The Hidden Dangers of Benzodiazepines (Infographic)

benzos 5-28-14“In the last year there have been several studies/stories about the risks associated with benzodiazepine abuse.  And while benzodiazepines have been prescribed for decades to treat anxiety and seizure disorders, the possible threat of overusing them is real and with that comes dependency, overdose and the potentiality of death.  Did you know that since 2010, there have been 6,507 US drug overdose deaths that involved benzodiazepines?  Because of this rising number, Foundations Recovery Networkcreated an infographic to help familiarize those about benzodiazepines but most importantly help create awareness regarding the possible addiction with benzodiazepines.”

Broken down in sections, the infographic (http://www.dualdiagnosis.org/benzodiazepine-addiction/) goes into detail about:

  • What are benzodiazepines: their brand names and the amount of prescriptions filled in the US in 2011, the number of related ER visits in 2010 and the confiscations by law enforcement for each associated drug.
  • Why prescribe benzodiazepines, specifically the disorders that are treated
  • Common side effects and contraindications with benzodiazepine use
  • Key statistics related to the dangers of abuse
  • Symptoms of overdose

Source: Foundations Recovery Network– May 2014

 

Sharp Rise in ER Visits Tied to Abuse of Sedative, Study Finds

“There’s been a steep increase in the number of Americans being treated at emergency departments for abuse of the sedative alprazolam, best known as Xanax, federal officials reported Thursday.

The number of emergency department visits related to abuse of alprazolam (brand names Xanax, Xanax XR, and Niravam) climbed from more than 57,000 in 2005 to nearly 124,000 in 2011, according to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA).

In the United States, alprazolam was the most commonly prescribed psychiatric medication in 2011 and the 13th highest-selling medication in 2012, the report said.”

http://consumer.healthday.com/mental-health-information-25/addiction-news-6/jump-in-er-visits-tied-to-xanax-abuse-study-finds-688047.html

Source: HealthDay.com -May 22, 2014

Infographic: Benzodiazepine Use and Medication-Assisted Treatment

benzo2The Institute for Research, Education and Training in Addictions (IRETA) has prepared an infographic that addresses immediate consequences, long-term effects, and the relationship between benzodiazepine use and medication-assisted recovery.

The infographic is available for free download at: http://iretablog.org/2014/04/10/infographic-benzodiazepine-use-and-medication-assisted-treatment/

Source: The Institute for Research, Education and Training in Addictions – April 10, 2014

Jana Burson Blog: More about IRETA’s Guidelines for Benzodiazepines in OTPs

blog1“This is a continuation of my last blog post about the IRETA (Institute for Research, Education & Training in Addictions) guidelines for management of benzodiazepine use in medication-assisted treatment of opioid addiction. You can read all of the guidelines at: http://ireta.org/sites/ireta.org/files/Best%20Practice%20Guidelines%20for%20BZDs%20in%20MAT%202013_0.pdf

Under the section of recommendations regarding addressing benzodiazepine use is found the following statement:

“Many people presenting to services have an extensive history of multiple substance dependence and all substance abuse, including benzodiazepines, should be actively addressed in treatment. People who have a history of benzodiazepine abuse should not be disallowed from receiving previously prescribed benzodiazepines, provided they are monitored carefully and have stopped the earlier abuse.”

The experts, after reviewing the best data, are saying that if a patient has abused benzos in the past, but isn’t abusing prescribed benzos now, it may be OK to continue benzos, with careful monitoring.

I don’t like this statement. It doesn’t conform to my present thoughts on the topic. I fear that the majority of patients with a history of benzodiazepine abuse or addiction will, sooner or later, revert back to problem use of the medication. That’s my anecdotal experience. Anecdotal experience is worth something, but data from clinical trials trumps anecdotal experience, and IRETA’s guidelines are based on both clinical trials and expert opinion.

So now I need to challenge my previously held views about benzos in the OTP. It’s unpleasant and uncomfortable to change a long-held view. But isn’t that what I ask of my patients? In the interest of science, I will re-consider my present opinion, but I won’t ignore the last part of the statement, which says careful monitoring needs to be done.”

 http://janaburson.wordpress.com/2014/02/02/more-about-iretas-guidelines-for-benzodiazepines-in-otps/

Source: Jana Burson - February 2, 2014

Philadelphia Releases Benzodiazepine Draft Guidelines for MAT

benzo2benzo 1Important guidelines to help opioid treatment programs (OTPs) determine how to handle benzodiazepine use by their patients have been developed by the Institute for Research, Education and Training in the Addictions (IRETA) for the Philadelphia Department of Behavioral Health and Intellectual disAbility Services (DBHIDS). Roland Lamb, MA, director of the DBHIDS Office of Addiction Services, talked with AT Forum about what the draft guidelines mean to OTPs who are struggling with ways to manage patients who use benzodiazepines while in medication-assisted treatment (MAT).

