It is little wonder that stress levels today are higher than ever across the United States. Overloaded work schedules, juggling family and a career and making ends meet financially can all lead to anxiety and can affect nearly everyone from time to time.
Yet the kind of anxiety that strikes without notice for no apparent reason — such as panic attacks and social phobias — can be debilitating. And no one is immune. Not even celebrities like Demi Lovato and Selena Gomez, who have openly admitted their ongoing struggles with anxiety; Oprah Winfrey, who suffered a panic attack in 2013; and John Mayer, who suffered from severe panic attacks growing up and would often deal with his anxiety by isolating himself in his room to play guitar. In an interview with Katie Couric, musician Chance The Rapper said he used to be addicted to Xanax and in 2015 that "Xanax is the new heroin."
Today more than 40 million adults in America suffer from anxiety, and it is the most common mental illness in the United States. But even more of a crisis than the number of those diagnosed with anxiety is the number of people who are addicted to the drugs that treat it — and the rising number of people dying from overdoses.
Now many mental health experts are sounding the alarm, claiming that benzodiazepine addiction is an epidemic as frightening and serious as the opioid crisis.
Overdose deaths involving benzodiazepines — such as Xanax, Librium, Valium and Ativan, drugs commonly used to treat anxiety, phobias, panic attacks, seizures and insomnia — have quadrupled between 2002 and 2015, according to the National Institute on Drug Abuse. In 2015 benzo overdoses accounted for 8,791 deaths, up from 1,135 in 1999. The trend is fueled by the fact that benzodiazepine prescriptions increased 67 percent between 1996 and 2013, with the number of adults filling a benzo prescription in the United States tallying 13.5 million, according to a study.
Like opioids, there's plenty of money to be made in the general anxiety-disorder drug market, which includes antidepressants, benzodiazepines and buspirone. In 2014 this sector was valued at more than $3.3 billion in the United States. It's expected to reach about $3.8 billion by 2020, revealed a Zion Market Research report.
Justin LaPilusa, a licensed clinical psychologist in San Diego, said that in his experience he's noticed that many people develop anxiety in their early 20s, a time age in which they don't always have the personal resources to manage their symptoms. People in this age group are also experiencing plenty of new external stressors, he said, like new jobs, relationships and colleges.
"It's a time of great discovery," he said. "It can also be a time of great emotional upheaval. … The individuals at that age as well don't always have the wherewithal to seek out mental health treatment."
Antidepressant medications, such as Prozac, Zoloft and Paxil, are also prescribed to treat anxiety, as they are the "first line of treatment for anxiety disorders," said Dr. Anna Lembke, chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. Yet doctors may shift toward benzodiazepines depending on the individual, their needs and their type of anxiety. Some people build up a tolerance to antidepressants and may experience rebound anxiety, or a worsening of anxiety symptoms.
Benzodiazepines work by binding to GABA receptors and enhancing their function, said Lembke. GABA (gamma-aminobutyric acid) is an inhibitory neurotransmitter in the brain. By enhancing their function, benzodiazepines ultimately calm the brain down.
"The brain basically compensates … by downregulating its own internal mechanisms for calming the brain," Lembke said. "Ultimately, the individual becomes dependent on benzos to remain calm."
If the drugs aren't available, the individual experiences heightened anxiety, Lembke said. She said there isn't enough data from long-term studies to definitively declare the likeliness of addiction, but she estimated that about 10 percent to 15 percent of users will develop addiction, while a larger proportion may develop a physiological dependence.
Lembke said that if benzodiazepines are needed daily, people shouldn't take them for longer than two to four weeks. If used long term, then it's best only to take them two to three times a week.
The withdrawal process for benzodiazepines is even more dangerous than it is for opioids, she said. Withdrawal symptoms could include increased anxiety, insomnia, depression, irritability or muscle jerks. Seizures can also occur in severe cases.
Dr. Wilson Compton, deputy director at the National Institute on Drug Abuse, said withdrawal depends on the type of drug. Xanax, for example, is known to cause more severe withdrawal symptoms, as it is a short-acting benzodiazepine. Longer-acting drugs, such as Librium and Valium, may be less prone to withdrawal, he said.
"All of these medications can cause significant withdrawal when stopped abruptly after being used consistently for an extended period of time, he said. "That's why someone cutting back or stopping these medications needs medical supervision."
Dr. Beth Salcedo, board president of the Anxiety and Depression Association of America, said one of the reasons for the escalating number of prescriptions is that they are written by primary doctors, who typically don't provide psychotherapy or have resources to give referrals for good psychotherapy.
