Benzodiazepine Epidemic

[Chrish]

Greetings,

Pharmacist here. I see plenty of benzos being prescribed where I am. I would say vast majority are being prescribed by PCPs or midlevels. I understand the rationale. Psychiatrists aren’t easily accessible and hence PCPs end up managing the anxiety symptoms.

However, I am bit curious about the prevalence of benzos being prescribed for chronic use. Current evidence points out benzos shouldn’t be used for managing everyday anxiety or panic attacks. In fact, it actually worsens the anxiety if taken daily! Also, in rare conditions where some patients are stable on benzos, Xanax should never be used according to all threads in psychiatry forum. It’s more addictive compared to something like klonopin, results in more cases of OD and harder to get off of. However, it’s by far the most popular choice among PCPs (plenty of folks on 0.25, 0.5 and even 1 mg bid/ tid dosing where I am).

My question is why is this the case? Benzos are great for MRI or getting off the plane in the same manner as opioids for fracture or kidney stones. However, daily use is very dangerous and not backed up by evidence. In my humble opinion, benzo epidemic is just as dangerous as opioids and hasn’t received enough attention from DEA and state licensing boards.

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[VA Hopeful Dr]

I would disagree that the daily use of benzodiazepines is very dangerous (though this might be dose dependent) as well as the idea that the epidemic of this is as dangerous as opioids.

But that aside, speaking for myself its a matter of conflict avoidance. I almost universally refuse to start people on chronic benzodiazepines and never prescribe xanax, but if they come to me on a non-xanax medication with a fairly low dose and at most twice a day its not usually worth the fight to force them off of it.

I'll be honest, if patient satisfaction wasn't a thing and I could just refuse to see people on those medications (and so avoid arguments with patients), I bet I would prescribe them way less than I do now.

 

[B1GM0N3Y86]

Coming out of residency few years ago, I would use longer acting Klonopin or short courses of Ativan for select cases. However after my first gig as an attending, I found out weeks into the job it was basically a pill mill w/ a 70 year old doc who loved throwing Xanax 1-2mg TID-QID with Norco and Ambien mixed in, a pushover middle aged doc who ran a pain practice and was leaving in a month (btw it was fun inheriting his panel of patients that could be on more than 2-300 MME per day while mixing BZD/Soma/Lyrica), and two idiot midlevels who would moan but still write combos of controls to patients since it makes "them feel better and the doctors have done it this way in this practice." Got to love rural medicine....

All while the providers in that office would expect you to fill all their controls since most worked part time while I was going to be the only full time physician in the office. After two years of doing opiate/bzd/ambien tapers on inherited patients, doing many specialist referrals, finding safer alternatives for patients, getting yelled at by addicts, and having multiple conversations with the providers how current guidelines were a bit different than the current office's prescribing patterns I told myself I would ask more questions on prescribing patterns of the current providers of the practice I was interviewing at and only join a practice that had a similar philosophy to mine on this subject. Doing the prior mentioned things took far too much time and was mentally draining.

So since leaving that last job and starting my new job about 1 year ago I haven't prescribed a BZD. All new patients in my new practice are screened for controlled substances. If a new patient lights up PDMP, they are given notification that our office does not prescribe controlled substances but are more than welcome to establish still. This has pretty much eliminated the headache of dealing with other loose prescriber messes who leave the area or who have retired recently.

And to make things clear, I am not saying that these medications are evil. I just had a very poor experience and would rather not deal with it again for at least some time for my own health. My views on BZD and other controlled substances have changed since I graduated from residency. I am sure they will change over time, just not at this time....

 

[scharnhorst]

I do klonopin 10 tabs a month for people on chronic anxiety not responding to buspirone or vistril ( like 1 out of 30 anxiety patients)
Ofcourse SSRI or SNRI as maintaince
I tell them choose to use it wisely if you run out before 30 days then sol , no early refills
People who don’t like it leave , those that stick around never go back to higher doses
Bipolar is an exception but those eventually see psych

 

[FrustratedFamDoc]

I believe most of what you see now are legacy patients who were maintained and escalated on this improper regimen 3 decades ago when they were touted as ‘safe’ and highly effective. Yes, there are still modern trained physicians who do start patients on the road to badness, but it’s far less prevalent, and the quantity of these life ruining quacks is low. Hopefully.

With a few mouse clicks, we have the potential to really screw peoples lives up in a big way.

The legacy patient is largely what you’re probably seeing, and it’s really a judgement for me, as it is all physicians.

