Journal of Psychiatric Research 128 (2020) 33–37

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Journal of Psychiatric Research

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Benzodiazepine misuse among adults receiving psychiatric treatment T

a,b,∗ a,b a,b a
R. Kathryn McHugh , Andrew D. Peckham , Thröstur Björgvinsson , Francesca M. Korte ,
Courtney Bearda,b
a
McLean Hospital, 115 Mill Street, Belmont, MA, 02478, USA
b
Department of Psychiatry, Harvard Medical School, 25 Shattuck St., Boston, MA, 02115, USA

A R T I C LE I N FO A B S T R A C T

Keywords: Benzodiazepines are among the most commonly prescribed psychiatric medications and have the potential for
Benzodiazepines misuse. People with psychiatric disorders may have a heightened liability to the reinforcing effects of benzo-
Prescription drug misuse diazepines. Yet, the prevalence of benzodiazepine misuse in psychiatric care settings is not well characterized.
Anxiety The aim of the current study was to characterize the prevalence and correlates of benzodiazepine misuse in a
Substance misuse
sample of adults receiving psychiatric treatment (N = 589). The majority of participants reported a lifetime
history of benzodiazepine prescription (68%) and 26% reported a lifetime history of misuse (defined as use
without a prescription or at a dose or frequency higher than prescribed). Multivariable analyses indicated that
history of a benzodiazepine prescription and drug use problems were significantly associated with lifetime
benzodiazepine misuse. People with a history of benzodiazepine prescription had four times higher odds of
misusing benzodiazepines and the primary source of misused benzodiazepines was from family or friends.
Results suggest that benzodiazepine misuse is not exclusive to substance use disorder populations. The misuse of
benzodiazepines should be assessed in psychiatric settings. Further research is needed to understand the impact
of benzodiazepine misuse in this population and to develop tools to identify those at risk for misuse.

1. Benzodiazepine misuse among adults receiving psychiatric
treatment
Benzodiazepines are among the most commonly prescribed psy-
chiatric medications, with more than 1 in 20 adults in the United States
filling benzodiazepine prescriptions each year (Agarwal and Landon,
2019; Olfson et al., 2015). Both the frequency and potency of benzo-
diazepine prescriptions have substantially increased since the mid-
1990s (Bachhuber et al., 2016). For example, the number of prescrip-
tions for benzodiazepines increased 67% from 1996 to 2013 and the
dose of prescriptions increased 140% of that time period (Bachhuber
et al., 2016).
Benzodiazepines can also be misused (i.e., taken at a frequency or
dose higher than prescribed or without a prescription). People with
substance use or other psychiatric disorders appear to be more sus-
ceptible to the reinforcing properties of benzodiazepines and are more
likely than people without these disorders to be exposed to benzodia-
zepines via prescription (see Licata and Rowlett, 2008). Despite the fact
that benzodiazepines are more commonly misused than cocaine (Center
for Behavioral Health Statistics and Quality, 2019), their misuse re-
mains understudied. Understanding the scope of benzodiazepine misuse
is particularly important because of the many health and mental health
consequence of misuse (see Votaw et al., 2019a), including a highly
distressing and potentially fatal withdrawal syndrome. Furthermore,
benzodiazepines are a growing contributor to drug overdose deaths
(Bachhuber et al., 2016), particularly among women (VanHouten et al.,
2019).
In the general population in the United States, the estimated past-
year prevalence of benzodiazepine misuse is approximately 2% (Center
for Behavioral Health Statistics and Quality, 2019), and increases to
over 7.5% in people with significant psychiatric distress (Substance
Abuse and Mental Health Services Administration [SAMHSA]'s public
online data analysis system [PDAS], 2020). Misuse is much more pre-
valent in people with substance use disorders; for example, approxi-
mately 27% of people with alcohol use disorder and 70% of people with
opioid use disorder have misused benzodiazepines in their lifetime
(Votaw et al., 2019b). Research has indicated that psychiatric disorders
and symptoms are associated with increased risk for benzodiazepine
misuse in people with substance use disorders (see Votaw et al., 2019a).
