Co-prescription of benzodiazepines and opioids has increased over the last 10 years

In primary care clinics not only has there been an increase in opioid prescriptions, but there is also a persistent increase in benzodiazepine prescriptions over the last decade, according to new research.

Ming-Chih Kao, PhD, MD, a clinical assistant professor at Stanford University Medical Center in Cupertino, Calif., and colleagues evaluated a database of 3.1 billion primary care visits documented in the National Ambulatory Medical Center Survey between 2002 and 2009.

“The co-prescription of these two classes of medications, which will have dangerously synergistic effects, was on the rise as well,” noted Dr. Kao. The findings were presented at the American Academy of Pain Medicine (AAPM) 30th Annual Meeting in Phoenix.

Dr. Kao and colleagues also found that 12.6% of the primary care visits involved benzodiazepine or opioid prescriptions. Benzodiazepine prescriptions were found to increase by a rate of 12.5% per year (95% CI, 9.4%–15.7%), while prescription for benzodiazepine with opioids increased by 12.0% per year (95% CI, 5.0%–19.4%). Adjustment was made for demographic factors, payer status, psychiatric illnesses, and pain diagnoses.

They also evaluated data approximately 730 million emergency department visits in the same time period and found almost one third of patients had benzodiazepine or opioid prescriptions. After adjusting for the same factors as primary care visits, the data showed an increase of 3.4% per year in prescription of opioids in the emergency department setting and an increase of 3.7% per year for benzodiazepines. However, prescriptions for benzodiazepines with opioids increased by 6.4% per year.“While we do not yet fully understand all of the forces at play in increasing benzodiazepine prescription in the primary care clinics, we are beginning to understand some of the drivers,” Dr. Kao said.

“Some of these are intrinsic and stem from provider preference, such as the use of benzodiazepines as the go-to muscle relaxant. Others are external such as the lack of insurance coverage for nonpharmacologic management,” he continued. “Reductions in physical therapy coverage nudges the primary care physician toward opioid medications for back pain-which is on-going work by our group-and reductions in mental health coverage nudges the primary care physicians towards benzodiazepine medications. These forces, in fact, cut across specialties. We have observed similar trends in specialist clinics as well.”

Dr. Kao said that it is important to note that while the regulatory and media attention are directed at opioid medications, “in truth pain management is quite a bit more than the simple binary choice of starting versus not starting opioid medication,” he said. “Chronic pain is a complex disease that  . . . costs the United States more resources than any other diseases. In order to provide comprehensive multidisciplinary pain management, there needs to be consideration of biomedical, psychosocial, and biomechanical factors.”

It is also important to make the distinction between medical and non-medical uses of pharmaceuticals, he pointed out. “Much of the work on morbidity and mortality of opioids and benzodiazepines studies both, whereas our work is focused on the medical use of these medications,” he said.

“I'd like to point out that this work is not about pointing fingers,” Dr. Kao continued. “It is about discovering systemic forces that underlie this trend. As a primary care physician in the community in San Francisco, I have personal experiences struggling with the complexities of patients with co-morbid pain and psychiatric illnesses. In fact, I entered this field because of that experience.”

In a recent issue of Pain Medicine, an overall strategy for individual physicians to work with benzodiazepine and opioid co-prescription was offered, Dr. Kao cited. An accompanying editorial also outlined a national strategy for education of clinicians and patients, and the regulatory framework necessary to support the clinicians.