Take a Chill Pill: America's next drug problem

This story was originally published on September 1, 2018 at Jotmagsb.com

Brown stained carpets, dry beer splattered on the walls, a jug of some concoction of cheap vodka and Kool-aid called “jungle juice,” and college kids sucking on vape pens. But Xanax? “You won’t find any of that here,” said a frat house resident in East Setauket, who requested his name be kept private for safety reasons.

“Xanax has a weird thing of turning people into crazy people and then you get holes like that,” he said, pointing to a hole in the wall of his kitchen that someone punched during a party last semester. He said that the person took a combination of Xanax and alcohol before throwing the punch.

Says the resident, “Xanax is actually very dangerous when mixed with alcohol, where you [someone] pass out and its hard to tell if they’re sleeping or dead.” He and his housemates since banned Xanax in the house.

America is on track for a new epidemic of addiction and overdoses driven by anti-anxiety medication, a top clinician warns. But doctors, college kids, and rap stars are trying to stop the epidemic before it begins.

These sedatives are called benzodiazepines, sometimes referred to as “benzos.” They treat depression, anxiety, and panic attacks by depressing the central nervous system, which allows the user to feel calmer and less likely to become fearful or anxious. Xanax, Librium, Klonopin, Ativan and Valium are among the most popular brands of benzos.

According to The National Center for Biotechnology Information, over 5 percent of the adult population in the United States takes benzos. In fact, prescriptions for benzos increased by 67 percent between 1996 and 2013, from 8.1 million to 13.5 million. And the number of pills found in these prescription bottles more than tripled during that same period.

Xanax is the largest selling psychiatric drug in the U.S. and the fifth most frequently prescribed drug overall. And like other benzos, it has a depressive effect on the central nervous system, which limits a user’s breathing and heart rate. This leaves the body vulnerable to other substances like opioids.

Rising star and Long Island native Lil Peep, born Gustav Ahr, died at age 21 last November. According to a toxicology report, the rapper’s cause of death was the “combined toxic effects of fentanyl and alprazolam,” the latter a generic form of Xanax. The medical examiner ruled the death an accidental overdose.

In 2016, the Journal of Substance Abuse Treatment reported that people trying to curb opioid addiction frequently take benzos prior to detox “to help manage anxiety.” As a result, they end up getting addicted to both, with a 30 percent higher risk of overdosing.

Overdoses involving benzos multiplied sevenfold between 1999 and 2015, increasing from 1,135 to 8,791 deaths. Three quarters of these deaths involved an opioid.

“Benzos alone can kill, are addictive, and can cause other long term harm,” said Dr. Anna Lembke, an associate professor of psychiatry and behavioral sciences at Stanford University. “In combination with opioids and other sedatives, they become more lethal.”

In a New England Journal of Medicine review, Lembke explained that the fact that opioids were involved in so many benzo-related deaths may explain why, in the context of the nationally recognized opioid epidemic, the harms associated with benzos have gone overlooked. “There are parallels [between opioids and benzos] in terms of the addictive and overdose potential,” she wrote in an email. “Both create dependence, tolerance, and withdrawal when reduced or stopped. Both have the potential for addiction. Both can contribute to death by slowing heart rate and respiratory drive.”

Mixing alcohol with benzos is not recommended either. According to Anne Marie Peters, a family psychiatric nurse practitioner in Island Park, since both alcohol and benzos are central nervous system depressants, the combination of the two can lead to death. She said that people who mix them are “more likely to become sedated or blackout, and if they blackout, they can become aggressive and will not remember any of it.”

But the creators of benzos never intended for the effects to be so dangerous. In 1956, Dr. Leo Sternbach created the first benzo, chlordiazepoxide, a drug more commonly known as Librium, as a less addictive way to treat anxiety. Then, in 1976, he worked with the Upjohn Company to create and patent alprazolam.

The Food and Drug Administration approved alprazolam in October 1981 after years of research. One month later, it was assigned as a Schedule IV controlled substance, which meant that it had a low potential for abuse. In 1990, it was the first benzo to be approved by the FDA to treat panic disorder, a psychiatric disorder in which debilitating anxiety and overwhelming fear reoccur without reasonable cause. Eventually, the drug became the preferred treatment for panic disorder because it was less toxic and more effective than other drugs that were available at the time, like Valium and Librium. Xanax became widely used to treat anxiety disorders because it proved to be fast-acting, providing symptom relief to patients within a week of starting treatment. It was prescribed so often that panic disorder became widely known as the “Upjohn illness” in the 1990s.

While the nickname didn’t last, prescriptions have gone up and abuse has increased. Today, 10 to 25 percent of long time benzo users are dependent on them.

