August 21, 2019

The drug epidemic that's largely flown under the radar

Daily Briefing

    The opioid epidemic has received widespread attention as public health officials direct more resources to combat the drugs' deadly outcomes. But experts fear another prescription drug problem is mounting, citing steadily increasing prescription rates and associated deaths—much like what was seen in the early years of the opioid epidemic.

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    The rise in benzodiazepinesand associated deaths

    In an Axios "Expert Voices" piece published this month, the Boston University School of Public Health's Nambi Ndugga, Elsa Pearson, and Melissa Garrido cite data showing that prescription rates for benzodiazepine sedatives have grown on a trajectory similar to that of opioids—with prescription rates nearly doubling from 2003 through 2015.

    Benzodiazepine medications most commonly are prescribed to treat anxiety and mood disorders, such as depression and insomnia, and also can be used to treat seizures. Common name-brand benzodiazepine drugs include Xanax and Valium.

    But data show the drugs can be dangerous, particularly if they're misused. For instance, a study published last year in Psychiatric Services found 5.3 million respondents to the 2015 and 2016 National Survey on Drug Use and Health reported using prescribed benzodiazepines in a way not prescribed by their physicians. Examples of misuse included taking the drugs without a prescription, taking higher doses than prescribed, and taking benzodiazepines more frequently or longer than prescribed.

    Ndugga, Pearson, and Garrido raise similar concerns regarding overprescribing of benzodiazepines. They note that benzodiazepines "are intended to be used for less than 14 days," but "chronic use—over 120 days—is common," citing a study published last year in JAMA Internal Medicine that found one-third of older adults' benzodiazepine prescriptions were for "long durations."

    These patterns of misuse and overprescribing appear to be driving an increase in overdoses and deaths associated with benzodiazepines, Ndugga, Pearson, and Garrido write. Federal data show U.S. deaths associated with benzodiazepines increased from 135 in 1999 to 11,500 in 2017. Ndugga, Pearson, and Garrido note that the risk of such deaths is "particularly acute for adults over 50, who have experienced the largest increase in [benzodiazepine] prescriptions."

    Marcus Bachhuber, the lead author on a study published in the American Journal of Public Health in 2016, noted that his research—which also found an increase in benzodiazepine prescriptions and associated death rates—showed "[o]verdoses rose at a faster rate than prescriptions, suggesting that people were using benzodiazepines in a riskier way over time."

    Opioids and benzodiazepines: A potentially deadly combination

    Keith Humphreys, a professor of psychiatry at Stanford University and an affiliated faculty member at Stanford Law School and the Stanford Neurosciences Institute, in a Washington Post perspective published earlier this year wrote that while "[b]enzodiazepines can be fatal by themselves," they "typically cause overdose in combination with opioids, because the sedative effects of the two drugs exacerbate each other."

    And data reveal a particularly concerning spike in the percentage of people who use both prescription opioids and benzodiazepines.

    Researchers in a study published in BMJ in 2017 found that 17% of individuals who used prescription opioids in 2013 also used benzodiazepines, up from 9% in 2001. And FDA has said the number of individuals who were prescribed both opioids and benzodiazepines grew by 41%, or 2.5 million, between 2002 and 2014.

    According to Ndugga, Pearson, and Garrido, federal data suggest dual prescribing could have fatal consequences, as "one-third of opioid-related overdoses and one-fifth of opioid-related deaths also involve" benzodiazepines.

    What can be done?

    So how do we stem the rise in benzodiazepine-related overdoses?

    Researchers in the BMJ study estimated that halting the concurrent use of opioids and benzodiazepines could have prevented an estimated 2,630 deaths overdose deaths in 2015.

    To that end, FDA has mandated that opioids and benzodiazepines include so-called "black box" warnings detailing that the drugs can be fatal if taken together. In addition, Humphreys notes that the Veterans Health Administration "is educating its prescribers about safer alternatives to benzodiazepines," and "[a]t the state level, benzodiazepines are increasingly being included in prescription drug monitoring programs [PDMPs]."

    However, Humphreys writes that "many health care organization[s], physicians, and patients remain unaware of the country's benzodiazepine problem," and "[t]hat must change if we are to reverse the rising tide of drug overdose deaths."

    Ndugga and colleagues call for "[n]ew research" to "better establish the scale of this growing problem," writing that health care providers and caregivers should "watch for increases in drug-seeking behaviors, memory problems, drowsiness, and dizziness" in patients taking benzodiazepines.

    Further, Ndugga and colleagues write that officials should bolster enforcement of PDMP guidelines, better track benzodiazepine prescriptions, and alert stakeholders to the drugs' risks. They note, "Policy reform—coupled with prescriber accountability and provider and patient education—could mitigate dangerous trends of misuse."

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