Both rate and dose of prescriptions of benzos increasing

[birchswing]

http://www.newser.com/story/220829/fatal-overdoses-of-common-anxiety-meds-are-spiking.html

The first part of this (that benzo prescriptions are increasing) isn't news, but I found it interesting that the average dose in each prescription is rising.

I don't think people are sharing a single reality on this issue. Some doctors I talk to think this is a problem of the past, but if these numbers are correct it looks like it's an increasing problem.

I hope this gets more and more attention. Opiate addiction is in presidential stump speeches and in the State of the Union address, but I've never heard a legislator or other person of high influence at a national level speak about benzos.

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[smalltownpsych]

Benzos have a much lower fatality rate than opiates and there is no powerful street equivalent like heroin, thus it's neverr going to get the same anount of attention. In fact, what I have been hearing more about lately is the danger of benzos and opiates together.

 

[nexus73]

The article contains a lot of hypotheses, but no real data to support a substantial theory. Benzodiazepine prescribing is certainly concerning, and I would never have someone on longer than a few weeks, at most a couple of months, and only in the setting of severe emotional crisis. And I tend to avoid benzodiazepines to begin with. My hypothesis is overuse of benzodiazepines plus other drugs in lethal combination are the likely culprit. We know benzodiazpine only overdoses are less commonly fatal.

Ultimately, the doctor who can limit benzodiazepine prescribing to a few weeks in the setting of severe crisis (or the occasional patient with panic disorder who gets an rx of xanax 1 mg x 4 tabs every three months), and can limit opioids to acute pain issues, again likely a month or less, will have a much healthier patient panel. The doctor will also have a lot less stress.

 

[splik]

I think benzos have their role including occasionally in the long term. It is important to know the indication, and choose patients appropriately. I don't use PRN benzos on an outpatient basis as this reinforces avoidance and dysfunctional beliefs about emotions being harmful or dangerous which only worsens or exacerbates anxiety states in the long run. Also PRNs aren't all that helpful as the anxiety/panic has already dissipated by the time the drug kicks in leading patients falsely to assume the drug was what helped. I do think the use should be very limited, but the problem is once you start someone on a prescription it can be hard to stop it, and that is why the best thing to do is to avoid prescribing them as far as possible. If you do use them, you should anticipate the possibility of having to continue them long-term and be okay with this. I have my long-term patients sign a contract and provide informed consent regarding the risks of increased mortality, accidents, dependency, withdrawal which can be fatal, and lack of evidence for long-term effectiveness, as well as no early refills and instances which will lead to tapering (diversion, doctor shopping, abuse of other substances, failure to attend appointments, lost/stolen prescriptions, escalating use) However there are a number of cases where it would be indicated to use benzos:

- patients with mania or hypomania, particularly to reduce the burden of neuroleptics which are far more neurotoxic than benzos. In patients declining other drugs it may be acceptable to use clonazepam alone
- catatonia, including periodic catatonia, and catatonia in the absence of major mental illness (for example in patients with neurodevelopmental disorders and intellectual disability)
- management of REM-sleep behavior disorder
- patients with severe OCD who have debilitating anxiety and have not responded to or been able to tolerate ERP and anafranil. Personally would prefer to use benzos than risperidone or other antipsychotic as adjunctive treatment
- patients with traumatic brain injury with significant agitation or aggression. There is risk of paradoxical reaction but it can often be helpful
- patients with agitation and aggression in the setting of advanced dementia (may be used as an adjunct or instead of neuroleptics- neither is ideal)
- patients with complex PTSD (for example from genocides, prisoners of war etc) who are still experiencing current threat. These patients do not really respond to PE or CPT and may not respond or tolerate SSRIs, SNRIs, mirtazapine, trazodone, or prazosin. They may respond somewhat to narrative approaches and then there are interpreter challenges too. We often manage these patients with significant improvement on as little as 0.5mg clonazepam which they can stay on for years without dose escalation
- patients with chronic psychotic illness who do not respond to, cannot tolerate, or choose not to take neuroleptics

Richard Balon wrote a short defense of Benzos in JAMA Psychiatry

 

