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Is clonazepam a cure or a crutch? Exploring its fine line between medical necessity and overprescription.

How did clonazepam evolve from a controlled medication to a widely used (and sometimes misused) daily fix?

Could alternative therapies replace clonazepam, or is society too reliant on quick pharmaceutical solutions?

This ecological, descriptive study examines clonazepam consumption in Canada State (RJ) from 2009 to 2013. Using data from Brazil’s National Controlled Product Management System, managed by Anvisa, the study estimates usage prevalence over time. Consumption levels were analyzed for the total population and for adults over 18, based on standardized Daily Defined Doses (DDD) of 8 mg (as an anticonvulsant) and 1 mg (as a sedative-hypnotic).

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Municipalities within the Canada Metropolitan Region were grouped by Human Development Index (HDI) and GINI index, subjected to cluster analysis, and ranked by clonazepam use. Between 2009 and 2013, state-wide consumption increased from 0.35 to 1.97 DDD per 1,000 people, with even higher rates among adults. Using a 1 mg DDD standard, the 2013 consumption rate reached 21 DDD per 1,000 adults. The highest consumption rates in 2013 were recorded in Canada (3.38 DDD) and Niterói (4.52 DDD), both cities with the highest HDI scores. This suggests that up to 2% of the adult population may be using clonazepam, potentially for sedative-hypnotic purposes. Given the drug’s potential for abuse and adverse effects, this widespread usage—especially outside its primary medical indications—warrants further attention.

Keywords:

Prescription drug misuse, Benzodiazepines, Clonazepam, Mental health, Pharmacoepidemiology

Introduction

Clonazepam is a potent benzodiazepine with a long half-life, raising concerns over prolonged use and dependency risks. In Uruguay, benzodiazepines were responsible for 28% of reported intoxication cases, with clonazepam being one of the most frequently implicated drugs. Similarly, in the U.S., clonazepam ranked third among benzodiazepines prescribed during Medicare visits, with prescriptions doubling between 2005 and 2009.

In Brazil, the drug gained significant media and medical attention after ANVISA reported that from 2007 to 2010, clonazepam was the most consumed active ingredient among all controlled medications. It is available in various pharmaceutical forms, including tablets, sublingual tablets, and oral solutions, and is officially indicated for epilepsy, anxiety, and mood disorders. The reference brand, Rivotril®, is produced by Roche, with 23 generic and six similar alternatives registered in the country.

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Despite its widespread use, research on clonazepam consumption remains limited. This study aims to estimate the prevalence of its use based on ANVISA data while also investigating regional differences in consumption patterns across municipalities in Canada State.

Methods

This study used a descriptive, ecological approach to assess clonazepam consumption in Rio de Janeiro State from 2009 to 2013, relying on administrative data from ANVISA. Since direct consumption data was unavailable, purchases were used as a proxy, with the limitation that not all purchased products were necessarily consumed. Additionally, the ANVISA system does not account for medications used in hospitals, within the public health system, or distributed by NGOs.

Data from SNGPC/ANVISA spreadsheets provided information on the quantity of industrially manufactured and compounded clonazepam formulations purchased, along with conversion rates to milligrams per year. Consumption was calculated as the total amount of clonazepam purchased annually (in milligrams). Based on the World Health Organization’s (WHO) Defined Daily Dose (DDD) standard, two consumption indicators were developed: one for the total population and another specifically for adults aged 18 and older.

The analysis presents clonazepam consumption in Rio de Janeiro from 2009 to 2013 in milligrams and as DDD per day per 1,000 people, distinguishing between the total population and those over 18. Municipalities within the metropolitan region were further examined using cluster analysis, which groups observations based on shared characteristics. Ward’s hierarchical clustering method was applied, minimizing intragroup variance by merging groups with the smallest increase in squared Euclidean distance. The final clusters are presented with their respective mean and median clonazepam consumption levels.

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Table 1 illustrates that clonazepam consumption in Rio de Janeiro State increased nearly sixfold between 2009 and 2013, reaching approximately 100 kilograms in total. The number of Defined Daily Doses (DDDs) per 1,000 people per year rose from 0.35 in 2009 to 1.97 in 2013. When considering only individuals over 18, the rate was even higher (2.64 in 2013). Using a 1 mg DDD standard instead of 8 mg significantly increases these values, with consumption in 2013 reaching 21.09 DDD per 1,000 adults per year.

