Classified as a Controlled Substance on Par with Heroin in the U.S. … A Doctor Explains the Risks of “Depas,” Prescribed for Insomnia, Headaches, and Stiff Shoulders

“Stiff shoulders,” “headaches,” “trouble falling asleep at night”—

There are likely many people who have visited a medical facility for these common symptoms and been prescribed “Depas.” The generic name for Depas is etizolam. In Japan, it has been used across a wide range of medical specialties since the 1980s. However, there is a surprisingly large difference in how this drug is treated in Japan and the United States.

This year, the U.S. Drug Enforcement Administration (DEA) permanently classified etizolam as a “Schedule I” controlled substance. Schedule I is the strictest classification in the U.S. drug control system and includes substances such as heroin, LSD, and MDMA.

In Japan, on the other hand, it is still not uncommon for it to be prescribed not only for anxiety and insomnia but also for everyday complaints such as headaches and stiff shoulders.

A drug with the same active ingredient is subject to enforcement as an illegally distributed substance in the U.S., while in Japan, it is routinely dispensed at hospitals and pharmacies. Why has such a significant disparity arisen? We asked Dr. Yushi Yamada, a geriatric medicine specialist practicing in the U.S. (Quotes below are from Dr. Yamada).

“In the United States, Depas (etizolam) is not approved as a prescription drug, so doctors cannot prescribe it to patients for therapeutic purposes. It has historically been treated as an illegal drug traded outside the legitimate pharmaceutical distribution system. Because it has no recognized medical uses and abuse and illegal distribution have become major issues, it has been placed in the strictest regulatory category.”

Just because it has been designated as a Schedule I substance does not mean that Depas has the same toxicity as heroin, MDMA, or LSD. What is viewed as a problem in the U.S. is the abuse and dependence associated with Depas. However, a drug that is not recognized as a legitimate treatment in the U.S. continues to be prescribed in Japan for common symptoms.

The Deep-Rooted “Depas First” Mindset

In Japan, in October 2016, etizolam was designated as a Class III psychotropic drug. Although it had been a prescription-only medication prior to that, it was not subject to regulations as a psychotropic drug and was widely prescribed for insomnia, headaches, stiff shoulders, and lower back pain; there was even a time when it was treated like a “magic pill that works for everything.”

Patients can easily feel its effects and often request it. Furthermore, it was not uncommon for doctors to mindlessly repeat prescriptions simply because “it’s working.” In this way, the habit of “Prescribing Depas Just in Case” became entrenched in Japan’s medical practice.

However, lurking behind this trend are the problems of dependence and long-term use. As patients continue taking the medication, they become anxious when they run out, and the same dose becomes less effective over time. Discontinuing the medication can lead to symptoms such as insomnia, anxiety, sweating, palpitations, and hand tremors.

While some doctors claim, “It’s safe as long as you take it as prescribed,” it has been medically established that Depas is both habit-forming and addictive. In fact, there are patients who have been taking it continuously for decades.

“At least for now, I don’t think it’s a drug we should actively use as a first-line treatment, ” Dr. Yamada emphasized.

“I have never prescribed Depas (etizolam), but I have never had any difficulty treating patients without it. Today, there are more appropriate treatments and medications that take dependency into account for each specific condition. There is no need to continue choosing it simply because it has been used for a long time.”

Given the system in which a drug that is highly addictive and difficult to quit is prescribed indiscriminately, it is no surprise that critics are asking, “Isn’t this an addiction business?” Dr. Yamada also points out, “We cannot deny the possibility that prescribing this drug ultimately leads to profits for medical institutions.”

“The biggest problem is that ‘old treatment conventions’ remain in place without being updated. When Depas first came onto the market , treatment options were limited. However, both medications and diagnostic technologies have evolved since then. Doctors who continue to prescribe it simply because ‘it’s been prescribed for a long time’ are not keeping up with the latest knowledge. I have to say they are failing to keep pace with the times.”

Prescribing doctors are also under scrutiny

In the United States, there are also benzodiazepine-based drugs approved for medical use, such as diazepam, lorazepam, and alprazolam. However, the regulatory framework is far stricter than in Japan.

In the U.S., registration with the DEA is required to prescribe controlled substances, and many states operate a prescription drug monitoring program (PDMP), which records which doctor prescribed which medication to which patient, when, and in what quantity.

This system prevents patients from obtaining the same medication from multiple healthcare providers and also prevents physicians from prescribing unnaturally large quantities of medication.

“In the U.S., both patients and prescribing physicians are monitored. The idea that prescribing controlled substances entails responsibility is built into the system.”

In Japan, too, the sharing of medication information is advancing through the My Number health insurance cards and electronic prescriptions. However, it is difficult to say that a system is in place to proactively prevent abuse and duplicate prescriptions, or to verify physicians’ prescribing patterns.

That said, please avoid making a decision on your own after reading this article—such as deciding, “Depas is dangerous, so I’ll stop taking it starting today.” This is because patients who have been taking the medication for a long time may experience withdrawal symptoms—such as insomnia, anxiety, palpitations, sweating, and tremors—if they suddenly stop taking it on their own. In severe cases, seizures may also occur.

“When tapering off the medication, it is necessary to consult with your primary care physician and gradually reduce the dosage while monitoring your condition. This is not just the patient’s responsibility; it is paramount for physicians to build a relationship of trust with their patients, address their anxieties, and take the time to support them through the tapering process.”

The strict regulations in the United States have brought to light issues regarding the prescribing practices of benzodiazepines in Japan and the problems within the healthcare system that has tolerated overly casual prescribing.

“This isn’t limited to Depas. Are we prescribing the necessary dosage for the necessary duration to patients who truly need it? I believe we need to reevaluate whether prescriptions are continuing based on past practices, even when safer alternatives are available. To achieve this, I believe it is paramount for each physician to continuously learn the latest evidence and maintain a proactive stance toward updating their prescribing practices.”