[nexus73]

I think benzos have their role including occasionally in the long term. It is important to know the indication, and choose patients appropriately. I don't use PRN benzos on an outpatient basis as this reinforces avoidance and dysfunctional beliefs about emotions being harmful or dangerous which only worsens or exacerbates anxiety states in the long run. Also PRNs aren't all that helpful as the anxiety/panic has already dissipated by the time the drug kicks in leading patients falsely to assume the drug was what helped. I do think the use should be very limited, but the problem is once you start someone on a prescription it can be hard to stop it, and that is why the best thing to do is to avoid prescribing them as far as possible. If you do use them, you should anticipate the possibility of having to continue them long-term and be okay with this. I have my long-term patients sign a contract and provide informed consent regarding the risks of increased mortality, accidents, dependency, withdrawal which can be fatal, and lack of evidence for long-term effectiveness, as well as no early refills and instances which will lead to tapering (diversion, doctor shopping, abuse of other substances, failure to attend appointments, lost/stolen prescriptions, escalating use) However there are a number of cases where it would be indicated to use benzos:

- patients with mania or hypomania, particularly to reduce the burden of neuroleptics which are far more neurotoxic than benzos. In patients declining other drugs it may be acceptable to use clonazepam alone
- catatonia, including periodic catatonia, and catatonia in the absence of major mental illness (for example in patients with neurodevelopmental disorders and intellectual disability)
- management of REM-sleep behavior disorder
- patients with severe OCD who have debilitating anxiety and have not responded to or been able to tolerate ERP and anafranil. Personally would prefer to use benzos than risperidone or other antipsychotic as adjunctive treatment
- patients with traumatic brain injury with significant agitation or aggression. There is risk of paradoxical reaction but it can often be helpful
- patients with agitation and aggression in the setting of advanced dementia (may be used as an adjunct or instead of neuroleptics- neither is ideal)
- patients with complex PTSD (for example from genocides, prisoners of war etc) who are still experiencing current threat. These patients do not really respond to PE or CPT and may not respond or tolerate SSRIs, SNRIs, mirtazapine, trazodone, or prazosin. They may respond somewhat to narrative approaches and then there are interpreter challenges too. We often manage these patients with significant improvement on as little as 0.5mg clonazepam which they can stay on for years without dose escalation
- patients with chronic psychotic illness who do not respond to, cannot tolerate, or choose not to take neuroleptics

Richard Balon wrote a short defense of Benzos in JAMA Psychiatry

This is a problematic quote from Balon's letter: "In the case of selective serotonin reuptake inhibitors, these phenomena have been termed discontinuation syndromes but are in no way milder or less troublesome than those entailed by benzodiazepines."

 

[splik]

i think he has clearly overstated the case, but the point he is making is correct which is that SRIs cause withdrawal symptoms, it's nothing other than euphemistic to call them "discontinuation syndromes" and they can be particularly terrible with some people reporting persistent symptoms or being completely unable to get off SRIs and experiencing brain zaps and other phenomena. but of course you can't die from it unlike benzo withdrawal but most patients on benzos aren't going to die from benzo withdrawal.

 

[nexus73]

i think he has clearly overstated the case, but the point he is making is correct which is that SRIs cause withdrawal symptoms, it's nothing other than euphemistic to call them "discontinuation syndromes" and they can be particularly terrible with some people reporting persistent symptoms or being completely unable to get off SRIs and experiencing brain zaps and other phenomena. but of course you can't die from it unlike benzo withdrawal but most patients on benzos aren't going to die from benzo withdrawal.

Agreed. Though the lack of craving in SRI withdrawal is a huge difference between the drugs as well, and what makes benzos much more concerning from an addiction standpoint. Nobody develops SRI use disorder.

 

[TexasPhysician]

Have we considered the possibility of a national benzodiazepine deficiency?

In all seriousness, there are many drugs that should be used sparingly by physicians, but I disagree that government regulation is the answer. If anything, it pushes more Norco users to heroin. Creating chronic pain centers that increase paperwork and government taxes has done little to fix the problem except irritate physicians.

