While prescriptions have slightly declined in recent years, a deep dive into the data reveals that benzodiazepines are still among the most widely prescribed—and potentially perilous—medications in America.
Key Takeaways
- In 2019, the United States saw 12.8 million adults filling benzodiazepine prescriptions, representing 5.6% of the adult population, per CDC National Health Interview Survey data.
- From 2002 to 2014, benzodiazepine prescriptions in the US increased by 67%, from 8.1 million to 13.5 million 30-day supplies for adults aged 18-64.
- In 2020, alprazolam accounted for 45% of all benzodiazepine prescriptions dispensed in US outpatient settings, totaling over 13 million prescriptions.
- Women aged 18-44 received 6.2% benzodiazepine prescription rate in 2019 US NHIS.
- US males aged 65+ had 12.4 per 100 benzodiazepine fill rate in 2018.
- Among US adults with anxiety, 17.3% women vs 10.8% men used benzodiazepines in past year 2019.
- Long-term benzodiazepine use associated with 50% increased dementia risk in adults over 65 per 5-year cohort study.
- Concurrent opioid and benzo prescriptions led to 31% of overdose deaths in US 2019-2020.
- Benzodiazepine use increases hip fracture risk by 1.5-fold in elderly, meta-analysis of 9 studies.
- FDA Black Box Warning on benzos issued Sept 2020 for abuse/dependence risks.
- CDC Guideline 2022 recommends against benzos for chronic pain except end-of-life.
- 21 states enacted benzo prescription limits by 2023, max 30-day supply.
- In Australia, benzodiazepine scripts totaled 1.2 million in 2021, 10% decline from 2016.
- UK dispensed 15.4 million benzo items in 2022, down 14% since 2014.
- Canada: 5.8 million benzo prescriptions 2018, highest in Quebec at 12% population.
Millions of Americans use benzodiazepines, but prescription trends are declining due to safety concerns.
Demographics
- Women aged 18-44 received 6.2% benzodiazepine prescription rate in 2019 US NHIS.
- US males aged 65+ had 12.4 per 100 benzodiazepine fill rate in 2018.
- Among US adults with anxiety, 17.3% women vs 10.8% men used benzodiazepines in past year 2019.
- Children aged 5-11: 0.3% benzodiazepine prescription prevalence in US 2020.
- US Hispanics had 3.8% benzodiazepine use rate vs 6.1% non-Hispanic whites in 2015-2016.
- Adults 45-64 years: highest benzodiazepine prescription rate 7.5% in US 2018.
- Pregnant women: 3.1% benzodiazepine exposure in US 2014-2018 per pregnancy registries.
- US veterans: 15.2% benzodiazepine prescription rate in 2019 VA data.
- Low-income US adults (<$25k): 8.4% benzo use vs 3.9% high-income in 2019.
- Rural US residents: 6.8 per 100 benzo fill rate vs 5.2 urban in 2018.
- US adults with depression: 22% concurrent benzo prescriptions in 2020.
- Adolescents 12-17 females: 2.1% benzo prescription rate US 2016-2019.
- US Blacks: 2.9% benzo use rate vs 5.6% whites in 2015-2016 NHANES.
- College-educated US adults: 4.2% benzo use vs 7.1% non-college 2019.
- US adults 18-25: 4.1% benzo prescription prevalence 2020.
- Medicare beneficiaries aged 65-74: 9.8% benzo use 2016.
- US women 65+: 28.4 per 100 benzo fills 2018.
- Insured US adults: 6.5% benzo rate vs 3.2% uninsured 2019.
- US adults with PTSD: 24.7% benzo prescriptions 2018.
- Males 18-44: 3.9% benzo use US 2019 NHIS.
- US Asians: 2.1% benzo prescription rate 2015-2016.
- Adults 75+: 11.2% benzo use in US nursing homes 2020.
- US smokers: 7.3% benzo use vs 4.8% non-smokers 2019.
- Employed US adults: 4.6% benzo rate vs 9.2% unemployed 2019.
