When Medications Affect More Than the Patient: Opioids and Family Members

PAIN MANAGEMENT

When physicians prescribe medications, usually the only thing we need to consider is how the drugs will affect the person for whom we are prescribing. We make choices based on the problems for which they are being prescribed and the risks and benefits based on the overall health of the patients. We rarely have to give much consideration to what, if any, impact the medications may have on the medical status of the patients’ families.

However, three new studies highlight how important it is that when physicians prescribe opioids there can be significant and even potentially fatal consequences for the family members of those for whom they are being prescribed.

The first study examined opioid overdoses among family members of people prescribed opioids using data supplied by a commercial insurance provider that provided information on both the patients and family members.¹ The findings indicate that although opioid overdoses by the family members of those prescribed opioids were relatively infrequent, they occurred at almost three times the rate as for members of families where no one was prescribed an opioid. Furthermore, the risk of family member overdoses correlated with the dosage of the prescribed opioids. The risk of overdoses was present across all age groups from children to adults and prescription of long acting/extended release opioids and fentanyl patches increased the risk for overdoses.

Certainly one might expect that the availability of opioids in a household would increase the risk of someone other than the patient taking the medications and overdosing. The authors note that the overdoses in children are quite probably accidental while those in adolescents and adults are more likely to be the result of intentionally taking the opioids. However, in either case they acknowledge that health care professionals need to make patients aware that they need to closely monitor the opioids prescribed for them and do their best to prevent family members using them to prevent misuse and potentially life threatening overdoses from occurring.

A second study examined the association between opioids prescribed for parents and the risk of suicide attempts by their children aged 10 to 19 years.² It, too, found that while suicide attempts by children of parents who were prescribed opioids were relatively rare, they occurred at more than two times the rate for children whose parents were not prescribed opioids.

The authors of the study noted that other factors such histories of substance use disorder, depression, or suicide attempts by the parents or substance use disorder or depression in the children who overdosed did not fully explain the results.

It is also worth noting that the study found that the greatest risk for suicide attempts among children were those where one or both parents were taking a prescribed opioid and a medication for insomnia, either a benzodiazepine or a “Z drug,” although over two times as many were using a benzodiazepine rather than a Z drug.

The researchers did not have an explanation for their results apart from the potential accessibility of medications with which children can attempt suicide in their home but do recommend that when physicians prescribe opioids for parents, they make them aware of the issue and tell them and their children’s health care providers to watch for behaviors that might indicate suicide is being considered.

Finally, a third study looked at opioid and benzodiazepine prescriptions for family members of people whose prescriptions for these medications had been discontinued. The authors identified patients who had filled prescriptions for opioids or benzodiazepines for a 30 day or more supply during the 10 year period between 2007 and 2016. Based on the total number of prescriptions filled during the period, the 10% of patients who filled the most prescriptions were identified as “high-volume users” and those who were in the bottom 50% with regard to the least number filled were “low-volume users.”

When opioid prescriptions were discontinued among high-volume users, 0.2% of family members filled a prescription for an opioid within 2 days and 0.5% within 14 days. The same results were found among high-volume benzodiazepine users with regard to filling a prescription for a benzodiazepine during those periods.

Among low-volume users, only .06% of family members of opioid or benzodiazepines users whose prescriptions were discontinued filled prescriptions for the respective medications within 2 days after discontinuation while 0.4% of family members of low-volume opioid users and 0.3% of benzodiazepine users filled prescriptions for the medications within 14 days after discontinuation.

Although the authors appreciated that the percentages of family members filling prescriptions after discontinuations was quite small, they noted that their findings did raise the concern that family members might have sought prescriptions for opioids or benzodiazepines in order to continue to provide the medications to those whose prescriptions have been discontinued. Another possible explanation is that the patients originally prescribed the medications were either willingly or unwillingly sharing them with family members and when the prescriptions were discontinued, the family members had to seek their own prescriptions in order to continue their use.

Certainly considering the large numbers of patients in the US who have opioid prescriptions for chronic pain and in light of current recommendations that in most of these cases opioids are not appropriate, doctors may feel they are under increased pressure to stop prescribing these medications.³ It is possible that family members subsequent seeking of opioid prescriptions may be a growing problem and something clinicians need to be aware of.

The last two studies highlight concerns physicians should have about the over prescription of benzodiazepines, a topic that has unfortunately taken a backseat to the opioid epidemic. Another new study notes the important role that both benzodiazepines and opioids can play in mortality and ongoing opioid use following noncardiac surgery.⁴ The study examined the use of opioids and benzodiazepines during the 6 months prior to surgery and found that patients who had been prescribed both medications had a greater 30 day mortality rate and long-term risk of mortality.

Use of opioids, benzodiazepines, or both prior to surgery all were associated with persistent opioid use following it. 43% of preoperative opioid users and 23% of benzodiazepine users were persistent opioid users while 65% of those who used both medications became persistent users of opioids. This was in contrast to only 12% of patients who took neither opioids nor benzodiazepines preoperatively who became persistent opioid users.

Despite the fact that there has been little literature to support the co-prescription of opioids and benzodiazepine and much to recommend against it, it still continues to occur not infrequently. How hard it has been to change the habits of doctors who are doing the coprescribing is demonstrated by another new study.⁵

This study examined the impact of the 2016 Centers for Disease Control and Prevention guideline on the use of opioids for chronic pain, which strongly advised against the co-prescription of these with benzodiazepines. A small but statistically significant decrease in the rates of co-prescription was seen in the two years following the release of the guideline among patients using opioids for extended periods. However, there was no change in what the researchers described as “intensity of co-prescription” measured by the number of days both medications were prescribed concurrently. Curiously, although the study found that there was a reduction in co-prescription for patients with Medicare Advantage no reduction was seen among patients with commercial insurance.

One other interesting finding of the study was that in most cases the same physician prescribed both the opioids and benzodiazepines, which suggests that the problem was not due to lack of coordination between physicians where different ones were prescribing each medication.

None of the findings of any of these studies indicate that physicians should cease to prescribe either opioids or benzodiazepines to patients who truly require them. They do, however, highlight the many issues associated with their use that they may not need to consider when prescribing other medications but do with these two classes.

Disclosures:

Dr King is in private practice in Philadelphia.

References:

1. Khan NF, Bateman BT, Landon JE, et al. Association of opioid overdose with opioid prescriptions to family members. JAMA Intern Med. 2019;179:1186-1192.

2. Brent DA, Kur K, Gibbons Rd. Association between parental medical claims for opioid prescriptions and risk of suicide attempt by their children. JAMA Psychiatry. 2019;76:941-947.

3. Barnett ML, Hick TR, Jena AB. Prescription patterns of family members after discontinued opioid or benzodiazepine therapy of users. JAMA Intern Med. 2019;179:1290-1292.

4. Sigurdsson MI, Helgadottir S, Long TE, et al. Association between preoperative opioid and benzodiazepine prescription patterns and mortality after noncardiac surgery. JAMA Surg. 2019;154:e191652.

5. Jeffery M, Hooten WM, Jena AB, et al. Rates of physician coprescribing of opioids and benzodiazepines after the release of the Centers for Disease Control and Prevention Guidelines in 2016. JAMA Network Open. 2019.2:e198325.