Benzodiazepine, Opioid Prescribing Rises in Primary Care

Nancy A. Melville

March 12, 2014

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.

Dr. Ming-Chih Kao

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.

Dr. Kao's study received funding from the Redlich Pain Endowment. Dr. Mchaourab's study received funding from the Office of Specialty Care Transformation, Veterans Affairs Central Office. Dr. Kao and Dr. Mchaourab have disclosed no relevant financial relationships.

American Academy of Pain Medicine (AAPM) 30th Annual Meeting. Abstracts 109 and 101. Presented March 7, 2014.


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