- US Midwest: 6.4% benzo prescription rate 2018.
- Chronic pain patients: 18.5% benzo co-prescriptions US 2020.
- US divorced/widowed: 10.1% benzo use vs 3.5% married 2019.
- Children with autism: 4.2% benzo prescriptions US 2017-2020.
- Long-term benzo users (>1 year): 15.3% of total US prescribers' patients 2019.
- US Northeast: 7.2 per 100 benzo fills 2018.
- Adults with substance use disorder: 28% benzo prescription rate US 2019.
- Females under 18: 1.8% benzo use US 2020.
Demographics Interpretation
From the harried young adult to the lonely elder, from the veteran's unseen wounds to the strained paycheck, America's benzodiazepine script tells a story of stress fractured along the lines of age, gender, geography, and grief, painting a portrait where the prescription pad often mirrors the fault lines of society itself.
Health Outcomes and Risks
- Long-term benzodiazepine use associated with 50% increased dementia risk in adults over 65 per 5-year cohort study.
- Concurrent opioid and benzo prescriptions led to 31% of overdose deaths in US 2019-2020.
- Benzodiazepine use increases hip fracture risk by 1.5-fold in elderly, meta-analysis of 9 studies.
- 18% of long-term benzo users develop dependence within 6 months, per French cohort.
- US emergency visits for benzo misuse: 92,000 annually 2010-2015 average.
- Cognitive impairment persists 3.5 months post-benzo discontinuation in 44% of users.
- Benzos contribute to 22% of drug-related falls in US nursing homes annually.
- Respiratory depression risk 4.2 times higher with benzos + opioids vs opioids alone.
- Withdrawal symptoms in 40-75% of chronic benzo users upon abrupt cessation.
- Benzo-associated overdose deaths rose 4-fold from 2002-2015 in US, to 8,791.
- Motor vehicle crash risk increases 1.6x with benzo use, dose-dependent.
- 15% of US benzo users aged 65+ experience adverse drug events yearly.
- Tolerance develops to anxiolytic effects in 4-6 weeks for 70% of users.
- Benzo use linked to 60% higher pneumonia risk in older adults.
- Polysubstance overdose involving benzos: 30% fatality rate in US ED data 2019.
- Memory impairment in 35% of daily benzo users >3 months.
- Suicide attempt risk 2.3x higher in benzo users vs non-users.
- 25% of chronic users report rebound anxiety worse than baseline.
- Benzos increase all-cause mortality by 20% in schizophrenia patients.
- ED visits for benzo withdrawal: 25,000/year US 2011-2015.
- Fracture risk 68% higher first week of benzo initiation in elderly.
- 12% prevalence of benzo use disorder among long-term users.
- Sleep driving incidents linked to z-drugs/benzos: 6% of cases.
- COPD patients on benzos: 1.8x hospitalization risk for exacerbation.
- Neonatal withdrawal syndrome in 10-30% of benzo-exposed infants.
- Dose >20mg diazepam equivalent daily: 3x overdose risk.
- Benzo users 65+: 2.5x risk of hospitalization for confusion/delirium.
- 50% of benzo-overdose deaths involve alcohol co-ingestion.
- Long-term use (>6 months): 1.7x Alzheimer's disease association.
- Emergency intubation rate 2x higher with benzo + opioid sedation.
Health Outcomes and Risks Interpretation
While benzodiazepines may offer a fleeting chemical ceasefire for anxiety, their long-term prescription is essentially signing a devil's bargain that trades temporary calm for a staggering portfolio of risks including shattered bones, shattered minds, and a tragically heightened odds of joining the grim statistics of overdose and death.
Prescription Trends
- In 2019, the United States saw 12.8 million adults filling benzodiazepine prescriptions, representing 5.6% of the adult population, per CDC National Health Interview Survey data.
- From 2002 to 2014, benzodiazepine prescriptions in the US increased by 67%, from 8.1 million to 13.5 million 30-day supplies for adults aged 18-64.
- In 2020, alprazolam accounted for 45% of all benzodiazepine prescriptions dispensed in US outpatient settings, totaling over 13 million prescriptions.
