New Study Documents Significant Increases in Fatal Benzodiazepine Overdoses

Fatal Overdoses Increased Five-Fold from 1996 to 2013

According to a study recently published in the American Journal of Public Health [See Bachhuber, Marcus A., MD, MSHP, et al., “Increasing Benzodiazepine Prescriptions and Overdose Mortality in the United States, 1996–2013,” Am J Public Health, Vol. 106, No. 4, pp. 686–688, April 2016 (doi:10.2105/AJPH.2016.303061)], both the number of benzodiazepine prescriptions and the number of deaths associated with benzodiazepine overdoses increased significantly between 1996 and 2013, the years of the study. The researcher’s findings are consistent with earlier studies showing that the use of benzodiazepines, particularly when joined with opioids, significantly increases workers’ compensation costs.

While the data suggests the incidence of fatal overdoses has plateaued overall, the researchers also note that no group of U.S. adults has experienced any decrease in overdose deaths. Moreover, the number of annual fatal overdoses is still five times the rate observed at the beginning of the study period. The researchers conclude that in order to reduce morbidity, two things are required: interventions to reduce the use of benzodiazepines, particularly when used concurrently with opioids, and general improvements in their safe use.

A group of occupational medicine experts has released results of an important, soon-to-be published study indicating that the addition of benzodiazepines to an opioid treatment regimen significantly increases workers’ compensation costs

Data Gleaned from Medical Expenditure Panel Survey and Centers for Disease Control

Utilizing the Medical Expenditure Panel Survey (“MEPS”), the researchers examined data related to benzodiazepines prescriptions filled between 1996 and 2013. MEPS, which began in 1996, is a set of large-scale surveys of families and individuals, their medical providers, and employers across the United States. MEPS collects data on the specific health services that Americans use, how frequently they use them, the cost of these services, and what sort of payment method is used in securing them. The most complete source of data on the cost and use of health care and health insurance coverage in the country, MEPS also gathers data on the cost, scope, and breadth of health insurance held by and available to U.S. workers.

The researchers separately culled morbidity data related to the overdose of benzodiazepines from the Centers for Disease Control and Prevention (“CDC”) for the period 1999 to 2013. The researchers noted that their methods captured all benzodiazepine overdose deaths, including those involving other medications or illicit drugs.

Study Results

The researchers observed that between 1996 and 2013, the number of adults annually filling a benzodiazepine prescription increased by 67 percent. Indeed, as other studies show, benzodiazepines are among the most commonly prescribed medicines in the United States. The researchers observed that for the average individual taking benzodiazepines during the study period, the median quantity annually filled more than doubled. The increase in the total quantity of benzodiazepines annually filled was even more pronounced—the 2013 quantity was more than three times the quantity dispensed in 1996.

From the MEPS data, the researchers observed that the most common reasons for benzodiazepine prescriptions during the study period were:

> Anxiety disorders

> Mood disorders

> Codes in the “unclassified” category, which includes codes for insomnia

The researchers indicated that there was a hint of good news: the number of annual overdose deaths generally leveled off after 2010. Unfortunately, all groups studied did not enjoy that plateau. The researchers specifically noted that after 2010, the rate of benzodiazepine overdose deaths continued to increase for adults aged 65 or older and also for Black and Hispanic adults.

What is Causing the Increase in Benzodiazepine Overdose Deaths?

The researchers reiterated that based on the increases in both the number of individuals filling benzodiazepine prescriptions and the increases seen in the median quantity filled in any given year per individual, patients were either getting a higher daily dose or more days of treatment. Either factor could result in additional overdoses.

The researchers noted other potential causative factors, including the fact that:

> Persons at the highest risk of fatal overdose could be securing benzodiazepines from illicit sources

> Increases in alcohol use or combining benzodiazepines with other medications—particularly opioids—could increase the risk of fatal overdose

> Opioids were involved in approximately 75 percent of the overdose deaths involving benzodiazepines

> Other studies showed that the number of opioid prescriptions had increased rapidly during the same study period.

As to the leveling off of the overall number of fatal overdoses, the researchers observed that the phenomenon appeared to coincide with the period of time during which the health care industry had devoted increased attention to opioid safety.

Study’s Limitations

The researchers noted a number of limitations in their study, including the fact that:

> MPES data is limited to the civilian, noninstutionalized population. Those in correctional facilities or in skilled nursing facilities are likely to have different rates of benzodiazepine use and overdose.

> Over time, there was some variation noted in the characterization of deaths from state to state, a factor that might led the study to underestimate the number of fatal overdoses observed during the test period.

> MPES data was not aggregated so as to allow the researchers to differentiate between long-term versus short-term use of benzodiazepines.

Study’s Implications

According to the researchers, while the rate of overdose deaths involving benzodiazepines has stabilized somewhat during the past few years, it remains more than 5 times the rate observed at the beginning of the study period and the rate has decreased for no group of adults. Moreover, in some groups—most notably adults over the age of 65 and Black and Hispanic adults—the annual increase in number of overdose deaths continues.

The study joins a number of others that point out the dangers of prescribing benzodiazepines and opioids concomitantly. As noted recently by other researchers, the risk of overdose from taking opioids at the same time as benzodiazepines is four times the risk from taking opioids by themselves (See Holzman, David C., “New study highlights risks of combining benzodiazepines and opioids”, Pain Medicine News (02/10/2016).  Note also that on March 15, 2016, the CDC released voluntary guidelines that instruct primary care doctors to sharply deter use of the medicines for chronic pain).

While the researchers do not offer specific suggestions, they indicate interventions to reduce the use of benzodiazepines are needed to reduce the number of overdose deaths. Other efforts to increase the safe use of benzodiazepines need to be identified and implemented.

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