Some people have known for decades that benzodiazepines and opioids are a potentially deadly combination of drugs.
A 2012 article from the Journal Drug and Alcohol Dependence called “Polydrug abuse: A review of opioid and benzodiazepine combination use,” cites research dating back to the 1980s, which found that together they caused breathing problems, and clinical studies dating back to 1996 that linked them to overdoses.
There have been recommendations against prescribing them together since before 2009, according to Dr. Tom Evans, the director of the Atlantic Pain Clinic in Moncton.
Yet, about 40 per cent of the patients who end up there are still taking the dangerous cocktail — often without realizing the risks.
“I suppose I’m kind of jaded by now,” said Evans. “I mean, it’s just more of the same … the surprising thing is, week after week, this comes as news to patients. ‘Why was I prescribed this? I didn’t know.'”
In 50 of 82 opioid-related deaths in New Brunswick in the last three years, the deceased also had benzodiazepines in their system, according to figures from the Department of Justice and Public Safety.
Evans said he’s not sure why the two types of drug are so often prescribed together, but said it could be due to anything from a lack of training in pharmacology to overly busy physicians who find it a challenge to keep track of prescriptions.
New Brunswick does have a prescription monitoring program. However, that system is designed to pick up on “double-doctoring” by patients who are getting controlled substances from multiple physicians. It doesn’t detect “bad prescribing,” Evans said.
If a pharmacist happens to notice combined benzodiazepine and opioid prescriptions and tries to intervene, it doesn’t always go well.
“There’s still a hierarchy. It’s not collaborative practice out there … There’s a very defensive reaction. It’s, ‘I know what I’m doing. It’s my patient. I know them better than you.’ … After a few of those phone calls, they just stop making them. … They just dispense.”
To top it off, Evans said the available information is hard to decipher.
“We ask for a complete pharmacy list on everyone who comes in to see us. I can’t make sense of many of them. I have to have pharmacists go through them line by line. So, if I’m having a hard time to see it quickly from a comprehensive list, I’m wondering what pharmacists see on their screen and if they’re able to keep track of these folks.”
One solution Evans proposed in order to cut down on the dangerous combination is to require special certification for any doctor who wishes to prescribe opioids.
“That’s a good point,” said Dr. Ed Schollenberg, registrar of the New Brunswick College of Physicians and Surgeons.
However, Schollenberg cautioned that cutting down on the number of prescribing physicians would have a “significant impact” on the province’s long-term opioid users, many of whom are already addicted.
To quit, he said their options are limited to either going cold turkey or trying a therapy such as methadone.
But few patients want methadone, and access is limited because few doctors want to prescribe it.
“Until we have greater access to alternatives like methadone and other drugs, I think we have to be very, very cautious about cutting people off,” he said.
“It’s hoped that eventually this alternative will be better available and maybe down the road there will be some process which puts restrictions on the ability of physicians to prescribe narcotics.”
The college published guidelines a couple of years ago that call for extreme caution in prescribing opioids and recommend against prescribing them in combination with benzodiazepines, but Schollenberg admits that message hasn’t gotten through to everyone.
“When they are prescribing narcotics … they are in essence handling plutonium and they should do it as carefully as possible.”
He recommends a similar level of caution in prescribing benzodiazepines, which may not have the severe withdrawal effects of opioids, but can still result in strong dependencies.
“I’ve spoken to physicians who tried to cut patients back and just had huge fights.”
But the executive director of the New Brunswick Pharmacists’ Association said there’s good reason to keep making the effort.
“A study in Quebec … indicates that if a prescriber mentions to the patient that they should stop taking benzodiazepines … 71 per cent of them will do it,” said Paul Blanchard.
However, Blanchard agreed with Evans that doctors aren’t always receptive to pharmacists who question their prescribing.
Pharmacists are allowed to “adapt” most prescriptions if they feel the dosage is too high, but that’s not the case for narcotics and other federally regulated drugs such as benzodiazepines, he said.
“They do have to call the physician and say, ‘Look, are you sure you want to prescribe this much?'” he said. “So, yeah, that can lead to some confrontation. … Physicians will have their reasons for prescribing.”
There’s also a chance that some combination prescriptions are simply going unnoticed because of the shortcomings of the prescription monitoring program.
“It’s sort of working, but it’s not generating the information we need,” said Schollenberg.
Users are able to log into the external government website to seek out a patient’s full profile, but the system doesn’t issue automatic red flags.
And they have to manually look for drug interactions.
“That just takes too much time,” said Blanchard.
The pharmacists’ association is asking the province to implement a system similar to Nova Scotia’s, where a pharmacist at any given store can see a patient’s complete drug profile and potential adverse reactions.
“We’re working with the province to try to upgrade or improve the prescription monitoring program, but we’re not quite there yet,” he said.
Schollenberg said the next issue will be what to do with the information once they get it.
“The response and what you want to happen has to be a lot clearer and we just really don’t have that set up well,” he said.
“Obviously there’s other things we could be doing, but those resources are limited. Could they be seeing a psychologist? Yes, but then they’ll have to pay for it. And on and on it goes.”