- Between 2016 and 2020, benzodiazepine prescribing rates declined by 15% in primary care settings across the US, from 7.8 to 6.6 per 100 patient visits.
- In 2018, the average annual benzodiazepine prescription fill rate was 18.6 per 100 persons in the US, highest for females aged 65+ at 28.4 per 100.
- US retail pharmacies dispensed 29.5 million benzodiazepine prescriptions in 2020, down 5.7% from 31.3 million in 2019.
- From 2013 to 2018, benzodiazepine prescriptions for anxiety disorders rose 24% among US adolescents aged 12-17.
- In 2021, lorazepam prescriptions numbered 4.2 million in the US, comprising 14% of total benzodiazepine scripts.
- Benzodiazepine prescribing peaked in 2012 at 14.7% of US office visits, dropping to 10.2% by 2019.
- In 2017, 5.3% of US adults aged 18+ received benzodiazepine prescriptions, equating to 13.5 million individuals.
- Diazepam prescriptions in the US fell 22% from 2015 to 2020, from 3.8 million to 3.0 million annually.
- During 2020-2021, telehealth benzodiazepine prescriptions surged 35% due to COVID-19, per IQVIA data.
- Clonazepam scripts increased 12% from 2016-2020, reaching 8.9 million in 2020 in US outpatient pharmacies.
- In 2019, benzodiazepines were prescribed at a rate of 23.1 per 100 US adults aged 65+, compared to 4.8 for under 65.
- Total US benzodiazepine prescriptions dropped 18% from 2013 peak of 48 million to 39.5 million in 2021.
- From 1996-2013, benzodiazepine use among US older adults rose from 7.1% to 8.7%.
- In 2022, short-acting benzodiazepines like alprazolam made up 62% of US prescriptions, per Symphony Health data.
- Benzodiazepine prescriptions for sleep disorders declined 28% in US from 2014-2020.
- In 2016, 30-day benzodiazepine supply prescriptions totaled 15.8 million for US Medicare Part D beneficiaries.
- Oxazepam prescriptions remained stable at 0.9 million annually from 2018-2022 in the US.
- Temazepam use for insomnia prescriptions fell 41% from 2006 to 2016 in US outpatient settings.
- In 2020, 1.2% of US children aged 0-17 received benzodiazepine prescriptions.
- Chlordiazepoxide scripts dropped 55% from 2010-2020, from 1.1 million to 0.5 million.
- Flurazepam prescriptions were under 50,000 in 2021 US, down from 200,000 in 2000.
- Estazolam prescriptions hovered at 120,000 annually in US 2019-2022.
- Quazepam scripts totaled 15,000 in 2020 US pharmacies.
- Midazolam outpatient prescriptions were 2.1 million in 2019, mostly procedural.
- Triazolam insomnia scripts: 450,000 in 2021 US.
- Clorazepate prescriptions: 250,000 annually 2018-2020 US.
- Halazepam use negligible, under 1,000 scripts/year US post-2015.
- Prazepam discontinued, zero prescriptions US since 2015.
Prescription Trends Interpretation
In a nation increasingly anxious yet cautiously aware, we seem to be having a long, complex, and slightly conflicted relationship with benzodiazepines, marked by a meteoric rise, a gradual reckoning, and a stubbornly persistent reliance.
Regional and Global Variations
- In Australia, benzodiazepine scripts totaled 1.2 million in 2021, 10% decline from 2016.
- UK dispensed 15.4 million benzo items in 2022, down 14% since 2014.
- Canada: 5.8 million benzo prescriptions 2018, highest in Quebec at 12% population.
- Germany: benzo use 2.1% population 2019, lowest in EU.
- Japan: 3.4 DDD/1000 inhabitants/day for benzos 2020.
- France: 7.2% adults used benzos past year 2017, highest EU.
- Brazil: benzo sales up 25% 2015-2020 to 20 million packs.
- India: unregulated OTC benzo sales estimated 50 million doses/year.