However, very few studies have examined misuse in samples with
psychiatric disorders (de las Cuevas et al., 2003; de las Cuevas et al.,
2000; Yen et al., 2015). People receiving psychiatric treatment may be

∗
Corresponding author. McLean Hospital, Proctor House 3, MS 222, Belmont, MA, 02478, USA.
E-mail address: kmchugh@mclean.harvard.edu (R.K. McHugh).

https://doi.org/10.1016/j.jpsychires.2020.05.020
Received 15 April 2020; Received in revised form 18 May 2020; Accepted 23 May 2020
0022-3956/ © 2020 Elsevier Ltd. All rights reserved.
R.K. McHugh, et al.
at a particularly heightened risk for misuse due to their higher like-
lihood of receiving a prescription, and thus being exposed to benzo-
diazepines. However, the prevalence of benzodiazepine misuse in psy-
chiatric patients is unknown.
The few studies in psychiatric samples published to date have fo-
cused exclusively on samples of patients who have been prescribed
benzodiazepines and only one has examined benzodiazepine misuse.
Two studies examined dependence on benzodiazepines (e.g., worry
about a missed dose, desire to stop use) and found that dependence is
common, with estimates in the range of 29–47% (de las Cuevas et al.,
2003; de las Cuevas et al., 2000; Yen et al., 2015). One study specifi-
cally assessed benzodiazepine misuse (i.e., taking benzodiazepines at a
frequency or dose higher than prescribed); this study of elderly people
receiving inpatient psychiatric hospitalization found that 7.9% misused
benzodiazepines (Yen et al., 2015). However, these estimates only in-
clude people receiving benzodiazepines and do not consider other types
of misuse (i.e., recreational use or use of someone else's prescription).
The paucity of studies investigating the prevalence or correlates of
benzodiazepine misuse in people with psychiatric disorders is a sig-
nificant gap in the literature. In particular, estimates of the prevalence
of benzodiazepine misuse in this population are needed to inform the
need for screening and treatment for this issue in psychiatric treatment
settings. Characterizing the scope of benzodiazepine misuse in psy-
chiatric settings may be particularly important to informing prescribing
practices.
The overarching aim of this study is to characterize the prevalence
and correlates of benzodiazepine misuse in adults presenting for psy-
chiatric treatment. Our first aim is to characterize the prevalence of
benzodiazepine prescription, length of prescription, and frequency of
misuse. Our second aim is to examine correlates of misuse, based on
prior literature in substance use disorders, including sociodemographic
and clinical correlates. We hypothesized that history of a benzodiaze-
pine prescription, younger age, female sex, sexual orientation, anxiety
symptom severity, and other substance use severity would be sig-
nificantly associated with benzodiazepine misuse, consistent with
findings from studies of people with substance use disorders (Votaw
et al., 2019a).
2. Methods
This paper reports a planned analysis of an ongoing naturalistic
study of adults receiving acute care (partial hospitalization) for psy-
chiatric disorders.
2.1. Participants
Participants were adults presenting for acute psychiatric care at a
partial hospital program within a private psychiatric hospital in the
Northeastern United States. Participants were adults 18 years of age or
older, who were referred from inpatient, community, or outpatient le-
vels of care for brief psychiatric treatment. Adults with primary sub-
stance use disorders were not admitted and were instead referred to
clinics focusing on treatment for substance use. Primary diagnoses for
participants in this sample included major depressive disorder or other
mood disorders (63%), bipolar disorder (22.6%), or an anxiety disorder
(5.8%); the remaining participants had primary diagnoses of psychotic
disorders (4.2%), obsessive-compulsive disorder (3.2%), or another
diagnosis (1.2%). Participants completed self-report measures as part of
routine clinical care and were invited to consent for their clinical data
to be used for research purposes (89% of patients in the program pro-
vided consent). For the present study, participants were included in
analyses if they provided informed written consent to research and
were undergoing their first admission to this program.
