Nationwide trends in diagnosed sedative, hypnotic or anxiolytic use disorders in adolescents and young adults enrolled in Medicaid: 2001–2019

Abstract

Background and Aim

Sedative, hypnotic or anxiolytic use disorders (SHA‐UD) are defined by significant impairment or distress caused by recurrent sedative, hypnotic or anxiolytic use. This study aimed to measure trends in the prevalence of SHA‐UD diagnoses in adolescent and young adult US Medicaid enrollees from 2001 to 2019.

Design

Annual, cross‐sectional study, 2001–2019.

Setting

Medicaid Analytic eXtracts (MAX) and Transformed Medicaid Analytic Files (TAF) from 42 US states with complete data.

Participants/Cases

Adolescents (13–17 years) and young adults (18–29 years) with ≥10 months Medicaid enrollment in the calendar year; analytic sample contained 5.7 (2001) to 13.2 (2019) million persons per year.

Measurements

Annual prevalence of SHA‐UD in adolescent and young adult Medicaid enrollees [defined as an inpatient or outpatient ICD code (304.1x, 305.4x, F13.1x, F13.2x) in the calendar year] was stratified by sex, race/ethnicity, receipt of a benzodiazepine, z‐hypnotic or barbiturate prescription, and selected mental health diagnoses. Absolute and relative percent‐changes from 2001 vs. 2019 were summarized. Secondary analyses were restricted to states with more consistent data capture.

Findings

The prevalence of SHA‐UD diagnoses statistically significantly increased for adolescents (0.01% to 0.04%) and young adults (0.05% to 0.24%) from 2001 to 2019. Increasing trends were observed in sex and race/ethnicity subgroups, with greatest relative increases among Non‐Hispanic Black (624%) and Hispanic (529%) young adults. The trend increased among those with and without a benzodiazepine, z‐hypnotic or barbiturate prescription; i.e. young adults with (2001 = 0.39% to 2019 = 1.77%) and without (2001 = 0.03% to 2019 = 0.18%) a prescription. Most adolescents (76%) and young adults (91%) with a SHA‐UD diagnosis in 2019 had a comorbid substance use disorder.

Conclusions

Sedative, hypnotic or anxiolytic use disorders (SHA‐UD) diagnoses increased 3‐ to 5‐fold between 2001 and 2019 for adolescent and young adult US Medicaid enrollees, with prevalence remaining low in adolescents. The increase over two decades may be attributed to changes in the availability, use and misuse of sedative, hypnotic and anxiolytic medications and to increased detection, awareness and diagnosing of SHA‐UD.

INTRODUCTION

Sedative, hypnotic and anxiolytic (SHA) substances include benzodiazepines (BZD), z‐hypnotics and related medications. The majority of prescription medications used to treat sleep and anxiety disorders fall within the SHA category. Many of these medications are scheduled substances by the Drug Enforcement Administration, meaning that they have been identified as carrying a risk of misuse and dependency. Almost half of adolescents reporting medical prescription SHA use also report non‐medical misuse by age 18 [1]. The past year prevalence of SHA misuse is estimated to be 0.9% in adolescents (12–17 years) and 2.6% in young adults (18–25 years) [2] with 13% of 18‐year‐olds reporting lifetime SHA misuse [1]. A subset of individuals who misuse SHA substances develop a sedative, hypnotic or anxiolytic use disorder (SHA‐UD) [2, 3].

SHA‐UD is defined by significant impairment or distress caused by recurrent SHA use [4]. Impairment can include health problems; failure to fulfill obligations at work, school or home; interpersonal problems; reduction in work, school or social activities; persistent or increasing use; and unsuccessful effort to control use [4]. In a 2021 national epidemiologic survey, 2.2 million individuals in the United States (US) were estimated to have a SHA‐UD², with 0.5% of adolescents (12–17 years) and 0.9% of young adults (18–25 years) meeting criteria for a SHA‐UD [2].

The prevalence of SHA‐UD is consistently reported to be higher in young adults than adolescents and adults [2, 3, 5, 6, 7], but variation by sex and race and ethnicity is less understood. Although medical prescriptions for SHA medications are more common in females than males, the misuse of these substances appears more similar by sex [6]. SHA use and misuse are higher in white, non‐Hispanic individuals than individuals of other racial and ethnic groups [8]. Past year misuse of SHA medications ranged from 2.1% among white individuals followed by Hispanic (1.3%), Black (1.3%) and Asian (0.5%) individuals [2]. However, BZD use disorder was observed to be more common in Black adults than in white adults [3].

