Benzodiazepine, Opioid Prescribing Rises in Primary Care

PHOENIX, Arizona — Benzodiazepines are being prescribed alone and in combination with opioids in increasing rates at primary care practices across the nation, according to new research.

The trend is particularly alarming in light of the association between benzodiazepine-opioid combinations and prescription drug deaths, said coauthor Ming-Chih Kao, PhD, MD, a clinical assistant professor at Stanford University Medical Center in Cupertino, California.

“[Statistics show] that from 1999 to 2006, there was a 250% increase in fatal overdoses in the US involving opioid medications,” he told Medscape Medical News. “More than half of the overdoses involved more than one type of drug — most commonly benzodiazepine.”

Their findings were presented here at the American Academy of Pain Medicine (AAPM) 30th Annual Meeting.

To better understand prescribing trends in their preliminary study, Dr. Kao and his colleagues evaluated a database of 3.1 billion primary care visits documented in the National Ambulatory Medical Center Survey (NAMCS) between 2002 and 2009.

They found that 12.6% of the primary care visits involved benzodiazepine or opioid prescriptions.After adjustment for demographic factors, payer status, psychiatric illnesses, and pain diagnoses, the prescription of benzodiazepines was found to increase by a rate of 12.5% per year (95% confidence interval [CI], 9.4% – 15.7%), while coprescribing with opioids increased by 12.0% per year (95% CI, 5.0% – 19.4%).

The researchers also evaluated data on 733 million emergency department visits in the same time period and found 32.4% of patients had benzodiazepine or opioid prescriptions.

After adjustment for the same factors as primary care visits, the data showed an increase in prescription of opioids in the emergency department setting at a rate of 3.4% per year and an increase of 3.7% per year for benzodiazepines. However, the prescription of benzodiazepines in combination with opioids increased by twice as much — 6.4% per year.

Various Influences

A variety of factors likely contribute to the increase in benzodiazepine prescription along with opioids in primary care clinics, ranging from benzodiazepines simply representing the go-to muscle relaxant to the lack insurance coverage for nonpharmacologic management, Dr. Kao explained.

“Reductions in physical therapy coverage nudges the primary care physician towards opioid medications for back pain, and reductions in mental health coverage nudges the primary care physicians towards benzodiazepine medications.” The influences cut across specialties, he added. “We have observed similar trends in specialist clinics as well.”

Dr. Kao noted that in his own previous experience as a community primary care physician, patients who ended up on both opioid and benzodiazepines were typically started on the medications at different episodes of care.

“The opioid would likely be started during an acute or acute-on-chronic pain episode, whereas the benzodiazepine started during time of heightened anxiety,” he explained.

“Sometimes these medications are individually continued while the attention is paid elsewhere, for instance in managing hypertension, diabetes, or arranging cancer screening.”

In addition to being linked to opioid-related deaths, benzodiazepines are also associated with problems, including falls among the elderly, hospitalization, and the development of physical and psychological dependence, the authors noted.

With that in mind, clinicians should consider their alternatives before writing the benzodiazepine prescription, Dr. Kao said.

For back pain that presents in the primary care clinic, for instance, he suggested the ideal management strategy should start with nonpharmacologic approaches, in particular physical therapy.

“The level of intensity involved can be adjusted based on the patient’s condition [and] escalation to pharmacologic therapy should start with nonopioid medications,” he said.

For patients presenting with mood issues, clinicians should consider reasonable nonpharmacologic options, such as relaxation exercises and meditation with the guidance of mental health professional, Dr. Kao added.

“In terms of pharmacologic therapy, it is important to note that short-acting benzodiazepine formulations can be more difficult to discontinue.”

Educational Interventions for Clinicians

In another study presented at the meeting, Ali Mchaourab, MD, described a telemedicine program that he directs through the Cleveland Veterans Affairs Medical Center in Ohio, which focuses on training primary care clinicians on proper opioid prescribing practices with weekly video-teleconference sessions.

In preliminary data from a 1-year pilot study of the specialty care access network, called the Cleveland VA SCAN ECHO project, involving 13 remote outpatient clinics, the findings showed significant declines in the number of opioid analgesic prescriptions at the clinics (P < .05).

