Benzodiazepines: The Other Prescription Drug Problem

The prescribing of benzodiazepines during office visits has risen over the past decade; benzodiazepines are often coprescribed with opioids and other sedating medications, frequently for conditions other than anxiety and insomnia, new research shows.

Given that benzodiazepines have been implicated in a growing number of overdose-related deaths, this finding is concerning, the investigators told Medscape Medical News.

"The pendulum has begun to swing in how we prescribe opioids, but we really need to be cautious in how we prescribe benzodiazepines too. Benzodiazepines are easy to start but hard to stop," said study investigator Sumit Agarwal, MD, from Brigham and Women's Hospital in Boston, Massachusetts.

"I'm surprised that we're not talking about this more. This has been called our 'other' prescription drug problem," Agarwal added.

The study was published online January 25 in JAMA Network Open.

No Guidelines

Agarwal and coauthor Bruce Landon, MD, from Harvard Medical School, used nationally representative data to examine patterns in outpatient prescribing of benzodiazepines. The analysis included more than 386,000 ambulatory care visits from 2003 through 2015.

During the 13-year period, the rate at which benzodiazepines were prescribed during ambulatory care visits in the United States nearly doubled, from 3.8% in 2003 to 7.4% in 2015.

The rate of benzodiazepine prescribing during psychiatrist visits held steady during the study period (29.6% in 2003 and 30.2% in 2015) but increased among all other physicians. This increase included a doubling of prescribing by primary care physicians (PCPs), from 3.6% to 7.5%. As a group, PCPs accounted for more than half of benzodiazepine prescriptions (52.3%).

From 2003 through 2015, benzodiazepines were increasingly prescribed for anxiety and depression (from 26.6% to 33.5%), neurologic conditions (from 6.8% to 8.7%), and back pain or chronic pain (from 3.6% to 8.5%).

Coprescribing of benzodiazepines with opioids quadrupled during the study period, from 0.5% in 2003 to 2.0% in 2015, and coprescribing with other sedating medications doubled, from 0.7% to 1.5%.

"What is most striking is not just that the use of benzodiazapines has risen in the outpatient setting but also that it is increasingly being prescribed alongside opioids and other sedating medications, where the risks of adverse events are much more pronounced," said Agarwal.

The authors note that "surprisingly few guidelines exist for a medication that is prescribed by so many different types of physicians and for so many different indications."

Benzodiazepines "can be effective medications when used in appropriate patients for short-term use. But I fear that we're seeing a lot of chronic use, even though there isn't much evidence supporting its use past 8 or 10 weeks. In these patients, we should broach the idea of deprescribing with slow tapers," said Agarwal.

The study had no specific funding. Dr Agarwal receives salary support from the Health Resources and Services Administration and the Ryoichi Sasakawa Fellowship Fund. No other relevant financial relationships have been disclosed.

JAMA Netw Open. Published online January 25, 2019. Full text

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