Understanding the Shift Away from Benzodiazepines
Benzodiazepines, commonly known as benzos—a class of medications including drugs like Xanax (alprazolam), Valium (diazepam), and Ativan (lorazepam)—have long been prescribed for anxiety, insomnia, and seizures. These sedatives work by enhancing the effect of the neurotransmitter gamma-aminobutyric acid (GABA) in the brain, producing calming effects. However, their use has sparked ongoing debate due to potential for dependence, tolerance, and serious side effects, particularly in vulnerable populations.
Recent data reveals a significant nationwide decline in benzodiazepine prescribing across the United States, with the most dramatic reductions occurring among older adults. This trend signals a pivotal change in clinical practices, driven by heightened awareness of risks and evolving guidelines. Led by researchers at Columbia University's Mailman School of Public Health, a new study highlights how usage dropped sharply from 2018 to 2022, offering insights into safer mental health care strategies.
Key Findings from the Columbia Mailman School Study
Published in the Journal of Clinical Psychiatry on February 25, 2026, the study by Mark Olfson, MD, MPH, and colleagues analyzed data from the Medical Expenditure Panel Survey (MEPS)—a nationally representative survey of over 104,000 U.S. adults aged 18 and older spanning 2018 to 2022. Overall benzodiazepine treatment fell from 4.7% of adults in 2018 to 3.4% in 2022.
The steepest decline was among those aged 56 and older, plummeting from 7.2% to 4.7%. Middle-aged adults (36-55 years) saw a drop from 4.4% to 3.4%, while young adults (18-35 years) experienced a modest decrease from 2.1% to 1.8%. Mean annual prescriptions for older adults also decreased from 5.4 to 4.3 fills per year.
| Age Group | 2018 (%) | 2022 (%) | Change |
|---|---|---|---|
| 18-35 years | 2.1 | 1.8 | -0.3 |
| 36-55 years | 4.4 | 3.4 | -1.0 |
| ≥56 years | 7.2 | 4.7 | -2.5 |
| Overall | 4.7 | 3.4 | -1.3 |
This research underscores a welcome shift toward caution, especially as older patients face amplified sensitivities to adverse effects.
Demographic Patterns in Benzodiazepine Prescribing
Benzodiazepine use varied significantly by sociodemographics. White non-Hispanic adults had over twice the usage rate of Black non-Hispanic, Hispanic, or other non-Hispanic groups (around 1.8% for minorities). Separated, divorced, or widowed individuals showed 6.9% usage, compared to lower rates among married or single adults. Publicly insured patients (6.1%) and the nonemployed (6.0%) were most likely to receive prescriptions, while uninsured rates hovered at 1.0%.
- Rural residents: Higher prescribing rates than urban dwellers.
- Lower income/education: Steeper gradient toward increased use.
- Anxiety/stress: Primary reason in young adults (78.6%); insomnia dominant in older adults (18.5%).
Co-prescribing with other central nervous system (CNS) depressants—like opioids, Z-drugs (e.g., zolpidem), or antidepressants—affected 41.6% of benzo users, rising to 72% among those in fair/poor health and 63% with serious psychological distress (K6 score ≥13).
Driving Factors Behind the Decline
Several forces contributed to declining benzodiazepine use in US, particularly among older adults. The American Geriatrics Society's Beers Criteria explicitly flags benzos as potentially inappropriate medications (PIMs) for those 65+, citing risks of cognitive impairment, delirium, falls, and fractures.AGS Beers Criteria
FDA black box warnings emphasize dependence and withdrawal risks, while CDC opioid guidelines strongly caution against concurrent benzo-opioid use due to overdose potential. Post-2016 opioid crisis scrutiny amplified this, as co-prescribing tripled from 1990-2016. The 2025 ASAM Benzodiazepine Tapering Guideline provides structured deprescribing protocols, promoting gradual reduction to minimize withdrawal.ASAM Tapering Guideline
Provider education campaigns, electronic health record alerts, and pay-for-performance metrics like NCQA's Deprescribing of Benzodiazepines in Older Adults (DBO) measure have accelerated change.
Risks of Benzodiazepines in Older Adults
Older adults metabolize benzos slower due to reduced liver/kidney function, prolonging effects and heightening dangers. Key risks include:
- Falls and fractures: 50-70% increased risk; hip fractures alone cost billions annually.
- Cognitive decline/delirium: Short-term memory impairment, confusion; controversial link to dementia (some studies show association, others none).
- Dependence/addiction: Tolerance develops quickly; 25-30% long-term use in elderly.
- Overdose: Especially with opioids (18x risk); respiratory depression.
- Motor vehicle crashes: Impaired driving akin to alcohol intoxication.
SAMHSA's 2025 Dear Colleague Letter urged deprescribing in elderly due to these vulnerabilities.
Persistent Challenges: Co-Prescribing and Long-Term Use
Despite declines, 43% of older benzo users receive concurrent CNS depressants, peaking at 72% in poor health. Long-term use (≥90 days) remains concerning, though data shows mean fills dropping. Vulnerable groups—rural, low-SES, distressed—lag in reductions. Withdrawal symptoms (anxiety rebound, seizures) complicate deprescribing without support.
Effective Alternatives for Anxiety and Insomnia
Guidelines prioritize non-drug therapies first:
- Cognitive Behavioral Therapy for Insomnia (CBT-I): Gold standard; apps like Sleepio effective long-term.
- SSRIs/SNRIs: Escitalopram, sertraline for anxiety; slower onset but safer.
- Low-dose antidepressants: Doxepin (3-6mg), mirtazapine for sleep.
- Orexin antagonists: Suvorexant, daridorexant; non-addictive.
- Melatonin agonists: Ramelteon; limited evidence in elderly.
Deprescribing: Slow taper (10-25% dose reduction every 1-4 weeks), adjunct CBT, monitor withdrawal.Olfson et al. Study
Expert Perspectives and Public Health Implications
"The decline reflects growing caution, but co-prescribing vigilance is crucial," says lead author Mark Olfson. Columbia's research exemplifies university-led efforts advancing evidence-based care. Reduced benzo use could prevent thousands of falls/overdoses yearly, lowering healthcare costs.
For professionals, explore opportunities in psychiatric research via higher ed jobs or career advice at higher-ed-career-advice.
Photo by David Trinks on Unsplash
Future Outlook: Sustaining Momentum
With updated 2026 guidelines anticipated, AI-driven prescribing alerts and telehealth CBT-I could further benzo reductions. Policymakers eye expanded DBO metrics. Columbia's work paves the way for safer aging, emphasizing prevention over reaction. Patients: Discuss deprescribing with providers; rate experiences on Rate My Professor for psych educators.
