Warnings About Benzodiazepine Use in the Elderly Go Unheeded

Alicia Ault

August 24, 2018

Despite years of warnings about the hazards of prescribing benzodiazepines for the elderly, these drugs continue to be used at a higher rate than what is considered appropriate in older Americans — particularly older women, new data show.

A recent report released by Athena Health shows that individuals older than 65 years are prescribed benzodiazepines — including alprazolam (multiple brands), lorazepam (multiple brands), diazepam (multiple brands), and clonazepam (Klonapin, Roche) — more than other age groups are.

In 2017, 8.4% of individuals aged 65 and older were prescribed one of the drugs, a drop from 8.7% the previous year. Just over 8% of 50- to 64-year-olds were prescribed a benzodiazepine in 2017, compared to 7.5% of those aged 40 to 49 and 6.6% of those aged 30 to 39.

Ten percent of women older than 65 were prescribed a benzodiazepine, compared to just under 6% of men.

The data come from a sample of 3 million patients treated by primary care providers who are part of the Athena Health data network.

The data "are consistent with earlier research that suggests significant benzodiazepine overuse, especially among older adults," Mark Olfson, MD, MPH, professor of psychiatry and epidemiology, Columbia University, New York City, told Medscape Medical News.

Since 2012, the American Geriatrics Society (AGS) has urged clinicians to avoid use of benzodiazepines in older adults. That recommendation is being reiterated in the AGS 2018 prescribing guidelines (called the Beers Criteria), which are under final review.

Physicians Not Getting the Message

The AGS notes that benzodiazepines increase the risk for cognitive impairment, delirium, falls, fractures, and motor vehicle crashes. The drugs can be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia, the AGS says.

Since benzodiazepines were first introduced in the 1960s, prescribing authorities and public health agencies have periodically issued warnings about the potential for addiction and other side effects.

In May, the deprescribing guidelines for the elderly project, based at the Bruyère Research Institute in Ottawa, Ontario, Canada, launched an effort to help clinicians wean long-term users off benzodiazepines and the benzodiazepine receptor agonists zolpidem (multiple brands), zopiclone (Zunesta, Suovion), and zaleplon (Sonata, Pfizer).

"We need to be a little bit more judicious with these," Nicole Brandt, PharmD, MBA, BCGP, BCPP, FASCP, executive director of the Peter Lamy Center on Drug Therapy and Aging, University of Maryland, Baltimore, told Medscape Medical News. Brandt said she continues to be concerned about the persistence of benzodiazepine use in the face of so many warnings and guidelines.

Robert Roca, MD, chair of the American Psychiatric Association's Council on Geriatric Psychiatry, said he was surprised — but not entirely — at the Athena data indicating that women received benzodiazepines at twice the rate of men.

"Women are more willing to express distress, and they're more likely to receive psychotropics of all kinds," Roca, vice president and chief medical officer, Sheppard Pratt Health System, Baltimore, told Medscape Medical News.

Women also have a higher risk for dementia, and, given the pressure to reduce the use of antipsychotics in patients with dementia, it's possible that benzodiazepines are being substituted, said Roca. But, he added, benzodiazepines "are not a particularly good alternative."

Olfson said that women "have higher rates of insomnia, anxiety disorders, and mood disorders, all of which are related to benzodiazepine use." He also noted, however, that "because women assume more caregiver roles than men, they are under greater stress, which contributes to anxiety and sleep problems."

Dementia Risk

Brandt agrees that caregiving is a major stressor for women. He noted that "it's easier to get a medication paid for than to get counseling paid for or respite care paid for." Benzodiazepines are prescribed for many medical problems, but "there are also lots of psychosocial issues where they may be the go-to agent," she said.

She added that she's seen benzodiazepines prescribed to help older people cope with losses, including the loss of mobility and the loss of friends or family members.

"I think benzodiazepines are a surrogate for a much bigger issue," she said.

Many factors account for the continuing popularity and persistent use of benzodiazepines. Olfson said there is limited access to alternative evidence-based treatments for insomnia and noted that there's "an unwillingness of some older people to consider reducing or discontinuing" the drugs.

In addition, said Olfson, "for some primary care physicians who have competing clinical demands on their time, given common comorbid medical problems in older adults, pharmacological options for managing insomnia and anxiety may be attractive."

Roca noted that they are generally safe and effective in reducing anxiety and generally are not abused, although "there is no question they are potentially addictive."

Benzodiazepines can also be a bridge therapy for patients who need an antidepressant, which can take weeks to start working, said Roca. He favors short-acting benzodiazepines, which, unlike long-acting ones like diazepam, are not taken up by adipose tissue.

But that type of analysis may not be familiar to physicians who more often prescribe the medications to younger people. "They are not so tuned in to the risks of prescribing to older people," said Roca.

Besides the risks outlined by the AGS, some data now suggest that long-term exposure may increase the risk for dementia, he said. "There are all kinds of reasons to be careful," said Roca.

Medicare has kept an eye on benzodiazepine use among older people who participate in the federal health plan. The Affordable Care Act initially banned coverage of benzodiazepines through Medicare Part D drug plans. That prohibition was lifted in January 2014; the drug class is now covered under Part D for any medically accepted indication.

A Hidden Epidemic?

The agency has taken an even closer look since it became clear that the drugs were often being prescribed in tandem with opioids. In 2015, the Centers for Medicare & Medicaid Services reported that 17% of Medicare beneficiaries were using benzodiazepines and that about a quarter were using them in conjunction with opioids.

A study published in JAMA Psychiatry in June found that rates of new opioid prescriptions written for adults using a benzodiazepine skyrocketed from 189 to 351 per 1000 persons from 2005 to 2010.

Although it decreased to 172 per 1,000 by 2015, "the likelihood of receiving a new opioid prescription during an ambulatory visit remained higher for patients concurrently using benzodiazepines compared with the general population after adjusting for demographic characteristics, comorbidities, and diagnoses associated with pain," the authors note.

The dual use — and continued high use of benzodiazepines — has alarmed many clinicians and public health officials.

"Despite the many parallels to the opioid epidemic, there has been little discussion in the media or among clinicians, policymakers, and educators about the problem of overprescribing and overuse of benzodiazepines and z-drugs, or about the harm attributable to these drugs and their illicit analogues," Anna Lembke, MD, Jennifer Papac, MD, and Keith Humphreys, PhD, wrote in an editorial published in the New England Journal of Medicine in February.

Overdose deaths related to benzodiazepine use continue to rise. Lembke noted that data from the National Institute on Drug Abuse (NIDA) show that overdose deaths involving benzodiazepines increased from 1135 in 1999 to 8791 in 2015. In 2016, NIDA reported 10,684 overdoses in which benzodiazepines were involved. Most of the deaths occurred in people who were also taking opioids, said NIDA.

Brandt said the opioid crisis provides lessons for how benzodiazepines should be monitored and prescribed. Benzodiazepines are not villains, however, she said. Like opioids, they are "a tool to address a problem," said Brandt. She noted that she would not want to see them blacklisted.

Both Roca and Olfson said they supported adding benzodiazepines to state prescription drug monitoring programs. Including them would help flag those people who are using benzodiazepines and opioids, said Olfson. He also said that because a lot of the risk with the drug class is associated with long-term use, "policies should be considered and evaluated that restrict the days' supply of benzodiazepines in a single prescription."

Roca expressed concern about overly restrictive policies. "If you put a target on the back of these medications, you may make it difficult for patients who need them," he said.

Dr Brandt, Roca and Dr Olfson have disclosed no relevant financial relationships.

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