Deadly mix: Opioid crisis fueled by ‘benzos’

Daily Hampshire Gazette - 1/1/2018

Editor’s note: This is Part 1 of a four-part series on the role of sedatives known as benzodiazepines in the nation’s opioid crisis.

By M.J. TIDWELL For the Gazette

Officials report an average of an overdose a week in Northampton. The media are saturated with coverage of the familial and community wreckage left in its wake.

The opioid crisis has been devastating not only in Massachusetts but across the nation.

And the people who have dedicated their lives to fighting this epidemic say part of the problem might be that the war is not being fought on all fronts.

“The ‘opioid problem’ is not just an opioid problem,” said Cherry Sullivan, coordinator for the Hampshire HOPE opioid prevention program. “It’s in general a challenge we are facing with multiple drugs in our community.”

While there is general awareness that dangerous drug interactions among opioids, alcohol and illegal drugs such as cocaine could result in a fatal overdose, another prescription drug fueling and abetting the opioid epidemic remains overlooked: benzodiazepines.

“In this area we’ve been blessed with the media bringing a lot of attention to the opioid crisis here,” Sullivan said, “but it’s more complicated than just opioids.”

Benzodiazepines are a class of sedatives prescribed for anxiety and insomnia that include household names like Xanax, Valium and Klonopin.

Commonly known as benzos, these drugs were involved in 30 percent of overdoses between 1996 and 2013 nationwide, according to a 2016 study by the American Journal of Public Health. The study also found that benzo prescriptions have increased by 30 percent over that time period.

The use of benzos has risen across different layers of society, mirroring the growth of opioid use, according to a Department of Public Health assessment of opioid-related overdoses in Massachusetts from 2011 to 2015.

“What is especially notable is the epidemic’s rapid and insidious geographic spread throughout the Commonwealth,” the report states. “Almost every community is affected.”

The study found that no matter what type of opioid caused the overdose, benzos were present in over half the cases.

Nationally, the U.S. Food and Drug Administration (FDA) has reported that the number of opioid prescriptions increased by 8 percent between 2002 and 2014, and benzodiazepine prescriptions rose by 31 percent during that same period. Furthermore, according to the FDA, 2.5 million more people were prescribed both an opioid and a benzo in 2014 than in 2002.

In the same period, the number of opioid overdose deaths that included a benzodiazepine went from 18 percent to 31 percent nationwide, according to the FDA study.

“It’s the combination of benzos and opioids that are killing people,” said Liz Whynott, director of Northampton’s Tapestry Health needle exchange program. A deadly mixture

A Stanford School of Medicine study released this year on the interaction of benzodiazepines and opioids found that although benzos have received less public safety attention than opioids, the combination of the two drugs is especially dangerous.

The study found that because both drugs act on the central nervous system, mixing the two can slow or even shut down heart and lung function.

The FDA noted this in 2016, when it began requiring a “boxed warning,” its strongest warning label, on 389 different products containing benzos to inform consumers about the risks of mixing opioids and benzodiazepines.

Mixing the two also limits the effectiveness of a drug used to bring overdose victims back from the brink of death.

“If you’ve taken a benzo, the Narcan is not going to solve it,” said Lynn Ferro, the director for opioid research and recovery support services in the Northwestern district attorney’s office. “You will die if you don’t get to the hospital.”

Narcan, the brand name for naloxone, is now commonly carried by police officers, first responders and anyone who might come in contact with an overdose victim. Once administered, Narcan removes opioids from the receptors in the brain that repress breathing, reversing the overdose.

In cases where someone has mixed benzodiazepines with opioids or still had benzos in their system, the Narcan will only remove the effect of the opioid, which may not be enough to fully bring the person out of overdose to start breathing again.

Northampton Police Chief Jody Kasper said the number of doses officers use to reverse overdoses has increased over the last few years.

“We give Narcan. If there’s not a desired response, essentially waking up, we give more. If there’s not a desired response, we give more,” she said. “We don’t always know what everybody’s on and people don’t always know what they’re on and that’s part of the problem.”

Whynott, of Tapestry Health, said some benzodiazepines can remain active in a person’s system for as long as 24 hours.

“We need to educate people that when they overdose, it’s not just what they took in the moment, it can be the buildup of other drugs,” she said.

Xanax, for example, can remain in a healthy adult’s system between 6.3 and 26.2 hours, according to the FDA.

Whynott said she always discusses the dangers of multiple drug overdose when giving demonstrations on the use of Narcan or distributing clean needles to users, an intervention allowed by state law since 2007 to reduce the spread of AIDS and other needle-borne diseases.

