‘Benzo Crisis’ Keeps Not Happening

By Roger Chriss, PNN Columnist

A new study published in The Journal of Clinical Psychiatry has found that the misuse and abuse of benzodiazepine is relatively rare, even though the drug is sometimes hyped as the next overdose crisis in healthcare.

Benzodiazepines – often called “benzos” -- are a class of sedative that includes Valium and Xanax. The medications are usually prescribed to treat anxiety and insomnia.

Data on over 100,000 adults in the 2015-16 National Surveys on Drug Use and Health was analyzed by researchers, who found that benzodiazepines were used by 12.5% of American adults. Of those, about 17% “misused” the drug at least once, but only 2% had what was diagnosed as a benzodiazepine use disorder.

The study found several risk factors for benzo misuse, including younger age, male gender, lower levels of education, lack of health insurance or employment, and lower income levels — factors often associated with other substance use disorders.

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The National Institute on Drug Abuse (NIDA) recently reported that most misusers obtained benzodiazepines from friends or relatives, with only about 20% receiving them from their doctor.

These findings, both the statistics and the specific risks factors and usage patterns, run counter to inflammatory media headlines such as “Xanax, Valium looking like America's next drug crisis” or “Benzodiazepines: our other prescription drug epidemic.”  

Instead, benzodiazepines are better viewed as part of an ongoing problem of drug abuse and addiction that primarily occurs outside of medical care. They are a factor in many drug overdoses, partly because of increasing rates of counterfeit Xanax and Valium being contaminated with illicit fentanyl, and because overdose rates increase when benzodiazepines are combined with opioids or alcohol.

Until recently, benzodiazepines were commonly co-prescribed with opioids to chronic pain patients, a practice that is now strongly discouraged by regulators and insurers.

There are indeed risks with benzodiazepines, including not only sedation and somnolence, but also cognitive effects and worsening of psychiatric symptoms. Moreover, chronic benzodiazepine use can lead to physiologic dependence independent of any abuse or addiction, and this dependence can make tapering off benzodiazepines difficult. Benzodiazepine withdrawal syndrome is sufficiently important to merit extensive treatment in the online guide known as the Ashton Manual.

But there are also benefits in using these drugs, even for long-term therapy. For instance, REM sleep behavior disorder is a sleep disorder in which people act out vivid, unpleasant dreams with violent arm and leg movements, often harming themselves or bed partners in the process. The benzodiazepine clonazepam (Klonopin) is the traditional choice for treatment for that. 

Stiff person syndrome is a rare neurological disorder involving intense muscle spasms in the limbs and trunk. The benzodiazepine diazepam (Valium) helps reduce those muscle spasms and stiffness.

There are also intriguing novel uses for benzodiazepines as well. Some researchers are investigating low-dose benzodiazepine therapy for people with treatment-resistant obsessive-compulsive disorder (OCD). This is not the cuddly version of OCD seen in TV shows like “Monk” but crippling dysfunction that renders a person incapable of leaving their bed for days at a stretch.

Benzodiazepines need careful consideration, but not a hyped crisis. In a reference to the opioid crisis, NIDA director Nora Volkow, MD, told Opioid Watch: “As always, science should be the driver of smart policies designed to reverse the course of this crisis.”

The same wisdom should be applied to all medications.

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Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Tom Petty Overdosed on Opioids and Anxiety Medication

By Pat Anson, Editor

Tom Petty died from an accidental overdose caused by a potent cocktail of opioid painkillers, anti-anxiety medication and an anti-depressant that the singer was taking for chronic pain and other illnesses, according to autopsy findings and family members. Two of the drugs detected were illegal fentanyl analogues.

The 66-year old rock legend died last October after suffering cardiac arrest and collapsing at his home in Malibu. He had just completed a grueling tour to mark the 40th anniversary of his band, Tom Petty and the Heartbreakers.

In autopsy results released Friday, the Los Angeles County Coroner listed Petty’s cause of death as  "multisystem organ failure due to resuscitated cardiopulmonary arrest due to mixed drug toxicity."

Toxicology tests showed the presence of two prescription opioids (oxycodone and fentanyl), as well as two benzodiazepines (temazepam and alprazolam) for anxiety and the anti-depressant citalopram. Doctors have long warned that such a combination of prescription drugs can be deadly, leading to respiratory depression and overdose.

In addition, the coroner also listed two chemical cousins of fentanyl: acetyl fentanyl and despropionyl fentanyl. They are not prescription drugs, but are illegal synthetic opioids increasingly appearing on the black market in counterfeit medication.  The brief statement by the coroner did not point this out, nor did it list the blood levels at which any of the drugs were detected.

