The association between benzodiazepine prescription and aberrant drug-related behaviors in primary care patients receiving opioids for chronic pain

Drug Safety and Suicidality Risk of Chronic Pain Medications

Chronic pain is one of the main leading causes of disability in the world at present. A variety in the symptomatology, intensity and duration of this phenomenon has led to an ever-increasing demand of pharmacological treatment and relief. This demand for medication, ranging from well-known groups, such as antidepressants and benzodiazepines, to more novel drugs, was followed by a rise in safety concerns of such treatment options. The validity, frequency, and diversity of such concerns are discussed in this paper, as well as their possible effect on future prescription practices. A specific caution is provided towards the psychological safety and toll of these medications, regarding suicidality and suicidal ideation. Most significantly, this paper highlights the importance of pharmacovigilance and underscores the necessity of surveillance programs when considering chronic pain medication.

Association between chiropractic spinal manipulative therapy and benzodiazepine prescription in patients with radicular low back pain: a retrospective cohort study using real-world data from the USA

OBJECTIVES

Although chiropractic spinal manipulative therapy (CSMT) and prescription benzodiazepines are common treatments for radicular low back pain (rLBP), no research has examined the relationship between these interventions. We hypothesise that utilisation of CSMT for newly diagnosed rLBP is associated with reduced odds of benzodiazepine prescription through 12 months' follow-up.

DESIGN

Retrospective cohort study.

SETTING

National, multicentre 73-million-patient electronic health records-based network (TriNetX) in the USA, queried on 30 July 2021, yielding data from 2003 to the date of query.

PARTICIPANTS

Adults aged 18-49 with an index diagnosis of rLBP were included. Serious aetiologies of low back pain, structural deformities, alternative neurological lesions and absolute benzodiazepine contraindications were excluded. Patients were assigned to cohorts according to CSMT receipt or absence. Propensity score matching was used to control for covariates that could influence the likelihood of benzodiazepine utilisation.

OUTCOME MEASURES

The number, percentage and OR of patients receiving a benzodiazepine prescription over 3, 6 and 12 months' follow-up prematching and postmatching.

RESULTS

After matching, there were 9206 patients (mean (SD) age, 37.6 (8.3) years, 54% male) per cohort. Odds of receiving a benzodiazepine prescription were significantly lower in the CSMT cohort over all follow-up windows prematching and postmatching (p<0.0001). After matching, the OR (95% CI) of benzodiazepine prescription at 3 months was 0.56 (0.50 to 0.64), at 6 months 0.61 (0.55 to 0.68) and 12 months 0.67 (0.62 to 0.74). Sensitivity analysis suggested a patient preference to avoid prescription medications did not explain the study findings.

CONCLUSIONS

These findings suggest that receiving CSMT for newly diagnosed rLBP is associated with reduced odds of receiving a benzodiazepine prescription during follow-up. These results provide real-world evidence of practice guideline-concordance among patients entering this care pathway. Benzodiazepine prescription for rLBP should be further examined in a randomised trial including patients receiving chiropractic or usual medical care, to reduce residual confounding.

Cognitive-Affective Transdiagnostic Factors Associated With Vulnerability to Alcohol and Prescription Opioid Use in the Context of Pain

The use of alcohol and prescription opioids is common among people in pain and poses significant public health burdens. This review identifies factors associated with motivation to use alcohol and prescription opioids in the context of pain. Pain-relevant, cognitive-affective, transdiagnostic vulnerability factors-expectancies/motives, pain catastrophizing, pain-related anxiety, distress intolerance, anxiety sensitivity, and perceived interrelations-were selected from theoretical conceptualizations of pain and substance use. Searches conducted in PubMed, PsycINFO, and Embase returned 25 studies that examined associations between identified variables of interest and the use of alcohol and prescription opioids in the context of pain. Consistent with a larger literature on pain and substance use, the studies included in this review demonstrated that people with chronic pain are motivated to use alcohol and opioids in response to negative affect and hold expectancies/motives for coping with pain. Vulnerabilities that engender difficulty managing aversive internal states (distress intolerance and anxiety sensitivity) and maladaptive responses to pain (pain-related anxiety and pain catastrophizing) also were implicated in motivation for alcohol and opioid use. Although one study found that pain-related anxiety was associated with co-use of alcohol and opioids, no studies examined simultaneous use. Future research directions that can explicate causal associations, identify patterns of alcohol and opioid co-use, clarify the role of pain in cessation processes, and inform treatment development are discussed.