In the program’s 90-minute sessions, cases submitted by primary care providers are discussed in front of a group of other providers as part of a 1-year curriculum covering the more common and relevant topics, such as management of back pain, opioids, and neuropathic pain, Dr. Mchaourab explained to Medscape Medical News.

“The SCAN-ECHO model has led to improved skills and knowledge, as well as a shift in the pattern of prescription opioids from short-acting to long-acting and from higher to lower doses among the clinics where SCAN-ECHO was implemented.”

Dr. Mchaourab noted that such interventions can be key to improving awareness on such issues as the risks in coprescribing opioids and benzodiazepines.

“Intervention needs to take place at multiple levels, but it really starts with physicians,” he said. “Physicians need to be educated about opioids and benzodiazepines management and their potential toxicities.”

“There needs to be a shift in our thinking from that of a passive acute care model to a chronic model where the patient takes an active role in his or her own care rather than receiving a pill, any pill.”

He called out pharmaceutical companies as sharing in the blame for the misperceptions on opioid safety. “I also believe that aggressive and often inappropriate marketing by pharmaceutical companies has led to these misconceptions about opioid safety, especially among nonpain physicians,” Dr. Mchaourab said.

He called for tighter regulations in pharmaceutical marking in the medical press as well as through medical societies and meetings, where lines between education and industry influence are too easily crossed.

The Mind of an Addict

The mind of an addict is an interwoven mass of guilt, pleasure, depression, denial and fear.  No one starts using drugs or alcohol in the hopes of becoming an addict; most believe that they can control the amount they use. Scientists believe that some of us are wired for a more addictive personality than others, whether this is true or not has been hotly debated for decades.  The one thing that is true is that addiction to prescription medications, alcohol and illegal drugs continues to increase, causing harm to the addict, and their loved ones.  Unfortunately over 30% of our population believes (2008 report by the Substance Abuse and Mental Health Services Administration) that overcoming addiction is just a matter of willpower.  Anyone that has been around an addict, works with recovering addicts, and addicts themselves, know it requires more than willpower alone.

New Found Life 

“Cold-turkey” and “just gut it out” our terms that individuals without any knowledge of addiction and recovery throw around.  In truth, addicts need structure, therapy, counseling, support, and willpower.  Few addicts are successful in the long-term of beating an addiction on their own.  Rehabilitation centers, recognize the need for a multi-disciplinary approach to both recovery and the maintenance of sobriety.  Through true gender-specific programs, recovering addicts find the support they need to delve into the cause of their addiction while developing effective relapse prevention strategies.  Relapse prevention should be, and is an essential part of any addiction recovery program.

Recovering from Addiction

While some individuals present addictive tendencies, people from all walks of life can fall prey to any addiction whether it be to food, alcohol, prescription medications, illegal drug addiction, gambling, sex., or even exercise addiction!  Recovering from the addiction takes time, patience, perseverance, understanding, and structure – both from the addict, and those that support them.  Through one-on-one counseling, recovering addicts explore their pasts to find the links that lead them to start using and abusing their drug of choice.  It is through this thoughtful and honest examination that true recovery begins.  Without this step, just discipline and willpower will inevitably fail.  An addict’s mind is wrapped tightly around the need to feel better, forget the past, experience euphoria, or just escape.  This does not stop when the abuse stops.

How to Combat and Reverse Addiction?

For some individuals, addiction may be fueled by past physical traumas or emotional traumas that have not yet been given the attention they need to heal.  PTSD is one of the common causes of addiction and can come from traumatic events witnessed, or realized.  Learning to manage, identify, and process fear, grief and guilt is essential for anyone wanting to overcome an addiction.  The next part of the puzzle is the preparation to reintegrate into life.  This is often the greatest fear that many recovering addicts face.  Depending on the length of their addiction, and the amount of damage that it caused to their professional and personal lives, they may need academic, career and financial counseling to prepare them for what lies ahead.

