By Mark Pew, Senior VP, Preferred Medical
This week I want to highlight two articles about prescription drug use in America and the dangers it causes. The first article is about benzodiazepines and the rise in prescriptions over the years. The second article is about opioids and trying to find a solution to the crisis in our country. Below you’ll find these articles and my thoughts on their implications.
Steep Climb In Benzodiazepine Prescribing By Primary Care Doctors
A recently published study reports benzodiazepine prescriptions have doubled from 2003 to 2015. Although these drugs (medications like Valium, Ativan and Xanax) are commonly used to treat anxiety, this study found that a large percentage of the prescriptions during this time were used for back pain and other chronic pain issues. What many people don’t realize is that benzodiazepines are very similar to opioids and you can easily develop a dependence and become addicted. This study highlights the problem we have in America with benzodiazepines and leads us to the question about what we need to do about the prescription drug problem.
The overuse of benzodiazepines is largely hidden from the mainstream. It’s been a problem for many years—at least as far back as 2003 when I saw them constantly co-prescribed with opioids (something the CDC said in 2016 should NOT be done). One psychologist friend calls Rx benzos “evil” and I know why—he deals with the after effects of addiction and the difficulties of weaning. Here are the ridiculous observations:
- “The percentage of outpatient medical visits that led to a benzodiazepine prescription doubled from 2003 to 2015”
- “About half those prescriptions came from primary care physicians”
- “The biggest rise in prescriptions during this time period was for back pain and other types of chronic pain”
- “From 2005 to 2015, continuing prescriptions (i.e. long-term use) increased by 50 percent”
- “Previous studies have shown a nearly eight-fold rise in mortality rates from overdoses involving benzodiazepines – from 0.6 in 100,000 people in 1999 to 4.4 in 2016”
Why are doctors prescribing even MORE? Why are we making matters WORSE? There is a legitimate role for benzodiazepines in some clinical circumstances. For example, during hospice care (from my personal experience with my Dad). For claustrophobic people getting an MRI where a single pill can help. And for people that have recurring panic attacks and high anxiety where a benzo controls those symptoms with limited side effects. But those examples—in my opinion—are not the majority. With the statistics outlined in this article it’s obvious that benzos are being used way too often, for the wrong clinical conditions, prescribed by the wrong clinicians, with a long-term negative impact. Abuse potential is high (they have tremendous street “value” in price and addiction) and discontinuing their use is complex and potentially dangerous…
Physiological dependence on benzodiazepines is accompanied by a withdrawal syndrome which is typically characterized by sleep disturbance, irritability, increased tension and anxiety, panic attacks, hand tremor, sweating, difficulty in concentration, dry wretching and nausea, some weight loss, palpitations, headache, muscular pain and stiffness and a host of perceptual changes. Instances are also reported within the high-dosage category of more serious developments such as seizures and psychotic reactions. Withdrawal from normal dosage benzodiazepine treatment can result in a number of symptomatic patterns. The most common is a short-lived “rebound” anxiety and insomnia, coming on within 1-4 days of discontinuation, depending on the half-life of the particular drug. The second pattern is the full-blown withdrawal syndrome, usually lasting 10-14 days; finally, a third pattern may represent the return of anxiety symptoms which then persist until some form of treatment is instituted. Physiological dependence on benzodiazepines can occur following prolonged treatment with therapeutic doses, but it is not clear what proportion of patients are likely to experience a withdrawal syndrome. It is also unknown to what extent the risk of physiological dependence is dependent upon a minimum duration of exposure or dosage of these drugs. Withdrawal phenomena appear to be more severe following withdrawal from high doses or short-acting benzodiazepines. Dependence on alcohol or other sedatives may increase the risk of benzodiazepine dependence, but it has proved difficult to demonstrate unequivocally differences in the relative abuse potential of individual benzodiazepines.
So tell me again why we should be prescribing more benzos? It’s time to get educated and make better choices!