Prescriptions of analgesics during chronic cancer disease trajectories: A complete national cohort study

PURPOSE

Pain management principles vary considerably between chronic noncancer, acute and cancer pain. Cancer patients responding to oncological treatment may live with low tumor burden for years. Opioid treatment should reflect that the ratio between benefits and risks in these patients is different from patients with a rapidly progressive disease. Our study investigated the prescription patterns of analgesics in patients who died 6 to 9 years after cancer diagnosis.

PATIENTS AND METHODS

A pharmaco-epidemiological study based on the Norwegian Prescription Database and Cancer Registry of Norway. The 1-year periodic prevalence of receiving different analgesics and of persistent opioid use were analyzed. Persistent opioid use was defined as >365 Defined Daily Doses or >9000 mg Oral Morphine Equivalents during 365 days with prescriptions in all quarters of the 365 days period. Data were reported for the first 7 years for patients who lived 8-9 years after cancer diagnosis (N = 1502), while for patients who lived 6-7 years (N = 3817) data was reported for the first 5 years after diagnosis.

RESULTS

Compared to age- and gender adjusted general population, the 1-year periodic prevalence of opioid prescription was doubled the first year after diagnosis and remained raised with approximately 50%. The prevalence of persistent opioid use was threefold of the general population. Approximately 55% of patients with persistent opioid use 4 years after a cancer diagnosis were co-medicated with high doses of benzodiazepines and/or benzodiazepine-related hypnotics.

CONCLUSION

The findings of increased opioid use raise concerns regarding whether the benefits outweigh risks and side effects in this population.

Drug Prescription Profiles in Patients with Polypharmacy in Spain: A Large-Scale Pharmacoepidemiologic Study Using Real-World Data

We aimed to identify and compare medication profiles in populations with polypharmacy between 2005 and 2015. We conducted a cross-sectional study using information from the Computerized Database for Pharmacoepidemiologic Studies in Primary Care (BIFAP, Spain). We estimated the prevalence of therapeutic subgroups in all individuals 15 years of age and older with polypharmacy (≥5 drugs during ≥6 months) using the Anatomical Therapeutic Chemical classification system level 4, by sex and age group, for both calendar years. The most prescribed drugs were proton-pump inhibitors (PPIs), statins, antiplatelet agents, benzodiazepine derivatives, and angiotensin-converting enzyme inhibitors. The greatest increases between 2005 and 2015 were observed in PPIs, statins, other antidepressants, and β-blockers, while the prevalence of antiepileptics was almost tripled. We observed increases in psychotropic drugs in women and cardiovascular medications in men. By patient´s age groups, there were notable increases in antipsychotics, antidepressants, and antiepileptics (15–44 years); antidepressants, PPIs, and selective β-blockers (45–64 years); selective β-blockers, biguanides, PPIs, and statins (65–79 years); and in statins, selective β-blockers, and PPIs (80 years and older). Our results revealed important increases in the use of specific therapeutic subgroups, like PPIs, statins, and psychotropic drugs, highlighting opportunities to design and implement strategies to analyze such prescriptions’ appropriateness.

Opioid stewardship: implementing a proactive, pharmacist-led intervention for patients coprescribed opioids and benzodiazepines at an urban academic primary care centre

