Are We Ignoring an Escalating Benzodiazapine Epidemic?

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Are We Ignoring an Escalating Benzodiazapine Epidemic?

By Indra Cidambi MD 06/09/16

Deaths from benzodiazepine overdose have grown at a faster rate than deaths from opiate overdose each year for thirteen consecutive years.

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Are We Ignoring an Escalating Benzodiazapine Epidemic?
What can we do now to arrest or reverse this trend?

In thinking about the current opioid overdose epidemic, most people think of opioid users and misusers as people singularly involved with opioids. In fact, many opioid users also use other drugs, and many opioid overdoses actually result from the over-ingestion of several drugs, often including benzodiazapines, which may be either prescribed by a health care provider or obtained illegally. Compounding the problem is that fact that detox from benzodiazapines is a complicated and often difficult process. Dr. Indra Cidambi teases apart the myriad issues that are involved in extricating users from both substances and calls for the kind of systemic change that will be needed in order for the U.S. to make progress in preventing future overdose deaths...Richard Juman, PsyD

As the opiate epidemic sweeps America, the focus is on addressing this contagion. However, here is a surprising statistic that will surely astound even seasoned professionals involved in the prevention and treatment of substance use disorders. According to recently revised data from the National Institute on Drug Abuse (NIDA) deaths from benzodiazepine overdose rose at a greater rate in the 2001-2014 period as compared to deaths from opiate overdose (prescription pain pills + heroin). The concomitant (simultaneous) use of benzodiazepines and opiates is also rising rapidly. While the absolute number of deaths from benzodiazepine overdose is far lower than those from opiates, the trend will likely create a drug pandemic as it will render public policy initiatives far less effective, complicate the medical detoxification process and make recovery much harder for individuals abusing opiates and benzodiazepines simultaneously.

Increasingly, patients wishing to detox off of opiates (pain pills, heroin) test positive for benzodiazepines as well during the initial evaluation. The patients do not view it as a problem, as a physician has been prescribing them benzodiazepines for years without being aware of the patient’s opiate use, or, sometimes, the same physician was prescribing them both medications. Patients initially resist coming off benzodiazepines, as they feel they need it for anxiety and are afraid of withdrawal. However, when educated of the heightened risk of respiratory depression when both medications are taken together, most reluctantly agree to detox off of benzodiazepines also. The process is more difficult than usual for the patient, as they have to face some withdrawal from both substances. Although alternate medication to ease withdrawal is administered and supportive therapy to cope is provided, it is still not easy. There have been instances when the patient goes back and uses one of the substances to gain immediate relief. Medication titration is a challenge for the physician, as overmedicating can lead to respiratory depression and under-medicating will leave the patient in severe withdrawal, which could lead to seizures or relapse.

As the founder and medical director of New Jersey’s first ambulatory (outpatient) detoxification facility, Center for Network Therapy, I have observed with increasing alarm the rising rate of concomitant use/abuse of benzodiazepines among opiate users over the past few years. This observation is tangentially supported by the National Institutes of Health/NCBI, which found that treatment admissions due to co-abuse of benzodiazepines and narcotic pain relievers increased by 570% from 2000 to 2010, while those related to all other substance abuse decreased by almost 10% in the same time period. Such concomitant use has the potential to increase or prolong the respiratory depressant effects of opioids, since benzodiazepines could increase the severity of respiratory depression caused by overuse/abuse of opiates, which could lead to death.

Data I gathered from public sources as well as interviews with my patients reveal two important drivers of this trend. One is that that opiate abusers can “spike the high” by abusing benzodiazepines in conjunction with opiates. The second problem is that patients were getting a prescription for an opioid pain killer from one physician (maybe a pain specialist) and for a benzodiazepine from another (maybe a psychiatrist), and consequently were not being educated on the dangers of using both these medications together.

At the root of this dilemma is that it is notoriously difficult for physicians to refuse to prescribe these two medications. Opioid medications are prescribed to address chronic or acute pain, assumed, at least initially, to be legitimate, and benzodiazepines are mostly prescribed to address anxiety. Unfortunately, and ironically, pain and anxiety are neither verifiable nor quantifiable through medical testing! Consequently, self-reported symptoms by patients are the sole basis on which prescriptions for these medications are written, enabling individuals addicted to these medications to obtain them fairly easily.

