The prescription benzodiazepine epidemic in a nutshell

[drusso]

http://www.nejm.org/doi/full/10.1056/NEJMp1715050?af=R&rss=currentIssue#.Wo4zQ67ZRSM.twitter

Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis

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[101N]

DrCommonSense posting a piece from PROP, my we've come a long way

 

[drusso]

DrCommonSense posting a piece from PROP, my we've come a long way

That's not me.

 

[lobelsteve]

Denial.....

I am just hoping to get my remaining folks down to 90meq before restarting my list on opi+bzd.
Currently I am counseling on risk of opi+bzd as well as 90+meq from medical standpoint.
SLowly, steadily.

 

[Ducttape]

If this association is causal, elimination of concurrent benzodiazepine/opioid use could reduce the risk of emergency room visits related to opioid use and inpatient admissions for opioid overdose by an estimated 15% (95% confidence interval 14 to 16).

what about the other 85% of visits and admissions?

some interesting decisions pertaining the study that may be limiting scope of the data.

however, it is a pretty thorough - but retrospective - study.

fairly obvious take home message - benzos increase risk of OD from opioids, above the underlying baseline risk of OD from opioids.

Among all opioid users, the annual adjusted incidence of an emergency room visit or inpatient admission for opioid overdose was 1.16% (95% confidence interval 1.13% to 1.18%; fig 3⇓) for those who did not use a benzodiazepine compared with 2.42% (2.32% to 2.51%) among concurrent benzodiazepine/opioid users, a significant difference (odds ratio 2.14, 95% confidence interval 2.05 to 2.24; P<0.001). Intermittent opioid users who used a benzodiazepine concurrently also experience a higher incidence of emergency room visits or inpatient admissions for opioid overdose (1.45%, 1.36% to 1.51%) compared with intermittent opioid users who did not use a benzodiazepine concurrently (1.02%, 0.996% to 1.04%), with an odds ratio of 1.42 (1.33 to 1.51; P<0.001). Chronic opioid users with concurrent benzodiazepine use also experienced a higher adjusted incidence of emergency room visits or inpatient admissions for opioid overdose (5.36%, 5.12% to 5.61%) compared with those who did not use benzodiazepines (3.13%, 2.94% to 3.31%), with an odds ratio of 1.81 (1.67 to 1.96; P<0.001).

 

[emd123]

Denial.....

I am just hoping to get my remaining folks down to 90meq before restarting my list on opi+bzd.
Currently I am counseling on risk of opi+bzd as well as 90+meq from medical standpoint.
SLowly, steadily.

That's all you have to do. It'll be worth it. And you'll stay plenty busy.

 

[drusso]

Antianxiety drugs — often more deadly than opioids — are fueling the next drug crisis in US

Today more than 40 million adults in America suffer from anxiety, and it is the most common mental illness in the United States. But even more of a crisis than the number of those diagnosed with anxiety is the number of people who are addicted to the drugs that treat it — and the rising number of people dying from overdoses.

 

[VA Hopeful Dr]

Xanax should be withdrawn from the market except for legacy patients 70 and older. The rest I don't love, but they don't cause near the same level of problems.

 

[lobelsteve]

Xanax should be withdrawn from the market except for legacy patients 70 and older. The rest I don't love, but they don't cause near the same level of problems.

Those at greatest risk of falls with typically lower TV and reserve? Class effect. They all stink. Use should be limited the same as opiates. 3 day supply. Limited to Psych Rx only for chronic use.

 

[Ducttape]

although 3 day supply is a lot less restrictive than opioids..........

 

[VA Hopeful Dr]

Those at greatest risk of falls with typically lower TV and reserve? Class effect. They all stink. Use should be limited the same as opiates. 3 day supply. Limited to Psych Rx only for chronic use.

Getting 80 year olds off of Xanax is quite problematic.

And I'm more worried about the mini-withdrawls that xanax users get multiple times per day right before their next dose.

 

[Ferrismonk]

Correct me if I'm wrong, but aren't benzodIazepines only indicated for short term use? Also, they are actually MORE dangerous in the elderly. In my anesthesia days, patients over 65 almost never got Versed from me.

 

[yankeeh8r]

Correct me if I'm wrong, but aren't benzodIazepines only indicated for short term use? Also, they are actually MORE dangerous in the elderly. In my anesthesia days, patients over 65 almost never got Versed from me.

Totally intended for short-term use only. The problem is the vast majority of Rxs, much like opioids, are from PCPs who just want to make the "problem" (i.e. the patient) go away. I have yet to meet a psychiatrist who supported or recommended benzos for anything other than clinically observable and debilitating panic attacks and even then wouldn't Rx more than a handful (i.e. 4-5 pills/month). Why is it that PCPs keep making these messes?

 

[Blitz2006]

Totally intended for short-term use only. The problem is the vast majority of Rxs, much like opioids, are from PCPs who just want to make the "problem" (i.e. the patient) go away. I have yet to meet a psychiatrist who supported or recommended benzos for anything other than clinically observable and debilitating panic attacks and even then wouldn't Rx more than a handful (i.e. 4-5 pills/month). Why is it that PCPs keep making these messes?

Agreed.

Benzos are usually used as a "bridge" to SSRIs for stuff like GAD, Panic Disorder. So like 8 weeks of benzos while increasing SSRI dose to optimal range (e.g. Zoloft 200 mg), and then taper off the benzo.


