Benzodiazepines Get Positive Reviews on Twitter

By Pat Anson

Benzodiazepines have gotten a bad reputation over the last few years. The anti-anxiety medications were once commonly prescribed to pain patients, until fears rose that Valium, Xanax and other benzodiazepines could lead to an overdose when taken with opioid medication.

In 2016, the FDA warned of a “public health crisis” because overdose deaths involving opioids and benzodiazepines had nearly tripled. That was followed in 2020 by updated FDA warning labels that strongly cautioned patients and doctors about the risks of benzodiazepine abuse, addiction and dependence.

It turns those public health messages have fallen flat, because many patients have entirely different attitudes about benzodiazepines. In an unusual study of social media posts on Twitter (now known as “X”), researchers found that over half the tweets praised how effective benzodiazepines are, with minimal discussion of their side effects.

“Social media platforms offer valuable insights into users’ experiences and opinions regarding medications. Notably, the sentiment towards benzodiazepines is predominantly positive, with users viewing them as effective while rarely mentioning side effects,” wrote lead author Óscar Fraile-Martínez, an academic researcher at the University of Alcalá in Spain.

Fraile-Martínez and his colleagues analyzed over 11,600 English-language tweets that mentioned benzodiazepines in 2019 or 2020. Zolpidem (Ambien), lorazepam (Ativan), and clonazepam (Klonopin) were the most frequently discussed medications.

Over half the tweets (57%) were posted by patients or their relatives, while healthcare professionals authored less than 1% of them. The remaining tweets were posted by other users who couldn’t be classified.

The study findings, published in BMC Psychiatry, show that only about 5% of the tweets discussed adverse side effects from benzodiazepines, such as daytime sleepiness, impaired cognitive functioning, memory problems, reduced mobility, and increased risk of falls and fractures.

Notably, a significant percentage of patients reported combining benzodiazepines with other psychiatric drugs, or with alcohol and other addictive substances. Yet there was hardly any discussion of overdoses, dependence or withdrawal.

Researchers say the minimal discussion of side effects may be due to the nature of social media, where posts tend to be shorter and provide little detailed medical information.  

“The predominance of positive mentions about benzodiazepines’ efficacy on Twitter could be due to several factors. Users may share personal experiences that highlight immediate relief from anxiety and insomnia, which are the primary benefits of these medications. This focus on short-term effectiveness may occur because individuals seek validation and support for their experiences or advice on similar issues, thus emphasizing positive outcomes,” wrote Fraile-Martínez. 

So who is right? Twitter users with positive views about benzodiazepines or public health experts who think the medications are potentially dangerous?    

The researchers in this study took the latter view. They say their findings show “an alarming minimization” of the risks associated with benzodiazepines and called for expanded efforts to educate physicians, patients, and families about their use.

Doctors who heed that advice may want to think twice about tapering patients on long-term benzodiazepine treatment. A recent study found that cutting off or rapidly tapering patients on benzodiazepines nearly doubles their risk of dying within a year. Deaths from suicide, accidents and other causes rose for patients after benzodiazepines were discontinued.

Illegal Online Pharmacies Still Advertise on Facebook

By Pat Anson, PNN Editor

At least two illegal online pharmacies are advertising on Facebook, offering to sell opioids and other controlled substances to people without a prescription and without visiting a doctor. The ads appear to be a direct violation of Facebook’s own policies and may be illegal.

“29 common medications, delivered fast and privately. No prescription required,” says one ad displaying an image of Adderall and Xanax tablets.

“Don’t leave your home, stay safe with us,” says another ad offering to sell Xanax. “Get our delivery services and we will have everything you need.”  

Of course, there’s nothing “safe” about the sale of medication – real or counterfeit -- by sketchy companies over the internet.

In addition to Adderall and Xanax, Canadian Online Pharmacy and BestPharm also offer home delivery of opioids, muscle relaxers, weight loss, anti-anxiety, and erectile dysfunction drugs – many of them brand name medications sold at inflated prices.  