Example: 70 y/o married, retired teacher who has taken 1 mg bid klonopin for 30 years. She’s high functioning. Feels great. PDMP checks out. Walks 2 miles a day. She will typically fill #30 of tramadol 3x a year as she’s trying to put off knee surgery. She and her husband are very pleasant and here to establish. Her previous doc retired and it’s taken 2 months to finally get in to see you. She really has no complaints and is up to date on everything.
#1. You dream of having a practice of these types of patients.
#2. This is a scenario that we all see, not uncommonly.

What is there to gain by stopping her klonopin besides royally pissing off her husband? There is nothing gained by weaning this patient. Would this be the way you would of managed her? Nope, but that chance has passed.

Example 2: 55 y/o former nurse now disabled. New patient I inherited from a colleague who left. Long story short: MVA in 2000. Broken ankle, surgery but no hardware. Mri lumbar showed arthritis. My Colleague inherited her on 72mcg fentanyl patch and a benzo. She’s now on 7.5 Percocet qid from pain mgt.

That’s criminal.

Very nice woman. I asked her point blank who the hell did this to you because I know you don’t want this. Of course she didn’t. I’m going to try to help her get her life back, because someone along the way took it from her.

I stopped her ambien and low dose klonopin and started a squeeze of low dose seroquel. I hope she actually comes back to see me.

The prescribing problem at hand is not a knowledge issue. You’re not saying anything that we don’t already know. The problem is that we are tasked with cleaning up someone else’s mess that was made 30 years in a patient that is probably not motivated to do so.

We all eat our share of this, and most try to push to a more responsible regimen. 1mg qid xanax weened down to .25 bid is a win, but doesn’t look that way at the pharmacy.

 

[goldsummer]

I'm a PCP
I ONLY prescribe BDZ for panic/flight anxiety/special circumstances. This would be about maybe 10 pills for 6 months for example.

MANY patients come to me already on Xanax nightly for sleep, daily for anxiety, etc etc etc. I tell them I don't prescribe these chronically and i discuss rationale and alternatives. I ween off and change meds.

As a result, I've had many upset patients and unpleasant visits. those patients rate me LOW on patient satisfaction, 0/10. Low patient satisfaction PREVENTS me from getting a bonus at the end of the year. Patient satisfaction scores must be >90% with my organization. This year I was 88%. Missed out on about 25k. I feel if I just did what all patient's wanted, I woulda received it.

I also have loans and a family. I'm also in one of the lower paying specialties.

I could see why some would be inclined to prescribe these. Medicine based around patient satisfaction is such crap.

 

[jacobus1919]

I was taking over a HUGE panel from a previous MD and 2 NPs when I started working. 75% of people who have GAD or Depression where on Benzodiazepines without clear history of taking SSRI or SNRI. I had one who tried Prozac for 2 weeks and was placed on Xanax coz she stopped Prozac. I am still currently cleaning everything up; the mess that these 3 previous providers made. But after explaining to 80% of these people on Benzos about the risks they immediately ask to be tapered off Benzos.

 

[FrustratedFamDoc]

Age is a major determining factor for me.

60+, reasonable dose, no red flags and high functioning? meh, we'll talk as long as things aren't stupid, but I will emphasize the "you really don't want to be hooked on this stuff, do you?" "I want to try to get you away from this crap, and not cause a divorce at the same time." For this group, It's a judgement call for me. 1 mg TID Klonopin. Do I enjoy writing it? Of course not, but I know how to not screw up a patient. There are still a lot out there that do and that REALLY bothers me. Do I write the 1 mg for now and hate it, or do I decline to write it, they see someone else who will, and they end up on 2 mg QID, or some quackery like that.


<60 and using daily? Frequently I'll see a new patient in this scenario. PDMP says #90 a month of whatever. Picked up monthly like clockwork.
"so hey bro, I see that you're also taking Xanax. How much are you actually having to use it a month?"

the answer is ALWAYS maybe 2-3 times a week.

I point out that we have a math problem since he's picking up 90 a month, regularly. So either there is a stockpile, you're lying to me, or there is something else that I REALLY don't want to have to talk about today (you look them in the eye for that last part with the 'I know what the F is going on here' look). And since it's only 2-3x a month, there won't be withdrawals and here's some attarax. (they know vistaril and buspar but don't know about no Attarax, and it sounds like Xanax so it's gotta be good).

They usually never come back. They know they've been caught.

