Benzos for Recovering People?

Recently, a colleague asked my opinion on the use of anti-anxiety medications called benzodiazepines in people either struggling with or recovering from an addiction (to something else of course.) Benzodiazepines (benzos for short) include common medications such as alprazolam (Xanax,) lorazepam (Ativan) and clonazepam (Klonapin.) Here is my reply:

First, I personally think that the idea that no-one who is in recovery from an addiction should ever ever be prescribed another potential intoxicant is a remnant of the all or none thinking in 12 step groups and programs. It's not based in fact. Yes, there may be a relative increase in risk, but the risk of true addiction to benzos (as opposed to development of tolerance and physical dependence) in an anxious pt is near zero in most people so the absolute risk is pretty low in someone with alcohol or opioid addiction, for example. The same holds true for pain medication in alcohol dependent people. I try to balance risks and benefits as I do with any patient or treatment. The science tells us for most people that an addiction is specific to a drug, not to "addiction" or intoxication of any type. There is no such thing as an "addictive personality." The other thing I'm impressed with is how poor any current pharmacotherapy is for chronic anxiety. The best treatment is good CBT, but it's hard to find and many pts aren't good candidates (although they might be for skillful psychodynamic therapy.) So I don't know about you, but I often find myself and the pt between a rock and a hard place.

An example patient is someone who had childhood onset of moderate to severe anxiety, often starting with separation anxiety and school refusal. Some patients report the onset of panic attack before the age of 10. Most of these people are extremely anxious all of their lives. I see them because they have became alcohol dependent. I generally prescribe an antidepressant, an SSRI or SNRI, but these seem to have poor efficacy in these primary anxiety patients, as opposed to people with depression and anxiety together. In one recent patient I  stopped benzos and the patient got to the point where I thought she would relapse to drinking w/o relief so I prescribed lorazepam and she almost immediately got much better, more stable, and with markedly reduced desire to drink. To my knowledge she hasn't used benzos in an addictive fashion, although the other problems of tolerance and lack of long-term efficacy haven't gone away. I usually try everything else I can: beta blockers, anticonvulsants, antidepressants, rarely antipsychotics if nothing else works. I always prescribe relaxation training and breathing exercises, give patients info about mindfulness approaches and also always recommend a CBT workbook for anxiety. I may recommend seeing a therapist. But sometimes it's only benzos that seem to help.

Some years ago a colleague of mine studied vets with severe chronic PTSD who were on benzos, expecting their outcomes to be worse than others. Theirs were better than others. Now that may simply be due to this group being more stable/adherent so therefore benzos were continued. But still, where is the evidence in the published lit that shows that long-term benzo use is often damaging? I worry that we prescribe truly toxic drugs like antipsychotics and depakote or lamotrigine to avoid benzos. And where is the evidence that many of these drugs actually help anxiety or are safe to treat it?

I think also there is a bias here: with very weak evidence of risk, we withhold benzos and with no evidence of efficacy or safety we prescribe toxic risky drugs instead. Make sense?

Also, underlying the bias is the pervasive idea, spread by 12 step treatment programs that 12 step treatment or groups are 100% effective if the person just does as they're told. You and I both know that's absurd and untrue. Medicine frequently involves compromise between ideal and pragmatic goals, and balancing various risks and benefits.

Finally, there is fairly strong evidence that untreated insomnia, pain and anxiety contribute substantially to increased relapse risk. It's easy to say "they should just tough it out or go to more meetings" but that seems pretty unreasonable and unsupportable to me.

In the end, I view it as all coming down to outcomes. Is the pt better off? Are their sxs less? Are they more functional? Does a rx for benzos help them recover more fully?

Be good to discuss some time....

Mark

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How Many Hospitalized Pain Patients are Addicted?

Here is a response I recently wrote to a colleague inquiring about my impression of pain management at United Hospital in St. Paul. The questions were about what proportion of inpatients were addicted to opioids and how to improve pain management in the hospital.

Hi XXXX,

The question about proportion of inpts with opioid addiction is complicated.

First, the number of clear opioid addicts is small. These addicts are people who use heroin for example, or inject or snort other opioids. This also includes people who clearly have use that is out of control. Remember, addiction is compulsive, destructive drug use. Examples of this latter group are people who use far in excess of what is prescribed, who go to multiple doctors, who use to get intoxicated, and whose use is clearly dysfunctional. Pain management for this group is difficult and these patients are usually grossly undertreated, out of both ignorance and moral condemnation. However, the approach to these patients in overall management is pretty clear in that ongoing prescription of regular opioids by a typical provider is contraindicated and these pts by and larger only respond to opioid agonist therapy (maintenance) with either buprenorphine or methadone. There is not a single study demonstrating efficacy of 12 step or other rehab in treating established opioid addiction and relapse is all but inevitable, usually shortly after leaving rehab. Unfortunately, that is usually what they are referred to. That's like referring a diabetic to a spa for a couple of weeks, and not offering any medication, but that's what's done.