Although the guidelines were prepared under contract with DBHIDS for use by Philadelphia-area MAT providers, Mr. Lamb said they can be used by anyone—and he hopes they will be, when finalized. “This is a collaboration that went beyond Philadelphia,” he said. Partners were the Community Care Behavioral Health (CCBH) and the University of Pittsburgh in Allegheny County, the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Pennsylvania Department of Drug and Alcohol Programs, he said. “We need to make sure the focus is on the disease of addiction and not just on managing medications. Methadone maintenance is so overregulated that it can become medication-focused, as opposed to treating people for their addiction.”

Treating Addiction

And while methadone maintenance is focused on opioid addiction, OTPs and all MAT providers must recognize that they are treating addiction per se, he said. “Once you have stabilized a person on methadone, you still need to pay attention to other issues.” Those other issues could include misuse of alcohol or other drugs, such as benzodiazepines

The concern for OTPs and patients is that benzodiazepines, in combination with methadone, buprenorphine, or any central nervous system (CNS) depressant, could result in respiratory depression and death. “There has been extensive writing about the synergistic effects,” he said.

But it’s not only about risk. Helping patients recover from addiction means counseling and a personal transformation away from seeking relief from drugs and alcohol.

“I believe that OTPs are failing their population if they don’t address addiction,” said Mr. Lamb. “It’s not just benzodiazepines, it’s everything.”

Lower Starting Dose, Inpatient Detox

One of the recommendations is for people on benzodiazepines to be inducted on a lower starting dose of methadone, but another is that all patients need an adequate starting dose. There seems to be a conflict between those two recommendations, but Mr. Lamb said that there isn’t. “What it really means is that you would need a longer lead time to get up to the optimal dose,” he said. “What you don’t want is to continue to follow through to the maximum dosage level, which could be 30 or 40 milligrams, at the onset of treatment,” he said.

The two recommendations are consistent when looked at together, because the main point is to ultimately get the patient up to the optimal dose. “In induction, they are in limbo, and will be struggling mightily to manage their addiction and perhaps find other means to do that,” he said. Some ways to bring patients up to optimal dosage and minimize the withdrawal symptoms that come with the very early days of induction for some is to provide a split dose during the day, to minimize the valleys, he said.

Another recommendation for patients who are using benzodiazepines is to taper their benzodiazepine use and then induct them into MAT. Sometimes, the best way to do this is inpatient detoxification, the guidelines state.

“It’s problematic that people think MAT is only done in an outpatient methadone program,” said Mr. Lamb. Philadelphia has established MAT across all levels of care. “We have people in residential treatment who receive MAT, as well as people who are in outpatient programs,” he said. “When a person isn’t responding to the outpatient milieu, you need to address the severity of the addiction.” And for OTPs, it may mean assessing the person as needing inpatient treatment. “‘If you didn’t have methadone, what level of care would this person be receiving?’ is a good question to ask,” he said.

Key Recommendations

The key recommendations of the IRETA report clearly state that use of benzodiazepines or other CNS depressants is not a contraindication for methadone or buprenorphine treatment—patients should not automatically be discharged from treatment because they are using benzodiazepines, either by obtaining prescriptions from other physicians or by buying them.

From the Recommendations:

  • CNS depressant use is not an absolute contraindication for the use of either methadone or buprenorphine in MAT, but is a reason for caution because of potential respiratory depression. Serious overdose and death may occur if MAT is administered in conjunction with benzodiazepines, sedatives, tranquilizers, antidepressants, or alcohol.
  • Individuals who use benzodiazepines, even if used as a part of long-term therapy, should be considered at risk for adverse drug reactions including overdose and death.
  • Many people presenting to services have an extensive history of multiple substance dependence and all substance abuse, including benzodiazepines, should be actively addressed in treatment.
  •  MAT should not generally be discontinued for persistent benzodiazepine abuse, but requires the implementation of risk management strategies.
  • Clinicians should ensure that every step of decision-making is clearly documented.

There wasn’t always unanimous agreement among the participants in the development process for the guidelines, said Mr. Lamb. “We narrowed down the guidelines to what we had consensus around.”

Risk Management vs. Addiction Treatment

At the core of the consensus process was reconciling risk management with treatment of addiction, two goals that can be at odds with one another. But is there really any conflict? If the goal is recovery, then treatment of addiction should include dealing with craving and the problems of patients who are suddenly living without getting high.

There is a desperate need for this information, said Mr. Lamb. “We had a number of providers who were struggling with how to manage the use of benzodiazepines.” That’s the reason for the guidelines, and also the reason for a physician’s town hall sponsored by DBHIDS at the November conference of the American Association for the Treatment of Opioid Dependence (AATOD), to be held in Philadelphia.

“Some people have a legitimate need for an anti-anxiety drug,” said Mr. Lamb. “However, there has to be a limit to how far a provider goes, if there is no cooperation from the patient.”

