It’s not exactly breaking news that Xanax has been having something of a moment. Famous musicians, at least until prominent voices like Lil Xan (yes, even him!) and Chance the Rapper began swearing off the stuff, have long been inclined to hype it. And Xanny bars have been touted across social media and even in old-school graffiti for some time now. The number of adults prescribed drugs in the class that includes Xanax (alprazolam)—known as benzodiazepines—rose by 67 percent between 1996 and 2013. Over the same period, the amount of these drugs that was actually dispensed more than tripled, according to a 2016 study.
But while many Americans tended to see benzos as harmless chill pills that even old folks used, the number of benzodiazepine overdoses rose by a factor of nearly eight between 1999 and 2015. And they have been a factor in more than a third of recent fatal opioid overdoses—including, last November, that of the rapper Lil Peep. Worse, even when taken daily as prescribed, they can lead to dependence and, in some patients, a lengthy and vicious withdrawal syndrome.
It's fairly clear that big pharma can't be blamed for the current Xanax explosion, and that its dangers have to be carefully unpacked from the country's bigger, and deadlier, opioid epidemic. But what, exactly, happened to lend benzos such incredible popularity—and why, despite high-profile disavowals and tragedies, have so many doctors, patients and recreational users seemed to remain oblivious to their hidden dangers?
Just as important is how America might respond in a sane fashion to this problem, rather than falling into yet another drug panic. Among other things, that means not cracking down on them in such a reactionary way as to make the situation worse—and more dangerous.
One factor in benzos' recent explosion was clearly the climate: It's pretty hard not to be anxious, even if you have nerves of steel, in our erratic and unpredictable political and cultural era, no matter where you lie on the ideological spectrum. And Americans, regardless of the war on some drugs, have a long, storied history of turning—and turning often—to chemical solutions to cope with strange times and systemic hardships.
Another element is generational. For many people in their 20s, 9/11 was one of their first major memories—and they’ve already lived through the Great Recession and the rise of Trump. Middle-class millennials have often experienced what critics call "hovering-" or "helicopter parenting"—and some research suggests such overprotection can, paradoxically, make children more anxious by signaling that they might not be competent to face challenges by themselves. On the other hand, those whose parents' lives were crushed by foreclosure, bankruptcy, unemployment or other results of the crash of 2008 have different reasons to be fearful.
"Anxiety is the first thing that comes up when I talk to them about their perceptions of themselves as people in world," said Ingrid Walker, author of High: Drugs, Desire, and a Nation of Users and an associate professor of American studies at the University of Washington in Tacoma. Walker, who teaches and lectures across the country, noted that the young people she meets often have been "told they have lot of anxiety and they perceive a lot of it."
Walker also pointed out that this generation has been raised to feel comfortable taking psychiatric medications: Many have been prescribed Ritalin or Adderall for ADHD from a young age and/or antidepressants, benzos and even antipsychotic medications. Previous generations were much more skeptical of psych meds, often raised to believe they were not intended to actually make people feel better—just to dull and control. That often left those with mental illness to self-medicate with recreational substances to avoid stigma, which, of course, can itself lead them to carry a different stigma and face an additional set of problems.
But college students these days, Walker noted, "are not skeptical or worried [about taking these medications]. There’s even a breeziness about dangers of pharmaceutical drugs."
Millennials consequently have more comfort with using drugs as a tool to manage moods and, often, a recognition that sometimes the line between "medical" and "recreational' is a fine one. Many see their parents use pharmaceuticals in the same utilitarian way, leaving them attuned to the hypocrisy of medicalizing drug use by one class of people while criminalizing use for exactly the same reason by another. "They really have embraced their psychotherapeutic suite of drugs as solutions for everything from having a bad day to an overloaded schedule," Walker told me.
But while this shift in thinking may be helpful in terms of de-stigmatizing medication use for psychiatric conditions, it could be causing harm in other ways. For one, it can create a false—and sometimes deadly—sense of security. One of the basic principles of risk perception research is the idea that familiarity can blind people to danger: when you safely do a potentially dangerous thing repeatedly without experiencing harm, it becomes much less scary, and that can lead to taking fewer precautions and becoming sloppy about protective procedures.