Second are those with no prior significant opioid use, or relatively minimal use, in other words, typical pts requiring pain management. I don't think we do very well with this group based on my observations, in large part due to ignorance about individual variation in pain sensitivity, pain tolerance, opioid metabolism, etc. This is the easiest group to demonstrate improvement.

Third are the most problematic. These poor folks have chronic severe pain requiring ongoing management with opioids. Unfortunately, there is a wide variability in how these pts and this treatment are perceived. There is a group of vocal opponents who strongly believe pts should never be offered this treatment. Most experts are in the middle, realizing that long term opioid treatment for chronic pain has modest benefit on average (about 30% reduction in pain, range 0-50%) and which comes with a fair amount of risk and baggage. Nevertheless the vast majority of pain experts understand that although some pts are able to tolerate severe pain without opioids, many are not and with with all of its baggage, we're stuck with opioids until something else comes along. Note that opponents of opioid therapy have no evidence on their side and there arguments are based on studies of highly select patients and animal models and they usually exaggerate the harms, so I think their beliefs are mostly based on moral judgements or at least wishful thinking. All the published expert guidelines recommend appropriate use of long term opioid treatment if managed properly.

Whether a pt like this is "addicted," a "drug-seeker," a "somatizer," "manipulative," a "drug-coper," "malingering," or other pejorative terms is therefore mostly in the eye of the beholder, and projection of the clinician's values, beliefs and judgments rule the day. Basically, the observers are voicing an opinion that the patient is asking for and using these medications for inappropriate or invalid reasons, such as emotional relief (as if one could discern between pain and one's response to it.) Here's my rule about the value of such judgements: Can this opinion be disproved? If not, to me it's worthless. For example, I might interpret pain behavior in a certain individual as a manipulation "just to get high" rather than to "relieve legitimate pain." Now try to disprove that. You can't. So I might respond to the clinician, "You're just saying that because your father was an alcoholic and your mother was histrionic and constantly complaining about various vague physical symptoms." Now try to disprove that. You can't. So if you ask certain other clinicians in the hospital, you're more likely to get a "diagnosis" of "addiction" than if you ask me. None of us can prove we're right because the science isn't there and this is an almost impossible problem to conduct rigorous studies on. I choose to stay with ignorance and not assume I understand something that we cannot (because the science isn't there) and to approach the problem pragmatically: "How can I maximize function and relief from suffering?"

In my practice, the rule I use is this: is the patient better or worse off with the medication than without? If the answer is better, and the patient takes the medication as directed, then that person isn't addicted. By definition, their use is not compulsive or destructive, so therefore they are not addicted. (Although they will have symptoms if they suddenly stop, but that's true with Effexor too.) 

So I think this last group of patients experiences wide fluctuations in attitudes, behaviors, opinions and treatments from one clinician or facility to the next. My patients complain bitterly about this, about how they feel that everyone sees them as "addicts" or "Junkies," how they are treated with contempt and judgment by some clinicians, and how often their pain is inadequately treated. They may be overtreated or undertreated, but undertreatment is much more common that overtreatment. This is a group that would require a concerted focused effort to improve pain management. Scott Tongen helped with this by developing new protocols for opioid tolerant patients, and Ben has been promoting the use of ketamine to reduce need for opioids, which I think is not well researched, but appears to be very promising.

Sorry for the lengthy reply, but there's no simple way to think/talk about this, unless you're one of the people who just says,"Man up!" 

As for quality improvement, I would guess that considerable work would need to be done to actually understand who is and is not getting good pain management before developing an intervention.

And no, I do not think UTD is better/worse than other places in this regard.

All the best!

Mark

Deaths from Prescription Opioids Not Evenly Distributed

Last November, the CDC issued a report detailing the rise of prescriptions for opioid (narcotic) pain killers such as oxycodone (Percocet, Oxycontin), hydrocodone (Vicodin, Norco), methadone, morphine (MS Contin), fentanyl patches (Duragesic), and others, from 1999-2008. As expected, prescriptions for these medications have increased pretty dramatically. Here's the chart from that report, showing sales of opioid pain relievers (OPR), admission for addiction treatment related to OPR and OPR deaths per 100,000 persons. Basically, sales more than tripled, treatment admission quadrupled and deaths almost tripled. Since 2008, these trends have continued if not accelerated. In Minnesota for instance treatment admissions for opioid addiction are now greater than that for cocaine, methamphetamine, cannabis or other non-alcohol drugs. (Alcohol of course, continues to be the elephant in the room, with all indicators much higher than all other drugs combined.)