In 2017, almost 4000 Canadians died from opioid-related causes. Coadministration of opioids and benzodiazepines is a risk factor for overdose. Few studies have evaluated leveraging pharmacists to address opioid-benzodiazepine coprescribing. Our aim was to develop and test a role for pharmacists as opioid stewards, to reduce opioid and benzodiazepine doses in coprescribed patients. We conducted Plan-Do-Study-Act cycles between November 2017 and May 2018 across two primary care centre clinics. A third clinic acted as a control. Our intervention included a pharmacist: (1) identifying patients through medical record queries; (2) developing care plans; (3) discussing recommendations with physicians and (4) discussing implementing recommendations. We refined the intervention according to patient and physician feedback. At the intervention clinics, the number of patients with pharmacist developed care plans increased from less than 20% at baseline to over 60% postintervention. There was also a fourfold increase in the number of patients with an active opioid taper. At the control clinic, the number of patients with pharmacist developed care plans remained relatively stable at less than 20%. The number of patients with active opioid tapers remained zero. At the intervention clinics, mean daily opioid dose decreased 11% from 50.5 milligrams morphine equivalent (MME) to 44.7 MME. At the control clinic, it increased 15% from 62.3 MME to 71.4 MME. The number of patients with a benzodiazepine taper remained relatively stable at both the intervention and control clinics at less than 20%. At the intervention clinics, mean daily benzodiazepine dose decreased 8% from 9.9 milligrams diazepam equivalent (MDE) to 9.3 MDE. At the control clinic, it decreased 4% from 10.8 MDE to 10.4 MDE. A proactive, pharmacist-led intervention for coprescribed patients increased opioid tapers and decreased opioid and benzodiazepine doses. Future work will help us understand whether sustaining the intervention ultimately reduces rates of opioid-benzodiazepine coprescribing.

Correlates of Benzodiazepine Use and Adverse Outcomes Among Patients with Chronic Pain Prescribed Long-term Opioid Therapy

OBJECTIVE

To examine the correlates and odds of receiving overlapping benzodiazepine and opioid prescriptions and whether co-prescription was associated with greater odds of falling or visiting the emergency department.

DESIGN

Cross-sectional study.

SETTING

A large private integrated health system and a Veterans Health Administration integrated health system.

SUBJECTS

Five hundred seventeen adults with musculoskeletal pain and current prescriptions for long-term opioid therapy.

METHODS

A multivariate logistic regression model examined correlates of having overlapping benzodiazepine and opioid prescriptions in the year before enrollment in the cross-sectional study. Negative binomial models analyzed the number of falls in the past three months and past-year emergency department visits. In addition to propensity score adjustment, models controlled for demographic characteristics, psychiatric diagnoses, medications, overall comorbidity score, and opioid morphine equivalent dose.

RESULTS

Twenty-five percent (N = 127) of participants had co-occurring benzodiazepine and opioid prescriptions in the prior year. Odds of receiving a benzodiazepine prescription were significantly higher among patients with the following psychiatric diagnoses: anxiety disorder (adjusted odds ratio [AOR] = 4.71, 95% confidence interval [CI] = 2.67-8.32, P < 0.001), post-traumatic stress disorder (AOR = 2.24, 95% CI = 1.14-4.38, P = 0.019), and bipolar disorder (AOR = 3.82, 95% CI = 1.49-9.81, P = 0.005). Past-year overlapping benzodiazepine and opioid prescriptions were associated with adverse outcomes, including a greater number of falls (risk ratio [RR] = 3.27, 95% CI = 1.77-6.02, P = 0.001) and emergency department visits (RR = 1.66, 95% CI = 1.08-2.53, P = 0.0194).

CONCLUSIONS

Among patients with chronic pain prescribed long-term opioid therapy, one-quarter of patients had co-occurring prescriptions for benzodiazepines, and dual use was associated with increased odds of falls and emergency department visits.

Opioid-limiting legislation associated with decreased 30-day opioid utilization following anterior cervical decompression and fusion

BACKGROUND CONTEXT

Since 2016, 35 of 50 US states have passed opioid-limiting laws. The impact on postoperative opioid prescribing and secondary outcomes following anterior cervical discectomy and fusion (ACDF) remains unknown.

PURPOSE

To evaluate the effect of opioid-limiting regulations on postoperative opioid prescriptions, emergency department (ED) visits, unplanned readmissions, and reoperations following elective ACDF.

STUDY DESIGN/SETTING

Retrospective review of prospectively-collected data.

PATIENT SAMPLE

Two hundred and eleven patients (101 pre-law, 110 post-law) undergoing primary elective 1-3 level ACDF during specified pre-law (December 1st, 2015-June 30th, 2016) and post-law (June 1st, 2017-December 31st, 2017) study periods were evaluated.

METHODS

Demographic, medical, surgical, clinical, and pharmacological data was collected from all patients. Total morphine milligram equivalents (MMEs) filled was compared at 30-day postoperative intervals, before and after stratification by preoperative opioid-tolerance. Thirty- and 90-day ED visit, readmission, and reoperation rates were calculated. Independent predictors of increased 30-day and chronic (>90 day) opioid utilization were evaluated.

