Tag Archives: diazepam

Benzodiazepine Prescribing Soars, Prompting Concerns

The number of prescriptions for benzodiazepines, a class of tranquilizing drugs, has increased dramatically, and benzodiazepine-related overdose deaths have increased as well. The drugs can also raise the risks of falls, fractures and cognitive impairment, especially in seniors.

Researchers looked at data on more than 386,000 doctor visits from 2003 through 2015. Over that period, the rate of benzodiazepine prescribing increased from 3.8% of doctor visits to 7.4% of them. Common benzodizepines as Valium (diazepam), Xanax (alprazolam) and Klonopin (clonazepam).

While the prescribing rate among psychiatrists remained stable at about 30% of visits, the rate among primary care doctors rose from 3.6% to 7.5% of visits, according to results published in JAMA Network Open. Primary care physicians accounted for about half of benzodiazepine visits.

One concern with benzodiazepines is that they can interact with other drugs, which can increase their effect, leading to oversedation. On the other hand, interaction can lead to lower benzodiazepine concentration in the bloodstream, potentially leading to withdrawal symptoms.

The researchers also say that benzodiazepine-related overdose deaths have significantly increased, from 0.6 per 100,000 adults in 1999 to 4.4 in 2016.

“Surprisingly few guidelines exist for a medication that is prescribed by so many different types of physicians and for so many different indications,” the authors conclude. “In light of increasing death rates related to benzodiazepine overdose, addressing prescribing patterns may help curb the growing use of benzodiazepines.”

MedShadow’s Top 10 Stories of 2018

What were the most popular stories we published in 2018? Our Top 10 includes two stories on drugs that have become popular among opioid abusers, as well as articles dealing with drug interactions, a controversial class of antibiotics and a first-person story on an herbal supplement that has come under attack from the FDA, among others. Here are excerpts of the stories with the highest readership.

1. Gabapentin’s Secret: The Drug Opioid Abuser’s Crave

By Ronni Gordon

For many people who take gabapentin – a drug prescribed to treat seizures and pain caused by shingles – side effects such as sedation can be a challenge, as those who take it off-label for neuropathic pain told MedShadow in the past.

But an increasing number of opioid abusers crave that side effect, reporting a calm feeling when combining gabapentin – developed by Pfizer under the brand name Neurontin – with opioids, muscle relaxants and anxiety medications. Some also get a marijuana-like high and an enhanced euphoria. But when overused or abused, it can cause significant organ or brain damage. Read more →

2. Managing Eczema: Are New Treatments Like Eucrisa Worth It?

By Madeline Vann

Eczema (atopic dermatitis) can feel like a moving target for people who live with it. They get control over one flare, only to have eczema redden and irritate another patch of skin. For some patients, changing their bathing and beauty habits along with a thick moisturizer and topical corticosteroid ointments are enough.

“Steroids are the mainstay of treating atopic dermatitis. They’ve been around for decades. They are generally inexpensive, and for the vast majority of patients, that’s how we start treatment,” explains dermatologist Amy Paller, MD, director of the Northwestern University Skin Disease Research Center in Chicago. American Academy of Dermatology (AAD) guidelines recommend using emollient moisturizers, lifestyle changes to avoid triggers, and corticosteroids at first. Read more →

3. How Imodium Became Appealing to Opioid Addicts

By Padma Nagappan

A sports injury from playing squash in high school lead to a herniated disc for Bob Johnson (name changed to protect his privacy), who was initially given codeine for his pain, and then bumped up to hydrocodone, which is more powerful and used to treat severe pain.

He stopped taking the drugs once he began recovering. All was well until he left for college in Philadelphia and started playing on the squash team — and his back began hurting again. He found it was easy to get access to drugs and began buying OxyContin (oxycodone) from a dealer. Read more → 

4. What is the Best Way to Treat Heat Rash?

By Dave Walker, RPh

Question: It’s summer and I’m going to be spending a lot of times outdoors. I’m susceptible to heat rash. What is the best treatment for it?

I remember anticipating summer vacation as a kid. We were always busy planning and participating in neighborhood sporting activities, biking, hiking, fishing and camping trips. The neighborhood moms always had a ready supply of Band-Aids, Bactine and antiseptic cream to take care of those expected and inevitable scratches, scrapes, cuts and insect bites along the way. Read more →

5. 4 Drugs That Interact with Anxiety Meds

By Christy Huff, MD

If you suffer from anxiety, panic disorder or insomnia, your doctor may have prescribed you a tranquilizer belonging to a class of drugs known as benzodiazepines.

Drugs such as Xanax (alprazolam), Valium (diazepam), Ativan (lorazepam), and Klonopin (clonazepam) are some of the most-prescribed medicines – more than 133.4 million such prescriptions were filled in the US in 2014. As with any medication, drug interactions can occur if you take a benzo with another medication, and in certain cases, may be life-threatening. Read more → 

6. Why Aren’t Seniors Getting the Shingles Vaccine?

By Rita Colorito

Nearly 12 years after the FDA approved Zostavax, the first vaccine to prevent shingles in adults 60 and older, the vast majority of seniors still haven’t received it. Only 30.6% of adults age 60 and older reported getting the shingles vaccine, according to the latest CDC (Centers for Disease Control and Prevention) assessment of vaccine coverage.