I was surprised to see the ads in my Facebook feed. I’ve been covering pain management for over a decade and frequently interact with PNN readers over Facebook, so it’s likely the ads are using Facebook algorithms and user history to selectively target me and my readers – many of them chronically ill -- even though Facebook and its parent company Meta have strict policies about pharmaceutical advertising.

“Promoting prescription drugs is not allowed without prior written permission from Meta,” Facebook states on its website, directing advertisers to an online application form that requires they first be registered and certified by LegitScript. Facebook and other e-commerce platforms use LegitScript to make sure they’re doing business with reputable companies that can pay them for advertising.

However, unlike other internet companies, Facebook does not use LegitScript to proactively monitor and screen ads to make sure they don’t promote questionable products or engage in illicit activity.

If they did, they would quickly learn that LegitScript classifies Canadian Online Pharmacy as a “rogue” pharmacy that uses fraudulent or deceptive business practices.  

“LegitScript has reviewed this Internet pharmacy and determined that it does not meet LegitScript Internet pharmacy verification standards,” LegitScript states on a webpage that anyone can use to check the URLs of online pharmacies to see if they are legitimate.  

“Additionally, LegitScript has determined that this pharmacy website meets our definition of a Rogue Internet Pharmacy.”

BESTPHARM FACEBOOK AD

BestPharm isn’t even listed in LegitScript’s database, which means Facebook shouldn’t be running their ads, according to its own policies.

Facebook and Meta did not respond to requests from PNN for comment on this story.

“Facebook has a role to play in enforcing their advertising policy and, in this case, their policy is not meeting their own expectations,” says Libby Baney, senior advisor to the Alliance for Safe Online Pharmacies, a trade group that estimates there are 35,000 active online pharmacies worldwide, about 95% of them operating illegally or engaged in fraud.     

“A number of years ago, the social media platforms were admonished by the FDA to try to do more to prevent this type of advertising or content to consumers. And many, including Facebook, made commitments or pledges to government and public health officials to do more to screen their ads for this type of content,” Baney told PNN.

“I was quite surprised actually to see how blatant the advertisements were that you found and I don't have a real explanation for it, other than they’re falling through the cracks of the advertising policy standards that many of these companies, including Facebook, have in place.”

‘How Can This Be Legal?’

Fortunately, many Facebook users who saw the same ads I did questioned whether the pharmacies are legitimate. They showed their skepticism in the comment section of the ads.

“Xanax being promoted on Facebook? Profits must be low,” wrote one poster who saw an ad that featured a hand holding about 20 Xanax tablets.

“Wow, that’s enough to sedate an entire neighborhood. Way to make yourselves look legit, LOL!” said another poster.

“Your Prices are INSANE.......... cheaper to buy from the dude slinging drugs on the corner,” wrote another Facebook poster.

“How can this be legal?” asked another.

Remember, these ads are deliberately targeting people with chronic pain and other illnesses, who often have trouble getting their medications. There are currently record shortages of prescription drugs and many pharmacies are out of stock or rationing medications in short supply.

CANADIAN ONLINE PHARMACY FACEBOOK AD

In a recent PNN survey, 90% of patients with an opioid prescription said they had trouble getting it filled.

Desperate people do desperate things. We’ll never know many Facebook users clicked the button to “Learn more,” which takes them directly to the advertiser’s website where they can place an order for drugs.

“It could be a total scam, meaning your credit card and personal information are stolen. Or it could be a partial scam that could endanger your health, which is you get something dangerous laced with fentanyl,” says Baney. “You're putting your life in the hands of some anonymous advertiser on the internet.”

‘No Prescriptions Needed’ 

A close look at an online pharmacy’s website may provide a clue to their legitimacy. Canadian Online Pharmacy, for example, bills itself as an “international” pharmacy that ships medications around the world.

