This story highlights the dangers of taking both opioid painkillers and anti-anxiety drugs called benzodiazepines–but it misses the mark in a few ways, primarily by proclaiming researchers “just uncovered a simple way to combat the opioid epidemic.”
A BMJ editorial accompanying this study states: “Since 1999, the US has witnessed a fourfold increase in deaths from overdose involving prescription opioids, a fact widely known by US residents. That benzodiazepines are present in over 30% of overdoses involving prescription opioids is less well known.”
This story does a public service by promoting awareness of the problem. But the headline does a disservice by calling it a “simple” fix. As BMJ points out, systemic changes are required to revamp prescribing patterns, and that will take time and investment in new treatment approaches.
While the cost implications may be murky, the story should have at least broached the topic. Changing treatment strategies for thousands of patients could reduce costs if patients drop medications without replacing them or increase costs if patients switch to more expensive therapies. Certainly, keeping people out of ERs and hospital beds would be a savings, but it also would cost money to transition people off these medications and use different treatments, such as therapy sessions.
The story does a good job conveying the risk increase of combining drugs versus using opioids alone, and we especially like its use of a bar graph to give a visual representation of the added danger. The story states that eliminating concurrent benzodiazepine and opioid use could reduce the risk for an opioid overdose–related emergency room or inpatient visit by 15 percent. Further, it says the study found that among all opioid users, concurrent use of benzodiazepines more than doubled the risk of an ER or inpatient visit for a drug overdose.
One quibble: It wanders into sketchy territory by extrapolating deaths: “If that reduced risk applies to overdose deaths as well, eliminating concurrent opioid and benzodiazepine use could have prevented up to 2,630 opioid painkiller–related overdose deaths in 2015.” This is an interesting perspective, but we’re wondering if it’s valid to assume that deaths would decline proportionally to hospital visits. An independent expert source would have been helpful here.
The story mentions alternative treatments, but doesn’t address potential harms of changing prescribing patterns. While reducing the risk of overdose may outweigh any potential negatives of taking patients off of a drug, it’s still worth addressing any drawbacks.
The story also does not explain how concurrent use of benzodiazepines and opioids cause harm (via the combined sedative effect which can lead to respiratory depression).
The story does a good job describing the potential weaknesses in the findings:
There are some caveats to the study. For one, emergency room visits and inpatient admissions for opioid overdoses likely aren’t a perfect one-to-one proxy for overdoses that didn’t involve a trip to a doctor. The study also only looked at legally prescribed opioid painkillers and benzodiazepines, missing the effects of concurrent use of illegally obtained pills or drugs. And since the research relied on patients who were continuously insured throughout the study period, it’s possible the findings don’t exactly apply to people with spottier coverage. (Although sensitivity analyses in the study for people who had lapses in insurance produced similar results.) Finally, since the study looked at correlation (not causation), it’s possible that it missed some other factor driving up overdose deaths among concurrent benzodiazepine and opioid users — perhaps, for whatever reason, these users may be more likely to misuse their drugs.
We did take issue with this sentence: “For one, emergency room visits and inpatient admissions for opioid overdoses likely aren’t a perfect one-to-one proxy for overdoses that didn’t involve a trip to a doctor.” Isn’t it, instead, that the researchers only measured ER visits and admissions, therefore not capturing overdoses that didn’t involve a trip to a doctor?
The story does some editorializing but accurately depicts the magnitude of the problem when it states that the opioid epidemic is the “deadliest drug crisis in U.S. history.”
This story quotes one source, an author of the study. It would have benefitted from comments from independent physicians and public health experts on the challenges of changing prescribing patterns, as well as adequately treating pain and/or anxiety.
The headline states that reducing simultaneous opioid/benzodiazepine use is “not the only answer” to opioid overdoses. But the story doesn’t provide discussion of other strategies, such as social services and behavioral healthcare to assist recovering addicts, regulation of pain management clinics, prescription drug monitoring laws, access to naloxone, and a host of others.
The article also does not address a critical point: That benzodiazepines are not the right treatment for chronic anxiety and there is little reason to prescribe them long-term (one issue is that patients may have been started on them years or decades ago and it’s very hard to get them off of them despite what we know now).
Other treatments such as antidepressants (eg. sertraline, fluoxetine) and therapy are much more effective and safer for chronic anxiety. The article does mention that opioids are, similarly, not the right treatment for most chronic pain, but this was buried toward the end of the article and should have been given more prominence.
On balance the story could have done a better job of exploring what it would take to halt these dangerous drug interactions. The headline describes their elimination as a “simple way to help combat the opioid epidemic,” but the story acknowledges otherwise:
For some patients, eliminating these co-prescriptions could involve some tough trade-offs. If someone genuinely suffers from pain and anxiety, doctors and patients will need to work out which condition is more important to treat and which one can be treated with alternatives — to avoid a potentially deadly overdose.
The story also could have addressed the difficulty in changing physicians’ prescribing patterns. If indeed, as the story contends, “it’s well established that benzodiazepine and opioids compound each other’s overdose risk,” why have so many dual prescriptions been written? Are there readily available and affordable alternatives to these two classes of drugs? The story doesn’t say.
The story says researchers “just uncovered” the danger of tandem opiod/benzodiazepine use and quotes a researcher saying the study “reveals an underappreciated policy lever for reducing drug overdoses: Making sure patients prescribed to opioids aren’t also prescribed to benzodiazepines, and vice versa.”
In fact, this has been the radar of the medical community for awhile. A 2015 study found veterans using opioids had a higher risk of death from drug overdose if they also used benzodiazepines. And last year two government agencies took action: The U.S. Centers for Disease Control and Prevention amended guidelines to discourage clinicians from prescribing both types of drugs simultaneously, while the FDA advised of the dangers of mixing the drugs and strengthened warning labels and patient medication guides for nearly 400 products.
Instead, the challenge has been figuring out how to get patients off of this drug combination and recent research/care delivery redesign efforts are tackling this issue (but this article doesn’t not get into this at all, nor is this what the research study is about).
The story does not appear to rely on a news release.