Since it became available, Zostavax has faced numerous barriers in terms of getting seniors vaccinated, the assessment found. In October, the FDA approved a new shingles vaccine, Shingrix, for people age 50 and older. Less than a week later, the CDC’s Advisory Committee on Immunization Practices (ACIP) recommended Shingrix as the CDC’s preferred shingles vaccine for adults age 50 plus due to Shingrix’s better efficacy and fewer side effects compared to Zostavax. Read more → 

7. Floxed! The Painful, Life-Lasting Effects of Some Antibiotics

By Suzanne B. Robotti

Last week, we ran a news story on antibiotics causing “rare” damages to people. We had a very passionate response from more than 75 people who all claimed to be harmed by a particular type of antibiotics. More than 60,000 people have complained to the FDA about them. It begs the question, how unusual are these “rare” harms.

The side effects and adverse events associated with Cipro, Levaquin and other fluoroquinolones (FQs) can be significant and life altering. Yet many people who have been damaged by fluoroquinolones complain that there are too few warnings. Many claim that doctors don’t believe that their new illnesses have come from the FQs. Worse, sometimes FQs are prescribed when other, less risky — and just as effective — antibiotics are available. Read more →

8. The FDA Has It Wrong on Kratom: How the Herb is Helping People Like Me

By Andrew Turner

Some may ask who are the consumers of kratom, an herb used to treat pain, depression and anxiety that has been the subject of controversy lately in the news. It’s complicated.

We can be anyone. We are your neighbor, the veteran in the supermarket, your college professor and even your best friend. There’s a lot of misconceptions about kratom, how it’s used to treat certain ailments and its potential for addiction. Read more →

9. Can An Opioid Addiction Drug Treat Autoimmune Disorders

By Deborah Lynn Blumberg

A slew of drugs, both new and old, are used to treat autoimmune disorders like multiple sclerosis (MS), lupus and Crohn’s disease. Most of them come with side effects, some of them serious. But research and experience from patients and doctors are mounting that a drug used to treat substance abuse, when used in lower doses, can effectively treat autoimmune conditions with few side effects.

The drug is naltrexone, which was first approved in the 1980s to treat heroin addiction. In recent years, it has been prescribed more and more at a low dose for patients with autoimmune disorders. But is this off-label use (yet to be approved by the FDA) safe and effective? Read more →

10. Pros and Cons: Prednisone

By Tori Rodriguez

If you visit the doctor from time to time for anything other than a routine checkup, it’s likely that at some point you’ve received a prescription for a type of drug called corticosteroids. These are among the most commonly prescribed medications in the US, and they are used in almost every medical specialty.

In a study published last year, researchers at the University of Michigan found that 1 in 5 American adults with commercial health insurance had been prescribed a corticosteroid at least once over a 3-year period. Read more →

Seniors That Take Multiple Meds Have Higher Car Crash Risk

While it’s no surprise that many older adults take a lot of different medications, many of those drugs can potentially increase their risk of getting into an automobile accident.

A new report from the AAA Foundation for Traffic Safety found that nearly 50% of active senior drivers used seven or more medications. An analysis of 3,000 older drivers that also monitored the drugs they were taking found that about 20% of the meds should be avoided because of limited therapeutic benefit and/or potential to cause excess harm. These drugs are on a list known as the Beers Criteria.

These inappropriate drugs include benzodiazepines such as Xanax (alprazolam) and Valium (diazepam), as well as first-generation antihistamines. These medications can cause blurred vision and confusion and can impact coordination, increasing a driver’s crash risk by as much as 300%, according to AAA.

Some of the most commonly prescribed medications in this age group can affect driving ability. For example, 73% of respondents said they took a heart medication, and 70% said they took a central nervous system drug, such as a pain medication, stimulant or anti-anxiety drug.

The AAA Foundation said prior research found that less than 18% of senior drivers say they received a warning from their doctor that their medication could impact their driving ability.

Benzo, Opioid Combination in Alzheimer’s Patients Potentially Dangerous

About 20% of people with Alzheimer’s disease (AD) take both a prescription opioid and tranquilizer medication together, and that’s problematic as it can lead to serious risks.

Researchers say that AD patients who took a benzodiazepine, such as Xanax (alprazolam), Valium (diazepam) and Ativan (lorazepam), along with an opioid had a higher incidence of lung disease, osteoporosis and hip fracture in the past. They added that using benzodiazepines, which are often prescribed to seniors as sleep aids, while also taking an opioid can boost the risk for pneumonia, fractures and drug misuse.

Researchers based their findings, published in the International Journal of Geriatric Psychiatry, on data on more than 70,000 diagnosed with AD in Finland.

Both benzodiazepines and opioids are on the Beers Criteria, a list of drugs that are potentially inappropriate for seniors because their risks may outweigh their benefits.

“Concomitant use of drugs that act on the central nervous system in an older population is concerning, as the use of these drugs has been associated with serious risks, especially in frail individuals with AD,” lead author Niina Karttunen, University of Eastern Finland, said in a statement. “Unnecessary co-use of these drugs should be avoided, as the benefits rarely outweigh the risks.”

Drinking and Drugs: How Alcohol Can Mess With Your Meds

Alcohol has strong associations with fun and relaxation, but it’s just another drug as far as your body is concerned. Beer, wine or hard liquor, combined with other drugs, can create dangerous, even life-threatening, interactions that include internal bleeding, heart problems and difficulty breathing.

This is true with prescriptions drugs, over-the-counter drugs and even herbal remedies like St. John’s wort or kava. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) lists more than 100 common drugs that, if taken with alcohol, can result in adverse events, ranging from drowsiness and upset stomach to liver damage and death.

That relaxing glass of wine contains ethanol (ethyl alcohol), a psychoactive chemical that depresses the central nervous system and can interfere with sensory input, what we see and hear, emotions, inhibitions and movement.

Alcohol Slows Body Down

“Pharmacologically, alcohol is a sedative hypnotic — it slows you down,” says NIAAA Director George Koob, PhD.