Final Considerations

The mind of the addict is complicated, and there is no one right protocol for long-term recovery.  However, a total mind, body and spirit rehabilitation is often what is required.  Each individual that fights an addiction has different needs to start living a sober life.  Compare Rehabilitation Centers and find one that is the right match for you and your particular symptoms.

Fighting addiction with a pill has potential for abuse, officials say

The spread of a “wonder drug” — one that could be instrumental in Ohio’s campaign against heroin and prescription painkiller addiction — is threatened by its own potential for abuse.Nearly 1,800 Ohioans — or 18 percent more than the year before — were participating in a buprenorphine program at a substance abuse treatment centers on a single day in 2012, according to new data from the federal government. Data from the Ohio State Board of Pharmacy show that prescriptions for the drug at least doubled from 2010 to 2012 in 29 of Ohio’s 88 counties.

Buprenorphine is a medication — often sold under the brand name Suboxone — that prevents symptoms of withdrawal from opioids. That includes street drugs such as heroin or prescription painkillers such as OxyContin and Vicodin.

More than half of Shepherd Hill’s opiate-dependent patients are treated with a regimen that includes Suboxone, according to Dr. Richard Whitney, medical director and addiction expert at the private rehabilitation facility in Newark.

Patients who take Suboxone are more willing to participate in the other facets of their treatment, such as counseling and education, and abstain from drug use, Whitney said.

People who complete treatment with Suboxone, he said, “get their children back, go back to work again, they stay out of jail. They have no cravings to go back and use drugs again. Those cases are not obvious. They don’t make the news. They simply get back into the mainstream of life and do very well.”

Potential for abuse

The reason Suboxone works is because it gives the addict just a little bit of what their body tells them they need. But it also can be used to get high. That creates the potential for misuse, especially when it’s provided by prescription to a population that has a demonstrated history of drug abuse.

Detective Kris Kimble, who handles prescription drug cases for the Central Ohio Drug Enforcement Task Force, said there were “hardly any cases” involving Suboxone in 2010 when he started in his current position. Last year, Kimble seized 2,062 doses of the drug, mostly in Licking County but also in Muskingum, Coshocton, Perry and Knox counties.

“Every heroin addict … either they have the package with (Suboxone) strips or a legitimate prescription,” he said. An 8-milligram Suboxone pill on the street costs $10, he said, while a dose of heroin costs $10 to $20.

That market for misuse has raised some alarms, according to Orman Hall, director of the Governor’s Cabinet Opiate Action Team.

“I think there are professionals in our state, criminal justice and treatment professionals, that are troubled by the diversion of Suboxone, who might not have had those concerns three or four years ago,” he said.

Ohio has been trying to crack down on the supply of opiates, but to stem demand robust medication-assisted treatment opportunities need to be available for addicts, Hall said. The latest figures from the Ohio Department of Health show prescription opioids were named on 1,154 death certificates in Ohio in 2011. Ohio Attorney General Mike DeWine said on Wednesday that 800 Ohioans died from heroin overdoses last year.

Whitney points out that the high from Suboxone is far milder than that of the drugs the patient is trying to kick and that the likelihood of overdose, especially death, is far lower.

“Suboxone is unquestionably a breakthrough drug with a documented clear ability to help patients reduce their cravings and get into sustained recovery,” Whitney said. “It has dramatically more benefits that downsides and the overwhelming majority of people who are opposed to the use of Suboxone simply don’t have all the information.”

Watching the doctors

In 2000, Congress relaxed rules governing the prescribing of opioids to treat addictions to heroin or prescription painkillers, creating a key distinction between methadone, which has been used to treat heroin addiction since the 1960s, and buprenorphine. Methadone is almost exclusively dispensed at treatment centers and consumed on-site. Buprenorphine, however, is also a prescription medication, meaning the patient can take the drug themselves outside close supervision.

Licensed physicians who take an eight-hour training course can apply for a waiver that allows them to prescribe Suboxone to as many as 30 patients in the first year, and up to 100 after that, said Dr. Melinda Campopiano, a medical officer with the U.S. Substance Abuse and Mental Health Services Administration.