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Petty’s wife Dana and daughter Adria released a statement saying the singer was prescribed "various pain medications for a multitude of issues including fentanyl patches," and that he suffered from emphysema, knee problems and a fractured hip.

“Despite this painful injury he insisted on keeping his commitment to his fans and he toured for 53 dates with a fractured hip and, as he did, it worsened to a more serious injury. On the day he died he was informed his hip had graduated to a full on break and it is our feeling that the pain was simply unbearable and was the cause for his over use of medication," the statement said.

“On a positive note we now know for certain he went painlessly and beautifully exhausted after doing what he loved the most, for one last time, performing live with his unmatchable rock band for his loyal fans on the biggest tour of his 40 plus year career. He was extremely proud of that achievement in the days before he passed.”

The family said it recognized Petty’s overdose may “spark a further discussion on the opioid crisis” and perhaps save some lives. “Many people who overdose begin with a legitimate injury or simply do not understand the potency and deadly nature of these medications,” they said.

Fentanyl and benzodiazepines were also linked to the deaths of the pop star Prince and the rapper Lil Peep.

In 2016, the Food and Drug Administration expanded the warning labels on all opioids and benzodiazepines because of the risk they pose when used together.

"It is nothing short of a public health crisis when you see a substantial increase of avoidable overdose and death related to two widely used drug classes being taken together," said then FDA Commissioner Robert Califf, MD. "We implore health care professionals to heed these new warnings and more carefully and thoroughly evaluate, on a patient-by-patient basis, whether the benefits of using opioids and benzodiazepines – or CNS (central nervous system) depressants more generally – together outweigh these serious risks."

Chronic Pain and Depression Common in Overdoses

By Pat Anson, Editor

People who die from opioid overdoses are significantly more likely to suffer from chronic pain and depression, according to a new study that highlights the risk of combining opioid pain relievers with benzodiazepines, a class of anti-anxiety medication.

Researchers at Columbia University Medical Center analyzed over 13,000 overdose deaths among Medicaid patients and found that over 61 percent had been diagnosed with back pain, headaches or some other chronic pain condition. Many also suffered from depression, anxiety, bipolar disorder, schizophrenia and other mental health problems.

Significantly, nearly half of those with chronic pain (49%) filled a prescription for opioid pain medication during the last 30 days of their lives, and just over half (52%) filled a prescription for benzodiazepines. Prescriptions for anti-depressants, anti-psychotics and mood stabilizers were also common.

“This medication combination is known to increase the risk of respiratory depression, which is the unusually slow and shallow breathing that is the primary cause of death in most fatal opioid overdoses," said Mark Olfson, MD, a professor of psychiatry at Columbia and lead investigator of the study.

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“Most persons with opioid-related fatalities were diagnosed with one or more chronic pain condition in the last year of life. As compared to people with opioid-related deaths without diagnosed chronic pain conditions, the decedents with chronic pain diagnoses were more likely to have also received substance use and other mental health disorder diagnoses. They were also more likely to have filled prescriptions for opioids, benzodiazepines, and other psychotropic medications and to have had a nonfatal drug overdose.”

The Columbia study included opioid overdoses linked to both pain medication and illegal opioids such as heroin, but was limited to Medicaid patients who died between 2001 and 2007. Since that time, opioid prescribing has declined, while illegal opioids and counterfeit medication have become increasingly available on the black market.

Public health officials have only recently started warning about the risks of combining opioids with benzodiazepines, and some insurers now refuse to pay for the medications when they are prescribed jointly.

A recent study of overdose deaths in Florida found that benzodiazepines such as Xanax and Valium killed nearly twice as many Floridians in 2016 as oxycodone. Another study in Pennsylvania also found that overdose deaths involving benzodiazepines exceeded those from opioid painkillers.

The Columbia study was published online in the American Journal of Psychiatry. The study was funded by the Agency for Healthcare Research and Quality, the National Institute on Drug Abuse, and the New York Psychiatric Institute.

Opioid Pain Meds Rarely Involved in Suicide Attempts

By Pat Anson, Editor

Opioid pain medication is involved in less than 5 percent of the attempted suicides in the United States, according to a large new study of emergency room visits.

Researchers at Johns Hopkins University School of Medicine studied a national database of more than one billion emergency department visits from 2006 to 2013, and found that antidepressants and anti-anxiety drugs were far more likely to be used in an attempted suicide than opioid medication.

The findings appear to contradict numerous government and media reports suggesting that opioids play a significant role in the nation’s rising suicide rate.  A recent VA study, for example, found that veterans receiving the highest doses of opioid painkillers were more than twice as likely to die by suicide.

