Prescribing of benzodiazepines to US adults declined between 2018 and 2022, especially among those aged 56 years or older, new research revealed.

Researchers found a decrease in overall prescribing rates among all adults, from 4.7% to 3.4% over the study period. The largest decline came in the ≥ 56 age group, which also showed a significant drop in the number of benzodiazepine prescriptions per person.

This finding is “reassuring” although somewhat surprising, lead author Mark Olfson, MD, professor of psychiatry, medicine and law, Columbia University, New York City, told Medscape Medical News.

“Some expected that rising rates of depression and anxiety during the COVID-19 pandemic, and the rapid expansion of tele-mental health care, would increase benzodiazepine prescribing,” he said.

However, the study showed that many adults receiving benzodiazepines were also prescribed opioids or other central nervous system (CNS) depressants. The drugs were most often prescribed for anxiety, and sociodemographic factors such as income and employment status appeared to influence whether patients received these prescriptions.

The results were published online on February 18 in the Journal of Clinical Psychiatry.

Closer Look at Recent Trends

Benzodiazepines can provide rapid relief of anxiety, insomnia, alcohol withdrawal, and seizures, and are an adjunctive treatment for depression. Their use had become somewhat common in past decades. Olfson cited research showing adult prescriptions grew roughly 30% from 1996 to 2013.

However, increased concerns over the misuse of these drugs and related risks for falls, impaired cognition, and problems with withdrawal led some groups to urge more conservative prescribing practices, especially among older adults who are particularly sensitive to such adverse events. In 2020, the FDA ordered updated boxed warnings on benzodiazepines to reflect these risks.

“Because the rate of US benzodiazepine prescribing increases sharply with age, especially after the age of 55 years, it is important to understand the extent to which prescription of benzodiazepines and other CNS depressants occurs among this age group, given the general increase in polypharmacy with advancing age,” the authors wrote.

To better understand more recent trends, researchers used the 2018-2022 Medical Expenditure Panel Surveys (MEPS), conducted by the Agency for Healthcare Research and Quality. These surveys involve ongoing nationally representative household samples regularly completing computer-assisted interviews.

The new analysis included 104,231 participants who were separated into three age groups (18-35 years, 36-55 years, and ≥ 56 years). Researchers determined the number of benzodiazepine prescriptions received during each survey year (1, 2-4, 5+), and classified benzodiazepines into long- and short-acting agents.

Researchers also assessed the psychological distress of participants using the Kessler-6, which evaluates past 30-day frequency (scores ≥ 13 indicate serious psychological distress, 12-5 moderate distress, and < 5 less than moderate distress). Participants reported reasons for each prescription (for example, anxiety, insomnia, depression, and pain conditions).

Significant Prescribing Decline

Benzodiazepine use was highest for those aged ≥ 56 years (5.9%) followed by those 36-55 years (3.8%) and 18-35 years (1.8%). The distribution of long- and short-acting benzodiazepine use did not differ across age groups.

Investigators found that prescribing declined significantly from 4.7% in 2018 to 3.4% in 2022. The decrease was greater for adults aged ≥ 56 years (7.2%-4.7%) than for those 36-55 years (4.4%-3.4%) or 18-35 years (2.1%-1.8%).

The mean number of benzodiazepine prescriptions also declined over time among adults aged 56 years or older, from 5.4 in 2018 to 4.3 in 2022 (difference of -1.0; 95% CI, -1.6 to -0.5).

Although the study wasn’t designed to evaluate the impact of recommendations for more restrictive prescribing or the boxed warnings added in 2020, it’s likely these factors influenced prescribing practices, said Olfson.

Use rates were highest among those who were widowed or separated or divorced from their spouse, publicly insured, and unemployed. Rates were lowest among those without insurance, Black non-Hispanic individuals, and other, non-Hispanic individuals, which included American Indian/Alaska Native, Asian, Native Hawaiian/Pacific Islander.

Use among White non-Hispanic individuals was more than twice as high as other racial and ethnic groups, and individuals with lower incomes and rural residents had higher prescribing than those with higher incomes and urban residents.

This could be due to factors such as differences in access to care, prescribing patterns, diagnostic practices, and racial and ethnic disparities in mental health treatment and medication use, especially involving controlled substances, said Olfson.

Anxiety was the most common reason listed for benzodiazepine use (64%), although benzodiazepine use for insomnia became more common with age.

Serious psychological distress was more common in benzodiazepine users aged 18-35 years (19.4%) and 36-55 years (16.9%) than ≥ 56 years (12.3%). Conversely, fair or poor general health status was more common in adults aged ≥ 56 years (32.0%) and 36-55 years (30.9%) than 18-35 years (23.1%).

Other CNS Prescribing

About 41.6% of adults treated with benzodiazepines also received other CNS depressants such as opioids, nonbenzodiazepine hypnotics, gabapentinoids, muscle relaxants, and antipsychotics in the same year.

“Given the well-established overdose risks associated with combining benzodiazepines and other CNS depressants, the high prevalence of these medication combinations highlights the need for careful prescribing and close clinical monitoring” said Olfson.

Over half of the adults who received benzodiazepines also received antidepressants, which can also be effective in treating anxiety. “The increased antidepressant use could partly explain the decline in benzodiazepine prescribing, although further research is needed to confirm this,” said Olfson.

As the MEPS relies on respondents accurately reporting medication use, underestimation of benzodiazepine use and misattribution of reasons for use is possible. Another study limitation was that statistical power was limited in certain subgroups, resulting in some unreliable estimates.

Prescription of benzodiazepines and other CNS-depressant medications in the same year doesn’t necessarily mean contemporaneous co-prescription. And information on whether prescriptions were from office-based or telemedicine visits was unavailable as was information concerning the medical specialty of benzodiazepine prescribers.

Exaggerated Reports

The decline in benzodiazepine use among older adults is good news given the susceptibility of negative effects in that population, wrote Edward K. Silberman, MD, professor of psychiatry emeritus, Tufts University School of Medicine, Boston, in an accompanying editorial.

However, negative reports about benzodiazepine use in general have been exaggerated, he told Medscape Medical News.

In reality, for most nongeriatric adults, benzodiazepines are well-tolerated, safe, and effective for acute and maintenance treatment of anxiety disorders, said Silberman. Research has generally found benzodiazepines to be more tolerable than antidepressants, with a faster onset of action. When managed closely, discontinuation isn’t an issue for most patients, he said.

In terms of cognitive concerns, the literature suggests the majority of patients don’t notice changes, said Silberman. “Most nongeriatric patients using these medications are not functionally impaired by them.”

Silberman insists much of the reluctance to prescribe benzodiazepines is “fear-based.”

“Clinicians are made to feel very uncomfortable” about prescribing benzodiazepines due to the many guidelines that recommend against their use as first-line and maintenance drugs, said Silberman.

But that unease seems to be generational, he noted. While younger doctors “have been taught how terrible benzodiazepines are,” older clinicians who started using them after they came out “have seen for themselves that the results can be very good with no particular complications,” said Silberman.

Writing in the editorial, Silberman suggested that aiming for a middle ground may offer the greatest benefit.

“If psychiatry can move away from both cavalier prescription of benzodiazepines and reflexive rejection of them to evidence-based use, our patients will be the major beneficiaries,” he wrote.

This study received no outside funding. Olfson and Silberman reported having no relevant conflicts of interest.