As of last week, 48 treatment programs and 555 doctors were permitted to prescribe buprenorphine in Ohio, according to the administration.The law does not specifically require doctors to follow up on whether a patient is regularly attending 12-step classes or meeting with a behavioral health professional, Campopiano said, but there is an ethical obligation to do so.“(Doctors) are required to make sure this person gets the help they need,” she said, “just the same way if you sent somebody to a cardiologist you would find out if they went and if they didn’t you would find out why.”A spokeswoman for the State Medical Board of Ohio said the board provided guidelines for medication-assisted treatment after the congressional changes and that they are working to develop rules specific to buprenorphine.There’s a possibility that something akin to a smaller model “pill mill” — clinics where unscrupulous doctors trade prescriptions for cash — could arise, or has already, using Suboxone.“There are, unfortunately, a number of physicians who can take a relatively short eight-hour online course and be able to prescribe Suboxone legally,” Whitney said. “In today’s environment this can be a relatively lucrative source of income.”There are likely many more doctors who aren’t employing Suboxone maliciously, but just aren’t following up as closely as they should, Hall said.

He said the state needs to root out any unscrupulous prescribers, but they need to be mindful not to discourage well-meaning doctors who want to incorporate Suboxone treatment into their practice.“As significant as the opiate problem is in our state, it’s unrealistic to think that we’ll have the capacity to accommodate everyone through the public treatment providers,” he said.

On Any Given Day

On any given day in the U.S., 18% of men and 11% of women drink more alcohol than federal dietary guidelines recommend, according to a new study that also finds 8% of men and 3% of women are full-fledged “heavy” drinkers.

That still means the great majority of Americans stay within the advised limit of two drinks a day for men, and one for women.

“And in fact, most adults don’t drink at all on any given day. But the fact remains that it is a significant public health problem that many people do drink in excess,” said lead author Patricia Guenther, from the U.S. Department of Agriculture’s (USDA) Center for Nutrition Policy and Promotion.

Guenther said members of the committee that drafted the current USDA guidelines on alcohol consumption wanted to know how many adults exceeded the limits.

She and her colleagues collected data from a nationally representative survey on health and nutrition, which included about 5,400 adults over age 21. Among other things, each was asked how much alcohol they drank the previous day.

The researchers found that 64% of men and 79% of women said they drank no alcohol at all that day, and another 18% of men and 10% of women drank within the recommended amounts.

Nine percent of men said they had three to four drinks the day before and 8% of women said they drank two to three alcoholic beverages, the researchers report in the Journal of the Academy of Nutrition and Dietetics.

The heaviest drinkers of all were the 8% of men who had five or more drinks, and 3% of women who had four or more.

“Overall the study confirms that rates of unhealthy alcohol use in the U.S. are significant,” said Jennifer Mertens, a research scientist at Kaiser Permanente Division of Research in Oakland, who was not involved in the study.

Regularly drinking more than recommended levels “is linked to increased alcohol-related problems,” Mertens wrote in an email to Reuters Health.

“Binge drinking (more than four drinks on any one day for men and more than three on any one day for women and older adults) even one time can increase the risk of injury from falls, motor vehicle accidents, and other accidents,” she added.

Among men, the 31-to-50-year-old age group had the most heavy drinkers – 22%. Among women, the heaviest drinkers – 12% – were between 51 and 70 years old.

Guenther said that’s important to note because it highlights that heavy drinking is not just part of life among the college-age set.

“People need to be aware that there are people of all ages who drink to excess,” she told Reuters Health.

The U.S. Preventive Services Task Force, a government-backed advisory group, urges health care providers to screen all adults for risky drinking behaviors (see Reuters Health story of September 24, 2012).

Guenther said her team’s study is also important in that it may help people recognize whether they themselves are drinking more than recommended.

“There are people who don’t realize that they are drinking more than what’s beneficial to their health,” she said.

Powerful new painkiller Zohydro stirs fears of overdose, addiction

Going against the recommendation of its own panel of outside advisers, the U.S. Food and Drug Administration, or FDA, has approved a powerful, pure hydrocodone painkiller that lacks features to eter abuse.