There is also limited data on SHA‐UD trends. Misuse of BZDs and muscle relaxants was observed to be relatively stable in individuals 12+ years of age from 2005/2006 to 2013/2014 [9], with minimal changes in adolescents (1.7%–1.8%) and young adults (5.3%–5.5%) from 2016 to 2017 [8]. In more recent years, self‐reported SHA misuse declined in high school students [10]. However, overdose deaths involving BZDs and other SHA medications increased significantly over the last two decades [11, 12]. How trends in diagnosed SHA‐UDs have varied over the past two decades and whether trends are consistent across age, sex and racial and ethnic groups remain unclear.

Although cross‐sectional epidemiological surveys have collected data on SHA misuse and SHA‐UD based on symptoms, to our knowledge, national trends of adolescents and young adults diagnosed with SHA‐UD have not been previously reported. Examining the prevalence and trends of youth diagnosed with a SHA‐UD offers an opportunity to broaden our understanding of SHA‐UD, focus on a sample more likely to need subsequent care and inform allocation of resources for this young population. Further, mental health and substance use disorders are more prevalent in individuals insured by Medicaid than by private insurance [13], representing an important population to examine SHA‐UD trends. We, therefore, sought to describe trends in SHA‐UD diagnoses in adolescents and young adults enrolled in Medicaid from 2001 to 2019 by age, sex and race and ethnicity.

METHODS

Our analysis used Medicaid Analytic eXtracts (MAX) and Transformed Medicaid Statistical Information System Analytic Files (TAF) administrative fee‐for‐service claims and managed care encounter data from 2001 to 2019. Medicaid MAX and TAF files (‘Medicaid’) cover individuals insured by Medicaid or the Children's Health Insurance Program (CHIP) [14]. Medicaid was designed to provide health coverage to low‐income people and represents the largest collection of healthcare data for youth in the United States. We used patient‐level information on enrollment, demographic characteristics and inpatient and outpatient services.

The study cohort included Medicaid data from 42 states with enrollment and inpatient/outpatient data available for all years during 2001 to 2019 (Table 1 footnote). Within each calendar year, we selected adolescents (13–17 years) and young adults (18–29 years). Age was based on end of calendar year. We included individuals with ≥10 months of Medicaid enrollment during that calendar year and full scope benefits. We excluded individuals with dual Medicaid‐Medicare eligibility, in long‐term care facilities or enrolled in separate state CHIPs (S‐CHIP) at any point in the calendar year.

TABLE 1.

Prevalence of SHA‐UD diagnoses in adolescents and young adults enrolled in Medicaid, 2001–2019.

Year	Adolescents (13–17 y)			Young adults (18–29 y)
	Total	No. with SHA‐UD dx	%	18–24 y			25–29 y
				Total	No. with SHA‐UD dx	%	Total	No. with SHA‐UD dx	%
2001	3 011 620	394	0.01	1 820 455	656	0.04	871 852	722	0.08
2002	3 381 900	425	0.01	1 997 537	816	0.04	949 719	843	0.09
2003	3 776 125	458	0.01	2 157 444	910	0.04	1 014 697	910	0.09
2004	4 009 419	509	0.01	2 199 324	1034	0.05	1 053 556	1136	0.11
2005	4 238 798	610	0.01	2 252 793	1188	0.05	1 082 753	1260	0.12
2006	4 209 175	634	0.02	2 242 496	1320	0.06	1 079 525	1490	0.14
2007	4 114 659	712	0.02	2 232 055	1392	0.06	1 048 888	1520	0.14
2008	4 173 366	772	0.02	2 381 457	1452	0.06	1 139 387	1759	0.15
2009	4 453 642	909	0.02	2 645 478	1930	0.07	1 238 884	2182	0.18
2010	4 735 240	1036	0.02	2 889 488	2315	0.08	1 352 005	2645	0.20
2011	4 919 603	1032	0.02	2 994 416	2833	0.09	1 441 976	3566	0.25
2012	5 212 486	1047	0.02	3 105 309	3181	0.10	1 498 762	4369	0.29
2013	5 433 347	1060	0.02	3 055 549	3291	0.11	1 509 500	4943	0.33
2014	5 900 963	1241	0.02	3 792 542	4003	0.11	2 113 745	6619	0.31
2015	6 122 983	1847	0.03	4 501 386	5989	0.13	2 804 247	10 126	0.36
2016	6 025 514	2406	0.04	4 235 690	6106	0.14	2 750 289	10 282	0.37
2017	6 244 473	2477	0.04	4 428 531	6541	0.15	2 899 437	11 454	0.40
2018	6 199 316	2521	0.04	4 351 897	6523	0.15	2 816 370	11 517	0.41
2019	6 279 083	2485	0.04	4 231 726	5996	0.14	2 654 466	10 794	0.41

Note: CMS Medicaid data, 2001–2019; pooled 42 states (Alabama, Alaska, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kentucky, Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming).