Another possibility: More people are talking openly about stress than ever before.
"People talk about anxiety much more than they did 20 years ago," Salcedo said. Now, she said, "people are more likely to present for treatment or even acknowledge they have an anxiety disorder."
LaPilusa said the increase could be due to an increased desire to remove discomfort instead of learning to cope with the feelings. The idea that negative emotions are harmful and must be removed in order to be successful and content is being sold to people, he said. As a result, people are so determined to eliminate discomfort that they turn to medication.
"We really don't have that push for learning how to get better at feeling. We don't teach that it's OK to feel these things," LaPilusa said.
Lembke agreed, further pointing out that the pharmaceutical industry, which oversells benefits and underreports risks, may also be largely to blame.
The medical community is finally pushing back. After soaring prescriptions earlier in this decade, the past three years has seen a decline, according to pharmaceutical consulting and research firm IQVIA, which tracks dispensed prescriptions at retail, mail order and clinical settings. It said the pattern with anti-anxiety drugs is similar to opioids. As prescriptions soared, the medical community, especially through associations like the American Medical Association, began to get the word out about a problem of epidemic proportions. In 2013, Benzo prescriptions were at a peak, but the tide has been turned since then.
But that hasn't necessarily lessened the crisis because as legal prescriptions have declined in the period from 2015-2018, people facing withdrawal find other means of purchase. As in the case of opioids — where overall dispensed, legal prescriptions have declined for the past five years while deaths from heroin derivatives and illegal fentanyl are at epidemic levels —smuggled, illegal Benzo or "Xanax" fakes on the street are rising.
Having feelings of anxiety throughout life is normal, said Salcedo. Yet when these feelings begin to negatively impact one or more areas of your life and limit functionality, it transitions into a disorder. Symptoms of general anxiety disorder typically include racing, catastrophic thoughts and difficulty breathing, she said.
"They just feel like they can't relax like they used to," said Salcedo of sufferers.
The disorder can also get physical, causing muscle tension, fatigue or restlessness and cause a vicious cycle. "These kinds of symptoms then can kind of feed into each other," said LaPilusa. "The more a person worries, the more physically drained or agitated they could get, which could lead to more worry."
Panic attacks, which are usually marked with shortness of breath, feelings of dread and a racing heart, occur in the most severe cases, said Salcedo. The attacks can last anywhere from several minutes to several hours. LaPilusa described panic or anxiety attacks as a blitzkrieg of symptoms that could even cause fainting.
Psychotherapy, particularly cognitive brain therapy, said Salcedo, is another way to treat anxiety. CBT usually spans over 12 to 16 sessions and helps patients learn to recognize and challenge anxious thoughts, along with behaviors that could be contributing to the anxiety. Within four to six sessions, people usually feel a change and improve, she said.
There's also acceptance and commitment therapy. According to LaPilusa, the therapy, which focuses on teaching mindfulness, can be given by a therapist or psychologist. It encourages people to stay in the moment and rediscover their values, meaning and purpose. This is especially helpful in the age of social media, where people often have hundreds of "friends" online but lose touch with their own identity.
While Lembke touts meditation, exercise and good sleep hygiene as sound alternatives to benzos, she also said that if medicine is your best option, selective serotonin reuptake inhibitors, a class of antidepressants, would be a safer alternative, since they're typically are not habit forming. She added that they also exhibit safer side effects and work better in the long term.
Compton, deputy director of the NIDA, and Ken Duckworth, director of the National Alliance on Mental Illness, both said they don't think benzodiazepines have the potential to be as catastrophic as the opioid crisis.
"It'd be hard to predict the next great catastrophic public health epidemic," Duckworth said. "My colleagues use these medicines for the short term, the vast majority of the time."
Compton pointed to the fact that people typically don't begin to like the feeling of benzodiazepines the way that they like opioids. And while he doesn't think benzodiazepines could be the next opioid crisis, he said they are dangerous — even more so when combined with opioids.
In fact, the Food and Drug Administration began requiring "boxed warnings and patient-focused Medication Guides" on labels to inform consumers about the risks of combined use of opioids and benzodiazepines in 2016, and said that combined use could cause risks including respiratory depression, dizziness and death.
"You have two different agents or medications ... that are both reducing our automatic breathing response, so the respiratory centers of our brain are suppressed by all of these different substances," Compton said. "The combination is what makes people stop breathing."