If you have safely taken a drug for a while and you’ve seen others do so, you may forget how powerful it is—and that this stuff you've always been fine taking can be much dangerous in higher doses or when mixed with alcohol or opioids.
This is especially true for pharmaceuticals which, after all, have your doctor's and the FDA's blessing (at least if it's your own prescription). Unfortunately, that has proved to be a huge problem for some people who take drugs like Xanax exactly as directed—and then find themselves struggling with extreme and disabling withdrawal symptoms for months and sometimes years.
Dr. Christy Huff is a cardiologist who graduated in the top of her class from the University of Texas Southwestern medical school. She recalled being prescribed Xanax because she had a painful dry eye condition and could not sleep during the period before she was able to get it treated. "About three weeks in, I started having anxiety during the day. I'd never experienced that before," she told me. She also recalled developing a tremor and having thousands of dollars worth of inconclusive and invasive tests to figure out what was causing it—eventually, it was determined to be linked to drug discontinuation.
Because Xanax's effects only last for a short time, people can experience withdrawal between doses, not just when they try to stop completely. This happened to Huff—but her doctor didn't believe she could be having such severe effects after only having taken it for around a month, she said, adding, "I got online and started reading that all these people have the same issue."
"[Benzodiazepines] work really well until they turn on you and then it's just utter living hell," she continued, describing a lingering experience of dread and "crushing fatigue."
And this despite taking the medication exactly as described, Huff noted. The dependence she developed is an expected consequence that affects almost anyone who takes benzodiazepines for long enough—it's not like addiction, which involves harmful, compulsive use of doses that are not medically recommended and only affects a minority of people. (While people with benzodiazepine addiction usually also have dependence, the reverse is not true).
That’s actually part of what tripped her up: Huff didn’t think dependence could produce such disabling symptoms, and didn't see herself as at risk for addiction. And neither her doctor nor her own medical training had provided much in the way of warning, she told me.
Huff is now a member of the board of directors of the Benzodiazepine Information Coalition in order to raise awareness of the problem. While there is not much research on the issue, Huff said, the data that exists suggests that about 10-15 percent of people who become physically dependent on benzodiazepines will experience severe and disabling withdrawal that can last for years, even if the drugs are tapered slowly.
Within psychiatry, there is an ongoing war over the use of these medications, with some arguing they do more harm than good in general—and others saying that, for select patients, they are essential. "I would rather they never were invented," said Dr. Allen Frances, professor emeritus of psychiatry at Duke University. "They have very minor utility but that has to be rated against huge harms. It's very hard to predict which given person will become so dependent that their are lives ruined by it."
(He added, "There are some people in the world for whom taking a benzodiazepine might be a reasonable solution to intermittent anxiety. They may be useful and safe for some people, particularly if taken for a short time.")
Richard Balon, a professor of psychiatry at Wayne State University in Michigan, recently joined an international task force on benzodiazepines made up a group of experts concerned that a backlash against these drugs may go too far. "Benzodiazepines are helpful for some," he said, taking care to add, "I'm not saying that they should be used indiscriminately."
Frances and Huff stressed that patients need to be given much better information about the possible risks—including the possibility of protracted and difficult withdrawal. "My big thing is that people need informed consent," said Huff, adding that health care professionals right now are not well-enough informed about the harm that can be associated with withdrawal and the appropriate way to manage it if symptoms do occur.
However, almost everyone agrees that any attempt to rein in prescribing of benzos must be done carefully: they don’t want to see patients forcibly or abruptly tapered, as is now happening with opioids for chronic pain. In fact, abrupt tapering of benzodiazepines can actually be fatal, an outcome that is not generally seen with opioids unless people are incarcerated and unable to get adequate fluids.
In this new era of relentless and unbounded anxiety, we don't need yet another thing to worry about. But patients and recreational users alike need to know that benzodiazepines, if used at all, carry significant risks and should be taken with open eyes about their dangers. And lawmakers need to remember that although just about every other drug panic in American history has led to a supply-focused disaster, it is possible to act wisely and reduce harm if we follow the data—and understand the culture.
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