Abbreviation: SHA‐UD, sedative, hypnotic and anxiolytic use disorder.

For a secondary cohort, we further excluded seven additional states because of potential concerns in capturing diagnoses over the study period. This was defined as states with more than a 200% year‐to‐year shift in SHA‐UD diagnosis prevalence for any year from 2001 to 2019. These states were excluded from the secondary cohort because of the possibility that the sudden changes in prevalence were a function of data capture or quality shifts rather than a true shift in SHA‐UD.

We defined a SHA‐UD as one or more International Classification of Diseases (ICD) diagnostic code during the calendar year from an inpatient or outpatient file. Included diagnostic codes were: ICD‐9‐Clinical Modification (CM): 304.1x (SHA dependence), 305.4x (nondependent SHA abuse); ICD‐10‐CM: F13.1x (SHA‐related abuse), F13.2x (SHA‐related dependence). Given increased specificity with ICD‐10‐CM codes, some SHA‐specific ICD‐10‐CM codes map back to general, non‐specific ICD‐9‐CM codes (e.g. 292.0 drug withdrawal; 292.1x drug‐induced psychotic disorders); these ICD‐9‐CM codes were not included as they are not substance‐specific.

Age, sex and race and ethnicity were included as primary stratification variables. Race and ethnicity were identified from enrollment files and classified into mutually exclusive groups: Black, non‐Hispanic; Hispanic, all races; White, non‐Hispanic; other, non‐Hispanic; (hereafter, Black, Hispanic, White, other, respectively); unknown. We stratified by persons with and without a BZD, z‐hypnotic or barbiturate prescription dispensed during that calendar year, because these are SHA medications that are controlled substances. We additionally stratified trends by persons with and without any anxiety disorder, attention deficit hyperactivity disorder (ADHD) or sleep disorder diagnosis as these are prevalent conditions correlated with SHA use. For those with a SHA‐UD diagnosis in 2019, comorbid diagnoses were identified through inpatient/outpatient ICD‐10‐CM codes for other substance related disorders and common mental health conditions in that calendar year. Adolescents and young adults were additionally grouped by Medicaid coverage type as of their last enrolled month in the year, classified as (a) fee‐for‐service; (b) comprehensive managed care; or (c) other managed care.

All results were stratified by adolescents and young adults. The proportion of individuals with a SHA‐UD diagnosis was estimated annually from 2001 to 2019, by dividing the number of eligible enrollees with a diagnosis during that calendar year by all eligible enrollees during that calendar year. Data were pooled across the 42 states. Trends were further stratified by sex, race and ethnicity, SHA prescription medication status and mental health diagnoses. Analyses stratified by race and ethnicity were restricted to states missing <25% of race and ethnicity information for each year of our study. The prevalence of SHA‐UD diagnoses was summarized across four timepoints (2001, 2007, 2013 and 2019), with the relative percent change and absolute percent difference from 2001 versus 2019, with the P‐value for absolute change within group. We described sex, race and ethnicity and comorbid substance use disorders and mental health diagnoses in youth with a SHA‐UD diagnosis in 2019. To examine if trends were influenced by shifting prevalence of managed care and changes in the capture of diagnostic claims, we stratified by provider payment arrangement (i.e. fee‐for‐service/managed care). Medicaid expansion [15] began under the Affordable Care Act in 2014 and broadened the eligibility for Medicaid enrollment in participating states. Given the shifting denominator, we examined whether trends were observed in states with and without Medicaid expansion by 2019. The analysis was not pre‐registered and the results should be considered exploratory.

RESULTS

There were 3 011 620 eligible adolescents and 2 692 307 young adults in 2001 and 6 279 083 adolescents and 6 886 192 young adults in 2019. In 2019, 48.6% of eligible adolescents were female and 35.9% Hispanic, 32.3% White and 19.6% Black. In 2019, 58.9% of eligible young adults were female and 35.6% White, 30.2% Hispanic and 18.4% Black.