“Your Global Source for Quality Medicines! No prescriptions needed, no awkward doctor visits! Enjoy convenience, privacy, and savings on top-notch medications, all delivered to your doorstep,” the website claims.

Where is the Canadian Online Pharmacy based? The company lists an address in Wheeling, West Virginia that is shared with dozens of other online companies, selling everything from pillows and audio equipment to cameras and pizza. The telephone that’s listed has a Washington DC area code.

BestPharm doesn’t provide a physical address or telephone number, but does share the names and pictures of several people who supposedly run the company in its “About Us” section. Their names and images appear to be fictitious or stolen off the internet.

The picture for Chief Operating Officer Jessica Pearson, for example, is the same one used by over a dozen other women online, only their names are Emma, Emily and Ella.

Emma is particularly notable. Her Linkedin page claims she works for Google on special projects involving artificial intelligence, and that she’s a graduate of the Massachusetts Institute of Technology, where she studied “the toggled self-assembly of colloidal suspensions in binary systems.”

BESTPHARM

LINKEDIN

All of this might be funny, if it wasn’t for the fact that people are getting ripped off and risking their lives by buying drugs from fake pharmacies.

“I hear about these types of incidents or patient experiences from parents who've lost loved ones, who have purchased counterfeit products online after seeing ads that are clearly in violation of U.S. law,” Baney said.

According to The Wall Street Journal, Meta is under investigation by federal prosecutors for its role in the illicit sale of drugs online. A grand jury has been convened to look into whether the company’s social-media platforms are facilitating and profiting from illicit drug sales. No criminal charges have been filed.

“The sale of illicit drugs is against our policies and we work to find and remove this content from our services,” a spokesman for Meta said in a statement to the newspaper.

‘When Are You Going to Take Down These Posts?’

In 2018, Meta CEO Mark Zuckerberg was grilled during a congressional hearing about Facebook publishing posts and ads for illegal online pharmacies.

“Your platform is still being used to circumvent the law, and allow people to buy highly addictive drugs without a prescription,” said Rep. David McKinley (R-WV). “When are you going to take down these posts that are done with illegal, digital pharmacies?”

“Right now when people report the posts to us, we will take them down and have people review,” Zuckerberg replied. “I agree that this is a terrible issue, and respectfully, when there are tens of billion pieces of content that are shared every day, even 20,000 people reviewing it can’t look at everything.” 

Six years have passed and illegal online pharmacies are still advertising on Facebook. The company heavily relies on artificial intelligence (AI) to screen the millions of advertisements it runs every year.

But clever advertisers find ways to outsmart AI. There’s even a tutorial on YouTube to help cannabis companies get around Facebook restrictions on cannabis advertising. The key is to avoid using certain keywords like “THC” or getting “high,” which could get an ad rejected by AI. It’s better to use emojis, images and vague terms to get your point across.

“The goal is not to try to break the rules, but to see where you can bend the rules. Be a little bit creative,” says Aaron Nosbisch, CEO and Founder of Brez, a cannabis-infused drink.

“My ads are saying you’ll experience euphoria, feelings of relief, and be a great alternative to alcohol. Promote the ideas of what the products do for people (without mentioning) THC and CBD. People are looking to feel good. People are looking to have a good night and have a good time. Sell that.”

What can Facebook do to stop advertisers from exploiting cracks in its screening system?

“Enforce their own policy,” says Baney. “We look forward to Facebook addressing these issues that they've committed to in public forums with government officials.”

Stopping Long-Term Use of Benzodiazepines Increases Risk of Death

By Pat Anson, PNN Editor

Abruptly stopping long-term treatment with benzodiazepines nearly doubles the risk of a patient dying within a year, according to a large new study.

Benzodiazepines such as Valium and Xanax have long been used to treat anxiety, insomnia and seizures, but their coprescribing with opioids is controversial because both drugs cause respiratory depression, increasing the risk of an overdose.