Some patients start abusing benzodiazepines when they enter MAT because they are no longer able to feel euphoria from opioids, according to Mr. Lamb. “Part of the disease of addiction is the preoccupation with feeling good or feeling better,” he said, referring to euphoria and to minimizing withdrawal symptoms. Others come into treatment managing collateral emotional pain and psychic confusion, he said. “We’ve often found that the need to self-medicate is strong.” That’s why getting a patient stable on methadone is only the first step, he said. “That’s when the hard part begins.”

The early stages of treatment, when patients are no longer experiencing “feeling better” from opioids, are when other drugs, such as cocaine, alcohol, marijuana, or benzodiazepines, get introduced, said Mr. Lamb. “Chemistry is a way of life in our population, always finding new combinations to feel good and to feel better.” A new patient on methadone, once stable, won’t feel any signs of withdrawal, so the need to “feel better” will be gone. “But with this population there is always the need to alter one’s consciousness.” And there may also be depression and anxiety or legitimate mental illnesses, which methadone will not treat, and which require medication. But that doesn’t necessarily mean medications are always the answer.

When opioid-dependent patients begin MAT, they may also be going to other physicians who are prescribing medications for anxiety. “Hopefully the doctors are talking to each other, communicating in the best interest of the patient,” said Mr. Lamb. But the patient may want just the opposite. “Those in care are interested in keeping those two doctors separate, not wanting them to collaborate, because that will interfere with their goals.”

For the draft guidelines, go to: http://ireta.org/sites/ireta.org/files/BZD%20and%20MAT%20FINAL%20REPORT%20Dec%202012%20marked%20draft.pdf

Admissions for Combined Benzodiazepine and Narcotic Pain Reliever Abuse Rise Sharply

In ten short years, substance abuse treatment admissions for combined benzodiazepine and narcotic pain reliever abuse jumped a startling 569.7 percent—from 5,032 in 2000 to 33,701 in 2010—while all other admissions dropped 9.6 percent.

These figures come from the Treatment Episode Data Set (TEDS) Report issued December 13 by the Substance Abuse and Mental Health Services Administration (SAMHSA). The report notes that benzodiazepines, used to treat anxiety and drug and alcohol withdrawal symptoms, are commonly used— licitly and illicitly—to boost the effects of narcotic pain relievers, such as oxycodone.

The “Combination” Group: A Treatment-Resistant Population

TEDS describes the characteristics of people who abuse benzodiazepines and narcotic pain relievers—we’ll call them the “combination” group—compared to the “other” admissions, those who did not abuse drugs of either type.  People who co-abuse the two drugs are a “high-need, treatment-resistant population.” They report more severe withdrawal symptoms and higher treatment attrition rates than people withdrawing from narcotic pain medications alone. This is no surprise, as benzodiazepine withdrawal is notoriously difficult—similar to alcohol and barbiturate withdrawal.

Compared to the “other” group, the “combination” group was

  • Mostly non-Hispanic white, with a low percentage of Hispanic and non-Hispanic black
  • More likely to be from the South
  • Evenly divided by sex (70% of the “other” group was male)
  • More likely to report a co-occurring psychiatric disorder
  • Concentrated in the age group 18-34 years (Chart 1)
  • Most often self-referred to treatment rather than referred by the criminal justice system (Chart 2)
  • Less likely to be receiving regular outpatient treatment
  • More likely to report daily use of any substance during the month before admission

There was no difference between the groups in education or employment status.

Implications for Treatment Programs

According to the report, daily use before admission points to “behavioral patterns that may be difficult to change.” Programs need to be prepared for the severe withdrawal effects from both drugs, “particularly since benzodiazepines compound the withdrawal effects of narcotic pain relievers. Providing medical and supportive services to mitigate the severe withdrawal effects may be critical to avoid treatment attrition and relapse.”

The report notes that the high rate of mental health disorders in the combination admissions group—perhaps partly due to using benzodiazepines for self-medication— may give programs a “unique opportunity to facilitate access to both substance abuse treatment and mental health services for people who co-abuse these drugs.”

A current review article summarizing data from about 200 articles on opioid and benzodiazepine combination use agrees with the self-medication possibility, but adds that the data suggest that the benzodiazepine use is primarily recreational. Co-users report seeking benzodiazepines to enhance “opioid intoxication or ‘high,’” and use doses exceeding therapeutic range. The review encourages further investigation and more cautious prescribing practices.

Chart I:  Age Distribution of Benzodiazepine and Narcotic Pain Reliever Combination Admissions and Other Admissions*: 2010

Chart 2: Sources of Referral to Treatment among Benzodiazepine and Narcotic Pain Reliever Combination Admissions and Other Admissions*: 2010

Full TEDS report: http://www.samhsa.gov/data/2k12/TEDS-064/TEDS-Short-Report-064-Benzodiazepines-2012.htm

Review article: Jones JD, Mogali S, Comer SD. Polydrug abuse: a review of opioid and benzodiazepine combination use. Drug Alcohol Depend. 2012; Sep 1; 125(1-2):8-18. doi: 10.1016/j.drugalcdep.2012.07.004. Epub 2012 Aug 2

Sharp Rise in Admissions for Certain Drug Combinations Over 10 Years

Substance abuse treatment admissions for addiction involving combined use of benzodiazepine and narcotic pain relievers (NPR) rose a total of 569.7 percent, to 33,701, from 2000 to 2010, according to a report by the Substance Abuse and Mental Health Services Administration (SAMHSA). Overall substance abuse treatment admissions of people ages 12 and older in the same period rose 4 percent, to 1.82 million, the agency said.