Law enforcement agencies and drug-addiction experts say the new opioid pain pill, Zohydro ER, will likely create more addicts and cause overdose deaths to increase. Zohydro will be the first pure hydrocodone medication available in the United States. It is expected to reach the market early next year.

Current forms of the medication, such as Vicodin, are combined with weaker painkillers like acetaminophen. Because of its purity, Zohydro is potentially 10 times stronger when abused than any version of hydrocodone medication currently available, experts say.

Hydrocodone belongs to the opioid family of medications, a highly addictive group of drugs that includes morphine, codeine, methadone and oxycodone, which officials say is one of the most abused and deadly drugs.

Opioid pain pills designed to release a drug over time, such as Zohydro, are often crushed and snorted by addicts seeking a stronger, immediate high, law enforcement officials have said. Purdue Pharma, the company that makes OxyContin, introduced a tamper-resistant form of the pill in 2010, making it harder to crush or dissolve, and experts say that has helped cut down on abuse

Zohydro does not include such features at present.

Zogenix, the company that makes Zohydro, has “started the development of an abuse deterrent formulation of Zohydro ER, and we are committed to advancing the program as rapidly as possible,” the company’s president, Stephen Farr, said in a statement.

“That the FDA has approved another incredibly powerful painkiller without (tamper-proof features) is both disconcerting and dangerous,” said Jeffrey Reynolds, the executive director of the Long Island, N.Y., Council on Alcoholism and Drug Dependence, who testified before the expert panel in opposition to Zohydro’s approval without safety features. “While this drug might be a godsend for people with acute pain, it’s a potential nightmare for those struggling with or at risk for addiction.”

An FDA advisory panel of experts voted 11-2 in December 2012 against approval of Zohydro because of concerns it would be abused. But the FDA is not bound by advisory opinions and has gone against panel decisions before.

The FDA said Zohydro should be prescribed only for the management of pain severe enough to require daily, round-the-clock, long-term treatment and for which alternative treatment options are inadequate.

“Due to the risks of addiction, abuse and misuse with opioids … Zohydro ER should be reserved for use in patients for whom alternative treatment options are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain,” the FDA said in a statement.

The FDA does not require abuse-deterrent formulations of opioids at present. But critics of Zohydro’s approval say the agency should have waited until that formulation was ready.

“It’s hard to believe that in the midst of an epidemic of opioid addiction and overdose deaths caused by opioid overprescribing that FDA would approve a new, easily chewable opioid that packs in a whopping dose of hydrocodone,” said Dr. Andrew Kolodny, the president of the national advocacy group Physicians for Responsible Opioid Prescribing, which presented its case against Zohydro to the FDA advisory panel. “A single pill can be lethal for someone not used to taking opioids.”

Addiction is a social disease

Call it a wave, a craze or an epidemic, cheap heroin on city streets and in rural areas of Ohio has become too common, and too costly to ignore. Erie County Sheriff Paul Sigsworth said alcoholism and drug addiction account for a majority of expenses to taxpayers for county jail services.

At the county child protection office, the number of children removed from homes in the current period is five times what it was a year ago, with drug addiction and heroin use in their homes causing the separations.

Many of those families, if not most, will never be re-united.

Yes, this is yet another call for broad reform of state and federal drug laws, sentencing guidelines, practices and treatment and rehabilitation services. It is not a call for law enforcement to fix the problem, or a plea for local, state or federal police agencies to better treat the consequences.

Law enforcement already has done it’s part, and stands ready to protect and serve. But alcoholism and drug addiction, first and foremost, are a social problem. Human behavior is not a law enforcement responsibility to fix or cure, but a society’s.

And drug addiction is much more complicated today than it was when President Richard Nixon launched the “War on Drugs.” There are a dozen times a hundred different medications, stimulants and relaxers, in addition to the cheap heroin in the streets.

It’s an overwhelming social problem.

Any meaningful reform must happen at the state and federal levels, with the cooperation and consensus of a broad coalition of professionals. Without support in Columbus and Washington, any chance at reform is doomed, and the War on Drugs will continue with the same results — a booming industry.