RESULTS

Demographic, medical, and surgical factors were similar pre-law versus post-law (all p>.05). Post-law, ACDF patients received fewer opioids in their first postoperative prescription (26.65 vs. 62.08 pills, p<.001; 202.23 vs. 549.18 MMEs, p<.001) and in their first 30 postoperative days (cumulative 30-day MMEs 444.14 vs. 877.87, p<.001). Furthermore, post-law reductions in cumulative 30-day MMEs were seen among both opioid-naïve (363.54 vs. 632.20 MMEs, p<.001) and opioid-tolerant (730.08 vs. 1,122.90 MMEs, p=.022) patient populations. Increased 30-day opioid utilization was associated with surgery in the pre-law period, preoperative opioid exposure, preoperative benzodiazepine exposure, and number of levels fused (all p<.05). Chronic (>90 day) opioid requirements were associated with preoperative opioid exposure (odds ratio 4.42, p<.001) but not with pre/post-law status (p>.05). Pre- and post-law patients were similar in terms of 30- or 90-day ED visits, unplanned readmissions, and reoperations (all p>.05).

CONCLUSIONS

Implementation of mandatory opioid prescribing limits effectively decreased 30-day postoperative opioid utilization following ACDF without a rebound increase in prescription refills, ED visits, unplanned hospital readmissions, or reoperations for pain.

Correlates of opioid and benzodiazepine co-prescription among people living with HIV in British Columbia, Canada: A population-level cohort study

BACKGROUND

Co-prescribing benzodiazepines and opioids is relatively contraindicated due to the possible overdose risk. However, people living with HIV (PLWH) may have concurrent psychiatric and/or chronic pain diagnoses that may lead to the use of opioids and/or benzodiazepines for symptomatic treatment. Consequently, some PLWH may be at-risk for the health harms associated with the co-prescribing of these medications. Given this, the objectives of this study were to first examine the prevalence of opioids and benzodiazepines co-prescribing, and second, to characterize patient factors associated with the co-prescribing of opioids and benzodiazepines among PLWH in British Columbia (BC), Canada.

METHODS

Using data derived from a longitudinal BC cohort, we used bivariable and multivariable generalized estimating equation models to establish the prevalence of a benzodiazepine and opioid co-prescription and determine factors associated with this practice.

RESULTS

Between 1996 and 2015, 14 484 PLWH were included in the study and were followed for the entire study period. At baseline, 548 people (4%) were co-prescribed opioids and benzodiazepines, 6593 (46%) were prescribed opioids only, 2887 (20%) were prescribed benzodiazepines only, and 4456 (31%) were prescribed neither medication. A total of 3835 (27%) participants were prescribed both medications at least once during the study period. Factors positively associated with concurrent opioid and benzodiazepine prescribing included: depression/mood disorder [adjusted odds ratio (AOR) = 1.32; 95% confidence interval (CI) = 1.22-1.43] and anxiety disorder (AOR = 1.45; 95% CI = 1.27-1.66), whereas female sex (AOR = 0.76; 95% CI = 0.64-0.91) and substance use disorder (SUD) (AOR = 0.82; 95% CI = 0.74-0.90) were negatively associated with the outcome.

CONCLUSION

Our findings indicate that co-prescription of opioids and benzodiazepines was seen at some point during study follow-up in over a quarter of PLWH. Given the known risks associated with this prescribing practice, future research can focus on the outcomes of co-prescribing among this patient population and the development of strategies to reduce the co-prescribing of opioids and benzodiazepines.

Screening for Psychotherapeutic Medication Misuse in Primary Care Patients: Comparing Two Instruments

INTRODUCTION

Prescription psychotherapeutic medication misuse is a growing problem in the United States, but no method exists to routinely screen for this in primary care. Our study sought to (1) describe the prevalence of prescription psychotherapeutic medication misuse in primary care and the characteristics of patients who misuse and (2) compare 2 screening instruments modified to identify prescription medication misuse in primary care.

