Mental Health | Benzodiazepine Harms Overlooked, Especially in Older Adults

As attention remains focused on opioid abuse, another drug epidemic rages outside the spotlight: inappropriate prescription of benzodiazepines.

In an editorial published in the February 22 issue of the New England Journal of Medicine, Anna Lembke, MD, Jennifer Papac, MD, and Keith Humphreys, PhD, from Stanford University School of Medicine in California,...

• ...point out that from 1996 to 2013, the number of adults who filled a benzodiazepine prescription rose from 8.1 million to 13.5 million, an increase of 67%. During roughly the same time (1999-2015), deaths from benzodiazepine overdose increased from 1135 to 8791.

"Despite this trend, the adverse effects of benzodiazepine overuse, misuse, and addiction continue to go largely unnoticed," they write.
Concurrent opioid use figured in three quarters of the overdoses, "which may explain why, in the context of a widely recognized opioid problem, the harms associated with benzodiazepines have been overlooked," the editorialists state. They cite data showing that co-prescription rates nearly doubled between 2001 and 2013, going from 9% to 17%.

Of particular concern is benzodiazepine use among the elderly, who are especially vulnerable to adverse effects, including an increased risk for falls, fractures, motor vehicle accidents, impaired cognition, and dementia. Professional societies in several countries, including the American Geriatrics Society, have issued guidelines recommending against prescribing benzodiazepines to these patients, as has the Choosing Wisely

Nevertheless, "prescribing to older adults continues despite decades of evidence documenting safety concerns, effective alternative treatments, and effective methods for tapering even chronic users," Donovan T. Maust, MD, MS, and coauthors wrote in the Journal of the American Geriatric Society in 2016. Other researchers have found that clinicians often are unaware of the dangers these drugs pose to seniors, or believe they have no other therapeutic options.

Now a new observational study of older adults in the United States, Canada, and Australia confirms that, despite a modest decline in benzodiazepine prescriptions in this population, "use remains inappropriately high — particularly in those aged 85 and older — which warrants further attention from clinicians and policy-makers," the authors write.

Jonathan Brett, MBBS, from the Medicines Policy Research Unit at the University of New South Wales in Sydney, Australia, and colleagues published their findings online February 12 in the Journal of the American Geriatric Society.

The authors used prescription claims data from the US Department of Veterans Affairs (VA), the Ontario (Canada) Drug Benefit Program, and the Australian Pharmaceutical Benefits Scheme to analyze annual incident and prevalent benzodiazepine use among people 65 years of age or older between January 2010 and December 2016. The entire cohort included 8,270,000 people.

They observed a significant and linear decline in prevalent benzodiazepine use, defined as people with at least one prescription claim for a benzodiazepine during a given calendar year, in all three countries during the period studied. In the United States, it declined from 9.2% to 7.3%; in Ontario, Canada, it declined from 18.2% to 13.4%; and in Australia, it declined from 20.2% to 16.8%.

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