Mixing alcohol and drugs can produce two types of reactions. In a pharmacodynamic reaction, alcohol intensifies the effect of the drug, or vice versa. With a pharmacokinetic reaction, the drug-alcohol interaction can affect how a drug or alcohol moves through the body.

First, a look at pharmacodynamic reactions: Taken with another sedative hypnotic — such as an opioid, barbiturates like Amytal, or tranquilizers like Valium — alcohol interacts in a “synergistic” way. That is, the total effect is greater than the sum of the individual effects of each drug.

“In this case, two plus two equals five,” says Koob.

With a drug like Valium, which can inhibit respiratory function, the synergistic effect can be fatal. One tragic case that made headlines involved Karen Ann Quinlan, who in 1975, while taking Valium (diazepam), drank alcohol at a party and later, at home in bed, stopped breathing long enough to suffer extensive brain damage. Her parents went to court to gain permission to take her off a respirator and allow her to die, but Quinlan lived in a vegetative state for an additional nine years.

Alcohol and Opioids: A Potentially Deadly Combination

“With a lot of drugs, these interactions can be lethal. That’s certainly true for the opioids,” Koob says. Conservatively, about 15% of deaths involving opioids today are actually alcohol-drug interactions, he says.

Mark Rosenberg, DO, Chair of Emergency Medicine at St. Joseph’s Healthcare System in Paterson, NJ, says patients with alcohol-opioid interactions in the ER are commonplace. “We see it every night. Opioids cause respiratory depression, which alcohol accentuates. The combined effect is what causes the death.”

Here are five drug and drug classes you should especially avoid mixing with alcohol:

  • Opioids [codeine, Oxycontin (oxycodone), fentanyl, etc.]. An estimated 15% of opioid deaths are actually the result of interactions between one of these potent drugs and alcohol.
  • Benzodiazepines [Valium (diazepam), Ativan (lorazepam) and Xanax (alprazolam)]. Taken with alcohol, they can depress respiratory function enough to cause death.
  • Tylenol (acetaminophen). This popular over-the-counter pain reliever, in concert with alcohol, can severely damage the liver.
  • Monoamine oxidase inhibitors (MAOIs). These drugs, which include Parnate (tranylcypromine) and Nardil (phenelzine), are used to treat depression. An MAOI-interaction with beer or red wine can raise blood pressure to dangerously high levels.
  • Sulfonylureas [Amaryl (glimepiride), Glucotrol (glipizide)]. This class of type 2 diabetes drugs can result in an acute reaction when taken with alcohol — flushing, nausea, vomiting, headache, rapid heartbeat, sudden changes in blood pressure and blood sugar levels.

With some drugs, a person will get much more intoxicated than on alcohol alone. That’s often because of a pharmacodynamic reaction, because also many medications contain alcohol too (especially many cold and cough syrups).  An individual who ordinarily takes the antihistamine Benadryl (diphenhydramine) without experiencing its common side effect of drowsiness may find it difficult to fight off sleep if they takes the allergy medicine while drinking alcohol.

These interactions can lead to people unwittingly engaging in risky behavior, like driving when they are in no shape to do so. Or, an interaction can simply “push the effect of the drug into the toxic range,” Rosenberg says.

Koob says those drugs that act on brain function are the most likely to interact in dangerous ways with alcohol, but quite a few other common drug types have risks, too. Tylenol (acetaminophen) and alcohol in tandem can be toxic to the liver, for example.

An example of a pharmacokinetic interaction is the “flushing” that can occur when some people take even a little alcohol with Diabinese (chlorpropamide), a sulfonylurea drug for type 2 diabetes, or some antibiotics, including Flagyl (metronidazole). This reaction is associated with potentially dangerous dilation of blood vessels, low blood pressure and rapid heartbeat.

Taking Multiple Meds and Alcohol

Those taking more than one drug have to be even more careful about taking a drink. “The more drugs you take, the higher your risk of an interaction,” says Rosenberg.

And some interactions can take place days after ingesting a long-lasting drug.

It’s wise to approach alcohol, even on its own, with a great deal of respect. Excessive alcohol consumption is the third-highest preventable cause of death (behind smoking and obesity) in our society, killing an estimated 88,000 Americans every year. The amount drunk, the period of time during which the drinking occurs, whether food is consumed with it, individual genetics, and an individual’s health and overall nutrition influence the effects of alcohol.

Other variables are important too:

  • Alcohol affects women more than men because women’s bodies tend to have less water than men’s. “There’s less water volume for the alcohol you take in to distribute itself over. It’s more concentrated,” Koob says.
  • Older people feel the effects of alcohol more, too. Their bodies metabolize alcohol more slowly, so not only are they likelier to feel the effect, but ethanol will stay in their systems longer. They’re also more likely to take more than one medication, which raises the risk of an interaction with alcohol, and to be injured if they fall during an intoxicated episode.

Many Older Patients End Up Using Benzodiazepines Long Term

Although tranquilizer drugs known as benzodiazepines are only meant for short-term use, about one-third of older adults who get a prescription for them end up continuing on them for the long term.

Researchers interviewed 576 older adults that were newly prescribed a benzodiazepine. Common benzodiazepines are Valium (diazepam), Xanax (alprazolam) and Klonopin (clonazepam). Participants were also asked questions relating to depression, anxiety, sleep quality and pain.

Results, published in JAMA Internal Medicine, found that experiencing poor sleep quality was most associated with long-term benzodiazepine use. Also, white patients and those patients prescribed pills for a longer number of days at the outset were more likely to end up using benzodiazepines for the long term.

