A United Nations report ranks Portugal among the countries with the highest consumption of psychotropic drugs. Psychiatrists say the drugs are important in acute cases, but warn of dangers when you take too much
Portugal is among the three countries with the highest consumption rates of benzodiazepines, according to the document Psychotropic Substances – Statistics for 2020 and Annual Medical Assessments and Scientific Requirements for 2022, which is part of the report of the International Narcotics Control Board (INCB, in the International Narcotics Control Board) of the United Nations, released in early March.
With consumption measured in S-DDD (term used in the report for defined daily dose for statistical purposes) per 1,000 inhabitants per day, Spain comes first (110 S-DDD), followed by Belgium (84 S-DDD) and Portugal (80 S-DDD). This means that in our country, in 2020, almost 80 daily doses of benzodiazepines were consumed per thousand inhabitants, the third highest value in the world.
Benzodiazepine is a class of psychotropic drugs used as an anxiolytic, sedative, hypnotic or muscle relaxant. They are psychotropic drugs “that act on the central nervous system and are often prescribed to treat depression, anxiety, insomnia, among others,” explains psychiatrist Maria Moreno.
According to the latest figures from Infarmed, an average of 28,036 daily packs of anxiolytics, sedatives and hypnotics were sold in 2020, a number that rose to 29,444 the following year.
“These figures are alarming and apparently indicate a high consumption of benzodiazepines in Portugal“, laments Maria Moreno.
The expert warns that prolonged use of this type of drug or in high amounts can lead to “tolerance, dependence and multiple unwanted side effects”, in which, as she explains, “the person needs increasingly larger doses to have the same effect or you feel unable to stop taking the drug, despite the negative effects it has on you.’
Gustavo Jesus, psychiatrist and clinical director of PIN – Partners in Neuroscience, sees these numbers as a mirror of the state of mental health in Portugal. “There could be a correlation,” he says. However, he is quick to explain that “we do not know whether the consumption shown in the report is chronic or sufficient, in the sense that it is done over a controlled period”, from eight to 12 weeks, including the “weaning” phase. .
“What we really know is that Portugal is one of the countries in the world with the highest rates of stress.“, adds the board member of the Portuguese Society of Psychiatry and Mental Health, referring to the study carried out by doctors Miguel Xavier and Caldas Almeida.
“On the other hand, we also know that with the pandemic there has been an increase in anxiety disorders worldwide”, he continues, explaining that perhaps this is the reason for the increase in the consumption of this type of psychotropic medication, but he regrets that no information is available in Portugal for consultation and analysis, and therefore it is not possible to understand whether high consumption leads to poor drug uptake.
According to Eurostat, in 2019, 7.2% of European Union citizens reported suffering from chronic depression. Portugal comes first (12.2%), followed by Sweden (11.7%), Germany and Croatia (both 11.6%). But the problem is not new: depression led to one in five hospitalizations for mental illness nationwide between 2008 and 2015, reveals a study by the University of Porto School of Medicine, Cintesis and Centro Hospitalar do Tâmega e Sousa.
Already in times of pandemic, “a 25% increase in the prevalence of anxiety and depression worldwide has been reported. In Portugal, studies carried out during the lockdown revealed an increase in the prevalence of these disorders,” says the study published last year in the journal European Journal of Public Health.
The most consumed benzodiazepines in Portugal
The United Nations International Narcotics Control Board document states that Portugal is among the countries with the highest consumption of alprazolam, diazepam, lorazepam and midazolam, four of the eight psychotropic drugs analyzed.
Looking at the numbers presented in the report, in the case of alprazolam, which is a gamma-aminobutyric acid-stimulating benzodiazepine used to treat anxiety, Portugal is the third country in the world (the first in Europe) with the highest consumption (27.8 S-DDD), following only Hungary (57.1 S-DDD) and Uruguay (37.9 S-DDD).
As for diazepam, a benzodiazepine anxiolytic with a sedative effect, Spain appears in the first place of consumption, followed by Portugal and Montenegro, which close the podium of the countries with the highest consumption rates, each with more than 10 S-DDD, well above the global average of 2.19 S-DDD.
