Benzodiazepines Have Highest Overdose Risk of Sleep Drugs Among Adolescents

Outcomes among 90,000 young people prescribed sleep drugs

The study, published in the journal JAMA Network Open, searched a national insurance claims database and found nearly 90,000 Americans aged 10 to 29 who were prescribed medication for insomnia between 2009 and 2018.^[1]

Of the 90,000 patients whose records were found, 23,000 were prescribed benzodiazepines, including diazepam (Valium), clonazepam (Klonopin), and lorazepam (Ativan) for sleep. 

Nearly 67,000 were given alternatives, including the antihistamine hydroxyzine and nonbenzodiazepine Z-drugs such as zolpidem (Ambien). Of those, researchers excluded patients prescribed the sedating antidepressant trazodone (Desyrel), due to the possibility of co-existing depression.

Of the young people prescribed benzodiazepines, 0.9% experienced an overdose in the following six months. Among those prescribed alternatives, the rate of overdose was 0.8%. 

When researchers adjusted for other factors, including co-morbid physical and mental health conditions, patients prescribed benzodiazepines had a 44% increased chance of overdose compared to those prescribed other drugs.

Opioids and benzos: a risky combination

The overdose risk was still higher among the 13.8% of the cohort concurrently prescribed opioids and sleep drugs.

Among those given benzodiazepines and opioids, 1.6% were treated for an overdose in the following six months. The risk was also elevated among those prescribed opioids and Z-drugs.

Opioids and benzodiazepines are central nervous system depressants, and the combination of several, particularly when doses aren’t closely monitored, can lead to respiratory depression and arrest and death.

In 2020, more than 12,000 Americans died of overdoses involving benzodiazepines, many times in combination with opioids. That’s up from under 7,000 overdose deaths in 2011 and just over 1,000 in 1999.

In 2016, the Food and Drug Administration (FDA) added a black box warning to both prescription opioids and benzodiazepines, highlighting the risks of combining the medications.

Doctors should prescribe benzos with caution

Researchers said the findings should give pause to doctors writing young people prescriptions for benzodiazepines.

The risk of overdose “should be an important safety consideration when treating young people for insomnia,” said lead author Greta Bushell, assistant professor of epidemiology at Rutgers Institute for Health. 

However, Bushell pointed to a 2021 study that found the rates of benzodiazepine prescriptions for teenagers and adults for any reason have fallen over the last decade, likely as a result of increased awareness of their risks.

Those risks include not just overdose but also dependence and dangerous withdrawal symptoms.

Non-pharmacological treatments are safest

“We don't have to treat insomnia with benzodiazepines, or necessarily use medication at all,” Dr. Sabra Abbott, associate professor at Northwestern University Feinberg School of Medicine, told HealthDay News.^[2]

She noted that many young people can reduce difficulties with sleep by making lifestyle adjustments, including reducing caffeine intake and screen use in the evenings.

Inadequate sleep among young people has increased dramatically over the last thirty years. In 1991, 44% of adolescents reported insomnia. By 2019, that had climbed to 66%. Researchers have attributed that increase at least partly to the use of screens, which emit a blue light that disrupts circadian rhythms.^[3]

However, Abbot noted that many people who see a sleep specialist have already tried those lifestyle adjustments without success. For those patients, cognitive behavioral therapy (CBT) is the first-line treatment.

"It's the best way to address insomnia for the long-term," she said. Medication should only be a “short-term aid.”

However, accessing CBT can be difficult in some locations and with some insurance providers, pushing doctors and patients toward pharmacological alternatives.