In 2016, the CDC warned doctors to avoid coprescribing opioids and benzodiazepines “whenever possible.” That same year, the FDA warned that taking the drugs concurrently has serious risks, including “profound sedation, respiratory depression, coma and death.”

Those warnings led many prescribers to abruptly take their patients off benzodiazepines, which many used safely for years. Some patients took opioids and benzodiazepines with a muscle relaxant, a combination known as the “Holy Trinity.”  

Researchers at the University of Michigan analyzed the insurance claims of over 350,000 adults prescribed benzodiazepines long-term from 2013 to 2019, expecting to find the FDA and CDC warnings validated. To their surprise, the risk of death from suicide, accidents and other causes rose for patients in the 12 months after benzodiazepines were discontinued.

“These results were unexpected,” researchers reported in JAMA Network Open. “Given the increased OD (overdose) risk and mortality associated with benzodiazepine prescribing, particularly when coprescribed with opioids, we anticipated that discontinuing benzodiazepine prescriptions would be associated with a lower mortality risk.

“However, for every outcome examined in this analysis, discontinuation was associated with some degree of increased risk — at odds with the assumption underlying ongoing policy efforts that reducing benzodiazepine prescribing to long-term users will decrease harms.”

Researchers found that patients on opioids who stopped taking benzodiazepines had a 6.3% risk of dying over the next year, compared to 3.9% of those who continued taking both drugs. Patients who were discontinued also had a slightly higher risk of a nonfatal overdose, suicidal thoughts, and emergency department visits.

Risk of Death for Opioid Patients Taken Off Benzodiazepines

JAMA NETWORK OPEN

"I think it is important to revisit the assumption that tapering stable long-term users should be the default and instead, perhaps, focus on those with clearly elevated risk of harms," lead author Donovan Maust, MD, a geriatric psychiatrist at UM Health, told MedPage Today.

Maust and his colleagues say patients discontinued from benzodiazepines could be suffering the effects of withdrawal or may be turning to other substances such as cannabis or alcohol. Given the risks involved, they urge prescribers to be “judicious” when prescribing benzodiazepines for the first time and to carefully limit their long-term use.

Stop Demonizing the ‘Holy Trinity’

Lynn Kivell Ashcraft, Guest Columnist    

If we are to have any hope of a rational, scientific discussion about the issues involved in both pain management and addiction treatment, we need to end patient shaming and the use of sensational language that has no basis in clinical practice.

First on my list is to stop using the term “Holy Trinity” when referring to the use of multiple medication classes to manage pain. It is a sensational propagandizing use of terminology that has no place in any meaningful clinical discussion.

Holy Trinity was a term coined by law enforcement when discussing the behavior of addicts. The original Holy Trinity – the so-called “Houston Cocktail” -- referred to the simultaneous ingestion of the short acting drugs hydrocodone (Vicodin), alprazolam (Xanax) and carisoprodol (Soma) by addicts. Other combinations of opioids, muscle relaxants and anti-anxiety drugs such as benzodiazepines are also used.

“The cocktail is commonly known on the black market as the ‘holy trinity’ and is particularly sought-after by addicts, but is also particularly dangerous,” is how the DEA describes the drugs in criminal complaints, search warrants and training guides.  

SOURCE: DEA TRAINING GUIDE

Taken together, the three drugs can be risky and cause respiratory depression, overdose and death. But when used under medical supervision, they enable individuals with painful and disabling conditions to improve their quality of life and restore bodily functions.

Holy Trinity was never used originally to refer to any medication combination prescribed by physicians caring for pain patients. But with the advent of the opioid crisis, the term is being used as a scare tactic by law enforcement and even some medical providers to deny patients a combination of medications previously used successfully.

The unintended consequence of this careless usage has been the deaths and needless renewal of pain and disability for patients who were being safely prescribed these medications.  

