Cafeteria Choice does not work in every place of Medicine: Concurrent use of prescription Opioids and Benzodiazepines.
This study is a nice addition to the literature of concurrent use of prescription opioids and benzodiazepines. In 2015, US Veterans Health Administration did a similar study and found that veterans receiving opioid analgesics and benzodiazepines were found to have an increased risk of death from drug overdose {1}. The patient population in this study is definitely more representative of United States. Employer based insurance comprises about half of US population {2}, but still only represents the working class. It leaves out the senior population with Medicare {3}. As the study did not include Medicaid patients, it leaves out children, pregnant women, seniors, individuals with disabilities and low-income families {4}.
In 1951, India pioneered National Family Welfare Program for the nation. The program now known as Reproductive Child Health-II program still uses “cafeteria choice” for the available range of contraceptive products {5}. One can very well understand the individualized treatment based philosophy behind it. It also works because it is a personal decision and most methods have minimal risks as compared to benefits. Victor Montori along with his colleagues have magnified and used this concept successfully as “Minimally Disruptive Medicine” for chronic medical illnesses {6, 7}. With the current evidence against concomitant use of opioids and benzodiazepines, one should aim for a discussion about benefit and harm in every case. Unfortunately, when the prescription trends ignore the black box warnings results could be disastrous. This is especially true for medications with drug-drug interactions, similar adverse effects and narrow therapeutic indices. The prescribing providers should not feel pressured by patient experience metrics. In a nationally representative sample, Fenton et al showed higher patient satisfaction was associated with higher prescription drug expenditures and increased mortality {8}.
Recent CDC guidelines for prescribing opioids for chronic pain also stress strongly on avoidance of concurrent use of prescription opioids and benzodiazepines {9}.
1. Park et al. Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study. BMJ 2015;350:h2698.
2. Kaiser Family Foundation. Health Insurance Coverage of the Total Population. http://kff.org/other/state-indicator/total-population/
3. Eligibility & Premium Calculator Home. U.S. Centers for Medicare & Medicaid Services. https://www.medicare.gov/eligibilitypremiumcalc/
4. Eligibility. U.S. Centers for Medicare & Medicaid Services. https://www.medicaid.gov/medicaid/eligibility/
5. Gupta et al. Determinants of Contraceptive Practices Among Eligible Couples of Urban Slum in Bankura District, West Bengal. J Family Med Prim Care. 2014 Oct-Dec; 3(4): 388–392.
6. Spencer-Bonilla et al. Minimally Disruptive Diabetes Care for the Elderly. Diabetes Technol Ther. 2016 Dec;18(12):759-761.
7. Gallacher et al. Understanding Patients’ Experiences of Treatment Burden in Chronic Heart Failure Using Normalization Process Theory. Ann Fam Med May 1, 2011 vol. 9 no. 3 235-243
8. Fenton et al. The Cost of Satisfaction A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Arch Intern Med. 2012;172(5):405-411.
9. Dowell et al. CDC Guideline for Prescribing Opioids for Chronic Pain— United States, 2016. JAMA. 2016;315(15):1624-1645.
Rapid Response:
Cafeteria Choice does not work in every place of Medicine: Concurrent use of prescription Opioids and Benzodiazepines.
This study is a nice addition to the literature of concurrent use of prescription opioids and benzodiazepines. In 2015, US Veterans Health Administration did a similar study and found that veterans receiving opioid analgesics and benzodiazepines were found to have an increased risk of death from drug overdose {1}. The patient population in this study is definitely more representative of United States. Employer based insurance comprises about half of US population {2}, but still only represents the working class. It leaves out the senior population with Medicare {3}. As the study did not include Medicaid patients, it leaves out children, pregnant women, seniors, individuals with disabilities and low-income families {4}.
In 1951, India pioneered National Family Welfare Program for the nation. The program now known as Reproductive Child Health-II program still uses “cafeteria choice” for the available range of contraceptive products {5}. One can very well understand the individualized treatment based philosophy behind it. It also works because it is a personal decision and most methods have minimal risks as compared to benefits. Victor Montori along with his colleagues have magnified and used this concept successfully as “Minimally Disruptive Medicine” for chronic medical illnesses {6, 7}. With the current evidence against concomitant use of opioids and benzodiazepines, one should aim for a discussion about benefit and harm in every case. Unfortunately, when the prescription trends ignore the black box warnings results could be disastrous. This is especially true for medications with drug-drug interactions, similar adverse effects and narrow therapeutic indices. The prescribing providers should not feel pressured by patient experience metrics. In a nationally representative sample, Fenton et al showed higher patient satisfaction was associated with higher prescription drug expenditures and increased mortality {8}.
Recent CDC guidelines for prescribing opioids for chronic pain also stress strongly on avoidance of concurrent use of prescription opioids and benzodiazepines {9}.
1. Park et al. Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study. BMJ 2015;350:h2698.
2. Kaiser Family Foundation. Health Insurance Coverage of the Total Population. http://kff.org/other/state-indicator/total-population/
3. Eligibility & Premium Calculator Home. U.S. Centers for Medicare & Medicaid Services. https://www.medicare.gov/eligibilitypremiumcalc/
4. Eligibility. U.S. Centers for Medicare & Medicaid Services. https://www.medicaid.gov/medicaid/eligibility/
5. Gupta et al. Determinants of Contraceptive Practices Among Eligible Couples of Urban Slum in Bankura District, West Bengal. J Family Med Prim Care. 2014 Oct-Dec; 3(4): 388–392.
6. Spencer-Bonilla et al. Minimally Disruptive Diabetes Care for the Elderly. Diabetes Technol Ther. 2016 Dec;18(12):759-761.
7. Gallacher et al. Understanding Patients’ Experiences of Treatment Burden in Chronic Heart Failure Using Normalization Process Theory. Ann Fam Med May 1, 2011 vol. 9 no. 3 235-243
8. Fenton et al. The Cost of Satisfaction A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Arch Intern Med. 2012;172(5):405-411.
9. Dowell et al. CDC Guideline for Prescribing Opioids for Chronic Pain— United States, 2016. JAMA. 2016;315(15):1624-1645.
Competing interests: No competing interests