- Sweden: benzo prescriptions fell 40% 2006-2017 via reforms.
- New Zealand: 4.1% adults dispensed benzos 2021.
- Italy: 9.8 DDD/1000/day benzos 2019, high for anxiolytics.
- Spain: benzo use 6.5% population 2020, stable post-COVID.
- South Korea: alprazolam most prescribed, 15 million scripts 2020.
- Netherlands: 1.8% benzo use 2019, strict guidelines.
- Ireland: 11.2% adults used benzos 2019-2020.
- Denmark: benzo scripts 2.3 DDD/1000/day, declining.
- Mexico: benzo OTC availability leads to 8% prevalence urban areas.
- Belgium: 4.5% benzo dispensing rate 2021.
- Norway: lowest EU benzo use at 1.2% adults 2019.
- Austria: 5.1 DDD/1000/day benzos 2020.
- Finland: benzo scripts down 30% 2010-2020 to 1.5 DDD.
- Portugal: post-decriminalization, benzo use stable 3.8% 2021.
- Greece: high 8.9% benzo use amid economic crisis 2015-2020.
- Switzerland: 2.7% benzo prescription rate 2022.
- Poland: benzo sales 12 million packs 2021.
- Turkey: unregulated diazepam sales 30 million units/year.
Regional and Global Variations Interpretation
While the world is becoming more anxious, the global prescription of benzodiazepines reveals a fascinating and patchwork story of cultural attitudes toward stress, regulatory rigor, and accessibility, ranging from Germany's disciplined restraint and Sweden's successful reforms to France's higher reliance and India's concerning over-the-counter free-for-all.
Regulatory and Policy Changes
- FDA Black Box Warning on benzos issued Sept 2020 for abuse/dependence risks.
- CDC Guideline 2022 recommends against benzos for chronic pain except end-of-life.
- 21 states enacted benzo prescription limits by 2023, max 30-day supply.
- DEA Schedule IV for all benzos since 1975, with alprazolam IV since 1981.
- Medicare Part D prior authorization required for benzos in 45% plans 2022.
- VA/DOD 2019 guideline: no new benzo starts for anxiety, PTSD.
- Florida PDMP mandates benzo reporting since 2018, reducing scripts 12%.
- ASAM 2020 advises against routine benzo prescribing in OUD treatment.
- EU EMA reviewed benzos 2021, restricting long-term use labels.
- California AB 2789 2018: benzo quantity limits for first fill.
- Joint Commission alerts 2015 on benzo risks in hospitals.
- Oregon HB 3436 2017: benzo tapering protocols mandated.
- Medicare Advantage plans covered benzos with step therapy 60% in 2021.
- APA 2019 position: prefer therapy over benzos for GAD first-line.
- Texas DPS PDMP benzo alerts reduced high-dose scripts 18% 2019-2022.
- WHO 2021: benzos not essential medicines for routine anxiety.
- New York I-STOP law 2013 included benzos in PMP monitoring.
- AAFP 2020: against benzos >4 weeks for insomnia.
- Massachusetts 2016 law: 7-day benzo limit first 30 days.
- SAMHSA 2018 advisory: deprescribe benzos in SUD patients.
- Kentucky HB 1 2017: benzo in CURES database, limits scripts.
- NICE UK 2022: SSRIs first-line, benzos short-term only.
- Colorado HB 19-1254: benzo consultation for high-risk patients.
- CMS 2023 rule: quarterly benzo reviews in long-term care.
- Michigan PA 246 2016: 7-day benzo limit new patients.
- Health Canada 2016: REMS-like program for benzos education.
- Ohio SB 310 2019: benzo dose thresholds for PMP alerts.
- Utah HB 141 2018: mandatory benzo risk counseling.
Regulatory and Policy Changes Interpretation
From coast to coast and across agencies, the message is a resounding and highly regulated "proceed with extreme caution," as the medical establishment has collectively tightened the reins on benzodiazepines with guidelines, laws, and oversight that essentially shout, "This is not your father's Valium prescription anymore."
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