Impact of Medicare's expanded benzodiazepine coverage

Xanax (Alprazolam), Ativan (Lorazepam), Valium (Diazepam), Klonopin (Clonazepam). These medications belong to a class of sedatives called benzodiazepines, which can help allow physicians to safely help a patient withdraw from alcohol by preventing fatal seizures. They can calm a patient who is in danger of hurting themselves or others. They can soothe a person dealing with a tragic life event.

But they can also result in dependence, dangerous falls in the elderly, and death in those who abuse benzodiazepines alongside other medications such as opioids.

Like any medication, benzodiazepines should be used with caution. However, the tremendous expenditure for these medications-just a year after Medicare Part D extended its coverage to include them in 2012-has some wondering why so many of these drugs are being prescribed. In 2013, almost 40 million prescriptions totaling more than $300 million were paid for and ranked among the most-prescribed medications that year.

Although the Centers for Medicare and Medicaid Services (CMS) says it can’t provide information as to whether those were new prescriptions or just newly covered under the change to the Medicare Part D policy, experts believe the move to cover these medications had little impact on prescribing practices.

OlfsonBenzodiazepines are psychoactive medications that were first introduced with the discovery of chlordiazepoxide (Librium) in the 1950s and 1960s. These medications have sedative effects. They are technically contraindicated in the elderly because the benefits are not believed to outweigh the risks-which include sedation, cognitive impairment, impaired motor function that could lead to falls, and dependence. However, many older adults are still prescribed benzodiazepines, particularly for problems with sleep cycles, says Mark Olfson, MD, MPH, professor of clinical psychiatry at the Columbia University Medical Center in New York.

Risks of benzodiazepine use are increased even further-not just in the elderly but in all populations-when benzodiazepines are mixed with other medications, particularly opioids. Patients with chronic pain may be prescribed opioid painkillers for their pain and benzodiazepines for other symptoms. When taken together, the effects can be fatal because of the respiratory depression the medications can cause. The prevalence of such events has led several organizations to ask FDA to add “black box” warnings to these medications to increase awareness of the risks associated with taking the two together.

Next: Troubling statistics

Troubling statistics

Olfson, who coauthored a paper on benzodiazepine prescribing practices in 2012, says patterns of benzodiazepine use began to change even before the medication was covered by Medicare Part D.

He adds that his research, conducted before the change in Medicare coverage, revealed that benzodiazepine use increases with age, particularly among women.“I think it’s more of a problem of over-prescribing among older adults that has been going on for a number of years,” Olfson says. “As a general clinical principle, these medications should be used sparingly in older adults, and for a short period of time.”

SchoenbaumMichael Schoenbaum, PhD, senior advisor for mental health services, epidemiology, and economics for the division of services and intervention research at the National Institute of Mental Health, coauthored the report with Olfson and says one in 10 women over aged 65 years received a prescription for a benzodiazepine during the year the research was conducted. Another concerning point, he says, is that most of the people who were prescribed benzodiazepines received prescriptions for 120 pills or more, despite recommendations for short-term use.

“We expressed concern in that paper that the fraction of women in particular receiving benzodiazepines seemed quite high compared to what one might expect to be clinically indicated,” Schoenbaum says. “These medications are not without risks.”

Michael Ong, MD, PhD, an associate professor in residence at the University of California Los Angeles (UCLA), says that he doesn’t believe the move to cover benzodiazepines under Medicare Part D had a big impact on prescribing practices, either.

“In research we conducted, we found that when Medicare stopped covering benzodiazepines, benzodiazepine prescriptions were reduced by only 25% and were still being provided despite lack of insurance coverage,” Ong says. “As a result, many prescriptions were likely continuing prescriptions that were not previously identified.”

Next: Addressing the problem

Addressing the problem

Some groups have proposed tracking benzodiazepine use in a manner similar to opioids, with a prescription drug monitoring system. Olfson says it’s a big and costly step but it’s something worth studying, even though the problems with benzodiazepines seem to be related to dependence and side effects, rather than doctor shopping and drug diversion.

The draw of benzodiazepines to treat problems such as anxiety is that they work quickly, without the need to buildup in a patient’s system like antidepressants. The quick, effective action of benzodiazepines, however, is a double-edged sword.

“Benzodiazepines are habituating and if someone takes them for more than a matter of days or perhaps a few weeks, the purpose of taking those medication is no longer because they are therapeutic, but because they are habituated and if they stop, they would have problems,” Schoenbaum says. “The problems people experience when they stop look like the reason they took it in the first place, but it’s not anxiety anymore. It’s withdrawal.”

Patients find these medications beneficial, and they also help with certain symptoms and with easing secondary health issues-such as sleep disturbances.

“Just as people’s vision erodes as they age, so does the quality of their sleep,” Olfson says. “Sometimes these mediations are prescribed with the unrealistic expectation that you can restore those sleep patterns in older adults.”

Physicians should examine behavioral alternatives or other medications before or instead of prescribing benzodiazepines, but there may be other issues complicating treatment.

“Doctors are stressed and they’ve got a lot of competing demands,” Olfson says, adding that when a patient has a host of other health problems the physicians is treating, sleep and sleep hygiene is usually the least of their concerns.

Other issues complicating treatment in the elderly in particular may be the use of benzodiazepines in some facilities as a chemical restraint, especially when staffing levels are low. There also is a stigma among elderly patients about seeing a mental health professional, Olfson says.

“It would be helpful to have a consultation, even if it’s only doctor-to-doctor, about the usage when used long-term, because mental health professionals are well-versed (in benzodiazepine use) and can consult on long-term use and surveillance,” Olfson says.

Plus, it wouldn’t hurt to have some sort of monitoring in the use of benzodiazepines, he says.  “What started as something to help them get through a rough patch often goes on for days or months,” Olfson says. “These medications just continue and therein lies some of the risks.”

Even when a physician does try to discontinue benzodiazepines, there is usually a lot of resistance from patients. “It’s very hard to take these medications away from people,” Olfson says. “People become dependent on them and it’s much easier if there’s other things going on to just let it slide.”

Next: More oversight needed

More oversight needed

Some health plans require attestation that medications such as benzodiazepines are still needed after a certain period of time, but not all, Olfson says.

Payers could help police use by programming audits to investigate the clinical justifications for benzodiazepine prescriptions, Olfson says.

Use should not be completely restricted in seniors, or in any population, but a bit more oversight may be helpful, he adds. “Most of these drugs aren’t being prescribed by psychiatrists. They’re being prescribed by internists and primary care physicians.”

Raising prices or reducing coverage isn’t the answer, Olfson says. “I think that essentially trying to ration these drugs by increasing their cost is a rather blunt way of controlling their use,” he says. When coverage is dropped or prices rise, typically it doesn’t help mitigate abuse or misuse, but it does have a negative impact on those who need the medication for valid, clinical reasons, Olfson explains.

Ong agrees that benzodiazepines should not be broadly limited-in spite of the risks. “The decision on medications should be based upon the needs of the patient rather than a universal restriction,” Ong says. “These medications do have benefits, as well. While guidelines do point out that other medications should be offered first, there may be patient-related reasons that may result in what would be considered the first option not being the best choice for a particular patient.”

Next: Prescription concerns

Rachael Zimlich is a writerin Columbia Station, Ohio.