Benzodiazepine use across the legal and illegal continuum in Europe and implications for clinical burden and deprescribing

Abstract Benzodiazepines (BZDs) remain widely used across Europe for anxiety, insomnia, and related indications, despite longstanding recommendations limiting treatment duration and prioritising non-pharmacological care. Alongside sustained prescribing, Europe is characterised by a “legal–illegal continuum” in which authorised medical use, diversion and non-medical consumption, and illicit markets—including novel BZDs monitored as new psychoactive substances—interact and amplify clinical harm. Recent European data demonstrate marked inter-country variability in consumption patterns and high prevalence among older adults, raising safety concerns in both community and long-term care settings. The associated clinical burden extends beyond physiological dependence and withdrawal to include falls, cognitive impairment, driving impairment, and elevated overdose risk, particularly in the context of polysubstance use involving opioids or alcohol. Deprescribing has therefore emerged as a key public health priority. Available evidence indicates that single-component interventions produce modest and inconsistent effects, whereas multicomponent approaches combining gradual tapering with behavioural or educational support are associated with higher discontinuation rates, although certainty of evidence varies. This narrative review examines European epidemiological, toxicological, and clinical evidence across the legal–illegal continuum, examines system-level drivers of persistent exposure, and proposes a pragmatic conceptual framework for European practice integrating stepped care, risk stratification, coordinated tapering, and implementation strategies at primary care, pharmacy, and policy levels.