Among adolescent Medicaid enrollees, the prevalence of SHA‐UD diagnoses increased from 0.01% in 2001 to 0.04% in 2019 (P < 0.01), with an average change of 0.0015 percentage points per year (Table 1; Figure 1). In young adult Medicaid enrollees, the prevalence of SHA‐UD diagnoses increased from 0.05% in 2001 to 0.24% in 2019 (P < 0.01), with an average change of 0.011 percentage points per year. Within the young adult age group, SHA‐UD diagnoses were twice as prevalent in those age 25 to 29 years versus 18 to 24 years (Table 1). Trends were consistent in the secondary cohort (Table S1).

FIGURE 1.

Prevalence of sedative, hypnotic and anxiolytic use disorder (SHA‐UD) diagnoses in adolescents and young adults by sex. CMS Medicaid data, 2001–2019; pooled 42 states.

Increasing trends in SHA‐UD diagnosis prevalence were observed in males and females. In 2016, the difference in SHA‐UD prevalence between males and females widened with a higher prevalence in males (Figure  1 ; Table 2). By 2019, 0.31% of young adult males had a SHA‐UD diagnosis versus 0.20% of females compared to similar prevalence previously (2014: 0.20% males vs. 0.17% females).

TABLE 2.

Prevalence of SHA‐UD diagnoses by patient characteristic in 2001, 2007, 2013 and 2019.

	2001	Row %	2007	Row %	2013	Row %	2019	Row %	2019 vs. 2001
	Use disorder diagnosis, No.		Use disorder diagnosis, No.		Use disorder diagnosis, No.		Use disorder diagnosis, No.		% relative change	% absolute change	P‐value within group, absolute change
Adolescents 13–17 y
Sex
Male	217	0.01	376	0.02	600	0.02	1521	0.05	232	0.03	<0.01
Female	177	0.01	336	0.02	460	0.02	964	0.03	165	0.02
Race, ethnicity a
White, non‐Hispanic	179	0.03	293	0.03	334	0.03	574	0.04	69	0.02	<0.01
Black, non‐Hispanic	24	0.00	38	0.00	57	0.01	130	0.02	284	0.01
Hispanic	59	0.01	90	0.01	198	0.02	1035	0.07	363	0.05
BZD prescription in year	28	0.11	46	0.11	84	0.13	106	0.18	60	0.07	0.12
No BZD prescription	366	0.01	666	0.02	976	0.02	2379	0.04	212	0.03
BZD, z‐hypnotic or barbiturate prescription	46	0.09	66	0.09	107	0.12	119	0.17	88	0.08	0.01
No BZD, z‐hypnotic or barbiturate	348	0.01	646	0.02	953	0.02	2366	0.04	224	0.03
Anxiety diagnosis in year	19	0.06	78	0.12	260	0.14	804	0.19	192	0.12	<0.01
No anxiety diagnosis in year	375	0.01	634	0.02	800	0.02	1681	0.03	128	0.02
ADHD diagnosis in year	49	0.04	151	0.05	304	0.06	634	0.11	210	0.08	<0.01
No ADHD diagnosis in year	345	0.01	561	0.01	756	0.02	1851	0.03	170	0.02
Sleep disorder diagnosis in year	a	a	32	0.10	91	0.12	221	0.19	a	a	<0.01
No sleep disorder diagnosis in year	a	a	680	0.02	969	0.02	2264	0.04	a	a
Young adults 18–29 y
Sex
Male	502	0.07	931	0.09	3167	0.20	8706	0.31	348	0.24	<0.01
Female	876	0.04	1981	0.09	5067	0.17	8084	0.20	346	0.15
Age group
18–24 y	656	0.04	1392	0.06	3291	0.11	5996	0.14	293	0.11	<0.01
25–29 y	722	0.08	1520	0.14	4943	0.33	10 794	0.41	391	0.32
Race, ethnicity a
White, non‐Hispanic	523	0.08	1215	0.14	2502	0.23	5837	0.38	367	0.30	<0.01
Black, non‐Hispanic	73	0.01	126	0.02	314	0.05	854	0.11	624	0.09
Hispanic	43	0.01	108	0.03	246	0.04	1141	0.09	529	0.07
BZD prescription in year	587	0.52	1300	0.73	3507	1.24	4745	2.00	284	1.48	<0.01
No BZD prescription	791	0.03	1612	0.05	4727	0.11	12 045	0.18	491	0.15
BZD, z‐hypnotic or barbiturate in year	694	0.39	1485	0.60	3893	1.04	5188	1.77	352	1.38	<0.01
No BZD, z‐hypnotic or barbiturate	684	0.03	1427	0.05	4341	0.10	11 602	0.18	547	0.15
Anxiety diagnosis in year	443	0.59	1186	0.88	4281	1.31	9527	1.25	111	0.66	<0.01
No anxiety diagnosis in year	935	0.04	1726	0.05	3953	0.09	7263	0.12	232	0.08
ADHD diagnosis in year	37	0.23	206	0.35	956	0.61	2183	0.95	322	0.73	<0.01
No ADHD diagnosis in year	1341	0.05	2706	0.08	7278	0.17	14 607	0.22	338	0.17
Sleep disorder diagnosis in year	98	0.42	314	0.59	1004	0.98	2574	1.48	254	1.06	<0.01
No sleep disorder diagnosis in year	1280	0.05	2598	0.08	7230	0.16	14 216	0.21	342	0.16