 “Clearly, the rise in this form of substance abuse is a public health problem that all parts of the treatment community need to be aware of,” said SAMHSA Administrator Pamela S. Hyde. “When patients are battling severe withdrawal effects from two addictive drugs, new treatment strategies may be needed to meet this challenge. These findings will help us better understand the nature and scope of this problem and to develop better approaches to address it.”

The report showed that 38.7 percent of those with this combined addiction began use of both drugs in the same year; 34.1 percent first used narcotic pain relievers, and the remaining 27.1 percent started with benzodiazepines.

Almost half of patients admitted for combined use also had a co-occurring psychiatric disorder, were largely self-referred, and were less likely to receive regular outpatient treatment than other admissions.

Specific demographic groups have higher rates of admission for combination benzodiazepine/NPR treatment when compared with admissions for other treatment. Non-Hispanic whites account for 91.4 percent of combination admissions versus only 55.8 percent of other admissions. Females make up 49.2 percent of combined admissions versus 30.2 percent of other admissions, and people aged 18-34 account for 66.9 percent of combined admissions versus 43.7 of other admissions.

“The public health and safety threat we face from the abuse of prescription drugs is indisputable and these data show the increasing need for treatment for those suffering from addiction to prescription drugs,” said Office of National Drug Control Policy Director Gil Kerlikowske. “While prevention is a critically important pillar of our prescription drug prevention plan, equally important is ensuring that treatment is available to those in need.”

http://www.samhsa.gov/newsroom/advisories/1212132836.aspx

Source: Substance Abuse and Mental Health Services Administration – December 13, 2012

Benzodiazepine & MAT Conference Videos Available From IRETA

On February 9, 2012 the Philadelphia Department of Behavioral Health and Intellectual Disability Services, the Institute for Research, Education, and Training in Addictions (IRETA), and Community Care Behavioral Health hosted a kickoff conference in Philadelphia that will lead to working guidelines for the management of benzodiazepines in medication-assisted treatment.

Recorded presentations from the conference are now available to view online. Experts in the field discuss local rates of concurrent use, the perspective of primary care, pregnancy, patient education, co-occurring disorders, and more. A total of 18 videos are available to view including: 

  • Jane C. Maxwell, PhD: Epidemiology, Morbidity and Mortality for Benzodiazepine Use
  •  James Schuster, MD, MBA: Rates of Benzodiazepine Use in Medication-Assisted Treatment
  •  Laura F. McNicholas, MD, PhD: Clinical Management of the Benzodiazepine-dependent Patient
  •  Karol Kaltenbach, PhD: Benzodiazepines and the Pregnant Patient: Special Challenges
  •  Peter R. Cohen, MD: Guidelines for Treating OMT Patients with Benzodiazepines

http://www.youtube.com/playlist?list=PLiML4AFpuB72QBVMT6bR2maChRvT5MXsr

Source: Institute for Research, Education, and Training in Addictions – November 2012

Blog: Benzos at the Opioid Treatment Program

“Should patients in opioid treatment programs ever be approved to take benzodiazepines? Even addiction medicine doctors hold widely varying opinions on this issue. In my state (North Carolina), all of the doctors who work in opioid treatment programs are invited to participate in a conference call once per month. The people who head the state’s methadone authority and the Governor’s Institute on Substance Abuse are also usually on the call. We discuss difficult issues we’re facing, and discuss difficult cases. Last month, the question was asked pointedly by one of the doctors: “Is zero-tolerance for benzodiazepines now the standard of care for opioid treatment programs in our state?” For the people on this call, the consensus was that the ideal was zero tolerance or at least a restricted policy regarding benzodiazepine use.”

The blog is available at: http://janaburson.wordpress.com/2012/11/03/benzos-at-the-opioid-treatment-program/

Source: Janaburson’s Blog – November 3, 2012

Well-Known Mechanism Underlies Benzodiazepines’ Addictive Properties

Work by NIDA-funded researchers has established that benzodiazepines cause addiction in a way similar to that of opioids, cannabinoids, and the club drug gamma-hydroxybutyrate (GHB). The discovery opens the door to designing new benzodiazepines that counteract anxiety but are not addictive. This article is available in the April issue of NIDA Notes.

http://www.drugabuse.gov/news-events/nida-notes/2012/04/well-known-mechanism-underlies-benzodiazepines-addictive-properties

Source:  National Institute on Drug Abuse – April 2012

I-Team: ER Visits Tied to Xanax, Similar Drugs Soar in NYC

Dr. Jeff Rabrich, who directs the Emergency Medicine Department at St. Luke’s Roosevelt Hospital in Manhattan, said he often sees the negative effects of illegal narcotics exacerbated by benzodiazepines.