There is no one-size-fits-all treatment for chronic severe centralized pain. In fact, the current Pain Management and Dosing Guide from the American Pain Society lists opioids plus other central nervous system depressants and valium (a diazepine) as potential treatments for neuropathic pain.

It is well acknowledged that successful treatment often requires polypharmacy regimens tailored to the needs of individual patients to achieve pain relief and provide quality of life. The potential risks of using multiple medications can be reduced by prescribing both long-acting forms of these drugs and by directing patients to take them separately. 

To use the Holy Trinity as an inflammatory term is to demonize certain medications that have been abused by addicts while being used successfully by intractable pain patients. The use of this derogatory term has caused the undeserved transference of the deeply held negative societal bias against “addicts” onto some of the frailest and medically complex patients, many of whom are struggling to achieve some quality of life. 

According to the CDC, about 20 percent of adults in the U.S. have chronic pain and 8 percent have severe “high impact” chronic pain that frequently limits their life or work activities. The 2011 Institute of Medicine report puts the number of Americans with pain at 100 million, which is more than those living with diabetes, heart disease and cancer combined.

The difference between the two reports highlights some of the issues with using and understanding statistics.  However, no matter which report you use, both numbers represent a staggering number of Americans living in pain who deserve effective treatment.

Let’s lose the term Holy Trinity and allow doctors to prescribe whatever medications they deem necessary for the restoration of function and the relief of pain in their patients. Name calling and the use of disrespectful terminology doesn’t solve either the problem of addiction or the problem of pain.

Lynn Kivell Ashcraft is an Analytic Software Consultant and writer who lives in Arizona. Lynn has lived with chronic intractable pain for almost 30 years and works with Dr. Forest Tennant as part of the Arachnoiditis Research and Education Project. 

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Counterfeit Pill Lab Exposed in BBC Report

By Pat Anson, PNN Editor

Counterfeit prescription drugs have emerged as a worldwide problem – from fake “Mexican Oxy” sold in United States to bogus cancer drugs recently found in Turkey, Argentina and Switzerland.

This week a chilling BBC documentary took viewers inside a dingy underground lab in the UK where counterfeit Xanax pills are made – often laced with illicit fentanyl and other dangerous chemicals.

One dealer bragged to BBC reporter Livvy Haydock that he could make 42,000 Xanax pills in three hours.

"I import the raw ingredients and chemicals needed and then I press the tablets with a tablet press machine,” he said.

"I've been doing this for many years and I've never been at the point where I can produce and supply enough to meet the demand for my product. I'm always turning away customers.”

BBC ‘INSIDE BRITAIN’S BLACK MARKET”

The fake anti-anxiety pills are manufactured in a converted cement mixer and tested on volunteer “guinea pigs” before being sold on the street, often to teenagers.

"They're taking that risk, they're paying the money. I'll make it and I'll do it as best as I can and I'll give a good service and provide a good product and the rest is on them," the dealer said.

He boasted that overworked customs officials send him warning letters when his shipments are seized, but they rarely tell police.

"I've had plenty of packages stopped from customs to addresses. A lot of the time you just receive a letter saying it's been seized,” he explained. “"They don't really follow it up. Sometimes they do, but the majority of the time they don't.”

A similar problem exists in the United States, where the Postal Service processes and delivers nearly half of the world’s mail. Postal inspectors can’t even open suspicious packages without a search warrant.

“Drug traffickers have familiarized themselves with and exploited vulnerabilities in the Postal Service network,” a recent Inspector General report warned. “Individuals can now order nearly any type of illicit drug online and have it delivered to a location of their choosing, all from the comfort of their own home.

“These illicit purchases often rely on mail shipment companies, including the Postal Service, to deliver products to customers as they provide greater opportunities for anonymity than other delivery options, such as human couriers.”

The Inspector General recommended that Congress pass legislation to give postal inspectors legal authorization to open and inspect domestic packages suspected of carrying illicit drugs.