Researchers also noted that long-term benzodiazepine patients were prescribed, on average, 8 months’ worth of the medication. Benzodiazepines are found on the Beers Criteria, a list compiled by the American Geriatrics Association of medications that are potentially inappropriate for seniors. The group says that benzodiazepines drugs can increase the risk for falls and mental decline, and its effects often last longer than expected.

“For new benzodiazepine users, prescribers should ‘begin with the end in mind’ and immediately engage patients in discussion regarding the expected (brief) length of treatment, particularly when prescribed for insomnia,” the researchers concluded.

4 Drugs That Interact with Anxiety Meds

If you suffer from anxiety, panic disorder or insomnia, your doctor may have prescribed you a tranquilizer belonging to a class of drugs known as benzodiazepines.

Drugs such as Xanax (alprazolam), Valium (diazepam), Ativan (lorazepam), and Klonopin (clonazepam) are some of the most-prescribed medicines – more than 133.4 million such prescriptions were filled in the US in 2014. As with any medication, drug interactions can occur if you take a benzo with another medication, and in certain cases, may be life-threatening.

With benzos, there are 2 areas of concern. The first is that interactions might increase the effects of the drug, which can result in oversedation, accidents and/or overdose. The second is that interactions could decrease the amount of a benzo in the bloodstream of a patient who has been on the drug for a long time, which can result in withdrawal symptoms, the most severe being seizures and death. Here are 4 drug classes that can have dangerous interactions with benzodiazepines.

1. Opioids

Opioids such as OxyContin (oxycodone), morphine, and Vicodin (hydrocodone) are painkillers. Katy LaLone, MD, a consulting psychiatrist with A Resilient Space Psychiatry Consultants in Cleveland, says combining benzos with “other sedative medications, especially opioids, can cause cardiorespiratory depression,” putting patients at risk of overdose and death. In fact, 75% of benzodiazepine-related deaths also involve an opioid. This combination is so dangerous that the FDA issued a black box warning in 2016 about prescribing the 2 drug classes together.

Dr. LaLone has even seen overdoses in patients who are on stable doses of the two drugs after developing a “compromised cardiorespiratory status, such as the flu or undiagnosed sleep apnea.” She adds, “overdose is almost always accidental.”

2. Insomnia drugs

Prescription drugs that treat insomnia, known as “Z-drugs” have a mechanism of action similar to benzos. These drugs include Ambien (zolpidem), Lunesta (eszopiclone), and Sonata (zaleplon). Dr. LaLone sees the combination of benzos and Ambien quite frequently in her clinical practice, usually in patients receiving prescriptions from more than one doctor. Patients are often prescribed benzodiazepines for anxiety and a “Z-drug” for insomnia, not realizing the drugs are similar in action.

She notes this “dangerous combination can cause amnestic episodes (blackout spells),” and she almost never prescribes the 2 drug classes together except in special cases. A 2017 study looking at emergency room visits for adverse events from benzos and/or “Z-drugs” found that the combination of the 2 drug classes led to a 4-fold risk for serious outcomes.

3. Proton Pump Inhibitors (PPIs)

These drugs, such as Prilosec (omeprazole), Nexium (esomeprazole), Prevacid (lansoprazole), and Protonix (pantoprazole), are used to treat acid reflux. They can increase blood levels of benzodiazepines by interacting with the same liver enzymes that clear them from the body. This can result in worsening side effects of benzodiazepines including confusion, sedation, dizziness, falls and impaired driving.

The most common offenders are Prilosec and Nexium. Mary Hall, a retiree living in North Carolina, was prescribed Prilosec by her doctor while taking clonazepam. She said, “The clonazepam started to build up, and I started feeling stoned like I was taking more doses of a benzo. I actually had to skip my night dose of the clonazepam and stop taking the Prilosec after three days.” She also developed a “horrible headache” that lasted for several days. She notified her doctor, and he was unaware of the potential interaction.

‘After the first dose of cipro, my heart started beating super fast, I felt really dizzy and had to hold onto the walls for balance. The world was spinning, and I was very shaky’

4. Fluoroquinolone Antibiotics

Fluoroquinolones include Cipro (ciprofloxacin), Levaquin (levofloxacin), and Avelox (moxifloxacin). They compete for the same binding site as benzodiazepines, which means 1 drug blocks the effect of the other. In this case, the fluoroquinolones block the benzodiazepine leading to acute withdrawal in those who are dependent on the benzo. There have been reports in medical literature and online communities of long-term benzodiazepine patients experiencing withdrawal symptoms after taking these antibiotics.

Kristie Walker, a former medical office biller who now lives in Florida, learned about the interaction firsthand after being prescribed ciprofloxacin for a urinary tract infection. She had been taking Xanax for around 15 years. “After the first dose of cipro, my heart started beating super fast, I felt really dizzy and had to hold onto the walls for balance. The world was spinning, and I was very shaky” she says. She informed her doctor of her symptoms and stopped taking the ciprofloxacin after 2 days.

At that point she was profoundly ill. Her heart rate went up to 200 beats per minute just walking from room to room, she was unable to eat due to severe nausea, and she was ultimately hospitalized. Her symptoms were so severe she contemplated suicide. “I thought I was going to die”, she says. After Walker began to research her symptoms online, she found an article on the interaction between benzos and fluoroquinolones and realized the antibiotic had caused her to have acute benzodiazepine withdrawal.

How to Avoid Dangerous Interactions?

There are numerous ways you can protect yourself from dangerous drug interactions involving benzos. Dr. LaLone recommends that you only take medications that are prescribed to you, and take them only as prescribed. Second, obtain your prescriptions from 1 physician and pharmacy, and have regular doctor visits to assess your medication regimen. Third, exercise caution with use of other sedating medications, especially opioids. And finally, inform your doctor of all medications you are taking, including over-the-counter medications and supplements.