“The Xanax potentially makes it a much worse overdose. It could turn a relatively mild overdose into something that could be fatal,” said Dr. Rabrich.

“A history of abuse of other substances, both licit and illicit, is associated with a higher prevalence of benzodiazepine abuse, a greater euphoric response to benzodiazepines, and a higher rate of unauthorized use of alprazolam during treatment for panic disorder.”

http://www.nbcnewyork.com/investigations/Xanax-Anti-Anxiety-Drugs-ER-Visits-Overdose-Deaths-NYC-151438745.html

Source:  NBCNewYork.com – May 15, 2012

AATOD Conference a Resounding Success

More than 1,350 people attended the American Association for the Treatment of Opioid Dependence (AATOD) meeting held in Las Vegas April 21-25 at the Venetian/Palazzo Hotel. Among the more than 60 attendees from other countries was a large delegation from Vietnam, reporting on that nation’s successful expansion of methadone treatment.

Under the theme “Recovery for Patients, Families, and Communities,” the conference was co-hosted by the Substance Abuse Prevention and Treatment Agency (SAPTA) of the Nevada Department of Health and Human Services/Division of Mental Health and Developmental Services.

Plenary Highlights

The conference opened with Gov. Brian Sandoval endorsing the work of Nevada’s opioid treatment programs (OTPs).  The governor remained to listen to Deborah A. McBride, MBA, SAPTA director, make her opening remarks. There are 11 OTPs in Nevada, and Ms. McBride expressed unwavering support for their valuable contribution in the wake of epidemic prescription-drug abuse in Nevada. AATOD president Mark Parrino, MPA, reported on AATOD’s national work. Gilberto Gerra, MD, director of the Drug Prevention and Health Branch of the United Nations Office on Drugs and Crime, Vienna, Austria, emphasized the international need for medication-assisted treatment (MAT). 

The second plenary session, dedicated to Lisa Mojer-Torres, lawyer, methadone patient, and tireless advocate, who died last year, focused on methadone as a valid pathway to recovery. The session was led by Carol McDaid, co-founder and principal of Capitol Decisions, and William L. White, MA, senior research consultant, Chestnut Health Systems, both in recovery themselves.

“The whole issue of methadone as part of recovery is critical,” remarked Mr. Parrino, noting the negative attitude in many states among legislators and judges who simply don’t think methadone maintenance treatment constitutes recovery.

Timothy P. Condon, PhD, visiting research professor at the Center for Alcoholism, Substance Abuse, and Addictions at the University of New Mexico, did an excellent job of highlighting the science and policy aspects of MAT during the closing plenary. There was also a presentation on MAT as part of health care reform, provided by Paul Samuels of the Legal Action Center.

And during the closing plenary, Justice Michael Cherry, now Chief Justice of the Nevada Supreme Court, expressed strong support for methadone and buprenorphine in the courts and criminal justice system. It is rare to have the highest judge in the state participate throughout an entire AATOD conference, said Mr. Parrino.

Hot Topics

Buprenorphine and Federal Register Notice

Nicholas Reuter, senior public health advisor with the division of pharmacologic therapies at the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), talked with AT Forum about hot topics at the conference, including the pending Federal Register notice allowing OTPs to dispense buprenorphine.

Mr. Reuter said the final rule is now in the Office of Management and Budget (OMB) regulatory review process, where it has been since March 8. The final rule will allow OTPs to prescribe buprenorphine under the same rules as DATA 2000-waived physicians, with some additional requirements.  Now, OTPs can dispense buprenorphine only with the same take-home and treatment rules that apply to methadone in 42 CFR Part 8.

This final rule has taken years to reach this point. The approval may be slowed by the interagency review, speculated Mr. Parrino, with one or two agencies expressing concern about diversion. Ironically, when the proposed rule was first published three years ago, comments expressed concern about OTPs causing buprenorphine diversion. Diversion of buprenorphine is now a major issue, without the final rule. Many OTPs feel that is due to the lack of counseling and other services in the office-based system.

Hepatitis C—A SAMHSA Priority

Robert Lubran, director of the division of pharmacologic therapies at CSAT, talked about the public health implications of hepatitis C virus (HCV) in the U.S., noting that SAMHSA will shift emphasis to screening and treatment for HCV. (See related article in this issue.)

Mr. Reuter added that CSAT has had a focus on HCV at many AATOD conferences: “We emphasize screening and treatment. This is the same situation we had with HIV,” he said. Programs are concerned that if widespread testing is undertaken, funds for treatment must be available.  Most states cover the medical treatment for HCV, but stigma against opioid dependence and OTP patients makes it harder for them to access care.  Mr. Parrino added that AATOD has trained over 700 clinical staff in hepatitis C testing and counseling, but few programs offer on-site treatment.