But I will swap over quite a lot of younger people that want to do so. Look them in the eye: "Hey dude/dudette, taking this sh** sucks, doesn't it. I know you're tired of it. Lets get it gone. It's going to suck getting away from it. No, I'm not cruel and will suddenly stop writing it for you, unless you give me a good reason. Here's the plan, I'll see you in 3 weeks for the next step."

You'll likely be the first doc he/she's ever seen that been 100% real with them, and they may actually buy in.

 

[Chrish]

I understand the customer satisfaction sentiment. I have few people at my pharmacy on high risk meds (opioids + benzos+ z-drug combo) but it’s hard to get rid of them even if I want to because they been coming to this pharmacy for over a decade and no one has told them no before. We just refuse new patients on this combo.

On interesting note, benzos are readily available in Mexico and South America. All you have to do is pay $10 and you can get any prescription for benzos or soma. I found that quite strange and interesting.

 

[SLC]

I'm a PCP
I ONLY prescribe BDZ for panic/flight anxiety/special circumstances. This would be about maybe 10 pills for 6 months for example.

MANY patients come to me already on Xanax nightly for sleep, daily for anxiety, etc etc etc. I tell them I don't prescribe these chronically and i discuss rationale and alternatives. I ween off and change meds.

As a result, I've had many upset patients and unpleasant visits. those patients rate me LOW on patient satisfaction, 0/10. Low patient satisfaction PREVENTS me from getting a bonus at the end of the year. Patient satisfaction scores must be >90% with my organization. This year I was 88%. Missed out on about 25k. I feel if I just did what all patient's wanted, I woulda received it.

I also have loans and a family. I'm also in one of the lower paying specialties.

I could see why some would be inclined to prescribe these. Medicine based around patient satisfaction is such crap.

Similar situation with me, fortunately patient satisfaction isn’t factored into my pay structure.

I’ve come to the conclusion that I’m just going to have some angry patients for a while when they find out I don’t do the meds they want. It’ll burn itself out eventually, word gets out not to come to me if you want benzos or narcotics, and eventually I’m left with a panel who is cool with the way I practice.

Just gotta put in the work I guess.

 

[Keona]

Similar situation with me, fortunately patient satisfaction isn’t factored into my pay structure.

I’ve come to the conclusion that I’m just going to have some angry patients for a while when they find out I don’t do the meds they want. It’ll burn itself out eventually, word gets out not to come to me if you want benzos or narcotics, and eventually I’m left with a panel who is cool with the way I practice.

Just gotta put in the work I guess.

Once I started I was told by a very annoyed patient. Word is out about you. You won’t prescribe anxiety pill, hormone pills or pain pills! (Wanted testosterone, Xanax and an opiate I think).
Me “yes that’s true” he got all huffy and walked out of the room. I didn’t regard that as a problem. (I’ve slowly weaned lots of patients off their benzos. It’s taken a long while. I don’t start anyone new on them and I don’t increase doses, do early refills etc on legacy patients (ones I inherited when I joined the practice or as other mds retire). I’m happy the word is out that I’m not a person to go to for those pills.

 

[TableMD]

If you, as a pharmacist, are uncomfortable with the prescribed medications, why do you fill them?

 

[Chrish]

If you, as a pharmacist, are uncomfortable with the prescribed medications, why do you fill them?

We definitely refuse something outright ridiculous: combination of Oxy 30 + Xanax + Soma.

But there are also too many people who fall under grey area: someone taking Norco 5 + Xanax 0.25 + Z-drug for several years.

Inappropriate regimen? Yes. But unfortunately not uncommon where I practice.

 

[ObsequiousAplomb]

We definitely refuse something outright ridiculous: combination of Oxy 30 + Xanax + Soma.

But there are also too many people who fall under grey area: someone taking Norco 5 + Xanax 0.25 + Z-drug for several years.

Inappropriate regimen? Yes. But unfortunately not uncommon where I practice.

Realistically, how dangerous is Norco 5 and Xanax 0.25? Because that's such an absurdly low dose of Xanax that I wouldn't be worried at all that someone would OD on a 30 day supply. Heck, that entire bottle would be less than the daily dose most patients with a use disorder would be taking.

 

[Chrish]

Realistically, how dangerous is Norco 5 and Xanax 0.25? Because that's such an absurdly low dose of Xanax that I wouldn't be worried at all that someone would OD on a 30 day supply. Heck, that entire bottle would be less than the daily dose most patients with a use disorder would be taking.

