and food insecurity. Beyond its adverse implications on physical health and the global economy, however, the pandemic has imposed a toll on people’s mental health. Deemed a “psychiatric epidemic,” COVID-19 has triggered a dramatic swell in the rates of depression and anxiety.

In the year preceding the outbreak of COVID-19 in the U.S., the average share of adults reporting symptoms of anxiety or depression was 11%. With the onset of the pandemic, this parameter rose by 30.1%—nearly four in ten U.S. adults now report struggling with these symptoms. To help combat the rising incidence of mental health disorders, physicians have taken to prescribing a class of nervous system depressants called “benzodiazepines” to patients who report struggling with anxiety. While benzodiazepines are often used for off-label purposes including chest pain, vertigo, hypertension, and chemotherapy-induced nausea and vomiting, they remain the gold standard for the treatment of psychiatric health and sleep disorders.

Discovered by Leo Sternbach, a Polish American chemist, benzodiazepines made their market debut in 1960, and with the advent of modern psychopharmacology, no less. ‘Benzos,’ marketed under several different names including Xanax (alprazolam), Ativan (lorazepam), and Klonopin (clonazepam), have since been the pharmaceutical industry’s top-selling class of prescription drugs. Due to their calming, palliative, and anticonvulsive effects, these psychotropic drugs quickly gained popularity with psychiatrists, who began prescribing them to treat insomnia, depressive anxiety, and alcohol dependence.

According to the FDA, approximately 92 million benzodiazepine prescriptions were dispensed by U.S. outpatient facilities in 2019—nearly one prescription for every three people. Since the pandemic began, however, this parameter has risen steeply.

Studies suggest that administering these drugs for limited periods and at lower doses may improve patient quality of life. It is precisely because these prescription drugs are so effective that physicians have been prescribing them for several decades now. Indeed, when benzodiazepines first hit the market, medical professionals greeted the drug class with enthusiasm, thereby bolstering its popularity as well as patient demand. By the 1980s, however, physicians’ tendency to prescribe created a new concern: the threat of abuse and dependence.

The use of benzodiazepines, however, is a double-edged sword. Although beneficial when used within their prescribed limits, these drugs have been shown to drastically reduce patient quality of life when taken for longer periods or at higher doses. The sedative effect of these medications, compounded by their addiction-forming chemical properties, makes them ripe for dependence and abuse. 

The onset of drug tolerance and dependence, however, is a more complex issue than meets the eye. Exposure to even trace amounts of these sedatives can initiate neuroadaptation, a process wherein the body rapidly acclimates to a drug’s presence and alters the central nervous system accordingly. Thereafter, the patient may develop a physical dependence on the substance and even experience severe withdrawal symptoms—seizures, delirium, panic attacks, and even death—upon discontinuing the medication.

That the FDA recently updated the Boxed Warning labels of all benzodiazepine medications to include the “risks of abuse, misuse, addiction, physical dependence, and withdrawal reactions consistently across all the medicines in the class,” therefore comes as no surprise. Given the highly addictive nature of benzodiazepines, the line between drug use and abuse is dangerously thin. 

The climbing rates of drug dependence and addiction are exacerbated by the fact that physicians are prescribing more freely than before the COVID-19 pandemic. According to a 2020 report from Express Scripts, a Cigna-owned pharmacy benefit manager, the number of prescriptions filled per week for antidepressant, anxiolytic, and anti-insomnia medications began rising in mid-February 2020, spiking 34% by March 15. This peak roughly coincides with the WHO’s declaration of a global pandemic on March 11 and the statewide lockdowns that ensued.

Due to this lowered threshold for prescribing, though, physicians now run the risk of over-prescribing or even authorizing patients to use medications for a longer duration than necessary. When taken on a long-term basis, benzodiazepines have been shown to amplify feelings of anxiety, causing panic attacks and agoraphobia in patients who have never experienced such symptoms before. These issues—from patients misusing medications to doctors over-prescribing benzodiazepines—have given rise to another equally deadly epidemic: dependence.

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