Epidemiology
Epidemiological studies of benzodiazepine use vary according to the population sampled. The Epidemiology of Vascular Aging (EVA) study in France showed that the incidence rate of benzodiazepine use in older people was 4.7/1000 person-months.[2] About 10% of the US older population use benzodiazepines regularly, mostly for sedative and anxiolytic purposes.[3] This figure is as high as 36% for adults receiving treatment for depression in mental healthcare settings.[4] Benzodiazepines are prescribed for 30% to 74% of patients with post-traumatic stress disorder (PTSD), despite research showing that benzodiazepines are ineffective for the prevention and management of PTSD.[5]
Benzodiazepine use is higher in white people than in other ethnic groups. Twice as many females as males use benzodiazepines. Prevalence of benzodiazepine use has been reported as ranging from 3.9% in middle-aged and older adults in Brazil, to 35.9% in people aged 65 years and older in Canada.[6][7] There is evidence to suggest that among older people, with or without Alzheimer's disease, benzodiazepine use may increase risk of stroke and hip fracture.[8][9][10]
While benzodiazepines are generally intended for short-term use, the proportion of patients on long-term benzodiazepine treatment increases with age from 14.7% (18-35 years) to 31.4% (65-80 years). In all age groups, around 25% of individuals receiving benzodiazepine involved long-term benzodiazepine use.[11]
Non-medical use of benzodiazepines is highest in people aged 18 to 25 years, with rates of 0.7% to 1.9%.[12] Use is especially common in those who abuse alcohol, with up to 40% reporting inter-current or concurrent self-medication with benzodiazepines.
With regard to illicit drug use, benzodiazepines are commonly misused and available as ‘street’ drugs. As these drugs are being used without a prescription or guidance and monitoring from a medical practitioner, the risks associated with their use are potentially much greater.
In particular, non-medical use of novel benzodiazepines such as flubromazolam is increasingly common.[13] Prolonged toxicity may occur due to its long half-life and the production of metabolites.[13]
Drug-related deaths continue to rise in all parts of the UK. In England and Wales there has been an increase in drug-related deaths in the last 10 years.[14] In particular, deaths involving benzodiazepines have increased by 13% (from 476 to 538 deaths) between 2020 and 2021.[15] In Scotland, 1,264 drug-related deaths were recorded in 2019; the highest number ever recorded and more than double the figure for 10 years ago. ‘Street’ benzodiazepines (e.g., etizolam) were implicated in 64% of these deaths, while ‘prescribable’ benzodiazepines (e.g., diazepam) were implicated in 15%.[14]
In the US, benzodiazepines account for approximately 31% of fatal overdoses involving prescription drugs, while 75% of these fatal overdoses also involve opioids.[16] Drug-related overdose deaths are increasing, with more than 106,000 individuals in the US dying from drug-induced overdose in 2021, compared with 52,000 in 2016.[17] Of these 106,000, approximately 12,500 deaths were associated with BZD use.
Risk factors
Ask the patient about depression or a history of depression and suicidal ideation.
This leaves the patient at risk of both accidental and deliberate overdose.
Many patients who are dependent on opioids also use benzodiazepines regularly, and this increases the risk of overdose of both drugs.[20][21][22] Patients who use drugs of abuse or who are dependent on alcohol often use drugs in combination, including benzodiazepines, and may have a history of depression or suicidal attempts.
Benzodiazepines may have been prescribed for a variety of conditions such as anxiety and back pain.
Common in patients who self-medicate.[23] May also occur in hospital settings.
Overdose is more likely with increasing age and decreased liver function.
Most common substances include alcohol, opioids, and amphetamines.
Consider recent life events and previous suicide attempts or ideation. Look for physical signs of deliberate self-harm, such as burns, cuts, or ligature marks.
Older people, who commonly have diminished drug clearance and polypharmacy, are at especially high risk of toxicity.[24]
People who have severe liver disease are at risk of toxicity from lower benzodiazepine doses.[24]
Not likely except with recreational co-ingestions, particularly alcohol and other central nervous system depressants.[25]
The risk is largely unknown, although considerable individual variation suggests possible genetic predisposition to overdose.
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