The sample included 589 participants (57.6% female) who com-
pleted a measure assessing benzodiazepine use. The mean age of the
sample was 33.7 years (SD = 13.9, range = 18 to 75). The sample self-
34
Journal of Psychiatric Research 128 (2020) 33–37
identified race as White (88.6%), Asian (2.9%), Black (2.7%), not listed
(1.2%), more than one race (3.4%), and don't know (0.3%); race data
were missing for 0.8% of participants. The majority of the sample self-
identified as non-Hispanic/Latinx (94.7%). The majority of the sample
reported that their sexual orientation was heterosexual (79%). More
than half of the sample had completed a college education or other
advanced degree (58.9%), with 35.6% completing some college, 5.3%
high school or equivalent and 0.2% less than high school. Most of the
sample reported that they were never married (61.4), followed by
married (25.4%). Employment status was 16.2% part-time employed,
35.9% full-time employed and 47.9% unemployed (41.4% of those who
were unemployed were students). More than half (55.6%) of partici-
pants reported at least one prior inpatient hospitalization.
2.2. Procedures
Self-report measures were administered to participants on their day
of admission to the program and on their day of discharge. Measures
were administered on a computer via Research Electronic Data Capture
(REDCap; Harris et al., 2009). Data collection for this project occurred
between September 2017 and October 2018.
2.3. Measures
All participants completed a battery of self-report measures.
Measures included in this secondary analysis are described below.
Demographic information was collected via a standardized ques-
tionnaire.
Anxiety symptom severity was measured using the Generalized
Anxiety Disorder 7-Item Scale (GAD-7; Spitzer et al., 2006). The GAD-7
is a brief, well-validated self-report measure of anxiety symptoms in the
past two weeks. Items are rated on a 0 (“not at all”) to 3 (“nearly every
day”) scale and summed. The total score values range from 0 to 21, with
higher scores reflecting more severe anxiety. The admission value on
the GAD-7 was used for this analysis.
The Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001)
was used as a measure of depression symptoms. The PHQ-9 is a 9-item
scale assessing symptoms of depression in the past two weeks. Each
item is rated on a 0 (“Not at all”) to 3 (“Nearly all the time”) scale, with
total scores ranging from 0 (minimal depression symptoms) to 27 (se-
vere depression symptoms). The PHQ-9 is a well-validated measure
with good psychometric properties in partial hospital settings (Beard
et al., 2016). The admission value on the PHQ-9 was used for this
analysis.
Substance-related problems were measured using the Alcohol Use
Disorder Identification Test-Consumption questions (AUDIT-C; Bush
et al., 1998) and the Drug Abuse Screening Test-10 item version (DAST-
10; Skinner, 1982). The AUDIT-C is a screening measure for hazardous
drinking that includes 3 questions assessing the frequency of alcohol
consumption in the past year. The DAST-10 is a screening measure that
assesses the severity of drug use problems during the past year, with 10
items answered in a “yes/no” format. The 10-item version used in the
present study has good psychometric properties (Yudko et al., 2007).
Participants only completed the full DAST-10 measure if they endorsed
drug use in the past year, using a single-item screening measure (“How
many times in the past year have you used an illegal drug or a pre-
scription medication for non-medical reasons?”) validated in previous
studies, including partial hospital settings (Hearon et al., 2015; Smith
et al., 2010). For the purpose of this analysis, participants with no drug
use in the past year were coded as a “0” on the DAST. The AUDIT-C and
DAST-10 were administered at admission.
We developed a brief questionnaire of benzodiazepine use and
misuse for this study using questions adapted from a prior study of
prescription drug misuse (Weiss et al., 2010). The questions assessed
the following domains relevant to prescription history: lifetime history
of benzodiazepine prescription, indication for the prescription, source
R.K. McHugh, et al.
Table 1
Sociodemographic and clinical variables by benzodiazepine misuse status.
Misuse (n = 153)
Age (mean, SD) 31.2 (11.2)
Female, % 54.9
Heterosexual, % 79.1
Lifetime benzodiazepine Rx, % 84.3
Alcohol use problems, AUDIT (mean, SD) 3.7 (2.7)
Drug use problems, DAST (mean, SD) 2.0 (2.5)
Anxiety, GAD-7 (mean, SD) 11.5 (5.4)
Depression, PHQ-9 (mean, SD) 14.7 (5.6)
Note. AUDIT = Alcohol Use Disorder Identification Test; DAST = Drug Abuse Screening Test; GAD-7 = Generalized Anxiety Disorder-7 Item Scale; PHQ-9 = Patient
Health Questionnaire-9.
of the prescription, and information received about the prescription
(expected duration of prescription). Participants were also asked about
misuse (In your lifetime how often have you used benzodiazepines without a
prescription to you or at a higher dose or more frequently than prescribed?).
