Benzodiazepines: The Other Epidemic
The opioid epidemic has become an all-too-familiar topic in hospital grand rounds, in political speeches, in daily news briefings, and in social media hashtags. However, there is another epidemic, one that in many cases actually overlaps with, and exacerbates, the opioid crisis: benzodiazepine misuse.
Benzodiazepines (which include Xanax, Ativan, Valium, and Klonopin) had an auspicious start, similar to that of the opioid pain medications. Initially developed for short-term use, the potential for tolerance and developing a substance use disorder was underappreciated, and providers started to prescribe more than necessary, for longer periods of time than necessary.
Benzodiazepines are used to treat various conditions, both on-label and off-label, including anxiety, insomnia and seizures. Whether it has been due to a rise in these diagnoses or greater social acceptance of taking such medications or some other rationale, between 1996 and 2013, there was a 67 percent increase in the number of adults who filled a benzodiazepine prescription, climbing from 8.1 million to 13.5 million. The average amount prescribed also increased by more than three times. Benzodiazepine overuse has even been recognized as a problem among geriatric patients, with a recent New York Times article on the subject citing a report that almost 9 percent of adults ages 65 – 80 were taking a benzodiazepine in 2008.
A sad but familiar story
Not surprisingly, this increased use has led to overdose deaths. Data from the National Institute on Drug Abuse show that overdose deaths involving benzodiazepines increased from 1,135 in 1999 to 8,791 in 2015. It is believed that 75 percent of deaths that involve a benzodiazepine also involve an opiate, which may help explain how the spike in benzodiazepine misuse has been overshadowed.
Overdose deaths are not the only danger to benzodiazepine misuse. Long-term use and overuse of benzodiazepines carry many risks, including dizziness, falls, impaired driving, memory problems, and a possible connection to the development of dementia. Additionally, respiratory depression and death are possible with a benzodiazepine overdose. Sudden cessation of benzodiazepine use when an individual has become dependent on them can cause withdrawal symptoms, including seizures.
It is believed that 75 percent of deaths that involve a benzodiazepine also involve an opiate, which may help explain how the spike in benzodiazepine misuse has been overshadowed.
When benzodiazepines are used in conjunction with opiates, the risks of sedation, respiratory depression, coma, and death are even greater; in 2017, the FDA issued a Boxed Warning about these two agents taken in combination. Meanwhile, a study of more than 300,000 insured patients with opioid prescriptions between 2001 – 2013 found that the proportion of those individuals who also received benzodiazepine prescriptions increased from 9 percent in 2001 to 17 percent in 2013.
What is to be done?
Awareness and education are the necessary first steps in trying to address the benzodiazepine epidemic. As with opiate use, many patients do not consider benzodiazepine use a problem, arguing that it is a prescription medication and they need it for their particular diagnoses.
Realizing that benzodiazepine dependence is a very real risk can shift how care managers address the situation when members call with an urgent request for a provider who will fill a Xanax prescription. We need to remind prescribers and pharmacies to be alert for red flags not only regarding opiates but also regarding benzodiazepines: patients asking for early refills or those who appear to have driven long distances in order to obtain prescriptions. They also need to be reminded to run reports through the Prescription Drug Monitoring Programs (PDMPs), which track the controlled substances that an individual has already been prescribed; such reports are useful in identifying patterns that indicate inappropriate use.
Another outreach effort is National Prescription Drug Take Back Day (the next one is April 28, 2018), which provides a way for safe disposal of unused medications, thereby reducing the chances they fall into the hands of those who might use them inappropriately. Certain pharmacies are also able to take back medications; a search for those that participate can be found at http://disposemymeds.org/medicine-disposal-locator/.