However, the rates for these indicators are not evenly distributed across the states. Here are two graphs from the same report showing rates across the US. What they show is that the rates for OPR sales and rates for overdose deaths vary widely across the country. For the most part, the rates of sales and deaths track together although there are exceptions (Oregon, Hawaii for example.) The national rate for overdose deaths is 11.9/100,000 but rates vary from 5.5 in Nebraska to a whopping 27 in New Mexico, a five-fold difference. Of note, nearly all of the deaths are in people taking them for medical purposes and the rates of non-medical use are low across the country. What these figures indicate is that there is no single solution for the entire country. Rather, the approaches need to be tailored to the particular states and regions with the highest figures. Not surprisingly, given the number of older adults living there, Florida tops the country for example in kilgrams of OPR sold.  However, the overdose death rate is 8th highest. New Mexico, however, with the highest overdose death rate, has OPR sales lower than the national average. Unfortunately, the federal government has taken a blanket approach focused on training physicians, which suggests that the appearance of doing something is more important than actually doing something that works.

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An Ordinary Weekend

Last weekend I was on call for psychiatry at United, the hospital in St. Paul that I work for. It's been a moderately busy weekend for me, but not because there isn't any more demand for services, but because our inpatient beds are full. And guess what? So are the inpatient psychiatry beds not only throughout the Twin Cities Metro Area, but also the entire state! Halfway through the weekend we sent a patient to the last open adolescent psychiatry bed in Fargo, ND! So there are two patients this weekend who have had to stay in the emergency department, because there is no place to admit them. I continue to be amazed that I live in a country that would send its mentally ill children hundreds of miles away from their families because it's not willing to pay for the services they need locally.

And as usual, among the patients newly hospitalized whom I saw, about half were addicted to a psychoactive substance, usually alcohol. This is also typical. Now that I'm cutting back on my clinical practice, I'm unable to offer them a new form of treatment, one that is oriented around treating the disease as it is, rather than as we would like it to be. I was able to offer that for the last 2 years, but now I'm moving more into efforts to change things more broadly, to help others provide that kind of service and thus leverage my knowledge and skill. And that is going well and finally seems to be picking up speed. This stuff really takes a lot of time and effort!

But I still find it hard not to offer these patients an alternative to another run through a rehab program they've already experienced multiple times before. Any treatment that has been shown to be ineffective in a particular patient ought no longer to be pursued. I don't continue to prescribe naltrexone or Prozac to someone after it repeatedly fails to alter the course of illness, thinking that perhaps someday it will become effective! But embracing fully another approach is not without its problems too.

That's because to do so takes us right into some painful insights. Our treatments are modestly effective at best. There are many people for whom we have no effective treatment. And it's not their fault, it's because the science isn't yet at a point where we can understand what's wrong and help correct it. Our instruments are crude, primitive. Well-meaning, yes. We can always provide comfort, understanding, and a willingness to stay with someone to the end. But all too often, there is nothing we can do to change what we see as the inevitable conclusion of a process we don't understand: addiction. And I can tell you that it is difficult indeed to stay engaged with someone who is dying of an addiction neither she nor I nor you nor AA nor rehab nor medication nor the criminal justice system nor anyone else can help. We accept that grim reality with other diseases like heart disease or cancer. But we have a hard time accepting that brain diseases like addiction or bipolar disorder can be incurable and ultimately fatal. And most importantly, it's not because the person dying does not want to live or isn't trying in every way to stop the march towards death. We have to stop blaming the victims when our treatments fail and at least offer them succor along the way.

Implementing the NIAAA Guide in Primary Care Clinics

After two years, it finally feels like things are coming together. Allina Health continues to be a great place to try out new ideas for addressing alcohol and pain, across hospitals and clinics. I've been able to recruit up to three primary care clinics in the SBIRT+ project, which is focused on addressing alcohol in primary care. (SBIRT+ stands for Screening, Brief Intervention and Referral to Treatment, Plus Point of Service Care. Point of service care reflects treatment for alcohol dependence (not just at-risk drinking) in primary care. The NIAAA Clinician's Guide uses this model.) Allina is also developing a collaborative care model at a pilot clinic and I expect to be involved in that effort, which is focused on coordination of care and reduction in preventable hospitalization for patients with complex chronic illnesses. Heavy drinking is common among people with chronic diseases who demonstrate high cost and poor outcomes. To reach the goals of reducing costs and improving outcomes requires addressing drinking and other co-morbidities such as depression in addition to improving care for their other chronic medical conditions.

This is a very ripe time for new ideas. Health care clinicians are disillusioned with the time-limited rehab system, where there is only one option that doesn't change even after repeatedly showing lack of effectiveness. They want guidance on what to do next. They are intrigued by the NIAAA Guide's clear guidelines for addressing heavy drinking across the spectrum of severity (from risk drinking to functional dependence to severe recurrent dependence) and by medical treatment options, especially anti-relapse medications. Contrary to what many in the addiction treatment field believe, doctors and other primary care clinicians want very much to help but have pretty much been told to "leave it to the addiction experts," which for the most part means counselors alone, and for relatively short periods. However, the patients spend much more time in primary care than they do in any treatment programs.

In the last week, I've presented SBIRT+ at two primary care clinics, and in the next week I'll be talking to two or three more. I'll fill you in as I go.

MW