Response options included never, rarely (< 5 times in your life), some-
times (a few times per year but less than once per month), often (once per
month), very often (once per week or more). The benzodiazepine ques-
tionnaire was administered at discharge to mitigate participant concern
about the impact of disclosure of misuse at treatment entry. Data on
reasons for misusing benzodiazepines were collected in a smaller subset
of participants (n = 41) due to a measure administration error.
2.4. Data analysis
We first used descriptive statistics to quantify the prevalence of
benzodiazepine prescription, length of prescription and frequency of
misuse in our sample (Aim 1). Subsequently, we compared people with
and without a history of misuse on correlates of interest (Aim 2). We
used logistic regression to examine correlates of misuse; bivariate as-
sociations were also calculated using t-tests and chi-square tests for
descriptive purposes.
3. Results
3.1. Benzodiazepine prescriptions
The majority of the sample reported a lifetime history of benzo-
diazepine prescription (67.8%). Of those with a history of benzodia-
zepine prescription, the most common indication was anxiety (81.2%),
followed by sleep (11.3%), other psychiatric condition (5.6%), and pain
or medical condition (2%). There was significant variability in the
length of the longest benzodiazepine prescription; however, more than
half of participants (54.6%) reported a duration of at least one year and
13.4% reported duration of more than 10 years. Most participants re-
ported that benzodiazepines had been described by their prescriber as
short-term treatment for acute symptoms (55.4%). The most common
currently prescribed benzodiazepines were clonazepam (30.3%), lor-
azepam (28.6%), alprazolam (5.9%) and diazepam (3.4%); 32% of
those with a lifetime history of benzodiazepine prescription did not
have a current prescription. Most participants with a current prescrip-
tion received it from a psychiatrist (72.3%), followed by primary care
physician (14.3%).
3.2. Benzodiazepine misuse prevalence
Benzodiazepine misuse was reported by 26% of the sample
(n = 153). Most participants in this subgroup reported that misuse was
rare (n = 67% of people who reported lifetime misuse). Others reported
misusing more than a few times but less than monthly (n = 32), once
per month (n = 8) and weekly or more (n = 11). Of note, 21 partici-
pants who denied misuse reported that they had taken a
35
Journal of Psychiatric Research 128 (2020) 33–37
No Misuse (n = 436) χ2/t p-value
34.6 (14.6) 2.57 .01
58.5 0.60 .44
79.5 0.01 .92
61.9 26.01 < .001
2.8 (2.3) −3.30 .001
0.7 (1.6) −6.08 < .001
10.9 (5.4) −1.11 .27
14.5 (5.5) −0.35 .73
benzodiazepine from someone other than a doctor at some time.
Although this would meet our criteria for misuse, we did not include
these participants in our misuse group because we could not verify that
this was inconsistent with a prescriber's recommendation.
Of the participants who reported a history of benzodiazepine misuse
(n = 113 due to some missing data), 66.6% reported that they obtained
misused benzodiazepines from friends or family, 12.5% reported
stealing and 1% reported purchasing on the internet. A small subset of
people who reported a history of benzodiazepine misuse also answered
questions about reasons for misuse (n = 41). In this group, the most
commonly reported reason for misuse was anxiety (85.4%). Other
motives for misuse included depression (43.6%), sleep (31.6%), out of
curiosity (22%), to relieve bad memories (18.4%), recreationally/to get
high (12.5%), because someone offered them (12.2%), to increase the
effects of alcohol (10.3%), to increase a stimulant effect (5.3%), and a
small percentage (2.6%) reported each of the following: misusing for
pain, to decrease a stimulant effect, to increase an opioid effect, to re-
lieve opioid withdrawal, to relieve mania, and to commit suicide.
3.3. Correlates of benzodiazepine misuse
Results from bivariate analyses are presented in Table 1. These
analyses indicated that people with a history of benzodiazepine misuse
were younger, had higher alcohol and drug problem scores, and were
more likely to have a history of benzodiazepine prescription. There
were no differences in anxiety or depression severity at admission be-
tween those with and without a history of benzodiazepine misuse.
There was also no significant sex difference in the prevalence of misuse.