My opinion: There should be better education of the risks of all addictive substances, routine checks by pharmacies of state controlled substance databases to cut off supply, and improved access to addiction centers.

Research shows that addiction often begins in the late teenage years and the drugs are much more likely to be obtained from family than anyone else. Second is from friends. Physicians initiating the addiction is but a small percentage of a large problem with addiction.

 

[Shikima]

i think he has clearly overstated the case, but the point he is making is correct which is that SRIs cause withdrawal symptoms, it's nothing other than euphemistic to call them "discontinuation syndromes" and they can be particularly terrible with some people reporting persistent symptoms or being completely unable to get off SRIs and experiencing brain zaps and other phenomena. but of course you can't die from it unlike benzo withdrawal but most patients on benzos aren't going to die from benzo withdrawal.

Try using Prozac to help with discontinuation syndrome. A low dosage for 2-4 weeks has helped to eliminate this in my practice when it happens. It's anecdotal but could help you.

 

[Shikima]

I think benzos have their role including occasionally in the long term. It is important to know the indication, and choose patients appropriately. I don't use PRN benzos on an outpatient basis as this reinforces avoidance and dysfunctional beliefs about emotions being harmful or dangerous which only worsens or exacerbates anxiety states in the long run. Also PRNs aren't all that helpful as the anxiety/panic has already dissipated by the time the drug kicks in leading patients falsely to assume the drug was what helped. I do think the use should be very limited, but the problem is once you start someone on a prescription it can be hard to stop it, and that is why the best thing to do is to avoid prescribing them as far as possible. If you do use them, you should anticipate the possibility of having to continue them long-term and be okay with this. I have my long-term patients sign a contract and provide informed consent regarding the risks of increased mortality, accidents, dependency, withdrawal which can be fatal, and lack of evidence for long-term effectiveness, as well as no early refills and instances which will lead to tapering (diversion, doctor shopping, abuse of other substances, failure to attend appointments, lost/stolen prescriptions, escalating use) However there are a number of cases where it would be indicated to use benzos:

- patients with mania or hypomania, particularly to reduce the burden of neuroleptics which are far more neurotoxic than benzos. In patients declining other drugs it may be acceptable to use clonazepam alone
- catatonia, including periodic catatonia, and catatonia in the absence of major mental illness (for example in patients with neurodevelopmental disorders and intellectual disability)
- management of REM-sleep behavior disorder
- patients with severe OCD who have debilitating anxiety and have not responded to or been able to tolerate ERP and anafranil. Personally would prefer to use benzos than risperidone or other antipsychotic as adjunctive treatment
- patients with traumatic brain injury with significant agitation or aggression. There is risk of paradoxical reaction but it can often be helpful
- patients with agitation and aggression in the setting of advanced dementia (may be used as an adjunct or instead of neuroleptics- neither is ideal)
- patients with complex PTSD (for example from genocides, prisoners of war etc) who are still experiencing current threat. These patients do not really respond to PE or CPT and may not respond or tolerate SSRIs, SNRIs, mirtazapine, trazodone, or prazosin. They may respond somewhat to narrative approaches and then there are interpreter challenges too. We often manage these patients with significant improvement on as little as 0.5mg clonazepam which they can stay on for years without dose escalation
- patients with chronic psychotic illness who do not respond to, cannot tolerate, or choose not to take neuroleptics

Richard Balon wrote a short defense of Benzos in JAMA Psychiatry

I would like to see head to head analysis in combining SSRI/SNRI/Abilfy compared to Benzos. Subjectively, I suspect Benzos would win out because it placates the reward center.

 

[Promethean]

Research shows that addiction often begins in the late teenage years and the drugs are much more likely to be obtained from family than anyone else. Second is from friends. Physicians initiating the addiction is but a small percentage of a large problem with addiction.

You and I agree that there are many drugs that should be used sparingly, and we agree that government regulation is likely to do more harm than good. We would do better to regulate ourselves, using extreme restraint in prescribing and monitoring patients to whom we do prescribe dangerous drugs. Every opiate or benzo prescription should be accompanied by a frank discussion regarding the potential danger of the drug, how to use it wisely and how to safely dispose of unused drug... (I was once given a script for a month's worth of demerol pills (& 2 refills!) with less counselling regarding addiction potential than I got regarding the rare side effects of atorvastatin.