According to the World Health Organization, the counterfeit drug market is worth $200 billion worldwide, with almost half of the fake and low-quality medicines sold in Africa. Up to 300,000 people may die from pneumonia and malaria every year due to substandard medications primarily made in China, India, Pakistan and the United Kingdom.

‘Benzo Crisis’ Keeps Not Happening

By Roger Chriss, PNN Columnist

A new study published in The Journal of Clinical Psychiatry has found that the misuse and abuse of benzodiazepine is relatively rare, even though the drug is sometimes hyped as the next overdose crisis in healthcare.

Benzodiazepines – often called “benzos” -- are a class of sedative that includes Valium and Xanax. The medications are usually prescribed to treat anxiety and insomnia.

Data on over 100,000 adults in the 2015-16 National Surveys on Drug Use and Health was analyzed by researchers, who found that benzodiazepines were used by 12.5% of American adults. Of those, about 17% “misused” the drug at least once, but only 2% had what was diagnosed as a benzodiazepine use disorder.

The study found several risk factors for benzo misuse, including younger age, male gender, lower levels of education, lack of health insurance or employment, and lower income levels — factors often associated with other substance use disorders.

The National Institute on Drug Abuse (NIDA) recently reported that most misusers obtained benzodiazepines from friends or relatives, with only about 20% receiving them from their doctor.

These findings, both the statistics and the specific risks factors and usage patterns, run counter to inflammatory media headlines such as “Xanax, Valium looking like America's next drug crisis” or “Benzodiazepines: our other prescription drug epidemic.”  

Instead, benzodiazepines are better viewed as part of an ongoing problem of drug abuse and addiction that primarily occurs outside of medical care. They are a factor in many drug overdoses, partly because of increasing rates of counterfeit Xanax and Valium being contaminated with illicit fentanyl, and because overdose rates increase when benzodiazepines are combined with opioids or alcohol.

Until recently, benzodiazepines were commonly co-prescribed with opioids to chronic pain patients, a practice that is now strongly discouraged by regulators and insurers.

There are indeed risks with benzodiazepines, including not only sedation and somnolence, but also cognitive effects and worsening of psychiatric symptoms. Moreover, chronic benzodiazepine use can lead to physiologic dependence independent of any abuse or addiction, and this dependence can make tapering off benzodiazepines difficult. Benzodiazepine withdrawal syndrome is sufficiently important to merit extensive treatment in the online guide known as the Ashton Manual.

But there are also benefits in using these drugs, even for long-term therapy. For instance, REM sleep behavior disorder is a sleep disorder in which people act out vivid, unpleasant dreams with violent arm and leg movements, often harming themselves or bed partners in the process. The benzodiazepine clonazepam (Klonopin) is the traditional choice for treatment for that. 

Stiff person syndrome is a rare neurological disorder involving intense muscle spasms in the limbs and trunk. The benzodiazepine diazepam (Valium) helps reduce those muscle spasms and stiffness.

There are also intriguing novel uses for benzodiazepines as well. Some researchers are investigating low-dose benzodiazepine therapy for people with treatment-resistant obsessive-compulsive disorder (OCD). This is not the cuddly version of OCD seen in TV shows like “Monk” but crippling dysfunction that renders a person incapable of leaving their bed for days at a stretch.

Benzodiazepines need careful consideration, but not a hyped crisis. In a reference to the opioid crisis, NIDA director Nora Volkow, MD, told Opioid Watch: “As always, science should be the driver of smart policies designed to reverse the course of this crisis.”

The same wisdom should be applied to all medications.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Chronic Pain and Depression Common in Overdoses

By Pat Anson, Editor

People who die from opioid overdoses are significantly more likely to suffer from chronic pain and depression, according to a new study that highlights the risk of combining opioid pain relievers with benzodiazepines, a class of anti-anxiety medication.

Researchers at Columbia University Medical Center analyzed over 13,000 overdose deaths among Medicaid patients and found that over 61 percent had been diagnosed with back pain, headaches or some other chronic pain condition. Many also suffered from depression, anxiety, bipolar disorder, schizophrenia and other mental health problems.