Xanax is the worst. It actually causes "rebound anxiety", because it has such a short half life.

Rebound anxiety in panic disorder patients treated with shorter-acting benzodiazepines. - PubMed - NCBI

" Eighty-two percent (39) of the patients rated clonazepam as being "better" than alprazolam due to decreased dosing frequency and lack of interdose anxiety. The authors conclude that clonazepam can be a useful alternative to alprazolam and other short-acting benzodiazepines in the treatment of anxiety disorders."

And this was published in 1987....

So when people "brag' about taking xanax to help them on a 12 hour flight...you're not.

Best for anxiety, panic disorder is CBT...

BTW, you can't even get Xanax in a hospital in the UK/NHS:

What you need to know about Xanax

"Xanax isn't available on the NHS, and can only be obtained on a private prescription in the UK."

 

[Ducttape]

they are viewed as less dangerous than opioids inasmuch as it is more difficult to die of a single drug OD with benzos than opioids.

Benzo withdrawal is definitely more dangerous than opioid withdrawal, though.

 

[Disciple]

Why is it that PCPs keep making these messes?

Because they don't want to see these patients. In many cases, they're forced to see them.

If they can't get out of seeing them, next best option is path of least resistance.

 

[VA Hopeful Dr]

Agreed.

Benzos are usually used as a "bridge" to SSRIs for stuff like GAD, Panic Disorder. So like 8 weeks of benzos while increasing SSRI dose to optimal range (e.g. Zoloft 200 mg), and then taper off the benzo.


Xanax is the worst. It actually causes "rebound anxiety", because it has such a short half life.

Rebound anxiety in panic disorder patients treated with shorter-acting benzodiazepines. - PubMed - NCBI

" Eighty-two percent (39) of the patients rated clonazepam as being "better" than alprazolam due to decreased dosing frequency and lack of interdose anxiety. The authors conclude that clonazepam can be a useful alternative to alprazolam and other short-acting benzodiazepines in the treatment of anxiety disorders."

And this was published in 1987....

So when people "brag' about taking xanax to help them on a 12 hour flight...you're not.

Best for anxiety, panic disorder is CBT...

BTW, you can't even get Xanax in a hospital in the UK/NHS:

What you need to know about Xanax

"Xanax isn't available on the NHS, and can only be obtained on a private prescription in the UK."

I stopped bridging with BZs several years ago. People always felt worse off of them and so always thought the SSRI wasn't working.

 

[drusso]

Prescriptions — and overdoses — are skyrocketing for anti-anxiety drugs that make opioids even more lethal

Experts say an explosion of benzodiazepine prescriptions in the middle of an opioid crisis is particularly concerning, because both drugs become much deadlier when mixed with each other.

www.philly.com

 

[willabeast]

Talked to a physician who had been in ETOH rehab. He had been addicted to alcohol 20+ years ago. He told me the only time he felt normal was when he was drinking. He basically never felt good unless he was drinking. Even 20 years later. Frightening.

 

[drusso]

https://www.washingtonpost.com/health/2022/02/10/cdc-opioid-prescriptions/

C.D.C. Proposes New Guidelines for Treating Pain, Including Opioid Use (Published 2022)

The agency threw out previous recommended limits on doses but encouraged “nonopioid therapies” wherever possible.

www.nytimes.com

"Though the dosing ceilings were merely a recommendation, dozens of states codified them. Fearing criminal and civil penalties, many doctors misapplied them as rigid standards, tapering chronic pain patients too abruptly and even tossing some from their practices."

 

[Baron Samedi]

Do these new guidelines mean that the CAM nonopioid modalities they mention such as massage and acupuncture will become covered insurance benefits?

I mention these to almost all my patients but none pursue it because the cash-only nature is prohibitive.

 

[drusso]

Do these new guidelines mean that the CAM nonopioid modalities they mention such as massage and acupuncture will become covered insurance benefits?

I mention these to almost all my patients but none pursue it because the cash-only nature is prohibitive.

There's no evidence that they work.

 

[RoloTomassi]

Hate how they always recommend CAM but never interventional pain treatment.

 

[lobelsteve]

Hate how they always recommend CAM but never interventional pain treatment.

Thank Roger

 

[bedrock]

Thank Roger

I must be a terrible person , but I seriously hope that guy develops severe back pain that can only be treated with RFA, or similar so he can then recant all the bull**** he has said over time.

 

[drusso]

I must be a terrible person , but I seriously hope that guy develops severe back pain that can only be treated with RFA, or similar so he can then recant all the bull**** he has said over time.

I confronted him at a restaurant. He was unrepentant.

 

[kstarm]

https://www.washingtonpost.com/health/2022/02/10/cdc-opioid-prescriptions/

C.D.C. Proposes New Guidelines for Treating Pain, Including Opioid Use (Published 2022)

The agency threw out previous recommended limits on doses but encouraged “nonopioid therapies” wherever possible.

www.nytimes.com

"Though the dosing ceilings were merely a recommendation, dozens of states codified them. Fearing criminal and civil penalties, many doctors misapplied them as rigid standards, tapering chronic pain patients too abruptly and even tossing some from their practices."

I got sucked into the comments...ugh. I always kick myself for doing that. Anytime there is any article about opioid prescribing you hear 100s of people writing about their severe fibromyalgia and the like, and the need for high dose opioids....I'll have to do better next time.