Methadone Mortality Form Becomes Optional

Surprising AATOD, CSAT announced the suspension of their methadone mortality form, introduced only about three years ago.  CSAT will do a “more formal information collection and analysis,” Mr. Lubran told the AATOD Board. “Instead of a voluntary form, we thought we would work with our colleagues in the Center for Behavioral Health Statistics and Quality to do something more official,” he said. “Right now we’re trying to come up with the best analytic procedure, and pursue a pilot. The idea is to do this in a way that is consistent.”  A Dear Colleague letter to the field about the change is dated April 3, but Mr. Parrino wasn’t given it until April 30. (For a copy of the letter, go to http://www.atforum.com/addiction-resources/documents/DearCollegueMethMortalitySuspension-04-2012.pdf).

Benzodiazepine Use in OTP Patients

The use of benzodiazepines in OTP patients was again a hot topic. Ron Jackson, MSW, LICSW, conducted an excellent, well-attended roundtable discussion about how to handle benzodiazepine use in OTP patients. The long-awaited benzodiazepine guidelines are expected to be part of a set of guidelines that cover the use of many different psychoactive substances in an OTP, instead of just benzodiazepines, Mr. Reuter said after the meeting. “We decided to broaden it, to talk about psychoactive medications in general,” confirmed Mr. Parrino. “But it’s really about benzodiazepines.” (See related article in this issue.)

Awards Banquet

Beny J. Primm, MD, executive director, Addiction Research and Treatment Corporation, presented the Nyswander/Dole “Marie” Awards to nine recipients.

Joseph V. Brady, PhD, Maryland

Otto C. Feliu, MS, New York

Hilary Jacobs, MSW, Massachusetts

Edward J. Johnson, MA, South Carolina

Barbara Schlichting, LCSW, New Jersey

Stacy Seikel, MD, Florida

Steve Tapscott, MA, Texas

Stephan Walcher, MD, Germany

William C. Wilson, California

Banquet honorees also included William L. White, MA, who received the prestigious Friend of the Field Award, and Roxanne Baker, CMA, recipient of the Richard Lane/Robert Holden Patient Advocacy Award for her work on behalf of methadone and recovery.

The next AATOD National Conference will convene in November 2013 in Philadelphia.

Some OTPs Discharge, Others Taper for Illicit Benzodiazepine Use

Benzodiazepine use and abuse by patients on methadone is a pressing concern for opioid treatment programs (OTPs) because of potentially dangerous drug interactions, especially during induction, so it was a natural selection for a “hot-topic” meeting at the American Association for the Treatment of Opioid Dependence (AATOD) conference in April. Ron Jackson, MSW, LICSW, moderated the session.

“We decided to have this hot topic because everybody talks about the problems of benzodiazepine use, so we wanted to figure out what treatment providers were doing and why they were doing it,” said Mr. Jackson, who is executive director of Evergreen Treatment Services in Seattle.

Some patients are prescribed benzodiazepines with the knowledge of the OTP.  There was a large degree of difference in program policies about approving such prescriptions as described by participants in the roundtable discussion, ranging from “If it’s being prescribed by a psychiatrist it’s OK” to “Our clinic has a discussion with the prescriber to coordinate care.” But of bigger concern are patients who are taking benzodiazepines but do not have valid prescriptions—they may be doctor-shopping or buying benzodiazepines on the street. For these patients, there is no consensus, at least not one Mr. Jackson detected during the AATOD session. “Program policies are all over the place,” he told AT Forum. Some refuse to admit anyone who says they use benzodiazepines. Some will admit these people but require them to self-taper during the first month—a risk, because the patient could have seizures. One OTP said patients are sent to a local facility for detoxification—but that could be a problem, because they are detoxified from opioids, too.

Some OTPs simply decrease methadone doses for patients whose urine drug tests are positive for benzodiazepines, but Mr. Jackson said there’s no science to support this, as the tests do not measure how much the patient is taking.

In fact, there aren’t many tools for patients who are abusing benzodiazepines, said Mr. Jackson. “I wish there were some sort of benzodiazepine antagonist. Other than cognitive-behavioral therapy to resist cravings, there isn’t anything.”

Evergreen’s PMP Experience

A combination of checking with the prescription monitoring program (PMP) and asking patients what they are taking helps identify which people are on benzodiazepines before they are admitted. The PMP will not tell whether patients have bought them on the street or obtained them in some other way without a prescription, which is why it’s important to also ask them, said Mr. Jackson.

Evergreen’s patients are required to register their prescriptions with the OTP, so the clinicians know about possible drug interactions and are able to coordinate care. Recently Evergreen queried the PMP about all of its patients in the Seattle clinic. It found that 31 percent (350 patients) in the clinic showed up on the PMP. Of these 350 patients, about 20 percent were taking exactly what they had registered they were taking. “I was happy with that,” he said. But of the other 80 percent, 45 percent were prescribed benzodiazepines. Some were taking them but did not inform the OTP, and some were selling them. The number of current benzodiazepine prescriptions per patient ranged from 1 to 19.

