Anxious Times and Anxiety Drugs

Noah Atlas and Austin McNeill Brown

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KEY TAKEAWAYS
• Americans are facing significant mental health problems, including increased anxiety, during the COVID-19 pandemic.
• Both over-prescribing and under-prescribing of anti-anxiety drugs carries risks.
• The risks of under-prescribing anti-anxiety medications include fatal withdrawal symptoms or potentially pushing individuals to pursue dangerous, counterfeit street drugs. The risks of over-prescribing include addiction and dependence.
• Mental health treatment providers must carefully attend to symptom monitoring, ongoing therapy, and eventual prescription reductions according to risk versus benefit during and after the pandemic.

These are anxious and difficult times in the United States. Rates of depression and anxiety have been on the rise due to the COVID-19 pandemic.1,2 A recent American Psychiatric Association (APA) poll indicated that 62% of people feel more anxious than they did at this time last year.3 At the very time when anxiety is at a high point, our health care system’s capacity to address the multiple public health issues wrought by the pandemic is under-resourced and overwhelmed. Public health agencies such as the U.S. Centers for Disease Control and Prevention have been politically hobbled and defunded right when they are most needed.4 As a result, the long-term physical and mental health of Americans is on the line.

The COVID-19 pandemic has inflamed pre-existing problems related to mental health, prescribing practices, and substance use.5 Pre-existing concerns about prescription drug misuse and the surge in availability of tainted, counterfeit drugs have been exacerbated by socioeconomic and racial/ethnic inequalities, a substandard social safety net, and the mental health burden of the pandemic.6   Short-term anti-anxiety medications, also known as benzodiazepines, are widely used in the U.S., and while sometimes beneficial, they are an area of concern for public health during our current mental health crisis. Before the COVID-19 pandemic, public health officials and medical experts were already worried about the rising rates of prescriptions for benzodiazepines, such as Xanax™ (alprazolam).7,8 This concern is supported by CDC data, which  shows that the number of fatal overdoses involving benzodiazepines increased from 1,135 in 1999 to 10,724 in 2018.9

In this brief, we discuss the implications of benzodiazepine prescribing practices and the challenges of such practices as the country emerges from the COVID-19 pandemic. Navigating the risks inherent to benzodiazepines during these stressful times will require extra vigilance and awareness for medical personnel and public health professionals.

Pre-Pandemic Concerns about Benzodiazepines
Pre-pandemic concerns regarding benzodiazepine use generally fell into two categories. The first involves the practice of over-prescribing benzodiazepines and the highly addictive properties of this class of drugs.10 Benzodiazepine withdrawal can be deadly. Patients taking benzodiazepines for as little as one to six months may experience significant withdrawal symptoms that must be medically managed.11,12 The second category of concern involves the supply of contaminated, counterfeit pills.14 The highly addictive nature of benzodiazepines like Xanax™ can create situations where people sometimes turn to illicit street markets where counterfeit pills are often laced with fentanyl, dramatically increasing the risk of overdose.16,17 Fentanyl is a powerful synthetic opioid that is similar to heroin, but much more potent and much cheaper. Fentanyl is the leading driver of the increase in drug overdoses in the U.S. over the past several years.9 In light of these two issues, maintenance and monitoring of patients prescribed benzodiazepines must be carefully considered.

Concerns about Benzodiazepines during COVID-19
The concerns described above have been amplified during the COVID-19 pandemic. Anxiety is the most commonly diagnosed mental health condition in the U.S., and COVID-19 has exacerbated the country’s existing mental health problems. In February, the share of Americans reporting anxiety began to climb, as did benzodiazepine prescriptions. From mid-February to mid-March, benzodiazepine prescriptions rose 34.1%. During the week of March 15th alone, prescriptions increased by 18%.15 Because of the stay-at-home orders issued in spring of 2020 and physical distancing precautions taken by health care providers to reduce the risk of coronavirus spread, it became challenging to schedule elective appointments, and prescription rates started to decline. According to prescription drug monitoring program data from Texas, there were initial reductions in both prescribing and filling of medications from March to June of 2020.16 Extreme increases and decreases in prescribing carry distinct risks of dependence and overdose. Any decline in prescribing by physicians can result in people turning to illicit markets, as we saw with the transition from prescription opioids to heroin once states began cracking down on overprescribing and prescription opioids became more difficult to get.17 Even when patients are able to see a physician using telehealth and telepsychiatry, they may be at risk of losing prescriptions in other ways, including job loss and the subsequent loss of employer-based health insurance.18 Patients taking medications that cause dependence without access to legitimate prescriptions may resort to tainted, black market drug supplies,as was the case when prescription opioids became more difficult to get from physicians. For example, the loss of employer-based health insurance in a state without Medicaid expansion might force an individual who is dependent on anxiety medication to seek out such medication on the street, or face withdrawal. The local supply may be inundated with fentanyl. Historical epidemiological data suggests this may increase localized overdose rates.19

Caution is Warranted as the Country Emerges from the Pandemic
There are several steps mental health providers should take over the next couple of months as the U.S. emerges from the COVID-19 pandemic. First, medical providers should be alert to the use of benzodiazepines and the mental health conditions of their patients. Given the temptation for expedient prescription of short-term solutions in a time of national crisis, rising anxiety represents a secondary tide of debilitation that practitioners will have to carefully navigate. Rebuilding lives and the economy will create additional sources of anxiety and challenges to physical and mental health. Behavioral therapies and carefully monitored anxiety medication must be accessible for the remainder of the pandemic and beyond. At the same time, given the danger of addiction, providers must be aware that pushing individuals off benzodiazepines may lead to deadly withdrawal or pursuit of street pills, which may be tainted with fentanyl. Managing anxiety within the U.S. population will be a persistent challenge as people struggle to rebuild their lives.  Prescribers should strongly urge clients to participate in regular telehealth, telepsychiatry, and online counseling. For patients who have been prescribed benzodiazepines during the pandemic, providers must carefully weigh symptom monitoring, ongoing therapy, and eventual prescription reductions according to risk versus benefit on a case-by-case basis.

References

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Acknowledgments
The authors would like to thank Megan Ray and Shannon Monnat for edits on previous drafts.

About the Authors
Noah Atlas (nhatlas@syr.edu) is an Undergraduate Research Assistant with the Lerner Center for Public Health Promotion in the Maxwell School of Citizenship and Public Affairs at Syracuse University. Austin McNeill Brown(abrown48@syr.edu) is a Ph.D. student in the Social Science Program and Graduate Research Assistant with the Lerner Center.