It is also important to know that if you are considering stopping a benzo after being on it for a long time, it should be tapered to avoid the risk of severe withdrawal, which can result in seizures and even death.

New Study Shows No Increase in Birth Defects Due to Use of Antidepressants During Pregnancy

Does the use of antidepressants during pregnancy lead to birth defects? Researchers in the 1970s said yes, but a new study by researchers at Yale refutes that finding.

The earlier studies found that the use of antidepressants — specifically diazepam and chlordiazepoxide — during the first trimester of pregnancy led to birth defects such as facial clefts, cardiac malformations and others. Since then, there have been other studies with varying results, leaving doctors and pregnant women unsure of the safety of taking antidepressants for anxiety, depression or other forms of mental illness.

The newest answer is: Antidepressants are mostly safe.

Dr. Kimberly Yonkers, a psychiatrist and professor at Yale University who studies the effect of benzodiazepines and SSRI antidepressants on the pregnancies of women who have anxiety, depression and/or panic disorders, led a cohort study that was published last week. The study revealed that gestation was shortened, but only by an average of 3 days. Other findings were equally encouraging for women with panic and anxiety disorders.

While there are still some risks to taking antidepressants during pregnancy, Yonkers told NPR, “it should be reassuring that we’re not seeing a huge magnitude of an effect here.” Her study found there was an increase in C-section deliveries, pregnancy was shortened by an average of 3.6 days, and the babies of mothers who used antidepressants during pregnancy were more likely to need respiratory support immediately after birth.

Quick Hits: Some Drs Swapping Anti-Seizure Drugs for Opioids, a Corticosteroid Study Stopped & More

In an effort to combat the opioid epidemic, doctors may be overprescribing anti-seizure drugs as an alternative, according to a letter from researchers published in of the New England Journal of Medicine. Physicians are frequently prescribing the epilepsy drugs Neurontin (gabapentin) and Lyrica (pregabalin) to treat chronic pain.

However, these medications are only FDA-approved to treat certain types of pain, and may cause serious side effects if prescribed for the wrong type of pain symptoms. Some of the side effects patients have experienced include allergic reaction, fatigue, balance problems, impotence, change in bowel movements, sluggishness, confusion and dizziness. Researchers have suggested that doctors direct patients toward non-drug methods of pain management instead, such as physical therapy and cognitive behavioral therapy. Posted August 2, 2017. Via US News.

Researchers concluded a clinical trial early when they found that patients who were using a corticosteroid called methylprednisolone experienced severe side effects, including such serious infections as pneumonia and meningitis. The research team randomly administered either methylprednisolone pills or an inactive placebo to 262 patients with a kidney disease that causes inflammation (immunoglobulin A [IgA] nephropathy). The study’s results, which are published in the Journal of the American Medical Association, showed that nearly 15% of patients experienced a serious “adverse event” –- mainly infections –- over a 2-year period. Posted August 1, 2017. Via Health Day.

Pregnant women who take opioid painkillers together with psychiatric drugs for depression or anxiety during pregnancy have a greater risk of giving birth to an infant in withdrawal, according to a Harvard Medical School study. The study found that the risk and severity of drug withdrawal symptoms in newborns significantly increased when opioids were taken with psychiatric drugs, particularly antidepressants, benzodiazepines such as Valium (diazepam) and the seizure drug Neurontin (gabapentin). After examining more than 200,000 pregnant women, researchers found that mothers who took narcotic painkillers — such as OxyContin or morphine — with psychiatric drugs have a 30% to 60% greater risk of giving birth to an infant in withdrawal than those taking opioids alone. The highest risk of withdrawal — more than 11% — occurred with a mother’s use of gabapentin along with a narcotic painkiller. Posted August 2, 2017. Via Health Day.

Drug Classifications, Schedule I, II, III, IV, V

The FDA has been overseeing drugs in the US since the beginning of the 20th century. In 1970, the FDA released the following drug classifications, or drug schedules, under the Controlled Substances Act (CSA). The drug classification organizes drugs into groups based on medical use, risk of abuse and risk of dependence Those drug categories with high risk and no counterbalancing benefit cannot be prescribed and are Schedule I drugs.

Definition of Controlled Substance Schedules

Drug Schedules
Click image for full-size chart

According to the DEA, drugs and other substances that are considered controlled substances under the CSA are divided into 5 schedules. An updated and complete list of the schedules is published annually in Title 21 Code of Federal Regulations (C.F.R.) §§ 1308.11 through 1308.15.  Substances are placed in their respective schedules based on whether they have a currently accepted medical use in treatment in the United States, their relative abuse potential and likelihood of causing dependence when abused. 

Some examples of the drugs in each schedule are listed below.
Jump to: Schedule I | Schedule II | Schedule IIN | Schedule III | Schedule IIIN | Schedule IV | Schedule V

Schedule I Controlled Substances

Substances in this schedule have no currently accepted medical use in the United States, a lack of accepted safety for use under medical supervision and a high potential for abuse.

Some examples of substances listed in Schedule I are:

  • heroin
  • lysergic acid diethylamide (LSD)
  • marijuana (cannabis)
  • peyote (mescaline)
  • methaqualone (Quaalude)
  • 3,4-methylenedioxymethamphetamine (“ecstasy”)
  • “bath salts”

The DEA is also considering listing the herb kratom under this schedule.

Schedule II/IIN Controlled Substances (2/2N)

Substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence.

Examples of Schedule II narcotics include:

  • hydromorphone (Dilaudid)
  • methadone (Dolophine)
  • meperidine (Demerol)
  • oxycodone (OxyContin, Percocet)
  • fentanyl (Sublimaze, Duragesic)

Other Schedule II narcotics include the opiates morphine, opium, and codeine.

