Cautions against the practice go unheeded by nonpsychiatrists.
by John Gever
Managing Editor, MedPage Today
About one in 12 older Americans were prescribed benzodiazepines in 2008, and one-third of those individuals took them for long periods — and much of this use was probably inappropriate, researchers said.
Analysis of a large prescription database for 2008 found that benzodiazepine prescriptions were filled by 11.5 million people 18 to 80 years old, about 5.2% of this population, according to Mark Olfson, MD, MPH, of Columbia University’s College of Physicians and Surgeons in New York City, and colleagues.
The proportion of individuals filling prescriptions increased with age: 2.6% of young adults were using medications compared with 5.4% of the middle-age and 8.7% of those 65 to 80, the researchers reported online in JAMA Psychiatry.
Long-term use — defined as filled prescriptions for supplies of at least 120 days — also rose with age. Among adults 18 to 35, long-term use rates fell just short of 15%, whereas the rates among those 51 to 64 and 65 to 80 were 28.0% and 31.4%.
Olfson and colleagues also found that women were far more likely than men in all age groups to use benzodiazepines, and that long-term use was more common in women as well.
“Several factors may contribute to the observed high rates of long-term benzodiazepine use in older adults,” the researchers wrote. These included the following:
Presence of persistent anxiety disorders
Prescribers’ lack of knowledge regarding risks of benzodiazepines in geriatric care
Limited access to alternative nonpharmacological therapies
Patients’ insistence on receiving the drugs
Clinicians’ time pressures and the need to address patients’ more pressing problems
Olfson and colleagues suggested that, because of these factors, many older patients are effectively addicted to benzodiazepines and their physicians should seek to withdraw them.
“An effective intervention involves gradual supervised benzodiazepine withdrawal combined with psychotherapy focused on coping with dependency symptoms and underlying psychiatric symptoms,” they wrote. But they acknowledged that this approach may not be practical in many cases, in which case “less intensive interventions” such as written advice to patients on how to taper the drugs could be attempted.
In an accompanying editorial entitled “Why Are Benzodiazepines Not Yet Controlled Substances?” Nicholas Moore, MD, PhD, of the University of Bordeaux in France, and two colleagues, argued that it might be advisable to allow only psychiatrists to prescribe this class of drugs — in part because Olfson and colleagues found that prescription rates by psychiatrists were far lower for geriatric patients compared with other types of prescribers. There was also no gender gap in prescriptions by psychiatrists.
“The next step is to consider them the same as other dangerous addictive substances and put them on a tight dispensation schedule using limited-duration prescriptions with no refills,” Moore and colleagues wrote. “Such barriers could help the public and prescribers think more about these risks before prescribing or using benzodiazepines.”
Olfson and colleagues asserted that most clinicians are aware of guidelines cautioning against long-term benzodiazepines in geriatric patients, but many don’t believe that it “poses a serious clinical threat.” Another factor may be that physicians are simply reluctant to make waves with older patients, the authors suggested.
For the study, Olfson and colleagues drew on the LifeLink LRx Longitudinal Prescription database maintained by IMS Health, which covers prescriptions filled at some 33,000 retail pharmacies filling an estimated 60% of all U.S. prescriptions. The researchers also used data from the federal Medical Expenditure Panel Survey to estimate the number of people not filling prescriptions for purposes of statistical analysis.
Limitations to the analysis included reliance on administrative records and lack of data on actual medication use and patients’ diagnoses. The dataset also lacked information on duration of benzodiazepine prescriptions that may have commenced before 2008 or ended afterward.
The study was supported by federal grants. Study authors and the editorialists declared they had no relevant financial interests.
Primary Source
JAMA Psychiatry
Source Reference: Olfson M, et al “Benzodiazepine use in the United States” JAMA Psychiatry 2014; DOI: 10.1001/jamapsychiatry.2014.1763.
Secondary Source
JAMA Psychiatry
Source Reference: Moore N, et al “Why are benzodiazepines not yet controlled substances?” JAMA Psychiatry 2014; DOI: 10.1001/jamapsychiatry.2014.2190.