The Accidental Deadly Drug Prescription

“There are many publications the medical world about opioid medications. Managing chronic pain without risking accidental death is hard. This article looks at anther much less known risk of opioid medications. The grave risk for some is combining an opioid with a benzodiazepine drug such as Xanax. This is a commentary in the Wall Street Journal. Dr. Wen shows you the difficulty in practicing the best medicine, being effective and keeps risks as low as possible. If you friends who take pain pills, tell them about the benzodiazepine class of drugs, all of their brand names. ” Bill Chesnut, MD

To go back to New Health News: http://billchesnutmd.com/new-health-news     

The Accidental Deadly Drug Prescription.   Many doctors are unaware that a drug like Valium or Xanax, taken with an opioid, could be fatal. By LEANA S. WEN,MD_______March 30, 2016

My patient was a college student brought into the emergency room after a minor car accident. Although CT scans showed no spinal fractures, he had severe neck pain and spasms. Instinctively, I prescribed Percocet for pain and Valium for muscle spasms. But I didn’t know then what I know now: These two drugs, when taken together, could interact and cost him his life.

Opioids—including prescriptions such as Percocet and OxyContin, as well as the illicit form, heroin—are under increased scrutiny. The number of Americans dying from an opioid overdose has quadrupled over the past decade, according to the Centers for Disease Control and Prevention. This week President Obama joined health officials and advocates to raise awareness of this growing epidemic. Clinicians and the public, however, are often unaware of the threat posed by opioid interaction with another frequently prescribed drug.

Benzodiazepines, known to most Americans as Xanax or Valium, typically treat anxiety or insomnia. But when combined with opioids, as they often are, they can suppress the instinct to breathe, increase sleepiness and cause death. In 2010, one in three unintentional overdose deaths in the U.S. from prescription opioids also involved benzodiazepines, according to the National Vital Statistics System. Maryland Department of Health data show more than 70% of deaths in the state associated with benzodiazepines also involved prescription opioids.

Despite this danger, doctors prescribe both drugs at increasing rates. The CDC reported that in 2012 there were over 259 million prescriptions of opioids in the U.S.—more than one for every adult. That year there were nearly 40 benzodiazepine prescriptions for every 100 Americans. Hospital admissions for patients with combined addiction to opioids and benzodiazepines have increased by 569% over 10 years, according to anotherfederal study.

Why do doctors continue to prescribe this deadly combination? In part, because that is what they are taught. When I was in medical school in the early 2000s, I learned to treat muscle pain and spasms with both opioids and benzodiazepines, so I routinely prescribed them together. A 2015 study published in the journal Pain Medicine found that one in three patients with chronic pain on opioids was also on benzodiazepines. Just as I acted on instinct with my ER patient, doctors prescribe medications based on habit.

Most overdose-education campaigns focus exclusively on the opioid epidemic, in part because there is an easy-to-use antidote available, naloxone. In Baltimore, we have increased its availability by allowing all 620,000 residents to obtain a naloxone prescription—no questions asked. Last year, we conducted over 8,000 targeted trainings, going to high-risk areas like jails, bus shelters and public markets to demonstrate use of this lifesaving medication.

Likewise, education for physicians has focused on increasing monitoring of opioid prescriptions, rather than on decreasing their use with benzodiazepines. But with mounting scientific and epidemiological evidence about this deadly combination, doctors must adjust their patterns. Shouldn’t they already know that combining these drugs is dangerous? Unfortunately, the figures suggest they don’t.

Last month, I co-led a coalition of over 40 city health-commissioners and state health-directors who sent a petition urging the Food and Drug Administration to require a “black-box warning”—the FDA’s strongest risk communication—any time that opioids and benzodiazepines are prescribed together. Such a warning would sound the alarm about the danger of taking these drugs at the same time. Thousands of health officials, academics, researchers, physicians and citizens signed our petition.

Studies show that black-box warnings change how physicians prescribe potentially dangerous medications. In the mid-2000s, a black-box warning was issued for an antidepressant associated with suicide in youth. This resulted in a 22% drop in prescriptions, according to a study in the American Journal of Psychiatry. Physicians listened to the warning and changed their practices.

The FDA recently proposed a black-box warning on opioids. It is a welcome move: 44 Americans die every day from prescription opioid overdose. Yet, while one-third of those deaths were associated with an unintentional combination with benzodiazepines, the FDA’s new warning doesn’t mention the dangers of combining the drugs.

When I look back at my practice, I wonder how many deaths my colleagues and I might have caused inadvertently—and how many we could have prevented if we had known the potential dangers sooner. It’s a harrowing thought that should spur physicians to change their prescribing practices and patients to look inside their medicine cabinets.

Dr. Wen is an emergency physician and the health commissioner for the city of Baltimore.