Examples of Schedule IIN (tN for non-narcotic) stimulants include:

  • amphetamine (Dexedrine, Adderall)
  • methamphetamine (Desoxyn)
  • methylphenidate (Ritalin)

Other Schedule II substances include: amobarbital, glutethimide, and pentobarbital.

Schedule III/IIIN Controlled Substances (3/3N)

Substances in this schedule have a potential for abuse less than substances in Schedules I or II and abuse may lead to moderate or low physical dependence or high psychological dependence.

Examples of Schedule III narcotics include:

  • combination products containing less than 15 milligrams of hydrocodone per dosage unit (Vicodin)
  • products containing not more than 90 milligrams of codeine per dosage unit (Tylenol with codeine)
  • buprenorphine (Suboxone)


Examples of Schedule IIIN non-narcotics include:

  • benzphetamine (Didrex)
  • phendimetrazine
  • ketamine
  • anabolic steroids such as Depo-Testosterone

Schedule IV Controlled Substances

Substances in this schedule have a low potential for abuse relative to substances in Schedule III.

Examples of Schedule IV substances include:

  • alprazolam (Xanax)
  • carisoprodol (Soma)
  • clonazepam (Klonopin)
  • clorazepate (Tranxene)
  • diazepam (Valium)
  • lorazepam (Ativan)
  • midazolam (Versed)
  • temazepam (Restoril)
  • triazolam (Halcion)

Schedule V Controlled Substances

Substances in this schedule have a low potential for abuse relative to substances listed in Schedule IV and consist primarily of preparations containing limited quantities of certain narcotics.

Examples of Schedule V substances include:

Hospital-Induced Delirium

I wasn’t prepared for the late-night call from the hospital. My elderly mother, who’d recently been admitted, was swearing at the nurses, demanding they call me. They put her on the line, and to my shock my normally sweet mom unleashed fury on me, speaking rapid-fire in her native Italian, saying I’d “gotten rid of” her, and refusing to listen to my reassurances. Meanwhile, the nurse who’d handed my mom the phone had left the room. My only choice was to hang up on my mother, and call the main desk to persuade the head nurse to rush to her room to calm her down.

What was going on? It took a call to my mother’s hospice physician to clue me in to the answer: Hospital-induced delirium, which is when patients (most often elderly ones) become confused, anxious, aggressive and in some cases have verbal and physical outbursts while in the hospital.

This sudden and severe change in mental status affects more than 7 million hospitalized Americans each year. It’s most common in the elderly, those with preexisting mental impairments, and the terminally ill, though anyone who is hospitalized, even children, are at risk, according to the American Delirium Society.

Because this hospital-linked confusion often comes on toward the end of the day, some call it sundowning, and while it may be easier to pinpoint thanks to the time of day, other hospital-induced delirium can go unrecognized, or misdiagnosed, and can have devastating consequences for the short-term and long-term health of the patient. One recent meta-analysis of delirium in critical care settings — a review of all studies on the subject — found the chance of dying is more than double in those admitted to intensive care units who become delirious. In addition, nearly a third of ICU patients will develop this brain dysfunction, and those that do face a 30% increased risk in long-term cognitive decline.

Delirium Triggers

So what causes delirium in patients admitted to an ICU or hospital? It’s often triggered by a combination of the unfamiliar setting and routines of the hospital — and possible drug reactions and interactions. What’s scary is that it can mimic dementia, and bring about the use of even more meds to help “calm down” the patient. Some drugs that can either cause or exacerbate delirium:

Sedatives

While sedatives appear to help in the short term to mitigate the effects of hospital-induced delirium, in many patients, particularly the elderly, they can contribute to a snowball effect, exacerbating and/or prolonging the delirium.

James Rudolph, MD, interim chief of geriatrics and palliative care at the VA Boston Healthcare System (VABHS), cautions against the use of sedatives for the elderly, particularly benzodiazepines. “There’s now good evidence that these medications can lower the threshold at which patients develop delirium,” he says.

Studies have found that sedatives may produce the opposite of their desired effect, causing rather than soothing agitation, disinhibition and confusion in elderly patients, notes a 2011 National Institutes of Health report. According to UpToDate, an evidence-based, physician-authored online clinical resource, some classes of drugs, especially sedatives such as lorazepam (Ativan) and diazepam (Valium), can build up in the bloodstream and cause the person to become more confused.

Diuretics

Drugs that work to pull excess fluid from the body and are known to have cognitive side effects. It happened to my mother. The reason I’d taken her to the ER that last time was because her feet and legs were swollen, causing pain and difficulty walking. There, she was diagnosed with congestive heart failure. Worried that fluid would begin to accumulate in her lungs, my mother was put on an IV drip of Lasix, a powerful loop diuretic. Not only was that a likely trigger for delirium (she had a change in mental status on another occasion she’d been given a diuretic), but the congestive heart failure itself is associated with impaired cognitive function. Studies show that the condition often manifests as delirium in hospitalized patients. As for my mom, once off diuretics the last time she’d taken them, her mental ability improved, but she never quite regained the total recall she once had.

Medication pile-on

It’s common for the elderly, especially, to be taking a range of different drugs, another factor in delirium. Says Dr. Rudolph, who is also a board member of the American Delirium Society, the aging human body is “a variable system. No one is going to be able to tell you what’s going to happen” when an elderly patient starts taking a lot of different drugs.