Abbreviations: ADHD, attention deficit hyperactivity disorder; BZD, benzodiazepines.

^a Race/ethnicity results limited to states with <25% missing race/ethnicity data for years 2001–2019; Included states: Arkansas, California, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Kentucky, Minnesota, Montana, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Dakota, Texas, Utah, Virginia, West Virginia, Wyoming.

Among adolescents and young adults with a SHA‐UD diagnosis in 2019, 38.8% and 48.1% were female, respectively, and the majority had another substance use disorder diagnosed and a comorbid mental health condition (Table 3). Cannabis use disorder was the most common comorbid substance use disorder in adolescents (61.9%), whereas opioid use disorder was the most common in young adults (66.6%) (Table 3).

TABLE 3.

Adolescents and young adults with a SHA‐UD diagnosis in Medicaid in 2019.

	Adolescents (13–17 y) with SHA‐UD in 2019, n = 2485	Young adults (18–29 y) with SHA‐UD in 2019, n = 16 790
Female, No. (%)	964 (38.8)	8.084 (48.1)
BZD prescription in year, No. (%)	106 (4.3)	4745 (28.3)
BZD, z‐hypnotic or barbiturate prescription in year, No. (%)	119 (4.8)	5188 (30.9)
Comorbid substance disorder diagnosis, any a , No. (%)	1901 (76.5)	15 241 (90.8)
Opioid	254 (10.2)	11 179 (66.6)
Cannabis	1537 (61.9)	7018 (41.8)
Stimulant	374 (15.0)	7874 (46.9)
Alcohol	483 (19.4)	5900 (35.1)
Other	790 (31.8)	7170 (42.7)
Comorbid mental health conditions, No. (%)
Any mental health diagnosis	1875 (75.4)	13 214 (78.7)
Anxiety disorder	804 (32.4)	9527 (56.7)
ADHD	634 (25.5)	2183 (13.0)
Depression disorder	1085 (43.7)	8284 (49.3)
Sleep disorder	221 (8.9)	2574 (15.3)
Race, ethnicity b , No. (%)	n = 1887	n = 8720
Black, non‐Hispanic	130 (6.9)	854 (9.8)
Hispanic	1035 (54.8)	1141 (13.1)
White, non‐Hispanic	574 (30.4)	5837 (66.9)
Other, non‐Hispanic	50 (2.6)	237 (2.7)
Unknown	98 (5.2)	651 (7.5)

Abbreviations: ADHD, attention deficit hyperactivity disorder; BZD, benzodiazepines; SHA‐UD, sedative, hypnotic, anxiolytic use disorder.

^a ICD‐10‐CM codes: F10, F11, F12, F14, F15, F16, F18, F19 (excludes nicotine dependence).

^b Race/ethnicity results limited to states with <25% missing race/ethnicity data for years 2001–2019; Included states: Arkansas, California, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Kentucky, Minnesota, Montana, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Dakota, Texas, Utah, Virginia, West Virginia, Wyoming.

The prevalence of SHA‐UD varied across race and ethnicity groups (Figure  2 ). In 2019, the prevalence ranged from 0.02% in Black adolescents to 0.07% in Hispanic adolescents and from 0.09% in Hispanic young adults to 0.38% in White young adults. An increasing trend from 2001 to 2019 was observed across all race and ethnicity groups (P < 0.01). The greatest relative increases in prevalence from 2001 to 2019 were among Black (624%) and Hispanic (529%) young adults (Table 2). The largest absolute change from 2001 to 2019 was in White young adults (0.30 percentage points) and, for adolescents, in Hispanic individuals (0.05 percentage points).

FIGURE 2.

Prevalence of sedative, hypnotic and anxiolytic use disorder (SHA‐UD) diagnoses in adolescents and young adults by race and ethnicity in states with limited missing race and ethnicity data. CMS Medicaid data, 2001–2019; limited to states with <25% missing race/ethnicity data for years 2001–2019; 25 states (included states: Arkansas, California, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Kentucky, Minnesota, Montana, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Dakota, Texas, Utah, Virginia, West Virginia, and Wyoming).