It’s not necessarily about risk of OD. I can’t think of a logical reason for someone to be on both norco and Xanax for chronic use (and sometimes ambien or gabapentin/ lyrica thrown in). Regardless of dose, it’s inappropriate regimen and yet so prevalent in certain areas.

I have young folks in their 30s and 40s hooked on this sort of combination. Sad!

 

[Ironheme]

Similar situation with me, fortunately patient satisfaction isn’t factored into my pay structure.

I’ve come to the conclusion that I’m just going to have some angry patients for a while when they find out I don’t do the meds they want. It’ll burn itself out eventually, word gets out not to come to me if you want benzos or narcotics, and eventually I’m left with a panel who is cool with the way I practice.

Just gotta put in the work I guess.

It took about 2-3 years for me to get these patients off the regimen. I had inherited this type of panel from another doc that locals called the "candyman." The classic triad he liked to prescribe was opioid + BZD +/- HRT or stimulant. These patients were *very* happy on this regimen even without any medical indication for it. Half of the patients I saw for a good 1-2 years were this and would come in yelling, screaming, telling me how I was a terrible doctor. Most of them left or a few got with the program. My patient satisfaction scores were affected, and my income is also affected. I will be missing the bonus this year for the same reason @goldsummer did - doing the right thing costs you $. I know that if I had done what some of the patients wanted, my PRC scores would be higher.

Over time, it will get to the point where my patient panel is full of patients where we jive on management and expectations. It's definitely painful to get to that point though...

It wasn't a good feeling to have the local pharmacist tell me that our practice prescribed the most controlled substances in the area, but this was the mess that we inherited.

 

[Splenda88]

The unfortunate fact is small towns in America are full with people taking these combos. Glad I practice inpatient. I usually give these people 10-15 pills and tell them have your PCP take care of refills.

I trained in a big city and I probably prescribed narcotics less than 5 times. Now I prescribed these things almost every week.

 

[ObsequiousAplomb]

It’s not necessarily about risk of OD. I can’t think of a logical reason for someone to be on both norco and Xanax for chronic use (and sometimes ambien or gabapentin/ lyrica thrown in). Regardless of dose, it’s inappropriate regimen and yet so prevalent in certain areas.

I have young folks in their 30s and 40s hooked on this sort of combination. Sad!

You can't? Chronic treatment of two conditions:

Panic disorder that is refractory to three SSRIs, two TCAs, 2 full courses of CBT, and 1 year + of dynamic psychotherapy. That's a condition where chronic benzodiazepines would be warranted. Patient has tried Ativan and Klonopin, found both too sedating. Got dizzy with Valium. Xanax would be a reasonable option. The fact that it's such an absurdly low dose of Xanax is laudable, not deplorable.

I don't prescribe any opioids that aren't buprenorphine as a psychiatrist, but I trust that at least some portion of the patients being given Norco by pain management are legitimate. The fact that it's such a low dose of Norco is also not deplorable.

Both conditions are quite common, and unsurprisingly frequently occur in the same person. Deciding unilaterally that this patient can't exist is a bridge too far. Obviously these are two abusable medications and the combination warrants concern and caution. Saying there's no legitimate patient with both conditions is incredibly short-sighted. I would probably want a specialist to be managing / weighing in on at least one if not both if I were in primary care, but as long as the PCP is applying reasonable medical consideration of the risks, benefits, and alternatives it is not unreasonable to manage in a primary care setting.

Say the person is diverting the Xanax. Why would they waste their time diverting 0.25 when the real money is in 2 mg bars? They would definitely make more money by getting a good dose of one or the other drug instead of small doses of both. If they're abusing both, they would be more able to afford both at fun doses if they got higher doses of one but not the other by Rx.

As for Lyrica or gabapentin being "thrown in" - you really can't see why a medication that has really good efficacy for BOTH chronic pain AND anxiety / panic would be added to a regimen for a patient with both conditions? Did you honestly attempt to come up with an explanation or are you being excessively judgmental and flippant for other reasons?

Also, you're a pharmacist. What do you mean by "hooked on" medications? You don't treat addictions. You would have no idea of knowing whether someone is "hooked" on a medication other than the fact that they come back for refills? Big surprise, people feel better in a way that leads to them refilling Xanax or Norco on time than the way they feel when it comes to refilling their Lipitor or Norvasc. Or are you certain they are "hooked" because of some other non-clinical judgement that you want to pass as the person who ensures the bottles are filled and the prescriptions are valid but not as the person who makes clinical decisions?