According to NIDA, the compounded annual growth rate for benzodiazepine overdose deaths over the 2001-2014 time period was roughly 13% compared to about 11% for opiates. It means that, on average, deaths from benzodiazepine overdose grew at a faster rate than deaths from opiate overdose each year for thirteen years straight! On an absolute basis, the number of overdose deaths from opiates (prescription pain pills + heroin) in America was over 29,000 in 2014 versus just under 8,000 for benzodiazepines, but the higher growth rate of overdose deaths from benzodiazepines is alarming for multiple reasons.

Firstly, as public policy focuses on the heroin epidemic, resources are being expended to rapidly expand the ready availability of naloxone (Narcan) to reverse opioid overdose. The policy is well intentioned and saves lives, but the increasing concomitant use/abuse of benzodiazepines and opiates could sharply curtail the effectiveness of this policy, as it may make it vastly more difficult for typically administered doses of naloxone to reverse respiratory depression caused by opiate overdose. Other policy initiatives are pushing for increasing medication-assisted maintenance treatment for opiate abuse utilizing buprenorphine (Suboxone, Zubsolv, Bunavail, etc.), methadone and naltrexone. Simultaneous use/abuse of benzodiazepines with buprenorphine and methadone has the same effect as concomitant use of benzodiazepines with opiates—i.e. increased risk of respiratory depression and death.

Secondly, the medical detoxification process for individuals using/abusing benzodiazepines and opiates is more complicated due to the need for delicate medication titration, which could increase risk of seizures. Consequently, the detoxification process is usually longer and, oftentimes, much more uncomfortable for the patient, which increases the likelihood of the patient stopping treatment against medical advice and reverting back to their substance of choice in order to gain immediate relief from withdrawal symptoms.

Lastly, for a person suffering from a substance use disorder, coming off of just one substance of choice proves a difficult task. When faced with the tribulation of quitting opiates and benzodiazepines at the same time, the chances of relapse, post detoxification, is higher, as post acute withdrawal (residual symptoms of withdrawal after completing detoxification) becomes more of a challenge. The resulting discomfort could weaken an individual’s resolve and drive him/her back to the comforting arms of either opiates or benzodiazepines.

So what can we do now to arrest or reverse this trend?

In my opinion, firstly, a national database of prescriptions should be created whereby physicians and pharmacists can verify that a patient has not been prescribed one of these medications recently before prescribing or filling a prescription for the other. While some states have made such databases available, it is not uncommon for individuals who wish to abuse these medications to obtain and fill prescriptions across state lines.

Secondly, physicians should be encouraged, with patient involvement, to develop and implement a very limited, short-term treatment plan at the outset to treat pain (non-cancerous) and anxiety with opiates and benzodiazepines respectively. Studies have shown the decreasing efficacy of long-term treatment for pain with opioid medications, and evidence-based treatment protocols for benzodiazepines clearly indicate that long-term use of benzodiazepines is not recommended. Consequently, after the use of opioids or benzodiazepines for a short, pre-determined period of time, the plan should be to move to alternate, non-addictive medications. 

Lastly, complementary treatment, such as physical/rehabilitation therapy for pain and Cognitive Behavioral Therapy (CBT) for anxiety should be coupled with non-addictive medications. Alternate treatment modalities such as massage therapy, acupuncture and relaxation therapies such as meditation also have the potential to help patients in pain or anxiety and could be used as adjuncts.

Without urgent action to arrest the trend of concomitant benzodiazepine and opiate abuse, it is quite evident that benzodiazepine abuse has the potential to significantly worsen our national drug epidemic into a pandemic. Consequently, it is critical that an effective response be formulated and implemented right now in order to save thousands of lives over the next several years.

Indra Cidambi, MD, is the Founder and Medical Director of Center for Network Therapy (CNT), New Jersey’s first state licensed outpatient detox treatment facility. Dr. Cidambi helps patients dealing with substance abuse addictions – from alcohol, to prescription and street drugs, among others. Dr. Cidambi has helped hundreds of people face, and overcome, their addictions. She is known as a leading expert board certified in psychiatry as well as addiction medicine, but beyond her strong resume, she is most importantly passionate about helping people, and emotionally invested in each and every patient. 

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