An Approach to Evaluate the Effects of Concomitant Prescribing of Opioids and Benzodiazepines on Veteran Deaths and Suicides (2019) / Chapter Skim
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1 Introduction
1 Introduction
Pages 19-42
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The chapter is not meant to provide in-depth information on the neurobiology and pharmacology of those drugs, nor is it meant to provide a discussion of all possible uses of opioids and benzodiazepines; however, the committee has included a very brief section on the neurobiology and principles of 1 The Department of Veterans Affairs is composed of the Veterans Health Administration (VHA) , the Veterans Benefits Administration, and the National Cemetery Administration.
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Chronic opioid use is associated with the development of tolerance, which develops at different rates in different people. Opioid overdose can result in respira tory depression and death (Turton and Lingford-Hughes, 2016)
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The Joint 5 With regard to cancer pain, in the 1970s and 1980s palliative care specialists recognized that opioids brought relief to terminal cancer patients, and several studies were published that suggested that patients rarely developed opioid use disorder when opioids were prescribed for cancer pain. Concurrently, the World Health Organization was developing cancer pain treatment guidelines that included pain treatment as a universal right.
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. The combination of these factors led to an increasing reliance on prescription opioids for pain management.
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(2019) found that between July 2012 and December 2017 many providers stopped initiating opioid therapy, but a sub-group of providers continued to write high-risk initial opioid prescriptions.11 Treating Cancer Pain with Opioids It should be noted that there has been some controversy surrounding the appropriateness of use of opioids for cancer pain, and guidelines recommend against using them along with benzodiazepines.
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The authors found that there are several key factors beyond opioid use that are related to suicide and overdose. Most mental health conditions are linked to an increased risk of suicide and unintentional overdose, including both illicit drug and medication-related overdoses, but the type of link differed according to the specific mental health condition.
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. The age-adjusted rate of drug overdose deaths involving synthetic opioids other than methadone (e.g., fentanyl, fentanyl analogs, and tramadol)
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found that the outpatient use of benzodiazepines had increased substantially -- from 3.8 percent to 7.4 percent of ambulatory care visits between 2003 and 2015; concomitant prescribing with other sedating medications had also increased. Furthermore, between 2002 and 2014 the number of opioid recipients who were also dispensed benzodiazepines increased from 7 to 10 percent (a relative percent increase of almost 43 percent)
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Furthermore, in the emergency department setting between 2004 and 2011, the percentage of opioid overdose deaths among adults that also involved benzodiazepine use increased steadily from 18 to 31 percent (Jones and McAninch, 2015)
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According to the National Vital Statistics Reports (Hedegaard et al., 2018a) , for the top 10 drugs involved in drug overdose deaths in 2016, the proportion of deaths involving both the referent drug and at least one other concomitant drug ranged from 50 percent for methamphetamine to 96 percent for the benzodiazepines alprazolam or diazepam.
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, nor does it provide a detailed look at VA's prescribing practices. The section also briefly describes the Clinical Practice Guideline for Opioid Therapy for Chronic Pain from the VA and the Department of Defense (DoD)
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A study of veterans recently returning from deployment reported a 12.5 percent prevalence of suicidal ideation in the previous 2 weeks. The authors found positive associations of suicidal ideation with depression and PTSD and negative associations with the availability of social support (Bossarte et al., 2012)
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. The authors note that, inasmuch as suicidal ideation is a known risk factor for suicide attempts and completed suicides, veterans with co-occurring PTSD and depression represent a vulnerable group that might need more intensive monitoring and treatment in order to reduce suicide risk.
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with the risk of opioid overdose death among patients with cancer, chronic pain, acute pain, and SUDs. The authors examined 19 Laurence Meyer's statement to the Senate Committee on Appropriations Subcommittee on Military Construction, Veterans Affairs, and Related Agencies, November 15, 2017.
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who used medical services in 2004 or 2005 and received opioid pain therapy. That analysis demonstrated that, among patients receiving opioid pain medication, higher doses of opioids were associated with an increased risk of opioid overdose deaths.
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(2019) conducted a nested case-control study designed to evaluate the association between dual-system opioid prescribing and death from prescription opioid overdose.
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and 117 control patients (14 percent) had received dual opioid prescriptions and that dual users had significantly higher odds of death from prescription opioid overdose than those who received opioids from the VA only or Part D only.
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The implementation of the OSI included the provision of a clinical "dashboard," based on the electronic health record data, that is used to identify patients who might be high risk for adverse outcomes with opioid use and identify providers whose prescribing practices might not reflect the best evidence for improving patient care. The OSI includes specific indicators, such as the number of unique pharmacy patients dispensed an opioid and the unique patients on long-term opioid therapy.
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APPROACH TO THE TASK AND ORGANIZATION OF THE REPORT The National Academies appointed an eight-person committee with expertise in pharmacoepidemiology, RCTs, pain management, addiction, and psychiatry to address the task. The committee held three in-person BOX 1-1 Statement of Task An ad hoc committee under the auspices of the National Academies of Sciences, Engineering, and Medicine will develop a protocol/study design to evaluate the relationship between concomitant opioid and ben zodiazepine medication practices at the Department of Veterans Affairs, for treating mental health and combat-related trauma, which potentially led to veterans' deaths and suicides.
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In Chapter 2 the committee describes protocols for target trials for opioid initiation and tapering to respond to the charge. In Chapter 3 the committee proposes strategies and analytic plans for implementing observational studies to emulate the target trials using existing VA data.
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2011. Association between opioid prescribing patterns and opioid overdose-related deaths.
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2018a. Drugs most frequently involved in drug overdose deaths: United States, 2011–2016.
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2015. Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: Case-cohort study.
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2018. Correlates of benzodiazepine use and adverse outcomes among patients with chronic pain prescribed long-term opioid therapy.
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