The Disturbing Rise in Benzodiazepine Prescriptions

Are the drugs helping to fuel the opioid crisis?

Posted Jan 23, 2020

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The U.S. National Center for Health Studies released a report this week on benzodiazepine use that points to prescribing rates soaring to “disturbing” new levels. Based on data from the National Ambulatory Medical Care Survey for 2014-16, the report—led by the Center’s Loredana Santo, MD, MPH—determined that benzodiazepines were prescribed in 66 million doctors’ appointments annually. Put differently, for every 100 adults nationwide who saw a doctor in one of those years, 27 left with a prescription for the psychiatric drug.

The results were “discouraging and disappointing,” Lois Platt of Rush University, Chicago, told New Scientist, among several prominent media outlets reporting on the study. “The statistics we have are disturbing, and everyone should be concerned about bringing them down.”

A class of depressants targeting the central nervous system, benzodiazepines (or “benzos”) such as alprazolam, diazepam, and lorazepam are widely prescribed for anxiety, pain, and insomnia. The surge in prescribing on both sides of the Atlantic has occurred despite the drugs’ repeated association with tolerance and dependency issues, particularly from long-term use, as well as their known withdrawal symptoms and other chronic adverse effects. Those include panic attacks and insomnia—two of the conditions for which the drugs are commonly prescribed, generating confusion over relapse and withdrawal. In the U.S., according to the NCHS report, primary care providers account for almost half (48 percent) of the prescriptions, with visits to psychiatrists accounting for a further 28 percent.

Prescribing rates are significantly higher for women than men, the report found, involving, on average, 34 visits per 100 women compared to 20 visits per 100 men. That ratio also widened with age, with women 65 and over accounting for the highest visit rate to doctors (19 per 100 women), despite studies tying benzodiazepine use to an increased risk of falls, cognitive impairment, and drug-associated hospital admissions among the elderly.

A sharp rise in associated overdoses and benzodiazepine deaths led the FDA to issue a black-box warning in 2016 against co-prescribing benzos and opiates. Across the U.S., the 1,000 annual fatalities recorded in 1999 surged to 11,000 by 2017. Even so, the report determined that a third of physician-related visits (roughly 23 million) continued to involve overlapping opioid-benzo prescribing. Indications of repeat prescriptions in the report will only add to concern that the drugs are not being restricted to short-term use.

With roughly “30 percent of what is labeled opioid overdose actually opioid-benzodiazepine overdose,” according to the National Institute on Drug Abuse Statistics, the report bolsters concern that benzodiazepines may be a “hidden element” in the U.S. and UK overdose epidemic. “Approximately 85 percent of the 2017 overdose deaths involving benzodiazepines also involved an opioid,” Santo and her colleagues observe of the U.S. Between 2003 and 2015, the number of ambulatory visits with one or more prescriptions for a benzodiazepine increased sharply from 27.6 million to 62.6 million.

“The enormous growth of benzodiazepine prescribing has flown under most policymakers’ and clinicians’ radar,” notes Keith Humphreys at Stanford University, who was not involved in the report, but has studied the drugs’ public health implications in associated work at the Veterans Health Administration.

“Maybe it’s because a lot of people” who have a dependency on benzodiazepines “are older,” he told CNN, “fewer are violent, and it’s not a [dependency] that will get noticed as much as people who are [dependent on] alcohol or meth or heroin, which have all kinds of impacts on people around them, or maybe people think that since they come from a doctor, they can’t be all that bad.” But with the new report implicating benzodiazepines in a third of all opioid overdoses, the health care system should, he said, “expand its ongoing safe-prescribing initiatives to cover them, too.”

The NCHS report comes in the wake of a new report by the Lown Institute, Medication Overload: How the Drive to Prescribe Is Harming Older Americans, which notes that “every day, 750 older people living in the United States (age 65 and older) are hospitalized due to serious side effects from one or more medications” and that “medication overload will contribute to the premature deaths of 150,000 older Americans over the next decade and reduce the quality of life for millions more.”

The study also coincides with the publication of Guidance for Psychological Therapists: Enabling Conversations with Clients Taking or Withdrawing from Prescribed Psychiatric Drugs, a detailed new report on benzodiazepine and SSRI antidepressant withdrawal problems in the UK, where addiction to prescribed drugs has been described as a “public health disaster.” Illegal and off-label benzodiazepines are fueling “a hidden drug overdose crisis” in Scotland, New Scientist independently reported last year, with “the number of drug-related deaths in the country” rising by 27 percent over the course of the previous year. The country was said to have “the highest drug-related death rate in the European Union,” with benzodiazepines and opioids again centrally co-implicated in the crisis.

Concern about withdrawal symptoms from prescribed psychiatric drugs extends far beyond those immediately affected, note the distinguished contributors to Guidance, the Council for Evidence-based Psychiatry report, due to rising concern “that our mental health services are not just failing due to lack of investment, but owing to peoples’ emotional and behavioral difficulties being over, unduly, and unhelpfully medicalized.”

In the UK, where prescribing guidelines for psychiatric drugs are currently being updated to align more closely with the evidence base, “expanding knowledge of withdrawal problems” from benzodiazepines and SSRIs is said to form part of a “growing understanding that [their] long-term is often associated with poor outcomes and increased harms.

Although in the U.S. the CDC’s Guideline for Prescribing Opioids for Chronic Pain does not recommend opioid and benzodiazepine co-prescription, researchers fear that the surge in 2014-16 co-prescribing has worsened in the years since. As Santo noted, “Our finding suggests that most patients prescribed these medications might be long-term users of these drugs.”

While primary care physicians and psychiatrists may be prescribing in good faith for anxiety, pain, and insomnia, the concern is that they are not getting the message about the risks of overprescribing and are instead inadvertently helping to fuel the crisis.

Platt at Rush University urges medical professionals to focus on alternatives for anxiety. “We have to keep making people aware that these drugs are not our friends.”

References

Santo L., R Pinyao, and J Ashman. (January 17, 2020). Physician Office Visits at Which Benzodiazepines Were Prescribed: Findings From 2014-2016 National Ambulatory Medical Care Survey. National Health Statistics Reports 137. U.S. Department of Health and Human Services. [Link]