Benzodiazepines, the drug class that includes diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan) and clonazepam (Klonopin), have been prescribed for anxiety, insomnia and seizures since the 1960s.
For most of the last decade, the public health message has been consistent:
prescribe fewer of them, and prescribe them for shorter periods. |
That message is working. Prescribing is down.
The problem is that the harm hasn't dropped with it. A run of studies published in 2026 shows why: the risk from benzodiazepines was never really about the raw number of prescriptions. It's about who is taking them, what else they're taking, how long they stay on them, and, increasingly, whether the pill came from a pharmacy at all.
What the numbers actually show
Researchers at Columbia University Mailman School of Public Health and Columbia University Irving Medical Center analysed national survey data and found benzodiazepine use among U.S. adults fell from 4.7% in 2018 to 3.4% in 2022. The steepest drop was among adults aged 56 and older, where use fell from 7.2% to 4.7%. Younger groups declined more modestly. The findings were published in the Journal of Clinical Psychiatry in February 2026.
That looks like a straightforward success story. The same study found the complication.
Among people taking benzodiazepines, co-prescribing with other central nervous system depressants, including opioids, remained common. It was most common in exactly the groups least able to tolerate it. Roughly 72% of benzodiazepine users in fair or poor health were also prescribed a medication that could interact dangerously with them, along with about 63% of those experiencing serious psychological distress.
In other words: fewer people are taking benzodiazepines, but the people still taking them are disproportionately the ones for whom the drug is riskiest.
Older adults: progress that stopped
A second Columbia-led study, published in Annals of Internal Medicine in July 2026, followed the trend for a full decade.
The researchers analysed IQVIA prescription claims from January 2015 through December 2024, data covering more than 90% of U.S. retail pharmacy prescriptions and roughly 75–80% of long-term care pharmacy dispensing. The study included nearly 25 million adults aged 65 and older who filled at least one benzodiazepine prescription. About two-thirds were women.
Prescribing declined steadily up to 2020. Then it flattened. And in two groups it went back up: adults aged 75 and older, and patients receiving medication through long-term care pharmacies.
"Our findings suggest that the COVID-19 pandemic may have disrupted progress in reducing benzodiazepine use among older adults," said lead author Mark Olfson, MD, MPH. "This is concerning because older adults are especially vulnerable to the medications' adverse effects."
The authors point to plausible contributors, social isolation, staffing shortages in long-term care, reduced access to behavioural therapy, and heavier reliance on medication during the pandemic, while noting the study can't establish cause.
Why it matters clinically: in older adults, benzodiazepines raise the risk of falls, cognitive impairment and motor vehicle crashes. Frailty, multiple chronic conditions and long medication lists amplify every one of those risks.
The hospital as a starting point
One of the more useful research threads in 2026 looks at where long-term use begins.
A retrospective study published in Scientific Reports in April 2026 examined every adult admission to Landspítali, Iceland's national university hospital, between 2010 and 2020. The researchers isolated patients who had taken no benzodiazepines in the year before admission, then tracked how many started one during an internal medicine stay, and how many were still filling prescriptions long afterwards.
A separate analysis from Amsterdam University Medical Center, drawn from the WEsleep trial, asked a similar question about Dutch hospitals: how often are benzodiazepine receptor agonists started on the ward, and how often does that prescription simply follow the patient out the door at discharge?
The pattern both teams are chasing is a familiar one to hospitalists. A sedative started for one bad night of sleep in an unfamiliar bed is rarely reviewed again. It gets copied forward at discharge, renewed by a family physician who assumes a specialist made a considered decision, and years later nobody can say who owns it.
The part that isn't in the prescribing data at all
While regulated prescribing falls, an unregulated supply has grown.
Designer benzodiazepines are compounds structurally similar to prescription benzodiazepines but never approved for medical use. Bromazolam is the clearest example. It is the bromine analogue of alprazolam, and it is overwhelmingly sold as counterfeit Xanax.