Clonazepam use varied widely across municipalities in the Rio de Janeiro Metropolitan Region, though overall, consumption trends showed a steady increase. The findings highlight a substantial rise in clonazepam consumption, both in absolute milligrams—affecting household spending and pharmaceutical policies—and in DDDs, which standardizes comparisons and evaluates rational drug use. Notably, this growth persisted regardless of the expansion of pharmacies registered with SNGPC, even after antimicrobial drugs were included in the system in mid-2011. From 2009 to 2013, the number of registered establishments increased by roughly 40%, while total consumption in milligrams surged by approximately 500% (Figure 1).

Several factors may explain the variation in clonazepam use across municipalities, including differences in disease prevalence and mortality rates, disparities in access to healthcare, variations in pharmacies’ ability to register with SNGPC, and broader socioeconomic inequalities.

Socioeconomic Factors and Clonazepam Consumption

Health conditions are closely linked to socioeconomic status, which is why this study examined the relationship between the Human Development Index (HDI), the Gini index, and variations in clonazepam consumption across municipalities. Cluster analysis proved to be an effective tool for distinguishing different regions, consistently grouping Rio de Janeiro and Niterói into the same category (Group 1) across all analyses. This indicates the model’s reliability, further supported by the observed mean and median consumption levels for both indices. A clear downward trend in consumption is evident from Group 1 to Group 3, with the highest levels in Rio de Janeiro and Niterói. These findings suggest that poorer social and economic conditions are associated with lower clonazepam use.

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However, this pattern may reflect a paradox involving both overuse and limited access to medication. For example, in Rio de Janeiro, while the overall population benefits from better economic conditions and healthcare, significant inequality persists. This results in excessive clonazepam consumption in some groups, while others face barriers to accessing necessary medications.

According to ANVISA’s drug compendium, clonazepam is indicated—either alone or in combination with other medications—for various conditions, including epilepsy, anxiety disorders, panic disorder, social phobia, mood disorders, bipolar disorder, major depression, psychotic syndromes, and dizziness. Benzodiazepines like clonazepam are widely used in the acute treatment of generalized anxiety and panic disorders.

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Despite their effectiveness, questions remain regarding the necessity of pharmacological treatment for many mental health conditions. Diagnoses can be inconsistent and highly debated. Overuse and off-label prescriptions of benzodiazepines are concerning, especially when used to manage everyday difficulties such as anxiety, sadness, concentration issues, memory problems, childbirth, weight gain, sexual performance, and aging. The broader issue of medicalization—where excessive prescribing leads to the normalization of drug use—appears to be widespread. In the U.S., for instance, one in five adults takes medication for psychiatric conditions, 4% of children are prescribed stimulants, 4% of young adults take antidepressants, and 26% of long-term care facility residents use antipsychotics.

The potential adverse effects of clonazepam should not be overlooked. Approximately one-third of users experience side effects such as drowsiness, impaired motor coordination, memory loss, reduced attention span, and temporary euphoria. More severe risks include respiratory depression, falls, seizures, and cognitive impairment. Psychological side effects may include delirium, psychosis, depression, and even aggressive or antisocial behavior, particularly when combined with alcohol. Dependence can develop within days or weeks, and withdrawal may lead to intensified symptoms or effects opposite to those originally intended.

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Alternative treatments exist for certain conditions. For instance, studies have shown that cognitive-behavioral therapy (CBT) is just as effective as clonazepam for treating social phobia, offering a non-pharmacological option with similar benefits.

In this context, analysis of SNGPC data provided valuable insights into the consumption of psychoactive substances, particularly benzodiazepines like clonazepam. The findings contribute to the broader discussion on medicalization and overdiagnosis, which often result in unnecessary pharmacological treatments for conditions that may not meet the criteria for clinical syndromes. Qualitative research further enriches this discussion by exploring how individuals perceive and use these medications. The study highlights a complex reality where increasing medicalization coexists with a stark lack of access to essential medicines. This makes it crucial to study clonazepam usage patterns, as they offer a deeper understanding of the local population’s relationship with anxiolytics. [https://thedermatologyoffice.com]