Evergreen worked closely with these doctor-shopping patients by trying to get them to quit. “We wanted to continue their OTP treatment while safely tapering them from benzodiazepines,” said Mr. Jackson. “But if patients cannot cooperate, and every drug test is positive for benzodiazepines, and the patient has been to the ER with overdoses, we say, ‘You may need a higher level of care. We can no longer safely give you the medications you need.’”

Many more patients—88 percent of the 350—were getting prescribed opioids, but some were not taking them – this was clear because the medications never appeared in urinalysis tests. Some were selling all of them, which was also true of those receiving prescriptions for benzodiazepines. “One patient said, ‘This is my way of making a living,’” said Mr. Jackson. That patient left treatment. Some were getting prescriptions for Suboxone and selling or giving away the pills.

For patients who had prescriptions for trivial amounts of drugs—for example, a prescription for 6 acetaminophen/ hydrocodone (Vicodin) after a root canal procedure– Evergreen didn’t take any action other than reminding such patients to register their medications. About 25 percent of the patients had prescriptions for these “trivial” amounts.

Seeking a High

The reality is that some people come to methadone treatment but aren’t interested in treatment, according to Mr. Jackson. “They’re interested in the medication. That way they can continue to live the life they want—without craving opioids—and instead can get high from other drugs, like benzodiazepines.” OTPs must face this reality, especially OTPs with limited capacity or waiting lists, noted Mr. Jackson. Patients come to OTPs with a history of seeking euphoria from drugs.  “You end up with this difficult triage decision: who is appropriate, who gets these slots?”

 

Scientific American: This is Our Society on Drugs: Top 5 Infographics


Infographics are graphic visual representations of information, data or knowledge that present complex information quickly and clearly. This compilation of infographics on addiction include:

  • This is Your Brain on Prescription Drugs
  • This is Your Body on Drugs
  • Prescription Drugs Go Figure
  • Medical Uses of Abused Drugs
  • Drug Use in Today’s Classroom

http://blogs.scientificamerican.com/white-noise/2012/04/20/this-is-our-society-on-drugs-top-5-infographics/

Source: ScientificAmerican.com  –  April 20, 2012

Why Xanax is the Most Popular Anti-Anxiety Drug in America


So reliably relaxing are the effects of benzodiazepines that ­SAMHSA’s director of substance-abuse treatment, H. Westley Clark, says they’ve gained a reputation as “alcohol in a pill.” And their consumption can be equally informal. Just as friends pour wine for friends in times of crisis, so too do doctors, moved by the angst of their patients, “have sympathy and prescribe more,” says Clark. There are a lot more benzos circulating these days, and a lot more sharing.

http://nymag.com/news/features/xanax-2012-3/

Source: New York Magazine – March 18, 2012

Study: Benzodiazepine Update: Alprazolam and Other Benzodiazepine Use Among People Who Inject Drugs

The use of benzodiazepines among people who use illicit drugs is complex as reasons for use are not always straightforward and use does not necessarily infer abuse. On the other hand, higher dosing than prescribed is common among drug users (Nielsen et al. 2008) and use in combination with drugs such as heroin and alcohol is likely to promote adverse effects.

http://ndarc.med.unsw.edu.au/sites/ndarc.cms.med.unsw.edu.au/files/ndarc/resources/IDRS%20April%202012.pdf

Source: McIlwraith, F., Hickey, S., and Alati, R. (April 2012). Benzodiazepine update: alprazolam and other benzodiazepine use among people who inject drugs. IDRS Drug Trends Bulletin April 2012, Sydney: National Drug and Alcohol Research Centre, The University of New South Wales.

Opioid Abuse Linked by Researchers to Mood and Anxiety Disorders

Individuals suffering from mood and anxiety disorders such as bipolar, panic and major depressive disorders may be more likely to abuse opioids, according to a new study led by researchers from the Johns Hopkins Bloomberg School of Public Health, who found that such disorders are highly associated with nonmedical prescription opioid use. The results are featured in a recent issue of the Journal of Psychological Medicine.

For the study, researchers examined individuals with mood and anxiety disorders and their association with nonmedical prescription opioid use and opioid disorder.

“Lifetime nonmedical prescription opioid use was associated with the incidence of any mood disorder, major depressive disorder, bipolar disorder and all anxiety disorders. Nonmedical opioid-use disorder due to nonmedical prescription opioid use was associated with any mood disorder, any anxiety disorder, as well as with several incident mood disorders and anxiety disorders,” said Silvia Martins, lead author of the study and an associate scientist in the Bloomberg School’s Department of Mental Health.