To curtail the effects of overuse or misuse of medication, patients or family members should bring an active medication list or actual medications to the hospital. “With computerized medical records, we may know what medications have been prescribed, but that’s often entirely different from what the patient is actually taking,” says Dr. Rudolph. Doctors would want to avoid, to use one example, giving a patient an antidepressant he or she had been previously prescribed, but never took, that may then potentially trigger delirium.

Anticholinergic drugs

Certain categories of drugs, such as OTC antihistamines, antidepressants, and certain gastrointestinal medications, have a high risk for precipitating delirium because they have anticholingeric side effects, explains Tamara Fong, MD, PhD, staff physician in neurology at Beth Israel Deaconess Medical Center in Boston, and an assistant scientist at the Aging Brain Center, Institute for Aging Research. A study recently published in the Journal of the American Medical Association found that taking even the minimum dose of these meds over a long time triggered delirium in older adults.

However, that doesn’t mean it’s a good idea to abruptly stop any medications for the elderly, including OTC medications, without talking to their doctor. Limiting the effects of delirium during hospitalization and after discharge often involves pairing down the number of medications an elderly person takes or reducing their dosages. In my mother’s case, her hospice doctor eliminated the use of statins, and reduced her use of torsemide, the diuretic she had been prescribed.

Other Delirium Triggers

In addition to medications and drug interactions, delirium can also be triggered by infection, dehydration, and lack of proper sleep. It occurs in hospitals and ICUs, but also in nursing homes and rehabilitation facilities.

My mother’s roommate had been blaring the TV the night my mother called me accusing me of dumping her somewhere, making it difficult for her to fall or stay asleep. And the diuretics, which drained my mother of excess fluid, could also have dehydrated her.

I later asked the nurses to see if her roommate would wear earphones or lower the volume at least, so my mother could get a good night’s sleep. Getting to know the patient’s hospital team, in fact, is another recommendation by Dr. Rudolph to help prevent delirium or catch it before it does serious damage. “A hospital doesn’t necessarily know what the patient’s baseline is or isn’t, but if you tell us that a week ago your parent was managing their own care, cooking, managing their finances and now she can’t, this signifies to everyone that there’s been a pretty dramatic change. Getting a baseline from the family allows us to set a reference,” explains Dr. Rudolph.

While hospital-induced delirium isn’t unique to the elderly, they may be more vulnerable, says James Jackson, PsyD, assistant professor of medicine in the Division of Allergy, Pulmonary, and Critical Care Medicine and the Center for Health Services Research at the Vanderbilt University School of Medicine. Older people, he says, may “come into the ICU or hospital already predisposed to not only develop delirium, but also to be particularly impacted by the effects of the delirium.” Something as simple as transitioning from daytime to evening — with a change of shift, a realization of how much their normal routine is disrupted by being in the hospital, or anything else that someone younger might handle better — can be the trigger for sundowning, tipping an elderly person into a cognitive decline.

Hospital-induced delirium can continue for months after the patient is discharged from the hospital. These patients are also at an increased risk of developing dementia, says E. Wesley Ely, MD, MPH, professor of medicine at Vanderbilt University School of Medicine and associate director of aging research for the VA Tennessee Valley Geriatric Research and Education Clinical Center. “A person who used to be okay can get delirium and then can look like they have had dementia for months or even years. We call that a dementia-like syndrome, or a delirium-acquired dementia. The person might need cognitive rehabilitation or an adjustment in medications.”

He calls hospital-induced delirium “one of the largest health problems the public doesn’t know about.” It could be, he notes, that people are being diagnosed with Alzheimer’s after an ICU stay that induced dementia-like problems, and no one (doctors or family members) connected the dots.

More than half of those with pre-existing dementia will experience delirium while hospitalized, another reason the elderly may be more at risk, says Dr. Fong. Unlike dementia, however, a mental condition that gets progressively worse, delirium is a reversible cognitive condition that can be fixed if it’s caught and treated early. Knowing what to look for makes the difference.

What Delirium Looks Like

Different patients exhibit delirium in different ways, with symptoms including confusion, agitation, difficulty concentrating or following directions, rambling speech or jumbled thoughts, hallucinations or paranoia, symptoms which come and go during the course of the day, says Dr. Fong.

Worse, patients may experience delusional memories, which means they misinterpret things that are actually happening around and to them, explains Dr. Jackson.

“For example, they have a catheter inserted and they think they are being assaulted or violated. Or they are being put into an MRI machine and they think they are being put in an oven.” These incidences feel very real to patients even after they return to a normal state of mind, says Dr. Jackson, noting that these memories can become the basis of mental health difficulties related to anxiety. In severe forms, it can lead to post-traumatic stress disorder (PTSD).

Another feature of hospital-induced delirium in elderly patients is dis-inhibition. “They may say and do some things that would otherwise be shocking,” says Dr. Jackson, “such as making sexual references that are at odds with their personality.” But family members should be aware that their loved one doesn’t realize what he or she is doing or saying. “It’s really important for families to try to relate to their elderly loved ones with understanding and compassion, rather than shame or scolding,” he says.

Fixing the Problem

Many hospitals have protocols in place to prevent sundowning in the elderly. One good idea is light therapy, in which rooms are kept bright during the day, with curtains open, and are darkened at night. Reminders of the time and day are also a good idea. My mother’s room had a clock and white boards on the wall in front of each patient’s bed that told the time of day, and the name of the nurse on duty for various shifts.

Preventing other forms of hospital-induced delirium is more complex and only now beginning to be understood and implemented. The good news is that up to 40% of delirium cases are preventable says Dr. Fong, whose colleague, Sharon Inouye, MD, director of the Aging Brain Center at the Institute of Aging Research, developed an intervention program for at-risk older adults known as HELP, the Hospitalized Elder Life Program. (Dr. Inouye also developed what’s called the Confusion Assessment Method or CAM, a widely-used means of identifying delirium). Now used in more than 200 hospitals worldwide, HELP has been successful at returning older adults to their homes following hospitalizations, says Dr. Fong.