Significantly, nearly half of those with chronic pain (49%) filled a prescription for opioid pain medication during the last 30 days of their lives, and just over half (52%) filled a prescription for benzodiazepines. Prescriptions for anti-depressants, anti-psychotics and mood stabilizers were also common.

“This medication combination is known to increase the risk of respiratory depression, which is the unusually slow and shallow breathing that is the primary cause of death in most fatal opioid overdoses," said Mark Olfson, MD, a professor of psychiatry at Columbia and lead investigator of the study.

“Most persons with opioid-related fatalities were diagnosed with one or more chronic pain condition in the last year of life. As compared to people with opioid-related deaths without diagnosed chronic pain conditions, the decedents with chronic pain diagnoses were more likely to have also received substance use and other mental health disorder diagnoses. They were also more likely to have filled prescriptions for opioids, benzodiazepines, and other psychotropic medications and to have had a nonfatal drug overdose.”

The Columbia study included opioid overdoses linked to both pain medication and illegal opioids such as heroin, but was limited to Medicaid patients who died between 2001 and 2007. Since that time, opioid prescribing has declined, while illegal opioids and counterfeit medication have become increasingly available on the black market.

Public health officials have only recently started warning about the risks of combining opioids with benzodiazepines, and some insurers now refuse to pay for the medications when they are prescribed jointly.

A recent study of overdose deaths in Florida found that benzodiazepines such as Xanax and Valium killed nearly twice as many Floridians in 2016 as oxycodone. Another study in Pennsylvania also found that overdose deaths involving benzodiazepines exceeded those from opioid painkillers.

The Columbia study was published online in the American Journal of Psychiatry. The study was funded by the Agency for Healthcare Research and Quality, the National Institute on Drug Abuse, and the New York Psychiatric Institute.

Florida’s Deadliest Rx Drug is Not a Painkiller

By Pat Anson, Editor

A new report from Florida’s Medical Examiners Commission is debunking a popular myth about the overdose crisis.

The most deadly prescription drugs in the state are not opioid painkillers, but benzodiazepines – a class of anti-anxiety medication that includes Xanax (alprazolam) and Valium (diazepam).  Xanax alone killed more Floridians last year (813) than oxycodone (723).

The medical examiners analyzed toxicology and autopsy results for 11,910 people who died in Florida in 2016, noting not only what drugs were present at the time of death, but which drug actually caused the deaths.

The distinction is important and more accurate than the death certificate (ICD) codes often used by the CDC, which merely list the drugs that were present. Critics have long contended that CDC researchers cherry pick ICD data to inflate the number of deaths "involving" or "linked" to opioid medication, in some cases counting the same death twice.   

Florida made an effort to get the numbers right.

“Florida’s medical examiners were asked to distinguish between the drugs determined to be the cause of death and those drugs that were present in the body at the time of death. A drug is indicated as the cause of death only when, after examining all evidence, the autopsy, and toxicology results, the medical examiner determines the drug played a causal role in the death,” the report explains.  “A decedent often is found to have multiple drugs listed as present; these are drug occurrences and are not equivalent to deaths.”

The five drugs found most frequently in Florida overdoses were alcohol, benzodiazepines, cocaine, cannabinoids and morphine. The medical examiners noted that heroin rapidly metabolizes into morphine, which probably led to a substantial over-reporting of morphine-related deaths, as well as a significant under-reporting of heroin-related deaths.

Benzodiazepines also played a prominent role as the cause of death, finishing second behind cocaine as the drug most likely to kill someone.  Benzodiazepines were responsible for almost twice as many deaths in Florida in 2016 than oxycodone. Like opioids, benzodiazepines can slow respiration and cause someone to stop breathing if they take too many pills.