“Of course, we’d prefer that people don’t use opioids and benzos together, but in reality they will,” she said. “Benzos are known and seen as a hard-core risk factor in opioid overdoses.”

Others offer a harsher message about the dangers of benzos and opioids. Richard Lewis, a licensed mental health counselor and addiction specialist in New Bedford, refuses to label the overdose body count as an opioid crisis.

“It’s a misnomer. It leads people away from finding a solution to the problem,” he said. “I would make the argument that in that deadly cocktail (of) benzos and opioids, benzos are actually the decisive component that kills people.”

Lewis is an active writer and blogger about the dangers of long-term use of benzodiazepines on their own, but his work has exposed him to the role of benzos in the opioid crisis as well.

Most opioid users “know their dosing,” he said. What they don’t know, is how that dosing can be affected by the addition of benzos, which Lewis said he’s seen many people use to cope with withdrawal symptoms or to enhance the high of weaker opioids.

“Every person who is opioid-dependent and taking benzos is playing with these odds where one day the perfect storm occurs,” he said.

The danger of mixing benzos doesn’t just apply to addicts or people using heroin.

The recently released annual Massachusetts Chapter 55 Report, a federally required report on overdose deaths in the state, showed benzos are present in 62 percent of deaths that involved a prescription opioid such as OxyContin or Percocet.

Lewis said he’s seen people start out using prescription opioids then move on to other substitutes when they are no longer able to obtain the pills from a doctor. When lesser synthetic opioids are the only drugs available, sometimes benzos may be used to enhance the high, he said.

The Chapter 55 Report shows that benzos were present 69 percent of the time when an overdose occurred with methadone.

Whynott said active users face another danger — heroin cut with benzos as a cheap way to enhance the high. In that case, a person would have no idea they were at risk of overdosing until it was too late. Growing in the shadows

For those working to stem the tide of the opioid epidemic every day, the dangerous interaction between benzos and opioids has been a well-known factor since prescriptions for the two drugs rose sharply in the early 2000s.

The increase in legal prescriptions may be traced back to 2001 when the independent nonprofit Joint Commission that accredits health care organizations and programs in the U.S. released its pain standards report.

The 2001 report is widely regarded as the point where pain became a fifth vital sign.

A patient who sees a physician is measured on four vital signs: body temperature, pulse rate, rate of breathing, and blood pressure. All of these can be measured objectively using a thermometer or blood pressure monitor. Pain, on the other hand, is measured by asking the patient to rate their level of pain on a scale showing a series of faces morphing from smiles to extreme frowns.

Lewis, the New Bedford therapist, is among those who point to the Joint Commission’s 2001 recognition of pain as a fifth vital sign as contributing to the opioid crisis.

The original 2001 report states that “Patients have the right to assessment and management of pain” and that “All patients are assessed for pain.”

But a 2016 letter from David W. Baker, the commission’s executive vice president, prominently displayed on the Joint Commission’s homepage, says this has been widely misinterpreted.

Baker wrote that pain experts had been calling for pain to be “made visible” since the 1990s and the commission’s 2001 report simply reflected what some health care organizations and programs were doing to make pain more visible, treating it like a fifth vital sign.

“The Joint Commission does not endorse pain as a vital sign, and this is not part of our standards,” Baker wrote.

But there are those who believe the system of assessing and treating pain did lead to an increase in opioid prescriptions after 2001, as well as a proliferation of pain clinics whose main purpose was to prescribe opioids and benzos.

Lewis said the 2001 report normalized the process of assessing pain, then prescribing medication to treat the pain. This, he said, led to an increase in opioid prescriptions and benzodiazepine prescriptions, too, because benzos can be used to ward off what may be considered pain-causing symptoms, such as anxiety, sleeplessness or panic attacks and seizures.

And it’s been the overprescribing of those drugs, Lewis said, along with polydrug use, that has resulted in the overdose epidemic seen today.

In 2000, the state Department of Public Health reported 338 opioid-related deaths in Massachusetts. In 2015, that number was 1,379.

According to the American Public Health Association report that found that both benzodiazepine prescriptions and overdoses increased by 30 percent between 1996 and 2013, the prescribed dosage of benzos per person doubled in that same period. That means more people were prescribed benzos, and prescribed more of them.

“Benzodiazepine prescriptions and overdose mortality have increased considerably,” the report concluded. “Interventions to reduce the use of benzodiazepines or improve their safety are needed.”

Coming Tuesday: A doctor recounts how easily she became addicted to a benzodiazepine and how hard it is to stop.

M.J. Tidwell writes for the Gazette from the Boston University Statehouse Program.