Prescribed for Insomnia, Headaches, and Stiff Shoulders—But How Dangerous Is Depas?

“I have stiff shoulders.” “I have a headache.” “I can’t seem to fall asleep at night.”

Many people who have visited a medical institution with these common complaints have probably been prescribed Depas. The generic name of the drug is etizolam, and in Japan, it has been used across a wide range of medical specialties since the 1980s. Yet there is a surprisingly stark difference between how the drug is treated in Japan and the United States.

This year, the U.S. Drug Enforcement Administration (DEA) permanently placed etizolam in Schedule I, the strictest category under the U.S. Controlled Substances Act. The same category includes heroin, LSD, and MDMA.

In Japan, meanwhile, etizolam is still not uncommonly prescribed not only for anxiety and insomnia, but also for everyday complaints such as headaches and stiff shoulders.

The same substance is treated in the United States as an illicit drug subject to enforcement outside the legitimate pharmaceutical system, while in Japan it is routinely prescribed and dispensed through hospitals and pharmacies. Why is there such a dramatic difference? The publication spoke with Dr. Yuji Yamada, a geriatric medicine specialist practicing in the United States.

“In the United States, Depas (etizolam) is not approved as a pharmaceutical drug, so doctors cannot prescribe it to patients for therapeutic purposes. Historically, it has been treated as an illicit substance sold and distributed outside the legitimate pharmaceutical supply chain. Because it has no recognized medical use in the U.S. and concerns arose over abuse and illegal distribution, it was placed in the strictest regulatory category.”

Being placed in Schedule I does not mean that Depas has the same toxicity as heroin, MDMA, or LSD. What concerns U.S. authorities is the potential for abuse and dependence. Yet while the drug is not recognized as a legitimate treatment in the United States, it continues to be prescribed in Japan for familiar, everyday symptoms.

The deep-rooted just prescribed Depas culture

In October 2016, etizolam was designated a Class III psychotropic drug in Japan. Even before that, it was a prescription-only medication, but it was not subject to regulation as a psychotropic drug. It was prescribed broadly for insomnia, headaches, stiff shoulders, and lower-back pain—and there was even a time when it was treated almost like a magic pill that works for everything.

Its effects can be easy for patients to notice, which can lead them to request it. Meanwhile, doctors have not infrequently continued prescribing it repeatedly simply because it works. Over time, this created a culture of when in doubt, prescribe Depas in Japanese medical practice.

Behind that, however, lies the problem of dependence and long-term use. With continued use, patients may become anxious about being without the medication, and the same dose may gradually become less effective. Stopping the drug can also lead to symptoms such as insomnia, anxiety, sweating, heart palpitations, and trembling hands.

Some doctors insist that it is safe as long as it is taken as prescribed, but it is medically established that Depas can cause tolerance and dependence. In fact, there are patients who have continued taking it for decades.

“At the very least, I don’t believe it is a drug that should now be actively used as a first-line treatment,” Dr. Yamada says emphatically.

“I have never prescribed Depas (etizolam), and I have never found that to be an obstacle to treatment. Today, we have treatments better suited to specific conditions, as well as medications that take the risk of dependence into greater consideration. There is no reason to continue choosing a drug simply because it has been used for a long time.”

Given a system in which a drug that can be habit-forming and difficult to stop is prescribed routinely, it is perhaps unsurprising that critics might question whether it has become an addiction business. Dr. Yamada also points out that it cannot be ruled out that prescribing the drug may ultimately contribute to a medical institution’s profits.

“The biggest problem is that outdated treatment practices have survived without being updated. When Depas first came onto the market, there were limited alternatives. Today, however, both medications and diagnostic techniques have advanced. If doctors continue prescribing it simply because we’ve always prescribed it, that reflects a lack of study. It is hard to say they are keeping up with the times.”

Doctors who prescribed it are also monitored

The United States also has benzodiazepine medications approved for medical use, including diazepam, lorazepam, and alprazolam. However, the system for managing them is far stricter than in Japan.

In the U.S., doctors must register with the DEA to prescribe controlled substances, and many states operate prescription drug monitoring programs, or PDMPs. These systems record which doctor prescribed which medication, to which patient, when, and in what quantity.

The system is designed to prevent patients from obtaining the same medication from multiple healthcare providers, while also helping to identify doctors who prescribe unusually large quantities of controlled substances.

“In the United States, both patients and the doctors who prescribe these drugs are monitored. The idea that prescribing controlled substances comes with responsibility is built directly into the system.”

Japan has also made progress in sharing prescription information through the My Number health insurance card and electronic prescriptions. However, it is difficult to say that Japan has established a system that actively prevents abuse and duplicate prescriptions—or that systematically examines individual doctors’ prescribing patterns.

That said, readers should not conclude that Depas is dangerous and decide to stop taking it immediately on their own. Patients who have been taking the medication for a long time may experience withdrawal symptoms if they suddenly stop, including insomnia, anxiety, heart palpitations, sweating, and tremors. In severe cases, seizures may also occur.

“If the dose is to be reduced, it is necessary to consult with the treating physician and gradually taper the medication while monitoring the patient’s condition. This is not simply the patient’s responsibility. Above all, it is important for doctors to build a relationship of trust with their patients, address their concerns, and support them through the process of reducing the medication over time.”

What the strict U.S. regulations have brought into focus is the broader issue of how benzodiazepine-type medications are prescribed in Japan, as well as the shortcomings of a healthcare system that has tolerated overly casual prescribing.

“This is not an issue limited to Depas. We need to ask whether these drugs are truly being prescribed to the patients who need them, in the necessary amounts, and only for the necessary length of time. We should also reconsider whether prescriptions are continuing out of old habits even when safer alternatives are available. To do that, it is essential for every doctor to keep learning from the latest evidence and continually update their prescribing practices.”