Benzodiazepines Are Often Inappropriately Prescribed

Marcia Frellick

May 26, 2016

Benzodiazepines are prescribed disproportionately to patients who either do not have a clear indication or have poor indications, such as depression, new data show. This leads to higher healthcare usage, greater health risk, and increased costs.

The drugs are commonly prescribed for anxiety and sleep disorders, but have known risks for adverse events in the elderly, including fractures, and in patients with substance abuse or lung disease. However, David S. Kroll, MD, from Harvard Medical School and the Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, and colleagues found they were frequently prescribed in these patient groups, often at high doses.

For example, among patients with high-dose benzodiazepine prescriptions, 52% were also concurrently prescribed antidepressants, the researchers found.

"Prescribers should take into account their patients' risk factors for adverse events when considering a benzodiazepine. For patients with COPD, substance use disorders, osteoporosis, and advanced age — those who appear to be the most likely to receive benzodiazepine prescriptions and, for the two former categories, at the highest doses — the choice of prescribing a benzodiazepine should be made with great caution," the authors write.

The findings, published online May 13 in the Journal of General Internal Medicine, are particularly relevant for primary care physicians. Researchers found nearly half (44%) of the patients who received benzodiazepine prescriptions received at least one from their primary care provider.

Primary Care Providers

Previous studies have shown that primary care providers write many of the prescriptions for benzodiazepine, yet there are few data regarding the type of patients who receive these drugs in the primary care setting, according to Dr Kroll and colleagues.

Therefore, they analyzed data from patients who visited any of 10 clinics from the Brigham and Women's Primary Care Practice-Based Research Network, which includes both hospital-based and community practices, between July 1, 2011, and June 30, 2012.

They found that among 65,912 patients, providers prescribed at least one benzodiazepine to 15% (9821). Of benzodiazepine recipients, 5% were given high doses.

Compared with nonrecipients, recipients were more likely to have diagnoses of depression (odds ratio [OR], 2.7; 95% confidence interval [CI], 2.6 - 2.9), substance abuse (OR, 2.2; 95% CI, 1.9 - 2.5), tobacco use (OR, 1.7; 95% CI, 1.5 - 1.8), osteoporosis (OR, 1.6; 95% CI, 1.5 - 1.7), chronic obstructive pulmonary disease (COPD; OR, 1.6; 95% CI, 1.5 - 1.7), alcohol abuse (OR, 1.5; 95% CI, 1.3 - 1.7), sleep apnea (OR, 1.5; 95% CI, 1.3 - 1.6), and asthma (OR, 1.5; 95% CI, 1.4 - 1.5).

Findings regarding high-dose benzodiazepine prescriptions were even more troubling, the researchers said. Compared with patients receiving a low dose, high-dose benzodiazepine recipients were even more likely to have certain diagnoses, such as substance abuse (OR, 7.5; 95 % CI, 5.5 - 10.1), alcohol abuse (OR, 3.2; 95% CI, 2.2 - 4.5), tobacco use (OR, 2.7; 95% CI, 2.1 - 3.5), and COPD (OR, 1.5; 95% CI, 1.2 - 1.9).

"Our finding that high-dose prescribing was also associated with diagnoses of COPD and substance use disorders raises special concern," the authors write. "The magnitude of the association between benzodiazepines and mortality in general appears to be dose-dependent, and dose-dependent relationships between benzodiazepines and mortality have been described independently for COPD and overdose deaths. Therefore, the disproportionate prescribing of high-dose benzodiazepines to patients with COPD and substance use disorders may amplify the effect of prescribing standard-dose benzodiazepines to patients already at risk of adverse outcomes."

The authors also found that healthcare use was higher among those prescribed benzodiazepine. Specifically, they had more primary care visits per 100 patients (408 vs 323), specialist outpatient visits (815 vs 578), emergency department visits (47 vs 29), and hospitalizations (26 vs 15; P < .001 for all comparisons).

"Prescribers should take into account their patients' risk factors for adverse events when considering a benzodiazepine. For patients with COPD, substance use disorders, osteoporosis, and advanced age — those who appear to be the most likely to receive benzodiazepine prescriptions and, for the two former categories, at the highest doses — the choice of prescribing a benzodiazepine should be made with great caution," the authors conclude.

The authors have disclosed no relevant financial relationships.

J Gen Intern Med. Published online May 13, 2016. Abstract

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