The U.S. Drug Enforcement Administration placed bromazolam in Schedule I on an emergency temporary basis in March 2026. The supporting documentation is stark. Between April 2021 and February 2026, the DEA was aware of at least 259 overdose cases involving bromazolam; 201 were fatal. A query of the National Forensic Laboratory Information System in February 2026 returned 16,614 bromazolam encounters. It has been found in all 50 states.
Two facts make this category especially dangerous:
Naloxone doesn't work on it. Naloxone reverses opioid-induced respiratory depression. It has no effect on benzodiazepine intoxication. When someone has taken both, and designer benzodiazepines frequently turn up as adulterants in the illicit opioid supply, naloxone may restore breathing while leaving the person heavily sedated and still at risk.
The co-exposure is close to universal. A CDC report found that among emergency department patients evaluated for suspected opioid overdose who had illicit benzodiazepines detected, at least one opioid was identified in 95% of cases.
Counterfeit tablets carry authentic-looking imprints. There is no way to identify them by sight.
What this means in practice
For clinicians
- Review the full medication list before initiating a benzodiazepine, with particular attention to opioids and other CNS depressants. Interaction risk concentrates in patients in poor health and those in psychological distress.
- Treat adults aged 75+ and long-term care residents as priority populations for structured medication review.
- Treat hospital discharge as a decision point, not a formality. Sedatives started on the ward need an explicit stop date or an explicit rationale for continuing.
- In suspected overdose, benzodiazepine co-exposure changes the monitoring picture even after naloxone appears to work.
For patients and families
- If you take a benzodiazepine, make sure every prescriber knows about it — including any opioid painkillers, sleep aids or muscle relaxants.
- Ask at each renewal: is this still doing what it was prescribed to do, and is there a plan?
- Never stop a benzodiazepine abruptly. Stopping suddenly after regular use can cause severe, occasionally life-threatening withdrawal. Any reduction should be planned with your prescriber.
- Any benzodiazepine that didn't come from a licensed pharmacy should be treated as potentially lethal, regardless of what the tablet looks like.
The headline trend is real and worth celebrating. Fewer people are starting these medications, and fewer older adults are on them than a decade ago. But a falling prescription count is a measure of exposure, not of harm. The 2026 research is a reminder that those two things came apart some time ago.
Sources
- Olfson M, et al. Benzodiazepine treatment trends among U.S. adults. Journal of Clinical Psychiatry, February 18, 2026. Summary: Columbia University Mailman School of Public Health, "Benzodiazepine Use Declines Across the U.S., Led by Reductions in Older Adults," February 25, 2026. https://www.publichealth.columbia.edu/news/benzodiazepine-use-declines-across-u-s-led-reductions-older-adults
- Olfson M, Xie F, Bushnell G, et al. Benzodiazepine prescribing among older U.S. adults, 2015–2024. Annals of Internal Medicine, July 2026. https://www.acpjournals.org/doi/10.7326/ANNALS-25-05594 — summary: https://www.publichealth.columbia.edu/news/progress-reducing-benzodiazepine-use-among-older-americans-stalled
- Love ESH, Jonsdottir F, Sigurdsson MI. The incidence and clinical variables associated with new and new persistent benzodiazepine use after admission to internal medicine: a retrospective study. Scientific Reports, April 18, 2026. https://doi.org/10.1038/s41598-026-49262-z
- Benzodiazepine receptor agonists in hospitalised patients in the Netherlands: initiation, continuation and discontinuation — a retrospective observational analysis (WEsleep trial subanalysis, Amsterdam UMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12887526/
- U.S. Drug Enforcement Administration. "Schedules of Controlled Substances: Temporary Placement of Bromazolam in Schedule I." Federal Register, March 16, 2026. https://www.federalregister.gov/documents/2026/03/16/2026-05064/schedules-of-controlled-substances-temporary-placement-of-bromazolam-in-schedule-i
- Designer benzodiazepines and toxicology testing, including CDC data on opioid co-exposure in emergency department presentations. https://utak.com/blog/designer-benzodiazepines-the-hidden-challenge-in-toxicology-testing/
This article is for general information and is not medical advice. Talk to your doctor or pharmacist about your own medications. Do not stop taking a benzodiazepine without medical guidance.