Our society has lost respect for how dangerous these drugs are, while simultaneously coming to expect them to be prescribed for even mild pain. That didn't happen on its own. It required an entire generation of prescribers (including mid-levels as well as physicians) repeating the lie that addiction doesn't happen to people who are treating real problems. I'm sure most of them believed it. I did, because it is what my professors told me. But it is a lie that deals a double blow... not only can you become addicted to a drug that you are using for legitimate reasons, but when it happens, that means that you must have been doing something wrong. The lie made addiction a moral fault, inevitably the result of some malingering or diversion or thrill-seeking by the patient. By refusing to acknowledge that addiction is an entirely predictable result of the biochemical properties of the drug itself, it becomes easier to assuage our own consciences.

There is a reason that our society has chosen to set up gatekeepers to control access to pharmaceuticals. They are useful, but very dangerous. Physicians aren't given the right to prescribe them because we are very smart people who deserve to be in charge of what others can and cannot access. We are entrusted with using our educated judgment to help people while minimizing the harm that comes to them.

No matter how pharmaceuticals end up in individual user's hands, they generally left the pharmacy as prescriptions. The physician may not have written for that teen who sampled the contents of their family medicine cabinet, but the physician did write for someone in the home. And for there to be "extra" pills laying about in such quantity as to lead to addiction suggests that those pills were prescribed in excess of the need of the intended patient. The unpleasant truth is, the responsibility for those patients that obtained prescribed drugs via household diversion still belongs partly to us. It is critical to embrace that, not just so that blame can assigned, but because responsibility implies opportunity to do better.

 

[TexasPhysician]

No matter how pharmaceuticals end up in individual user's hands, they generally left the pharmacy as prescriptions. The physician may not have written for that teen who sampled the contents of their family medicine cabinet, but the physician did write for someone in the home. And for there to be "extra" pills laying about in such quantity as to lead to addiction suggests that those pills were prescribed in excess of the need of the intended patient. The unpleasant truth is, the responsibility for those patients that obtained prescribed drugs via household diversion still belongs partly to us.

While there are certainly physicians too liberal with addictive meds, the solution above is not actionable. We can't exactly prescribe what is used.

When I had my wisdom teeth removed, I was Rxed some Norco that my mother filled. I never wanted it, so the entire script sat around.

It would be nice if the government made it easier to properly dispose of prescription drugs. There should be a disposal bin at pharmacies and physician offices. As it is now, the best solution may be digging a medication grave in the backyard.

 

[Promethean]

While there are certainly physicians too liberal with addictive meds, the solution above is not actionable. We can't exactly prescribe what is used.

When I had my wisdom teeth removed, I was Rxed some Norco that my mother filled. I never wanted it, so the entire script sat around.

It would be nice if the government made it easier to properly dispose of prescription drugs. There should be a disposal bin at pharmacies and physician offices. As it is now, the best solution may be digging a medication grave in the backyard.

It is incredibly easy to dispose of excess prescription drugs. Not only do municipalities, police, etc. sponsor all manner of formal "get rid of unwanted drugs" events, but a quick google search showed that the kinds of disposal bins you mention do exist at pharmacies and point of care facilities near me. I bet there are some near you, too. If not, dropping into your local police department (or pharmacy, etc) and requesting to turn in drugs for disposal would probably do the trick, or they would know where you could go.

And, while you can't determine the precise number of pills that a patient will need, so that they don't have one or two left sitting around, I am sure that one or two spare Norcos never addicted anyone. The problem comes from prescribing 30 days worth for an acute problem that will likely resolve to a tolerable level of discomfort in 3 days. Or giving multiple refills for the same issue. I mentioned that I'd been prescribed Demerol (probably the highest abuse potential of any pharmaceutical opiate because of its particular receptor affinities) for a problem that, like your wisdom teeth, I didn't really need any opiates to manage. That is what I'm talking about.