During the study period, 1.09% to 1.75% of enrolled adolescents and 4.26% to 9.01% of young adults had a BZD, z‐hypnotic or barbiturate prescription each calendar year. Among adolescents and young adults with a BZD, z‐hypnotic or barbiturate prescription in 2019, the prevalence of SHA‐UD was five and 10 times higher, respectively, compared to adolescents and young adults without a BZD, z‐hypnotic or barbiturate prescription (Table 2). In young adults with a BZD prescription, the prevalence of SHA‐UD diagnoses increased from 0.52% (2001) to 2.00% (2019) versus 0.03% (2001) to 0.18% (2019) in young adults without a BZD prescription (Figure S1). SHA‐UD was more common in adolescents and young adults with an anxiety, ADHD or sleep disorder diagnosis than those without these comorbid diagnoses (Table 2). The prevalence of SHA‐UD increased in those with and without a mental health diagnosis. Among adolescents with an anxiety disorder, the prevalence of SHA‐UD rose from 0.06% (2001) to 0.19% (2019) and from 0.01% to 0.03% in adolescents without an anxiety disorder.

Overall trends in SHA‐UD diagnoses were consistent across Medicaid provider payment arrangement (e.g. fee‐for‐service, managed care), with variation in magnitude (Figure S2). Increases in diagnosed SHA‐UD from 2001 to 2019 were seen in states with and without Medicaid expansion by 2019 (Figure S3).

DISCUSSION

In the last two decades, the prevalence of SHA‐UD diagnoses increased approximately threefold to fivefold in adolescent and young adult Medicaid enrollees. However, the overall prevalence remains low, particularly in adolescents. Although SHA‐UD remain less common than other substance use disorders [2, 16], SHA‐UDs in this young population warrant clinical attention given the associated morbidity, treatment difficulties and association with other substance use problems. Our results on diagnosed SHA‐UD complement reports of SHA‐UD prevalence based on in‐person interviews [2], and have more direct implications for SHA‐UD treatment. Further, for a subset of young people, there are opportunities for prevention through more judicious prescribing of SHA prescription medications.

Similar to results from survey data based on patient interviews [2, 3, 5, 6, 7, 8], we observed SHA‐UD diagnoses to vary by age, sex and race/ethnicity, with the highest prevalence observed in White, young adult males. This information can assist in targeting detection and treatment efforts. SHA‐UD are consistently found to be more prevalent in young adults, with SHA medications more commonly prescribed to, and misused by, young adults than adolescents [2, 17, 18, 19]. Further, we observed a higher prevalence of diagnosed SHA‐UD in White, non‐Hispanic young adults compared to other racial and ethnic groups. This aligns with reports on BZD misuse [6] and estimates on lifetime prevalence of any drug use disorder being higher in White adults than Black and Hispanic adults [16, 20]. However, the largest relative increases in SHA‐UD diagnoses were seen in non‐White adolescents and young adults, indicating a need for focused investigations on the recent rise in SHA‐UD diagnoses in non‐White youth.

SHA medications are accessed through medical prescriptions or non‐medical sources (e.g. friend, medicine cabinet and dealer) [21]. Pathways to SHA‐UD meeting the Diagnostic Statistical Manual of Mental Disorders (DSM) criteria include escalating use outside a medical prescription and originally obtaining SHA medication through a prescription [4, 22]. The majority of adolescents (95%) and young adults (69%) diagnosed with a SHA‐UD in 2019 did not have a SHA prescription dispensed in that same calendar year. This suggests that most SHA‐UD occur in young people without current SHA prescriptions. However, among adolescents and young adults with a SHA prescription dispensed, SHA‐UD diagnoses were substantially more prevalent. Further, SHA‐UD were more prevalent among adolescents and young adults with an anxiety disorder, ADHD or sleep disorder diagnosis, conditions that are associated with prescription SHA medications. Improving SHA prescribing and targeting SHA users may be means to reduce SHA‐UD in this young population. Prescribing substances with potential for misuse to younger patients should be approached with caution. Still, efforts targeting non‐medical use of SHA medications remains imperative as younger age of SHA misuse onset is associated with an increased risk of SHA‐UD [23, 24].