Results from the logistic regression indicated that benzodiazepine
prescription (OR = 4.08; 95% CI = 2.39, 6.97 p < .001) and drug use
problems (OR = 1.30; 95% CI = 1.17, 1.44; p < .001) were sig-
nificantly associated with benzodiazepine misuse (Fig. 1). In an ex-
ploratory analysis, we ran these models separately for males and fe-
males; however, there were no substantive differences in the pattern or
magnitude of effects (i.e., prescription and drug use problems were the
only significant correlates of misuse), suggesting that sex did not
moderate these associations.
4. Discussion
Benzodiazepines are among the most commonly prescribed medi-
cations and are also among the most commonly misused drugs (Agarwal
and Landon, 2019; Center for Behavioral Health Statistics and Quality,
2019; Olfson et al., 2015). Research in populations with substance use
disorders has found that benzodiazepine misuse is highly prevalent;
however, relatively little attention has been paid to people with psy-
chiatric disorders, who are also commonly exposed to benzodiazepines
(see Votaw et al., 2019a). In this study, we found that 1 in 4 adults
receiving acute psychiatric treatment reported a lifetime history of
benzodiazepine misuse. For two-thirds of these participants, misuse was
not common, however, one-third reported more frequent misuse.
R.K. McHugh, et al.
Fig. 1. Forest plot of factors associated with benzodiazepine misuse in adjusted analyses Unstandardized Odds Ratios and 95% Confidence Intervals are presented.
These results should not be interpreted as population estimates, as
our sample reflects a single treatment center and an acute level of care
(partial hospitalization). Indeed, our estimate is substantially higher
than the estimate among adults with significant psychiatric distress in
the National Survey of Drug Use and Health (approximately 7.5%;
SAMHSA's Substance Abuse and Mental Health Services Administration
[SAMHSA]'s public online data analysis system [PDAS], 2020). This
difference highlights the importance of the assessment of benzodiaze-
pine misuse in people who are receiving treatment, for whom exposure
to benzodiazepines due to prescription are high. Indeed, more than two-
thirds of our sample had a prior history of benzodiazepine prescription.
Nonetheless, representative surveys with greater geographic distribu-
tion and greater representation across levels of care and socio-
demographic factors are needed to estimate the prevalence of benzo-
diazepine misuse in people in psychiatric treatment. Our study
highlights the importance of this future research direction.
Consistent with hypotheses, history of a benzodiazepine prescrip-
tion and drug use problems were associated with a higher likelihood of
misuse. Specifically, people with a lifetime benzodiazepine prescription
had a more than 4 times higher odds of reporting a history of misuse.
For each 1-unit increase in DAST score there was a 30% higher odds of
misuse. This is consistent with the literature in other populations,
predominantly people with substance use disorders (Votaw et al.,
2019a). The strong association between benzodiazepine prescription
and misuse likely reflects a heightened exposure to the medication.
Nonetheless, it cannot be ruled out that people with a vulnerability
toward benzodiazepine misuse are more likely to be prescribed this
medication type or that some people sought out prescriptions with the
intention of misuse.
Other hypothesized correlates of benzodiazepine misuse, including
younger age and alcohol symptom severity were associated with misuse
only in bivariate analyses. Contrary to hypotheses, female sex and
minority sexual orientation were not associated with misuse. Studies
have been equivocal with respect to the association between sex and
benzodiazepine misuse (Votaw et al., 2019a); this study further sug-
gests that there may not be substantive sex differences in the prevalence
of benzodiazepine misuse. Sexual orientation findings may reflect the
relatively small representation of participants who did not identify as
heterosexual (approximately 20%), and thus replication is needed.
Additionally, contrary to hypotheses, anxiety symptom severity was
not associated with misuse. The finding that coping motives were the
primary reason for misuse without a corresponding association between
36
Journal of Psychiatric Research 128 (2020) 33–37
psychiatric symptom severity and misuse was unexpected. This re-
presents a distinction from the substance use disorder literature, where
psychiatric severity in general and anxiety in particular are associated
with benzodiazepine misuse (see Votaw et al., 2019a). Importantly,
anxiety was not associated with benzodiazepine misuse in bivariate
analyses, which suggests that this is not simply attributable to overlap
with other variables (e.g., prescription). Of note, the most common
primary diagnosis in the sample was depression; these findings may
have differed in a sample with a different diagnostic profile. Further-
more, the use of the GAD-7 rather than a measure more focused on
panic disorder symptoms may have impacted these results. For ex-
ample, several studies in substance use disorder samples have used
measures of anxiety sensitivity, which have shown strong links to
benzodiazepine misuse (e.g., McHugh et al., 2017, 2018). Future stu-
dies are needed to determine whether this is a reliable finding.