 

[BigPikachu]

To be honest, if a patient’s mental health is that bad to require regular and chronic prescription of benzodiazepines, they should really be under the care of a psychiatrist (and psychologist). Notwithstanding there is limited evidence that regular long-term use of benzodiazepines has significant benefit versus its well known harms and risks for overdose and addiction. I tend to only prescribe benzos for acute anxiety/stress or acute withdrawal situations with limited tablets and good follow-up plan in place, plus reminding them its to be used in conjunction with the focused psychological strategies that I have counselled and practiced with them (CBT, DBT, EMDR, etc.).

 

[VenusinFurs]

Basically: it's super ****ing hard to get people off chronic benzos, psychiatrists don't exist in certain states that I recently left because that state is basically letting its people die, and I generally tend to think it's better to maintain someone on the same chronic dose than risk them running off and trying harder stuff- I will readily admit I have not done a good job of addressing it with my patients I inherited. But I also have pretty much come to the conclusion that I need to have a no chronic benzo rule now because it always seems to cause the most problems. Chronic benzo patients who then need a short term opiod, chronic benzo patients who are also on stims which is inappropriate and raises a ton of flags on both pharmacist and cross coverage ends- I've had to deal with so many issues with trying to maintain these patients that it seems the most prudent course going forward is to insist on a wean.

Chronic low dose opiods in older patients don't seem to create a self-perpetuating problem the way chronic benzos do, chronic benzos absolutely hurt more than they help.

 

[FrustratedFamDoc]

You can't? Chronic treatment of two conditions:

Panic disorder that is refractory to three SSRIs, two TCAs, 2 full courses of CBT, and 1 year + of dynamic psychotherapy. That's a condition where chronic benzodiazepines would be warranted. Patient has tried Ativan and Klonopin, found both too sedating. Got dizzy with Valium. Xanax would be a reasonable option. The fact that it's such an absurdly low dose of Xanax is laudable, not deplorable.

I don't prescribe any opioids that aren't buprenorphine as a psychiatrist, but I trust that at least some portion of the patients being given Norco by pain management are legitimate. The fact that it's such a low dose of Norco is also not deplorable.

Both conditions are quite common, and unsurprisingly frequently occur in the same person. Deciding unilaterally that this patient can't exist is a bridge too far. Obviously these are two abusable medications and the combination warrants concern and caution. Saying there's no legitimate patient with both conditions is incredibly short-sighted. I would probably want a specialist to be managing / weighing in on at least one if not both if I were in primary care, but as long as the PCP is applying reasonable medical consideration of the risks, benefits, and alternatives it is not unreasonable to manage in a primary care setting.

Say the person is diverting the Xanax. Why would they waste their time diverting 0.25 when the real money is in 2 mg bars? They would definitely make more money by getting a good dose of one or the other drug instead of small doses of both. If they're abusing both, they would be more able to afford both at fun doses if they got higher doses of one but not the other by Rx.

As for Lyrica or gabapentin being "thrown in" - you really can't see why a medication that has really good efficacy for BOTH chronic pain AND anxiety / panic would be added to a regimen for a patient with both conditions? Did you honestly attempt to come up with an explanation or are you being excessively judgmental and flippant for other reasons?

Also, you're a pharmacist. What do you mean by "hooked on" medications? You don't treat addictions. You would have no idea of knowing whether someone is "hooked" on a medication other than the fact that they come back for refills? Big surprise, people feel better in a way that leads to them refilling Xanax or Norco on time than the way they feel when it comes to refilling their Lipitor or Norvasc. Or are you certain they are "hooked" because of some other non-clinical judgement that you want to pass as the person who ensures the bottles are filled and the prescriptions are valid but not as the person who makes clinical decisions?

Nailed it. There is a difference between benzo+narcotic and BENZO + NARCOTIC. lyrica/gabapentin is a miracle drug for some people.

I’ll preface in that I’m a mister meany pants and no is my favorite word.

If the .25 xanax or the .5 klonopin prn has been fine for 20 years in a 55 y/o teacher, what good is there to be done by changing? It’s better than divorce.

She’s trying to avoid back surgery and mainly has good days but occasionally needs something more. Sounds like Lyrica and norco prn is a good call.

She has insomnia and the get fat mood meds have only worsened her low level depression and pain. Here’s the lunesta. Try to not take it nightly.

I certainly get your argument, but patients are people, and every situation is unique. Being reasonable, responsible and compassionate is key. It’s easy to look at these kind of people as, ’oh you, too’ but that does a real disservice to what we’re supposed to be doing.