Caution is warranted when interpreting the increasing trends in SHA‐UD diagnoses as the increase is likely a function of multiple factors and partially related to increases in screening, recognition and diagnostic regimens. These changes could affect observed trends as we only capture diagnosed SHA‐UDs and, therefore, capture SHA‐UDs with sufficient severity to be brought to clinical attention and subsequently diagnosed. As such, studies based on self‐report symptoms find higher SHA‐UD prevalence, with estimates of 0.9% in young adults (2021, 18–25 years) [2] compared to our estimate of 0.24% (2019, 18–29 years). Further, regarding changes in diagnostics, individuals with SHA‐related conditions may have received non‐SHA specific diagnoses, which may have been more common under the ICD‐9‐CM coding system. For example, ICD‐9‐CM codes did not capture SHA‐withdrawal. Increases in the likelihood that a person with a SHA‐UD received a specific‐diagnosis during the last two decades would result in an observed increased prevalence of SHA‐UD diagnoses in Medicaid claims data. Additionally, the Affordable Care Act (2014) offered increased access to treatment of substance use disorders and required new parity mandates for behavioral health coverage including substance use disorder treatment [15, 25]. This may have affected diagnosing of SHA‐UD as screening and treatment access shifted.

SHA misuse and SHA‐UDs are associated with other substance use and other substance use disorders [3, 19, 26, 27]. The majority of persons reporting SHA misuse also reported alcohol use (91%), marijuana use (62%) and opioid misuse (54%) [9]. Similarly, we observed that the majority of adolescents and young adults with a SHA‐UD diagnosis in 2019 had a comorbid substance use disorder. Comorbid cannabis use disorder was particularly prevalent in adolescents (62%) and young adults (42%) with a SHA‐UD in our sample, which may be partially related to shared correlates for use, such as anxiety disorders [28]. The high prevalence of other substance use disorders in adolescents and young adults with a SHA‐UD carries important implications for this young population, including treatment that focuses on poly‐substance use/disorders. For example, BZDs were the secondary substance in the majority (84%–85%) of BZD‐related substance abuse treatment admissions in youth [29], highlighting the frequency of comorbid substance use disorders.

The increases in SHA‐UD diagnoses in the last two‐decades occurred within the context of rising prevalence of other substance use disorders. For example, cannabis use disorder diagnoses rose substantially from 2005 to 2019 (0.85%–1.92%) among patients treated in the Veterans Health Administration [30], opioid use disorder rose threefold in older adults from 2013 to 2018 [31], methamphetamine use disorder increased in adults from 2015 to 2019 [32] and treatment admissions involving BZDs and narcotic pain reliever abuse increased 570% from 2000 to 2010 [33]. More work is needed to examine the influence of other substance use disorders in the rise of SHA‐UD.

In the last two decades, variations in the prescribing, misuse and diversion of SHA substances may have led to increases in SHA‐UD. BZD‐related overdose deaths increased substantially from 1996 to 2013¹² along with increases in emergency department visits for BZDs [34], suggesting increases in BZD misuse. However, the percent of 12th grade students reporting past‐year SHA misuse declined since 2002/2005, reaching record lows in 2021 [10]. Prescriptions for BZDs and z‐hypnotics began trending downward in recent years in the United States [17, 35]. In privately insured youth, BZD prescriptions increased from approximately 2008 to 2013, then began to decline from 2015 to 2019 [17]. Although reported declines in SHA misuse and SHA prescriptions in young people are in contrast to the rising SHA‐UD diagnoses, SHA‐related treatment admissions have generally increased in the last two decades. The number of individuals receiving treatment for BZDs or muscle relaxants (‘tranquilizers’) almost doubled from 2002 to 2013 (197 000–376 000) [36] as did substance use disorder treatment admissions with tranquilizers as the primary substance (2005 = 8712; 2011 = 19 294; 2017 = 20 657) [37, 38]. Treatment admissions with barbiturates and other SHA medications as the primary substance, however, declined (2005 = 4509; 2019 = 2839) [37, 38]. A similar finding of declining opioid misuse with increasing opioid abuse and dependence was described, with authors highlighting the continued importance of appropriate opioid prescribing and expanding medication assisted treatment services for individuals with opioid use disorders [39]. There are multiple factors contributing to the rise in SHA‐UD diagnoses in youth, nevertheless, our findings highlight the need for available SHA‐UD treatment for this young population.

