
- Vol 38, Issue 11
Benzodiazepines: It’s Time to Prescribe Caution
How can the more cautious and conservative use and prescription of benzodiazepines save thousands of lives per year?
CLINICAL REFLECTIONS
The opioid epidemic has grown increasingly deadly, yet it is possible that an important component has been overlooked (
Benzodiazepine Misuse
During the time period studied by Agarwal et al,2 outpatient psychiatrists manifested a stable pattern of benzodiazepine prescribing, delivering benzodiazepine prescriptions to the patient in 30% of psychiatric visits. Overall, prescriptions written by psychiatrists account for approximately one-sixth of the more than 25 million prescriptions that are written each year.3 In 2015 and 2016, 30.6 million US adults reported benzodiazepine use in the past year; of these, 5.3 million were deemed to be misusing them.3 The most common type of misuse occurs when prescribed medications are diverted and utilized by individuals who did not receive them for a legitimate medical indication.
Thus, data suggest that some benzodiazepines prescribed by psychiatrists end up being misused by individuals who are also misusing opioids, and that some of these opioid overdose deaths are potentiated by benzodiazepines prescribed by a trusting psychiatrist. Are these benzodiazepines that originate in mental health settings a factor in hundreds, or thousands, of annual opioid overdose deaths? Although the magnitude of this problem is not known, it is likely that psychiatrists who exercise more caution can play a role in doing less inadvertent harm.
Nearly a decade ago, Jones et al4 conducted a comprehensive review of studies on the combined use of opioids and benzodiazepines and concluded that “that the co-abuse of opioids and benzodiazepines is ubiquitous around the world.” They further found that benzodiazepines are utilized by those who abuse opioids to potentiate opioid intoxication, and that the co-abuse of opioid and benzodiazepines “has negative consequences for general health, overdose lethality, and treatment outcome.”
Perhaps their 2012 conclusion that physicians should exercise more caution and vigilance in prescribing is reflected in the fact that psychiatrists have paid attention, and not increased our rate of benzodiazepine prescribing. Whereas psychiatric prescriptive practices have remained stable, other physicians, especially primary care providers, are delivering nearly twice as many benzodiazepine prescriptions to patients.1 However, in view of the subsequent progression of the opioid crisis and the mounting overdose death toll, reducing the rate of benzodiazepine prescriptions in psychiatric practice may indeed be a worthwhile, life-saving consideration.
By adhering to universal precautions in pain medicine, Gourlay et al5 suggested that physicians are able to routinize a cautious, non-stigmatizing clinical approach that facilitates their ability to limit opioid prescriptions. It might be helpful for psychiatrists to adopt a parallel set of best practices and universal precautions with regards to prescribing benzodiazepines and other psychoactive pharmaceuticals with abuse liability. (See the
Discussion
Epidemiological studies suggest that individuals with untreated anxiety and mood disorders may be prone to self-medicate with nonmedical use of opioids. Unfortunately, use and misuse of opioid drugs may themselves aggravate symptoms of anxiety.6 It is not surprising, then, that outpatient psychiatrists sometimes prescribe benzodiazepines to patients who may covertly be suffering from opioid use disorder. Substance use disorders (SUDs) have long been associated with behaviors that may be deemed antisocial,7 including deceptive communication;8 thus, community-based psychiatrists in high-volume clinic settings may be at risk of being fooled by patients who are drug-seeking.
The ease of integrating some or all of the 8 suggested universal precautions for initiating or continuing benzodiazepine pharmacotherapy will vary from treatment setting to treatment setting. At the very least, this aspirational list of precautions may facilitate the ability of mental health professionals to offer a clinically sound integrated approach for the treatment of cooccurring psychiatric and SUDs. Integrated treatment of co-occurring disorders is the accepted standard of care for this challenging, high-risk patient population.9
Dr Adelman is a coaching and consulting psychiatrist, and is board-certified in psychiatry, addiction medicine, and coaching (BCC). He launched www.AdelMED.com after 8 years directing Physician Health Services, Inc. On the faculty of the University of Massachusetts Medical School, he is a consultant in psychiatry in the Division of Alcohol and Drug Abuse of McLean Hospital, an affiliate of Harvard Medical School.
References
1. Park TW, Saitz R, Ganoczy D, et al.
2. Agarwal SD, Landon BE.
3. Maust DT, Lin LA, Blow FC.
4. Jones JD, Mogali S, Comer SD.
5. Gourlay DL, Heit HA, Almahrezi A.
6. Martins SS, Fenton MC, Keyes KM, et al.
7. Vaillant GE.
8. Young SR, Azari S, Becker WC, et al.
9. Kelly TM, Daley DC.
Articles in this issue
almost 4 years ago
PTSD in Late Life: An Update on Clinical Issuesalmost 4 years ago
Recognizing and Addressing Psychiatric Implications of Sleep Disordersalmost 4 years ago
COVID-19, Cognition, and Dementias: What Role Has the Pandemic Played?almost 4 years ago
Caring for Older Adults With Mental Health Disorders During the Pandemicalmost 4 years ago
Heal Thyself, Then Heal Others? The Power of Lived Experiencesalmost 4 years ago
Mirrors and Jeweled Netsalmost 4 years ago
Psychiatric Views on the Daily Newsalmost 4 years ago
Majority of Americans Favor President’s Vaccine Mandate: Pollalmost 4 years ago
Sorting Out Comorbiditiesalmost 4 years ago
Listening to Terry GrossNewsletter
Receive trusted psychiatric news, expert analysis, and clinical insights — subscribe today to support your practice and your patients.