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Terrifying Xanax Resurgence in America

Issued: 2018-03-28

Maia Szalavitz

Image by Lia Kantrowitz

On a recent Saturday, photographer Nan Goldin and a band of roughly 100 fellow activists threw pill bottles into the reflecting pool near the Temple of Dendur at the Metropolitan Museum of Art in New York City. The space was funded by the Sacklers, the family that owns the drug Oxycontin's manufacturer Purdue Pharma, and the group was trying to call the clan to account for the opioid overdose catastrophe, a crisis spurred in part by aggressive marketing of that pill.

“We are artists, activists, addicts,” Goldin shouted, according to a New York Times report. “We are fed up.”

But the simultaneous rise of another potentially addictive and deadly prescription in America has received far less attention. Understanding why could shed light on the best way to manage both the opioid epidemic and this less-notorious one—and help prevent or at least mitigate future crises.

Between 1999 and 2016, as many Americans are now at least vaguely aware, the number of deaths from overdoses that included opioids quintupled. However, during roughly the same period, the number of OD deaths that involved benzodiazepines (a.k.a. "benzos") increased by a mind-boggling factor of nearly eight. In terms of the absolute number of deaths, opioids are more deadly, but it’s important to note that over 30 percent of opioid-overdose deaths are actually better described as fatal mixtures of the two classes of drugs.

Benzodiazepines include drugs like Xanax, Klonopin and Valium, the drug immortalized in the Rolling Stones track “Mother’s Little Helper” for its sedative and calming (albeit, at least in the song, ultimately deadly) properties. As with opioids, a great deal of the harm associated with benzos comes when they are combined with other drugs. Opioids, alcohol and benzodiazepines are exponentially riskier when taken together because their effects in slowing breathing are synergistic, not simply cumulative. Indeed, research has suggested that as many as 90 percent of benzodiazepine-associated deaths also involved an opioid and about 80 percent of benzo recreational use was carried out in concert with other substances.

But while attention has rightly focused on the role of pharmaceutical marketing in the opioid crisis, which included pushing hospitals to declare pain as “the fifth vital sign,” that doesn't seem to explain the surge of benzo use and overdoses in recent years.

Benzodiazepines are overwhelmingly available in generic form, and no company was out there marketing them, at least in the last few decades, the way giants like Purdue promoted newer behemoths like Oxycontin. “The biggest seller now is Xanax, which came on the market in 1986,” explained Allen Frances, MD, a leading psychiatrist and author of Twilight of American Sanity.

Nor did most activists make the case that anxiety was massively under-treated or that benzodiazepines were not as addictive as previously believed. Hospitals did not dub anxiety—among the primary symptoms these drugs are used to treat—another "vital sign."

Nonetheless, filled benzodiazepine prescriptions increased 67 percent between 1996 and 2013 alone—and the amount of pills actually dished out, adjusted for potency, at least tripled. So what happened?

“America has had a love affair with sedatives, going back at least to the 20s and 30s,” said David Herzberg, associate professor of history at the State University of New York at Buffalo, and author of Happy Pills in America: From Miltown to Prozac. Drugs with sedative qualities include barbiturates and benzodiazepines—and, at some doses, alcohol and opioids. Basically, a sedative is any drug that makes you calm and sleepy; they are also sometimes known as depressants.

According to Herzberg, in the 1940s and 50s, measured on a per capita basis, the overdose death rate from barbiturate tranquilizers in the United States was actually worse than the rate associated with opioids in 2013, when opioid overdose deaths had already risen for 11 consecutive years. This is ironic, because, Herzberg noted, barbiturates first rose to popularity after concerns were raised about opioids—drugs like opium, morphine and heroin—in the 1910s and 20s. These fears, stoked in large part by panic over immigration and race, led to strict controls on supply, including complete criminalization of opium and heroin.

That, in turn, led doctors to switch to barbiturates for patients who had Insomnia, “nerves” or anxiety. Barbiturates, however, are at least as risky in terms of overdose as opioids—and withdrawal from them may be even worse because it can cause potentially deadly seizures.

Growing recognition of the barbiturate overdose and addiction problem in the 40s and 50s led to another substitution: The first benzodiazepine was introduced in 1960. This class of drugs is indeed significantly safer: barbiturates can be fatal at just ten times the therapeutic dose, while it takes 100 times an effective dose of benzodiazepines to kill, according to Herzberg. It took until 1975, however, for the potential harm that is nonetheless associated with benzodiazepines— including addiction, worsened anxiety, and physical dependence—to be recognized and for them to become controlled substances.

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