Whitney, whose name we changed to protect her privacy, sometimes has panic attacks. Her hands shake and her chest tightens. By the end of one, she’s drenched in sweat. To alleviate her worry about having another attack, she carries a prescription bottle of clonazepam, a benzodiazepine, with her everywhere she goes.
The medication works fast, and can end a panic attack within minutes. She uses it so rarely that the name has rubbed off the bottle and she often wonders if the medication is expired. But, simply having it on her acts as a sort of psychological safety blanket. She knows if she is going to have a panic attack in class, the clonazepam is there and will work. Because she hardly ever uses it, she never worried about her potential to misuse or abuse it. Until there was a global pandemic.
With the news of COVID-19 emerging, Whitney noticed she was using her clonazepam a lot more regularly. She felt panicked, and she turned to what she knew worked, even though she also knew there was a risk to it. That also meant she went through her prescription a lot faster than she usually does, and had to ask for a refill.
As psychiatrists, we have noticed that Whitney’s story is not at all unique. Many of our patients are coming to us asking for refills on their infrequently used prescriptions of benzodiazepines to help them cope with COVID-19. Some are also asking for new ones. It makes sense; these are anxiety-provoking times.
Because she hardly ever uses it, she never worried about her potential to misuse or abuse it. Until there was a global pandemic.
According to a recent poll by the American Psychiatric Association, 40% of Americans are anxious about becoming seriously ill or dying from coronavirus and 62% are worried about the same thing for their loved ones. Add to this the mental health problems that come with quarantine and widespread uncertainty, and we are left with a perfectly anxious storm.
Not surprisingly, benzodiazepine prescriptions have skyrocketed since the pandemic began. A new study of over 3 million people found that prescriptions for this medication class spiked 34% from mid-February to mid-March, right as the media started talking more about the novel coronavirus.
This bump is unfortunate, because we were finally making progress with benzodiazepine overuse, a problem that some have compared to the opiate epidemic. Prior to COVID-19, benzodiazepine prescriptions were down 12% from 2015.
While we know that these medications help in the short term, we need to be mindful of their long-term consequences. The first problem is that benzos stop working over time as people build up a tolerance. Anxiety levels may actually increase as tolerance builds, and they are at a greater risk of developing cognitive problems (particularly the elderly).
Chronic users also build up dependence. Benzodiazepine withdrawal is one of the scarier things we see as psychiatrists. If not carefully monitored and managed, it can result in seizures and death.
The stress right now feels acute, and it’s easier to approach anxiety with a band aid ... but overusing benzodiazepines will become more of a risk to the patient
Overuse of these medications can also lead people to stop breathing, a risk that increases dramatically when they are used with alcohol. (And alcohol use is also on the rise during the pandemic.) Social media isn’t doing us any favors right now, with people promoting the potentially fatal combination of Xanax (a benzodiazepine) and alcohol.
This doesn’t mean we don’t prescribe them or they don't provide a needed benefit for some. A lot of people find tremendous short term relief in taking benzodiazepines, especially as a bridge while longer-term medications, like SSRIs (commonly used first-line antidepressants that are also anti-anxiety), start to work. However, as these antidepressants kick in, the benzodiazepines should not be needed regularly. If they are, another medication adjustment may be necessary.
If you are taking benzodiazepines, bear a few things in mind: Don’t take more than prescribed without telling your doctor, and don’t mix them with drugs or alcohol. Remember that they aren’t meant to be long-term medications. If you’ve been on them for a prolonged period of time, raise the issue with your doctor.
During the pandemic, doctors may be letting their own anxieties interfere with their clinical judgment. The pressure to prescribe benzodiazepines can be intense: patients are asking for them, and it’s a quick fix. Psychotherapy and medications such as SSRIs have stronger evidence, but they take more work to administer and take longer to take work.
The stress right now feels acute, and it’s easier to approach anxiety with a band aid, but as the days grow into months, overusing benzodiazepines will become more of a risk to the patient, and this should be considered up front. Our clinical experiences and the data tell us that now, more than ever, we need to be mindful about our approach.
Jack Turban (@jack_turban) is a resident physician in psychiatry at The Massachusetts General Hospital. Jessica Gold (@drjessigold) is an assistant professor of psychiatry at Washington University in St. Louis.