According to a recent study, the percentage of outpatient medical encounters leading to a benzodiazepine prescription has doubled from 2003 to 2015, while over half of those prescriptions came from Primary Care Physicians (PCPs).
Benzodiazepines are a class of drugs that include the most commonly used medicines such as Valium, Ativan, and Xanax. While these are commonly prescribed for insomnia, anxiety and epilepsy, the study was able to find that the sharp rise in benzodiazepine prescriptions during this time period was primarily for backache and other types of long-standing pain. The results published online in JAMA Network Open.
Clonazepam and diazepam belong to benzodiazepines group of drugs and are better known by the brand names Klonopin and Valium, respectively. The drug family also includes Librium, Ativan, and Halcion.
According to researchers, the new study found that the long-term use of benzodiazepine has increased, while they are best when used for a shorter duration. From 2003 to 2015, benzodiazepine prescription increase by nearly 50 percent.
Long-term use of benzodiazepine class of drugs can increase the risk of drug dependence, addiction, and even death from overdose.
One of the authors of the study, Dr. Sumit Agarwal, a PCP and researcher at Brigham and Women’s Hospital in Boston, said, “I don’t think people realize that benzodiazepines share many of the same characteristics of opioids.” “They are addictive.” “They cause you to have slower breathing; they cause you to be altered in terms of mental status. And then, eventually, (they) can cause overdose and deaths.”
Previous studies have found a nearly eightfold rise in the mortality rates from a drug overdose, including benzodiazepines, from 0.6 in 100,000 people in 1999 to 4.4 in 2016.
“That’s somewhere around 10,000 to 12,000 deaths at the hands of benzodiazepines,” explains Dr. Agarwal. “This rise is happening quietly, outside of the public eye.”
According to a recent survey by the U.S. CDC, the mortality rate due to drug overdoses, including benzodiazepine, for women has increased by nearly 830 percent from 1996 to 2017.
Agrawal explains that PCPs often prescribe benzodiazepines to women because they are more likely to visit the clinic for the treatment of depression and anxiety.
Anna Lembke, an associate professor of psychiatry and medical director of addiction medicine at Stanford University School of Medicine, says, “The study highlights that we have a very serious problem with benzodiazepines.”
An associate professor at the department of medicine at the Albert Einstein College of Medicine, Dr. Joanna Starrels, says, “I am concerned that our national focus on opioids has hidden the problem related to benzodiazepines — that’s our next frontier.”
Lembke noted that the steep rise in outpatient medical visits that have led to the prescriptions of benzodiazepine was from PCPs and not from psychiatrists.
She reckons the biggest message here is that PCPs are left with the burden of dealing with chronic pain, opioid prescription, as well as benzodiazepine prescription.
She adds, “The trends reflect the incredible burden of care on primary care physicians, who are given little time, or resources to handle a high volume of pain patients with complex conditions.” “That’s partly what got us into the opioid epidemic in the first place.”
Starrels says, “Generally speaking, primary care physicians have not received the training that they need to prescribe medications that have such high risk for addiction or overdose.” “Primary care doctors are the frontline providers.”
In many settings, especially in rural areas, there are only PCPs. So they end up treating those conditions that are to be treated by specialists, such as chronic pain, addiction, and anxiety. Given the steep rise in benzodiazepine prescriptions for backache and chronic pain, it may be the situation where benzodiazepines are replacing opioids, explains Lembke.
However, Starrels mentions that there is a possibility they were advised benzodiazepines for insomnia or anxiety along with chronic pain. That because the new study could not determine whether they were advised benzodiazepines only for backache or chronic pain.
Lembke notes that the new study has also found that co-prescribing for benzodiazepines with opioids has increased during this period; however, that is not essentially a bad thing.
Furthermore, she says, “What we don’t want doctors to do is cut patients off of opioids.” “That’s neither humane nor medically the right path. Some of these co-prescribing may be because doctors are tapering patients off of opioids.”
However, co-prescribing can be dangerous. Benzodiazepines and opioids make your central nervous system sluggish, increasing the risk of death of overdose. So, it is dangerous so they are not prescribed together.
In fact, in 2016, the U.S. FDA warned physicians about the dangers of prescribing anxiety medications and opioids in conjunction.
Dr. Agarwal says that the FDA warning may have a good impact on the prescription rates of anxiety medications and it could be interesting to see the data of the next couple of years.
PCPs who want their patients to discontinue their long-term use of benzodiazepines should do it gradually over time; otherwise, they get vulnerable to withdrawal symptoms. Starrels cautions, “It has to be slow and medically monitored over time because sudden withdrawal can be fatal.”
She explained that PCPs should get better guidelines for prescribing drugs acting on the central nervous system. Dr. Agarwal says, “People have started calling this ‘our other prescription drug problem,’ the first one being opioids, but this one’s flying under the radar.” “It would be great if we address it before it becomes an epidemic if there isn’t already one.”