The Importance Of Patient-Centric Opioid Prescribing Guidelines
The opioid crisis in America has been front and center for a while now, with many regulators and health authorities attempting in various ways to reduce the number of opioids prescribed. Many think that the best route is to taper or stop prescribing. However, this can lead to worsening of pain, withdrawal and loss of function. It’s important to reduce the amount of inappropriate use but it must be done in a strategic and thoughtful way. A patient-centric view when prescribing opioids is the best approach, using the CDC guidelines to help physicians individually asses and tailor treatment based on patient evaluations.
I agree wholeheartedly with this article and the conclusions included in the referenced “Pain Medicine” letter. Their words are consistent with my words—AllOfTheAbove. You never know what’s going to work for a person so you need access to every single evidence-based modality possible. If it’s not working, change it. If it IS working, don’t change it. You know…common sense. Or as this author describes it…”a discussion focused on identification of best treatment practices for chronic pain patients.” If Rx opioid tapering is best for the patient, it needs to be done strategically and the Rx void needs to be replaced with other coping mechanisms. As I’ve often said, it is inhumane to take away someone’s drugs and not replace them with something else that will help them better manage their chronic pain (or any other condition). The goal is “Appropriate, Not Zero, Opioids” treatment that is “individualized and nuanced.” I agree that the CDC recommendations have perhaps been “misinterpreted” by both opponents and proponents. Their guidelines never say that opioids should never be used. “Start low and go slow” and establishing/measuring goals for pain and function is part of their advice, as well as inclusion of non-opioid/non-pharma treatment options. But the guidelines are also clear that opioids should not be “first-line or routine therapy for chronic pain” and that great care needs to be taken at 50mg MED and 90mg MED aggregate dosages. The combination of a complicated problem and a nuanced solution can create unintended consequences:
- “Overzealous use of the CDC’s opioid prescribing guideline is harming pain patients” from STAT…”As a result, some physicians who specialize in pain management are leaving their practices, while others are tapering their patients off of opioids, solely out of fear of losing their licenses or criminal charges.”
- “Opioid policy fallout” from Medical Economics…”‘But we also have to recognize there are no easy answers for dealing with that high-dose legacy group,’ he adds. ‘You can’t just make the problem go away by saying we won’t pay for that kind of [high-dose] prescribing anymore, because that throws patients into a state of withdrawal.’“
- “The Physicians’ Quandary with Opioids: Pain versus Addiction” from NEJM Catalyst…”Many front line physicians and clinical leaders feel caught in the middle – acknowledging the national crisis of opioid addiction and wanting to adhere to the new guidelines, but also wanting to decrease patients’ pain.”
Getting ourselves out of this mess is complicated. But what is not complicated is always focusing on doing the right thing for the patient.
To read everything on my mind this past week, please visit me on LinkedIn.
Disclaimer: The views and opinions expressed above are those of Mark Pew, and do not necessarily reflect the views of Preferred Medical.
About Mark Pew
Mark Pew, Senior Vice President of Product Development and Marketing for Preferred Medical, is a passionate educator and agitator. Known as the RxProfessor, Mark is focused on the intersection of chronic pain and appropriate treatment, particularly as it relates to the clinical and financial implications of prescription painkillers, non-pharma treatment modalities and the evolution of medical marijuana. He is a strong champion for the workers’ compensation industry to #PreventTheMess and #CleanUpTheMess, movements he created to drive attention to the importance of individualized appropriate treatment for injured workers. Mark is a vocal advocate of the BioPsychoSocialSpiritual treatment model.
Mark serves on the IAIABC’s Medical Issues Committee and SIIA’s Workers’ Compensation Committee. In addition, he serves as technical advisor to regulators and legislators in 20+ jurisdictions on subjects such as drug formularies, treatment guidelines, Opioid Task Force initiatives, encouraging support of non-pharma treatment options and the medicinal use of cannabis. Mark received the WorkCompCentral Magna Comp Laude award in 2016 and the IAIABC’s Samuel Gompers Award in 2017.