As for lorazepam, also with a sedative effect, consumption of more than 10 S-DDD was reported by Spain, Portugal, Montenegro, Belgium, Lithuania, Luxembourg and Malta (in descending order by quantity consumed); says the report, which returns. to rank Portugal among the most used.
Taking midazolam, a benzodiazepine drug used for anaesthesia, sedation for surgery and difficulty sleeping, also places Portugal on the list of most consumers. In 2021, global consumption was 46.7 S-DDD, “an increase of 19% compared to 2020 and 52% compared to 2019.” Of the 82 countries that sent data in 2021, consumption was highest in: Brazil (6.5 S-DDD), Israel (2.6 S-DDD), Uruguay (2.6 S-DDD), São Martinho ( Netherlands, 2.5 S-DDD ), Chile (2.5 S-DDD), Portugal (2.3 S-DDD) and El Salvador (2.2 S-DDD). Portugal is therefore the second region in Europe with the highest consumption of this drug.
Despite belonging to the same class of drugs, “different benzodiazepines vary” in several aspects, “such as their potency or duration of action,” explains psychiatrist Maria Moreno. However, warns the doctor, “high consumption of these drugs or for a very long time can be problematic, as they cause severe addiction.”
It is “my best friend”, but prolonged consumption brings “unwanted” results
Psychiatrists Maria Moreno and Gustavo Jesus explain that there is a place for taking benzodiazepines and that, in some cases, they are actually the drug that helps the person most to deal with pain. But both also argue that intake should be monitored and time-limited.
“Benzodiazepines are a pharmacological class that continues to have a place in therapy, there is the idea that they are bad and should be eliminated, but they do work. These are treatments that, as a rule, should not be chronic, they should be used for a maximum of eight to 12 weeks, including here reducing“, says Gustavo Jesus, who emphasizes that, contrary to what many believe, these psychotropic drugs do not replace psychotherapy, nor vice versa.
“Imagine someone dies or the person loses their job. In these cases the anxiety levels rise, the benzodiazepine makes sense in the short term and then it is withdrawn, but it is not a substitute for psychotherapy, which is very important. Psychological support can be given in the acute phase to alleviate the symptoms, but it is not always enough, the feelings of suffering are so severe that it may be necessary to take benzodiazepines”, explains the doctor, saying that, for example, in chronic cases are antidepressants, with psychotherapy, for example, the most appropriate option.
Benzodiazepines stand out for their immediate effect and, in an acute situation, that’s what you want. But this is a problem when taken incorrectly and for a long time, it can become addictive and the person may no longer know that they are under the influence of this psychoactive drug.
“My best friend”, “the only medicine that works”, “this is the one thing I can’t let go of”. These are some of the phrases that psychiatrist Maria Moreno hears in consultation, with patients classifying benzodiazepines as “the insurmountable solution, the rare drug that cures everything, instantly and without apparent illness.” But this is far from the truth, especially when the use is prolonged, either in time or in quantity.
“Benzodiazepines are drugs that can be very useful, but they present risks, especially when used for long periods of time, in high doses or without a clinical indication,” warns the doctor. Among the “multiple unwanted side effects” are “anxiety, changes in sleep phases, fatigue, confusion, memory problems, cognitive changes, and changes in balance and motor coordination.”
“These side effects exist and are real.” shoots Maria Moreno, who regrets it “Poor management of clinical conditions such as depression or anxiety by overprescribing these drugs, instead of others, more effective and with fewer side effects, and the easy availability of these drugs, even without a prescription, are among the main responsible behind these numbers”.
The psychiatrist points out that “it is important that health authorities in Portugal work with health professionals and patients to tackle the problem of high benzodiazepine consumption”, arguing that “health professionals should be encouraged to prescribe benzodiazepines only when necessary, at lower doses. and for shorter periods of time. It is necessary, the doctor concludes, “to inform, to warn and to regulate”.