Taken together, these findings have several clinical implications.
Most notably, these results demonstrate that benzodiazepine misuse is
not limited to people in substance use disorder treatment and should be
assessed in psychiatric treatment settings. Nonetheless, people with
other substance-related problems may be at heightened risk of misusing
benzodiazepines. These findings also highlight the importance of edu-
cation on safe medication storage and disposal. The majority of parti-
cipants who misused benzodiazepines acquired them from family or
friends.
Although these findings demonstrate that benzodiazepine misuse is
prevalent in this sample, they do not provide insight into the clinical
impact of misuse. Although benzodiazepine misuse has been associated
with myriad health, mental health and other functional consequences
(Votaw et al., 2019a), little is known about what level of misuse is risky.
Indeed, this is not well characterized for prescription drugs in general,
where the impact of occasional use without a prescription or in a
manner different than prescribed is not well understood. Several re-
search groups have recommended research on subgroups of this po-
pulation, such as distinguishing between those who occasionally use
extra medications in a way that is inconsistent with a prescription (e.g.,
taking extra medication during a symptom exacerbation) from those
who misuse more frequently or with the intention of feeling euphoric
(Barrett et al., 2008; Boyd and McCabe, 2008). Yet, it remains unclear
how such groups should be derived and based on which factors. Indeed,
misusing benzodiazepines to achieve a therapeutic effect (e.g., to re-
lieve anxiety or to help sleep) was the most common motive in this
sample, consistent with studies of people in substance use disorder
R.K. McHugh, et al.
treatment. Further empirical work is needed to identify meaningful
subgroups, particularly those that are associated with negative con-
sequences (e.g., craving, social or functional impairment).
This study has several limitations. First, questions were all assessed
via self-report and were not complemented with clinician-administered
or objective (e.g., urine drug screen) measures. Second, the sample was
homogeneous with respect to race, ethnicity and clinical severity; thus,
these findings cannot be assumed to generalize to other samples.
Similarly, these findings represent a single treatment setting and thus
provide only a local estimate of the prevalence of benzodiazepine
misuse. Representative surveys would be needed to provide more pre-
cise estimates of the prevalence of benzodiazepine misuse in this po-
pulation. Finally, this study was cross-sectional and thus temporality
cannot be assumed. Longitudinal studies of benzodiazepine use and
misuse—particularly studies that investigate predictors of benzodiaze-
pine misuse among new recipients of prescriptions—are sorely needed
to develop risk stratification tools that can be applied in clinical set-
tings.
Benzodiazepine misuse remains understudied and research has ty-
pically focused on populations with substance use disorders (see Votaw
et al., 2019a). The results of this study provide support for the heigh-
tened prevalence of benzodiazepine misuse in psychiatric populations
and suggest that additional attention should be paid to understanding
this issue. Providing education to patients on the potential for abuse of
these medications as well as education about safe medication storage
and disposal should be standard practice when prescribing these med-
ications. Future studies designed to investigate the consequences of
different levels of benzodiazepine misuse will help to clarify the public
health impact of these findings.
Funding
Effort for this work was supported by the National Institutes of
Health (F32MH115530) and the Sarles Young Investigator Award.
CRediT authorship contribution statement
R. Kathryn McHugh: Conceptualization, Formal analysis, Writing -
original draft. Andrew D. Peckham: Formal analysis, Writing - original
draft. Thröstur Björgvinsson: Resources, Methodology, Writing - re-
view & editing. Francesca M. Korte: Formal analysis, Writing - original
draft. Courtney Beard: Conceptualization, Investigation, Writing - re-
view & editing.
Declaration of competing interest
The authors have no conflicts of interest to report. Effort for this
work was supported by the National Institutes of Health
(F32MH115530) and the Sarles Young Investigator Award.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.jpsychires.2020.05.020.
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