Limitations of the work should be considered. First, observed trends may be influenced by shifts in the underlying population covered by Medicaid, because eligibility requirements varies by state and over time, and by changes in Medicaid coverage of behavioral health care, generally in the direction of increasing coverage over time. Second, Medicaid data completeness and quality may vary across states and years by provider payment arrangement; however, results were consistent when restricting to states with potentially more consistent data capture and when stratified by payment arrangement. Because this study aimed to estimate nationwide Medicaid trends, Medicaid data from 42 states were aggregated. The prevalence of SHA‐UDs varied by US state (2019 prevalence range by state, adolescents: 0.01%–0.12%, young adults: 0.06%–0.65%); state‐level changes were not evaluated. Third, we are unable to evaluate the range in the severity and symptoms among youth receiving a SHA‐UD diagnosis and the validity of the SHA‐UD diagnostic codes is unclear. ‘In‐remission sub‐codes’ were included in the definition. We did not separately consider SHA‐abuse and dependence diagnoses because extensive research shows that they form part of a single continuum of substance use disorders [40]. Fourth, no information was provided about commercially insured and uninsured young people. Fifth, we stratified trends by SHA prescriptions and mental health diagnoses within each calendar year, but we did not consider timing of SHA prescriptions and comorbid diagnoses in relation to the SHA‐UD diagnosis. Future investigations into the trajectory of common mental health comorbidities, such as ADHD, with SHA prescriptions, SHA misuse and SHA‐UD will inform prevention efforts. Sixth, current analyses do not estimate incidence, which would require data with a lifetime reference period. Finally, the transition from ICD‐9‐CM to ICD‐10‐CM diagnostic codes occurred in October 2015, with more specificity offered under ICD‐10‐CM. However, trends rose before and after the transition to ICD‐10‐CM. Strengths of the study include the utilization of two‐decades of Medicaid data covering the full publicly insured population from 42 states, estimating for the first‐time trends in diagnosed SHA‐UD, consistent methods across the study period, examination of trends by age, sex and race and ethnicity, and secondary and sensitivity analyses to evaluate consistency of trends.

The prevalence of SHA‐UD diagnoses increased substantially between 2001 and 2019 for adolescent and young adult Medicaid enrollees, but remains low, particularly in adolescents. These findings represent the first national estimates of diagnosed SHA‐UD among young people. The increase in SHA‐UD over the past two decades may be attributed to changes not only in the availability, use and misuse of SHA medications, but also an increased detection and awareness of SHA‐UD along with changes in diagnostic procedures.

AUTHOR CONTRIBUTIONS

Greta Bushnell: Conceptualization (equal); data curation (supporting); formal analysis (equal); funding acquisition (lead); methodology (equal); project administration (lead); resources (lead); writing—original draft (lead). Kristen Lloyd: Data curation (lead); formal analysis (equal); methodology (equal); writing‐review & editing (equal). Mark Olfson: Conceptualization (equal); formal analysis (supporting); methodology (equal); writing‐review & editing (equal); supervision (equal). Tobias Gerhard: Conceptualization (equal); formal analysis (supporting); methodology (equal); resources (supporting); writing‐review & editing (equal). Katherine Keyes: Conceptualization (equal); formal analysis (supporting); methodology (equal); writing‐review & editing (equal). Magdalena Cerdá: Conceptualization (equal); formal analysis (supporting); methodology (equal); writing‐review & editing (equal). Deborah Hasin: Conceptualization (equal); formal analysis (supporting); methodology (equal); writing‐review & editing (equal); supervision (equal).

DECLARATION OF INTERESTS

M.C. and K.K. have testified as an expert witness in litigation. T.G. reports grants from Sanofi outside the submitted work. G.B, K.L., D.H. and M.O. report no conflicts of interest relevant to this article to disclose.

Supporting information

Table S1. Prevalence of SHA‐UD diagnoses in adolescents and young adults with state restrictions applied *.

Figure S2. Prevalence of SHA‐UD diagnoses in adolescents and young adults enrolled in Medicaid, 2001–2019 stratified by type of payment arrangement.

Figure S3. Prevalence of SHA‐UD diagnoses in adolescents and young adults by states with and without Medicaid expansion by 2019.

Figure S1. Prevalence of SHA‐UD diagnoses in adolescents and young adults enrolled in Medicaid stratified by benzodiazepine, z‐hypnotic, or barbiturate prescriptions dispensed in that calendar year.

Bushnell G, Lloyd K, Olfson M, Gerhard T, Keyes K, Cerdá M, et al. Nationwide trends in diagnosed sedative, hypnotic or anxiolytic use disorders in adolescents and young adults enrolled in Medicaid: 2001–2019. Addiction. 2025;120(5):951–961. 10.1111/add.16749

DATA AVAILABILITY STATEMENT

The Medicaid data that support the findings of this study are available from the Centers for Medicare & Medicaid Services. Restrictions apply to the availability of these data, which were used under license for this study.