Benzos have proven useful for those prescribed when used occasionally and for less than one month at a time. But when they are used daily and for extended periods, the benefits of benzos diminish and the risks associated with their use increase. Lembke suggests that people who use benzos almost everyday should work with their prescriber to taper off. “Benzos should not be taken daily,” she urged. “The risks of daily long-term use exceed the benefits, and include depression, cognitive impairment, anxiety, falls, tolerance, withdrawal, dependence, addiction, and accidental death.”

Antigone Joannou, a licensed clinical social worker at Park Terrace Care Center who specializes in addiction, said that addiction starts with doctor shopping. In other words, patients are able to access multiple prescriptions of the same medicine from different doctors because doctors do not have access to a record of medications prescribed to a patient. “Converting to electronic medical records [EMRs] may be the solution to some of these problems because practitioners will have access to medical prescriptions across the board,” Joannou said. “So you [doctors] can monitor prescriptions or enhance your ability to assess for potential addiction.”

Peters said she only prescribes benzos to patients who have no history of addiction. Yet, some patients still fall victim to addiction. “[Patients who are prescribed benzos] are going to call you up in a week telling you, ‘I lost my Xanax,’ or ‘They fell in the sink,’” she said. “They’re going to want their prescriptions refilled sooner than they need it.” When a patient calls asking for a refill earlier than expected, Peters sits down with the patient to evaluate whether or not they are telling the truth. If she finds that the patient has been abusing the medication, she will help them recover by giving them a two-week supply of the medication to gradually reduce intake. She has a weekly meeting with the patient until she sees that they are no longer dependent on the drug. She warns that if the medication is stopped all together, the patient is at risk of withdrawal, which can lead to seizures and death.

“Benzodiazepines should be reduced slowly to avoid the risk of seizures and other life-threatening withdrawal symptoms,” Lembke urges. “The psychological withdrawal symptoms include depression, anxiety, insomnia, and irritability, but these are time limited. They will resolve with time, and don’t necessarily require additional treatment. A slower taper mitigates risk of these withdrawal symptoms. So just keep on keeping on.”

At Long Island Center Recovery in Hampton Bays, admissions director Danny Cervini said that better ways of coping with anxiety are out there. “When it comes to anxiety and depression, we use new age, holistic tactics and teach the resident coping techniques.” Coping techniques include yoga, meditation, nutrition, and breathing exercises.

Peters agrees that these tactics are helpful ways of managing anxiety, depression, and benzodiazepine recovery, adding that therapy may help as well. However, she says, some patients require medication.

The benzo crisis proves to have many parallels to the opioid epidemic. Lembke said that the overprescribing of opioids has led to increases in illegal heroin and fentanyl sales, just as the overprescribing of benzos is fueling black market sales. New highly potent forms of benzos are increasingly penetrating the black market. They are manufactured in secret labs in the United States and are indistinguishable from prescription drugs. They are also deadly.

After a college group chat was asked about Xanax sales, a Stony Brook University student named Matt, who requested his real name be kept private, responded. Matt buys hundreds of Xanax pills at a time from an unknown seller on the dark web and “occasionally" sells them for $5 a pill to his friends.

“Me and my friends took the liberty of testing it [the Xanax] out to see if it’s pure,” he said. “We put a chemical on it and if it turns a certain color, then we know if it’s laced with something. We’ve never received anything that was laced. It’s always pure.”

Matt said that sometimes he cuts his friends off because he is afraid they will overdose.

In order to prevent a patient from becoming addicted, education is key, Peters stressed. “With any medication that is prescribed, all of the risks and benefits are explained to them [the patients] in detail,” she said about her practice. Pharmacies require patients to sign a waver that states that the patient understands the risks of misusing a medication, but Peters said it is important for doctors to explain those risks before prescribing anyway. “In my practice, they usually have to sign a consent that they understand the risks. You absolutely want to let somebody know that if you do not take the medication as prescribed, you are at risk of becoming addicted.”

Meanwhile, Lembke says that little discussion of the benzo epidemic exists among the media, clinicians, policymakers, and educators. In fact, rappers seem to be taking the lead on the conversation.

Complex Magazine reported in January that in light of Lil Peep’s death, rappers including Lil Uzi Vert, Smokepurpp, and Famous Dex have all announced on social media that they quit using Xanax, supporting rapper Lil Xan’s anti-Xanax movement called “Xanarchy.” Lil Xan hopes that hip-hop fans will follow by quitting the drug.

“My whole movement is getting kids off of Xanax, that’s what we’re trying to do,” he told the Phoenix New Times. “I make it very clear on all social media aspects and the people know now. We’re going to keep pushing that until it's in your face and you can’t ignore it.”