It is absolutely actionable to treat every script as if it has the potential to be diverted, or to be misused by the intended patient, not because they are bad people but because that is a known adverse affect of the drug. It costs nothing to but a moment of time and attention to advise patients not to fill a script if they find that they don't need the drug, to advise them where and how to dispose of extra meds, to warn them of the risks associated with using these drugs and to talk about alternative pain/anxiety management approaches that they can use to minimize their reliance upon pharmaceuticals.

 

[TexasPhysician]

Police stations generally do dispose of drugs, but that isn't a practical solution. Few people are willing to make a trip there (especially if the drugs are illicit). It needs to be convenient. Pharmacies, physician offices, and grocery stores in my area do not accept unwanted meds.

I'm tired of politics putting the burden on physicians when politics is often to blame. There is still a focus on punishment over treatment. Government sponsored treatment facilities have huge wait times. Suboxone is more regulated than Norco. Disposing meds at a private facility has many regulations. Medicare pays physicians less for counseling/education than volume.

 

[Jester25]

What is your understanding of REM suppression by benzos in comparison to SSRIs/TCAs. I rarely prescribe benzos and the main reason for that is increased all cause mortality by 3-5x compared to general population, worsening cognitive function, worsening motor coordination, decreases/impairs learning, physiologic dependency, and their suppression on REM sleep. I was recently told that SSRIs/TCAs are more potent suppressors of REM than benzos which I was suprised about. I know the antidepressants suppress REM, but I have not read anywhere that it's worse than benzos. Can anyone comment on that?

 

[PistolPete]

What is your understanding of REM suppression by benzos in comparison to SSRIs/TCAs. I rarely prescribe benzos and the main reason for that is increased all cause mortality by 3-5x compared to general population, worsening cognitive function, worsening motor coordination, decreases/impairs learning, physiologic dependency, and their suppression on REM sleep. I was recently told that SSRIs/TCAs are more potent suppressors of REM than benzos which I was suprised about. I know the antidepressants suppress REM, but I have not read anywhere that it's worse than benzos. Can anyone comment on that?

Good question. I've mentioned this to a sleep physician, who states that benzos do suppress REM but that it's not clinically significant. Anyone have any further input?

 

[Shikima]

Yes, bzd do suppress REM. You can get REM rebound and REM parasomnia behaviors as the substance wears off. Just like ETOH. I have a running theory where DTs is REM intrusion into wakefulness. When I'm reading sleep studies and detect REM without Atonia (RWAT) without frank parasomnia behaviors observed, then I'm looking towards substances (working or wearing off) as the likely culprit.

TCA typically prolong the state of REM, not the same mechanism of action. Actually, there is no definitive knowledge on the biochem which is occurring for REM suppression. Or why depression has earlier onset of REM sleep. We're still learning about the brain. This will help you....

http://www.journalsleep.org/Articles/270219.pdf
"Antidepressants have substantial effects on REM sleep. Many studies show that they prolong REM sleep latency and suppress REM sleep time.5 They are also associated with reports of “vivid” dreams.6 In addition, case reports dating back 30 years show that antidepressants can induce RBD7 or reduce REM sleep atonia.8 In fact, medications with a wide variety of mechanisms of action have been implicated in producing loss of REM sleep atonia, including serotonergic reuptake blockers such as fluoxetine,9 monoamine oxidase inhibitors,10 β-adrenergic receptor blockers,11 the noradrenergic and 5-HT1A-mediated serotonergic enhancer mirtazapine,12 and the tricyclic antidepressants.13 However, no study has systematically assessed EMG tone during REM sleep in individuals chronically taking antidepressants. Given the number of individuals taking these medications, this issue is potentially of substantial public health importance."

One of the reasons which I typically avoid bzd as a first line agent for the treatment of insomnia is that it will make OSA worse. Even predicate the appearance of snoring. There was one research study which cited that 80% of sleep related disorders go undiagnosed - if this is a truism, I wouldn't want to make it worse for the person as they're already sleep deprived. Not to mention the heightened arousal state from the persistent anxiety has likely shifted their circadian rhythm into an unhealthy state.