Anyhow im going into psych, and I personally remember laughing with the psych residents and attendings about family docs doing chronic benzo + opiods for their patients. In retrospect, I regret it bc I see these patients are doing way better than I originally thought. And there doesn't appear to be any landmark rct study that would make this practice completely absurd. But maybe residency training will make me feel differently
You do not seem to understand the basic principles of epidemiology of evidence-based practice. You do not need an RCT to tell you that combined benzos and opioids are bad when people are dropping dead on a daily basis from this combination. RCTs are done where there is theoretical equipoise between two options such that significant uncertainty exists. It would be completely unethical to do an RCT to see whether one option was more harmful than another, and it would be unethical to expose patients to harm when it is clear that the combination is harmful.
Opioids are not an effective treatment for chronic non-cancer pain. the evidence is pretty overwhelming that long-term opioids in chronic pain patients do more harm than good. Apart from the risks of dependence and addiction are, hyperalgesia, allodynia, subtle hypoxic-brain injury which can impair frontal lobe functioning, central sleep apnea, gonadal failure in men, impaired coordination and increased all-cause mortality risk. the evidence is quite clear that in general chronic opioids for chronic non-cancer pain do not improve functioning. As for benzodiazepines, I believe they amongst are the most effective drugs in the psychiatrists pharmacopoeia when used appropriately and judiciously. For example they can minimize neuroleptic burden in the treatment of mania, have remarkable effects in the treatment of catatonia of any cause, and can provide rapid relief in severe anxiety states. However again, the evidence is clear that they do not usually work after a month or so. In the original Xanax studies funded by Upjohn, it was clear that after 8 weeks, patients with panic disorder were were off in the alprazolam group than with placebo. There is little in the way of SSRI to benzo comparisons, most of the studies compare TCAs or MAOIs to benzos and benzos do quite favorably in these short trials. The wide use of SSRIs instead of benzos for neurotic disorders was entirely driven by the pharmaceutical industry, as it was many years after it was known that benzos had significant problems, that physicians starting turning to SSRIs instead. They can sometimes be effective, but personally, they have been overhyped, are often not effective in the treatment of anxiety states, and once someone has had a taste of Xanax it is very hard to sell something that can take weeks or months to show much in the way of effect. psychotherapeutic treatments like CBT and relaxation training are still the first line and most effective treatment for anxiety states.
There are of course exceptions in clinical practice, such that sometimes it may be appropriate to use benzos and opiates together but this would be exceedingly rare. However this is not just a matter for tort law if it goes horribly wrong, physicians can (and will) often face criminal prosecution for 2nd degree murder if your patients turn up dead after you've prescribed benzos and opioids for them. You may even find yourself liable for both lawsuit or criminal prosecution if death results from the patient diverting the prescription and you did not take steps that any reasonably prudent physician would in monitoring for diversion.
From what I've seen docs who liberally prescribe benzos, opiates, and stims are often desperate for the approval of others, want to be liked, avoid confrontation and have a hard time saying no. It is much easier to acquiesce to patient demand, and find it encouraging when patients initially do better, and to hear what a great doctor you are, or how you've been the only one to help your patients. That can be very gratifying. But we are not here to be gratified by our patients or to pander to their desire to be off their faces and obliterate any feeling that they have. One of the reasons why satisfaction ratings and other market-based initiatives in healthcare are flawed is because patients are satisfied more with bad care than they are with good care. A good physician is able to say "no". A great physician is able to do so in a way where the patient understands that their doctor cares about their wellbeing.