METHODS

Primary care patients from underserved, urban clinics within a health system completed anonymous computer-directed health screens that included standard questions about prescription medication misuse. They were also administered the 4-item Cut down, Annoyed, Guilty, and Eye-opener questionnaire modified to focus on prescription medications (RxCAGE) and a 6-item Prescription Opioid Misuse Index (POMI-e) expanded to include other prescription medications.

RESULTS

Of 2,339 respondents, 15.3% were positive for at least 2 items on the RxCAGE and 18.6% were positive for at least 2 items on the POMI-e. Using our computer-directed health screen as a comparison, we found that POMI-e had a higher area under the curve (0.63). A positive POMI-e was associated with being male, white and unemployed, having depression and anxiety, and currently using illicit substances, smoking, and misusing alcohol.

CONCLUSIONS

Rates of prescription medication misuse were substantial with both RxCAGE and POMI-e showing promise as screening instruments. Future studies are needed to test prescription medication misuse screening tools in broader populations and pilot interventions for those screening positive.

Cultivating change door to door: Educational outreach to improve prescribing practices in rural veterans with posttraumatic stress disorder

BACKGROUND

Clinical guidelines for the management of posttraumatic stress disorder (PTSD) recommend against the use of benzodiazepines. Benzodiazepines and PTSD are both associated with addiction-related risks. The Department of Veterans Affairs (VA) prescribing trends show continued use of benzodiazepines and polysedative use in veterans with PTSD, particularly in rural areas. The authors examine the use of an educational intervention to improve pharmacologic management of veterans with PTSD in rural clinics.

METHODS

The VA Academic Detailing Service Informatics Toolset provides prescribing, demographic and risk factor data for veterans with PTSD treated at the White River Junction VA Medical Center (WRJ VA) and affiliated rural clinics in Vermont and New Hampshire. Individualized academic detailing visits were provided to clinicians identified by the informatics tool with the aim of increasing guideline-concordant care. Other educational efforts included traditional, didactic group education on evidence-based PTSD care and the development and dissemination of educational materials for clinicians and patients. Prescribing trends of benzodiazepines, off-label atypical antipsychotics, and prazosin were collected quarterly for 3 years (October 1, 2013, to September 30, 2016).

RESULTS

Prescribing rates of benzodiazepines during the educational intervention decreased from 13% to 9.3%. Use of off-label atypical antipsychotics, a class of medications not recommended for PTSD, stayed relatively flat at about 10%. Prescribing of prazosin, a medication recommended for treatment of trauma nightmares, increased from 9.8% to 14.3%.

CONCLUSIONS

Academic detailing and other educational programming appear to be effective for addressing gaps and lag in quality PTSD care and are associated with a positive trend of decreased benzodiazepine use. Efforts will continue, now with added focus on concurrent use of benzodiazepines and opioids and the use of off-label atypical antipsychotics in rural veterans with PTSD.

Medication Overuse in Chronic Pain

PURPOSE OF REVIEW

Chronic pain is usually managed by various pharmacotherapies after exhausting the conservative modalities such as over-the-counter choices. The goal of this review is to investigate current state of opioids and non-opioid medication overuse that includes NSAIDs, skeletal muscle relaxants, antidepressants, membrane stabilization agents, and benzodiazepine. How to minimize medication overuse and achieve better outcome in chronic pain management?

RECENT FINDINGS

Although antidepressants and membrane stabilization agents contribute to the crucial components for neuromodulation, opioids were frequently designated as a rescue remedy in chronic pain since adjunct analgesics usually do not provide instantaneous relief. The updated CDC guideline for prescribing opioids has gained widespread attention via media exposure. Both patients and prescribers are alerted to respond to the opioid epidemic and numerous complications. However, there has been overuse of non-opioid adjunct analgesics that caused significant adverse effects in addition to concurrent opioid consumption. It is a common practice to extrapolate the WHO three-step analgesic ladder for cancer pain to apply in non-cancer pain that emphasizes solely on pharmacologic therapy which may result in overuse and escalation of opioids in non-cancer pain. There has been promising progress in non-pharmacologic therapies such as biofeedback, complementary, and alternative medicine to facilitate pain control instead of dependency on pharmacologic therapies. This review article presents the current state of medication overuse in chronic pain and proposes precaution to balance the risk and benefit ratio. It may serve as a premier for future study on clinical pathway for comprehensive chronic pain management and reduce medication overuse.