“However, there is also evidence that the association works the other way, too,” she said. “Increased risk of incident opioid disorder due to nonmedical use occurred among study participants with baseline mood disorders, major depressive disorder, dysthymia and panic disorder, reinforcing our finding that participants with mood disorders might use opioids nonmedically to alleviate their mood symptoms. Early identification and treatment of mood and anxiety disorders might reduce the risk for self-medication with prescription opioids and the risk of future development of an opioid-use disorder.”

Using data from the National Epidemiologic Study on Alcohol and Related Conditions, a longitudinal face-to-face survey of individuals ages 18 years and older between 2001–2002 and 2004–2005, researchers assessed participants for a history of psychiatric disorders.

Nonmedical use of prescription opioids was defined to participants as using a prescription opioid without a prescription or in greater amounts more often or longer than prescribed or for a reason other than a doctor’s instruction to use them. Logistic regression was used to determine whether lifetime nonmedical prescription opioid use and opioid disorders due to this use predicted incident mood and anxiety disorders and the reverse. Researchers say they believe that these findings provide support for a bidirectional pathway between nonmedical prescription opioid use and opioid-use disorder due to nonmedical use and several mood and anxiety disorders.

Carla Storr, author of the study and an adjunct professor in the Bloomberg School’s Department of Mental Health, said, “With the current increased use of nonmedical prescription drugs, especially among adolescents, the association with future psychopathology is of great concern. Using opioids, or even withdrawal from opioids, might precipitate anxiety disorders, suggesting that there is a subgroup of people who are vulnerable to future development of anxiety disorders.” Individuals using prescription opioids need to be closely monitored not only for the possibility of engaging in nonmedical use but also for the development of co-morbid psychiatric disorders, she said.

Added Martins, “Additional studies are needed to examine the relationship between nonmedical prescription opioid use and prescription opioid-use disorder with mood and anxiety disorders since they could co-occur due to shared genetic or environmental risk factors.”

The study was written by Martins, M.C. Fenton, K.M. Keyes, C. Blanco, H. Zhu and Storr.

Source: John Hopkins Bloomberg School of Public Health – March 5, 2012

Deadly Duo: Mixing Alcohol and Prescription Drugs Can Result in Addiction or Accidental Death

Prescription drugs and alcohol can be a dangerous combination, Nora Volkow of the National Institute on Drug Abuse says. Painkillers and booze are perhaps the worst to mix, because both slow breathing by different mechanisms and inhibit the coughing reflex, creating “a double-whammy effect,” she says, that can stop breathing altogether. Alcohol also interacts with anti-anxiety drugs (including Xanax), antipsychotics, antidepressants, sleep medications and muscle relaxants—intensifying the drugs’ sedative effects, causing drowsiness and dizziness, and making falls and accidents more likely.

http://www.scientificamerican.com/article.cfm?id=mixing-alcohol-prescription-drugs-result-addiction-accidental-death

Source: ScientificAmerican.com – February 24, 2012

Abuse of Xanax Leads a Clinic to Halt Supply

Because of the clamor for the drug, and concern over the striking number of overdoses involving Xanax in Kentucky and across the country, Seven Counties Services, Inc. took an unusual step— its doctors stopped writing new prescriptions for Xanax and its generic version, alprazolam, in April and plan to wean patients off it completely by year’s end.

The experiment will be closely watched in a state that has wrestled with widespread prescription drug abuse for more than a decade and is grasping for solutions as it claims more lives by the week. While Kentucky and other states have focused largely on narcotic painkiller addiction, experts say that benzodiazepines, the class of sedatives that includes Xanax, are also widely misused or abused, often with grim consequences.

http://www.nytimes.com/2011/09/14/us/in-louisville-a-centers-doctors-cut-off-xanax-prescriptions.html

Source: The New York Times – September 14, 2011

Substance Abuse Treatment Admissions for Benzodiazepine Abuse Triple

The number of patients admitted to substance abuse treatment who report benzodiazepine abuse tripled from 1998 to 2008, the Substance Abuse and Mental Health Services Administration (SAMHSA) reported in June. In 1998, benzodiazepines were involved—not necessarily as the primary drug of abuse—in 22,400 admissions. Ten years later, this number had grown to 60,200.

Substance Abuse Treatment AdmissionsBenzodiazepines were rarely the only drug used, or even the primary drug. In 82.1 percent of the cases, benzodiazepines were the secondary drug of abuse, with opioids (54 percent) usually the primary drug—a pattern that roughly held true for nearly every age group except adolescents and those aged 45 and older (see chart).

One major public health concern with multiple drug abuse is the risk of overdose. The SAMHSA report notes that “abuse of benzodiazepines in combination with other substances can have severe and sometimes fatal consequences.”

The report, based on the Treatment Episode Data Set (TEDS), was released by SAMHSA in June 2011. The report collects information from providers on the primary substance of abuse, and up to two additional substances, at admission to treatment.

The TEDS Report, Substance Abuse Treatment Admissions for Abuse of Benzodiazepines, can be found at: http://atforum.com/addiction-resources/documents/TEDS028BenzoAdmissions.pdf.

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