Some ways hospital settings can prevent delirium include careful use of sedatives, anesthesia and other medications that cause cognitive side effects; limiting the use of restraints; ensuring the patient gets proper nighttime sleep; and getting the patient up and moving as soon as possible.

One way family members and caregivers can prevent delirium if their loved ones becomes hospitalized is to stay with them as long as possible. “The family’s role is to be an orienting stimulus. Try to be present when they wake up so that there’s someone familiar there,” says Dr. Rudolph. And instead of sitting quietly with your elderly loved ones, or just turning on the hospital TV or a radio with favorite music, play cards or a board game, bring in albums of family photographs — anything you think might promote cognitive stimulation.

Another thing to do: Make sure they get out of bed. “That’s important because we think that mobility serves as a re-orienting stimulus,” explains Dr. Rudolph, as well as a way to promote physical recovery.

Patients should be both physically and mentally active. This year’s Alzheimer’s Association Conference presented 3 new studies that found physical exercise could be an effective treatment for improving the symptoms of Alzheimer’s and other dementia. “The wrong stance is to treat these patients as if they are cognitively fragile for the first 3 or 4 months after they are home,” says Dr. Jackson. “Even as you are trying to mobilize them physically, you should also mobilize them cognitively — either informally, such as trying to get them to read books, play chess, have conversations, or formally, such as taking a computerized cognitive training program.”

For those with a classic brain injury, such as from an accident or stroke, cognitive rehabilitation gets prescribed automatically, usually through a rehabilitation facility. Those with cognitive impairment caused by delirium face a tougher time getting the rehabilitative services they need, again, because the delirium often gets undiagnosed or misdiagnosed. Experts recommend elderly patients see a specialist, such as a geriatrician or a cognitive rehabilitation specialist, to coordinate their care.

A very few hospitals and medical centers have programs focused on helping people recover from ICU stays, and a study by Indiana University found that such critical-care recovery models can decrease the likelihood of further serious illness after discharge. Vanderbilt University has one such program, an ICU Recovery Center that offers a comprehensive online guide for families and patients. Also, many ICUs around the country are starting to implement an approach known as the ABCDEF Bundle, a step-by-step system that aims to guide healthcare professionals caring for ICU patients. The approach prompts healthcare providers to assess how much medication a patient needs, and — most importantly — prompts them to get family involved in their loved one’s care.

Most people who are experiencing the problem of hospital-induced delirium suffer a great deal, as do their families, says Dr. Ely. But “no one should accept that hospital delirium is inevitable, or accept the fact that it’s not a big deal, because it is a big deal,” says Dr. Ely.

Further Reading:

 

Are men and women equal?

The last thing anyone should want is gender equality when drugs are prescribed. Each year more studies add to our knowledge that men and women’s bodies process drugs differently, for a variety of reasons. Traditionally drugs were only tested on men. In the past couple of decades women have been represented in tests, but often in smaller numbers and certainly not during important health stages such as during pregnancy. Most of the drugs that were tested before women were included in the studies remain unstudied for women.

Women are 50% to 75% more likely than men to experience an adverse drug reaction, according to a study published in American Family Physician. Women also need to be more alert to drug interactions because more women take prescription medicine than men. Consider this: millions of perfectly healthy women take very strong prescription drugs daily: birth control pills. The Pill becomes such a part of their daily life that interactions with other drugs — used for a specific, short illness — might be overlooked. For example, antibiotics lower the efficacy rate of most oral contraceptives.

Most dosing guidelines are not yet tailored to women. A “standard” prescription, developed and tested on men, may well be harmful to a woman with significantly lower weight, higher body fat (a factor in metabolizing some drugs and vitamins) and smaller organs. Women tend to have lower compliance than men, perhaps because the side effects are magnified?

Women have “slower gastrointestinal motility” meaning their stomachs retain food longer. The time between eating and taking a medicine that should be taken on an empty stomach is longer for women (but we don’t know how much longer).

Women’s periods, and the stage of the menstrual cycle, changes how a drug is accepted in the body. Daily drugs like SSRIs (Selective serotonin reuptake inhibitors like Prozac and Zoloft, etc) may seem more powerful at one stage of a cycle and less in another. That makes adjusting dosages very difficult.

Here are some of the drugs that have been flagged as having different outcomes in women vs. men (from Society for Women’s Health Research):

  • Diazepam (Valium) – impair the control of voluntary movements more in women than men.
  • SSRIs – Selective serotonin reuptake inhibitors (Prozac, Paxil, Lexipro, Zoloft, etc) – seem to stay in the blood stream at higher concentrations for longer periods of time for women vs. men. Doctors don’t know what this means in terms of efficacy.
  • Acetaminophen (Tylenol) is deactived 50% more frequently in women taking oral contraceptives as compared to control groups.
  • Antibiotics lower the efficacy of many oral contraceptives.
  • Erythromycin (antibiotic) and Verapamil (for high blood pressure) are more effective in women.
  • Digoxin (made from digitalis, for heart failure) – women have a higher mortality rate than men when using this drug. via MedLine/NIH

Interestingly, women are more likely to have a regular doctor than men, and women are 48% more likely to take an abusable prescription drug.

When accepting a prescription from your health care provider, always discuss what the side effects might be and what dosing adjustments might be needed. Don’t assume that because the doctor prescribed 20mg of a drug that 20mg must be the correct amount for you. Report back to your doctor so that your health care provider can give you the prescription that is best for you and not for a statistical average.