The Alarming Rate of Overlapping Benzodiazepine & Opioid Prescriptions

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You're listening to The Drug Report on ReachMD, hosted by Linda Bernstein, Pharm.D., Clinical Professor on the Volunteer Faculty of the School of Pharmacy, University of California, San Francisco.

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Welcome to The Drug Report. I’m Dr. Linda Bernstein.

Today our topic is drawn from a National Health Statistics Report dated January 17, 2020 that offered insight into the characteristics of visits to office-based physicians at which benzodiazepines were prescribed, including visits where opioids were co-prescribed. The data were drawn from the 2014 to 2016 National Ambulatory Medical Care Survey.

Let’s start with a bit of background on benzodiazepines. They comprise a class of central nervous system depressant drugs indicated for anxiety, insomnia, seizure, and acute alcohol withdrawal. Their long-term use can lead to tolerance, requiring higher and more frequent doses to achieve the same effect, withdrawal symptoms, misuse and use disorder. Benzodiazepine use in the elderly place them at greater risk for falls, hip fractures, cognitive impairment and drug-associated hospital admissions. Concerns about their long-term use have not deterred physicians from writing prescriptions for these agents. Here are a few statistics about the continually growing benzodiazepine prescription rate in this country:

• The percentage of American adults with benzodiazepine prescriptions, went from 4.1% in 1996 to 5.6% in 2013.
• Ambulatory visits during which a benzodiazepine prescription was written rose from 27.6 million in 2003 to 62.6 million in 2015.
• Overdose deaths from benzodiazepines increased from 0.58 per 100,000 adults in 1996 to 3.07 in 2010. The National Institute on Drug Abuse reports 11,537 deaths involving benzodiazepines in 2017, 85% of which also involved an opioid. Use of these two agents together increases risk of respiratory depression.
• A recent trend analysis showed a rise in co-prescribing of benzodiazepines and opioids from 0.5% of physician office visits in 2003 to 2% in 2015.

And now let’s turn to the results of this study spanning 2014 to 2016.

• An estimated annual average of 65.9 million office-based physician visits involved the prescribing of a benzodiazepine, or a rate of 27 annual visits per 100 adults. Among those visits, about one-third (35%) involved an overlapping opioid prescription for a rate of 10 annual visits per 100 adults. Annually during 2014-2016, benzodiazepines and opioids were prescribed at about 23 million physician office visits or a little more than a third of the visits at which benzodiazepines were prescribed. Approximately one-half of visits at which benzodiazepines were prescribed were with a primary care provider (48%) and one-half were with a different type of provider (50%).
• A problem related to a chronic condition was the most frequent reason for visits at which a benzodiazepine prescription was written.

Visit rates when benzodiazepines were prescribed alone and when benzodiazepines were co-prescribed with opioids were higher among women than men and rose with age. 88% of visits where a benzodiazepine was prescribed represented continuing prescriptions.

The reason a benzodiazepine was prescribed with or without an opioid was most commonly due to a problem related to a chronic condition. Looking at diagnostic categories for visits in which benzodiazepines were prescribed, mental disorders were the most frequent primary diagnosis category (22% of visits). The mental disorders included primarily episodic mood disorder (40%) and anxiety (34%). Diseases of the musculoskeletal system and connective tissue (primarily spinal disorder) and diseases of the circulatory system (primarily hypertension and heart disease) each accounted for 11% of visits when a benzodiazepine was prescribed.

The most common primary diagnostic category for visits in which benzodiazepines and opioids were co-prescribed was diseases of the musculoskeletal system and connective tissue (22%), over half of which involved a spinal disorder. Circulatory system conditions, primarily hypertension and heart disease, comprised 10% of visits where co-prescribing of benzodiazepines and opioids occurred.

The source of payment for about half of patients in the 18-44 and 45-64 age groups was private insurance, while older patients, 65 and over used Medicare as the primary expected source of payment.

The authors concluded that “Analysis of office-based physician visits may help monitor benzodiazepine prescriptions and co-prescriptions of benzodiazepines and opioids.”

For The Drug Report, I’m Pharmacist, Dr. Linda Bernstein.

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