According to the Centers for Disease Control and Prevention, suicides in the U.S. increased by 31 percent over the past decade and are now the 10th leading cause of death. In 2014, nearly 43,000 Americans committed suicide, three times the number of overdose deaths that were linked to prescription opioids.

The Johns Hopkins researchers were puzzled to find that while suicides had risen, there was no corresponding increase in attempted suicides. Their findings are published in the journal Epidemiology and Psychiatric Sciences.

"What stood out to us the most is that while the rate of fatal suicide has increased, the overall rate of nonfatal suicide attempts has not changed much over the years, nor have the patterns -- age, sex, seasonality, mechanism, etc. -- changed much," said lead author Joseph Canner, interim co-director of the Johns Hopkins Surgery Center for Outcomes Research.

Canner and his colleagues analyzed over 3.5 million emergency department visits involving patients who were admitted for attempted suicide or self-inflicted injury. Poisoning was the most common means of injury, accounting for two-thirds of all suicide attempts. Benzodiazepines, anti-anxiety medication, tranquilizers and antidepressants were the most commonly used drugs.

Codeine, morphine, methadone and other opioid medications were involved in only 4.9% of the suicide attempts.

The study confirmed that suicide attempts peak during the spring, dispelling the popular myth that suicides increase during the holiday season. Attempted suicides actually decreased in November and December.

Over 80 percent of those who were admitted for a suicide attempt suffered from a mental health disorder, a broad category that includes depression, anxiety, substance abuse and alcohol disorders.

There have been anecdotal reports of suicides increasing in the pain community since the release of the CDC’s opioid prescribing guidelines in March, 2016. But the guidelines – and their impact on suicides – did not fall within the study period. Johns Hopkins researchers also did not study the relationship between chronic pain and attempted suicide.

“The study fails to reflect, evaluate or acknowledge suicides after the crackdown on opioid analgesics to relieve chronic and intractable pain,” said Twinkle VanFleet, a chronic pain sufferer, patient advocate and suicide survivor.

“Chronic pain sufferers are at a higher risk in contemplation, ideations, and actual attempts on their lives due to the CDC guidelines being developed without consideration to the suffering… inflicting fear in providers to prescribe and fear in patients to live.”

Earlier this year, VanFleet said she became suicidal due to her own undertreated pain. She sought help from two doctors and also went to an emergency room – and was sent away all three times without treatment.

“I still don't know why I'm still here,” she said.

Study Links Painkillers to Homicides

By Pat Anson, Editor

You can add the term “homicidal” to the list of stigmas faced by chronic pain patients.

A new study in the journal World Psychiatry has found that certain drugs that affect the central nervous system – particularly opioid painkillers – significantly increase the risk of committing murder.

The Swedish and Finnish researchers behind the study wanted to know if there was any scientific basis for the claim that anti-depressants and other psychotropic drugs can cause violent behavior. It’s an issue that was debated after massacres committed by young people in schools and other public places in Finland and around the world.

"It has been repeatedly claimed that it was the anti-depressants used by the persons who committed these massacres that triggered their violent behavior. It is possible that the massive publicity around the subject has already affected drug prescription practices," said lead author Jari Tiihonen of the Karolinska Institute in Sweden.

In one of the first studies of its kind, researchers analyzed a database of 959 people convicted of homicide in Finland between 2003 and 2011 to see what medications they were taking before their crimes.  

They found that anti-psychotic medication was not associated with a significantly increased risk of homicide, and there was only a slightly elevated risk for most people taking anti-depressants and benzodiazepines – drugs used to treat anxiety and insomnia.

But the study did find, rather surprisingly, that there was a significantly higher risk of committing a homicide associated with opioid pain medications like oxycodone and tramadol (93% higher) and anti-inflammatory pain relievers such as acetaminophen (206% higher).

The risk was even more elevated for young people. For someone under the age of 26, there was a 223% greater chance of them killing someone if they were taking opioids. Young people taking benzodiazepines had a 95% greater risk.

"Benzodiazepines can weaken impulse control, and earlier research has found that painkillers affect emotional processing. Caution in prescribing benzodiazepines and strong painkillers to people with a history of substance abuse is advisable," Tiihonen concluded.

Although alcohol and other intoxicants were also involved in a majority of the homicides, the researchers said their use did not explain the differences between the drug groups.

In 2007, an 18-year old Finnish high school student named Pekka-Eric Auvinen fatally shot eight people at his school before taking his own life. He had been taking anti-depressants for a year prior to the massacre.

The Citizens Commission on Human Rights UK has a list of several other massacres around the world linked to the use of anti-depressants. Opioids are not mentioned in any of the examples.