The Strange Double-Standard: Benzodiazepine vs Opioid Poisonings

Suppose I showed you alarming statistics that benzodiazepine overdose deaths have risen 7-fold in the past fifteen years. I say “There is an epidemic of benzodiazepine abuse!” I tell a narrative that doctors have been loose with the prescription pad in recent years, and so these drugs have become readily available for recreational use. I try to warn doctors against prescribing these drugs, and I try to scare patients against taking them. It would be a superficially plausible story, especially given the scary body count. But there would be very good reasons to doubt it.

Someone could politely point me to SAMHSA drug abuse survey and show me that abuse of tranquilizers (the category including benzos) is flat, and in fact has apparently declined in recent years. (See here on page 32 of the pdf.) The Monitoring the Future survey, which also measures drug abuse rates but concentrates on 8^th, 10^th, and 12^th graders, shows roughly the same pattern. A bit more tellingly, the “Availability” numbers have been falling. That is, high schoolers are finding it more difficult to get these drugs, not easier. (See here on page 39 of the pdf.) Someone could also point out that benzos are extremely difficult to accidentally overdose on. You can do it, but it takes a lot. Only about 1-2% of benzodiazepine-related deaths *only* involve benzodiazepines. Most of these deaths involve a multi-drug interaction, usually opioids or alcohol, which in combination with benzos suppress respiration.

Abuse of these drugs certainly exists, but it isn’t *rising*(unless two separate surveys are missing the trend, and unless the “availability” survey trend is moving in the opposite of the true direction).  So it can hardly explain the *rise* in benzodiazepine-related poisoning deaths, unless the population of recreational users is being far more reckless than it was 15 years ago. The “moral panic/rising epidemic” story just doesn’t make any sense when you start to include other pieces of information from various other sources. That’s what a good narrative should do: collapse information from several disparate sources into one coherent story. I think anyone who has all the data at hand will say something like: Okay, benzos aren’t dominating the will of helpless drug addicts and forcing them to swallow pills until they keel over. Rather, naïve users are mixing them with bad combinations of alcohol and opioid pain killers. Stopping the interactions will fix 98-99% of the problem. Let’s not raise the alarm bells of a moral panic here. Let’s just tell people to stop mixing drugs.

The double-standard referred to in the title of my post is the different standard by which the opioid painkiller poisonings are judged. Everything about the benzodiazepine story is true of the opioid story. Single-drug overdoses are rare; not in the 1-2% range, but more like in the 20-25% range. It’s still the case that the low-hanging fruit is avoiding drug interactions, not deterring use of these drugs *entirely*. Once again, according to the SAMHSA and Monitoring the Future surveys, abuse rates for these drugs are flat (in fact declining in very recent years) and perceived availability is down. So it’s probably the case that most of these deaths are legitimate users with legal prescriptions, naively taking different prescriptions in dangerous combinations. I don’t understand why we’re hearing about an opioid painkiller abuse epidemic but not a benzodiazepine abuse epidemic. The recent trends in drug poisonings are the same for both, suggesting an increasingly severe epidemic. Abuse rates, as determined by drug use surveys, are flat for both, suggesting abuse is not the problem. Multi-drug interactions are the culprit in the vast majority of poisoning deaths for both classes of drugs. So I’m not sure what’s going on here. Maybe the “benzodiazepine abuse epidemic” narrative is too easy to debunk, but the “opioid painkiller abuse epidemic” narrative is *just* plausible enough to get past a fact-checker?

I hear another “drug epidemic/moral panic” story on the radio or in my news feed every week. This is the wrong narrative. It is based on a single piece of information (CDC drug overdose figures), often with an anecdote or two thrown in for color. The correct narrative would be consistent with these other pieces of information. The journalists and “public health officials” who are selling the moral panic story could at least comment on these items that contradict the official narrative.