DRUG CAUSED DEATHS IN FLORIDA (2016)

Source: Florida Medical Examiners Commission

As in other states, deaths caused by cocaine, heroin and illicit fentanyl have soared in Florida in recent years. In just one year, the number of overdose deaths there jumped 22 percent from 2015 to 2016.

"We don't talk about it much now there's the opioid crisis, but cocaine and alcohol are still a huge issue, there are still a lot of deaths due to those things," Florida addiction treatment director Dustin Perry told the Pensacola News Journal.

Florida is not an outlier. Several other states are also using toxicology reports to improve their analysis of drugs involved in overdose deaths and getting similar findings.  In Massachusetts, deaths linked to illicit fentanyl, benzodiazepines, heroin and cocaine vastly outnumber deaths involving opioid medication.  Prescription opioids were present in only 16 percent of the overdose deaths in Massachusetts during the second quarter of 2017.

SOURCE: MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH

Although it is becoming clear that many different types of drugs -- opioids and non-opioids -- are fueling the nation’s overdose crisis, politicians, the media and public health officials still insist on calling it an “opioid epidemic” or an “opioid crisis” -- diverting attention and resources away from other drugs that are just as dangerous when abused.  We never hear about a Xanax epidemic or a Valium crisis.

President Trump's opioid commission recognized the need to improve drug overdose data when it released its final report this month.

"The Commission recommends the Federal Government work with the states to develop and implement standardized rigorous drug testing procedures, forensic methods, and use of appropriate toxicology instrumentation in the investigation of drug-related deaths. We do not have sufficiently accurate and systematic data from medical examiners around the country to determine overdose deaths, both in their cause and the actual number of deaths,” the commission found.

How Chronic Pain Killed My Husband

By Meredith Lawrence, Guest Columnist

So much has been written about the opioid epidemic, but so little seems to be out there about what living with true chronic pain is like. My husband, Jay, lived and died in incredible pain at the age of 58.  As his wife, I lived that journey with him. 

Jay is no longer here to tell his story, but I want the world to see what I saw.  I want you to know how he went from working 60 hours a week doing hard physical labor, until his pain grew worse and he could not even get out of a chair on his own. 

I want you to know the deterioration Jay went through over the last ten years. I want you to know what a good day and a bad day is like when you live with chronic pain.  I want you to know exactly what happened when the doctor decreased his pain medication. And I want you to know how my husband finally made the decision to commit suicide. 

I want people to understand that when chronic pain runs your life, eventually you just want the pain to stop. 

First a bit of history.  I met Jay in 2005, when we both stopped drinking.  Two years later, Jay began to lose feeling in his legs and started having falls, as a result of compressed nerves in his spine. The pain was so bad Jay had to stop working and go on disability, which started his depressive episodes.

JAY LAWRENCE

Jay had a series of lower back and neck fusion surgeries.  This was when he was first prescribed painkillers, antidepressants and anti-anxiety medications.  From 2008 to 2011, Jay tried various treatments to control the pain that lingered even after a third back surgery.  These included steroid shots, nerve blocks and a spinal cord stimulator.  Ultimately he had a drug pump implanted that delivered morphine, in addition to the pain pills he was being prescribed.

In 2012, Jay was diagnosed with trauma induced dementia.  I believe that diagnosis was right, based on his symptoms, but not all of the doctors agreed.  Some believed the confusion was due to high doses of morphine and/or his sleep apnea.  

By 2016, Jay’s confusion and memory issues were increasing. He was on a steady dose of 120mg morphine daily, in addition to the medication he was receiving from his pain pump. 

Jay’s depression seemed to come and go, depending on the day and his pain levels.  He was weaned down on his Xanax to 2mg a day to help him sleep. He was aware of the risks of combining Xanax and morphine. 

JAY AND MEREDITH LAWRENCE

Let me tell you what a good day was like before they changed his medications. I worked a full time job from 2 pm to 10 pm five days a week. I would get home, and Jay would have my coffee ready for me at night.  We would stay up and watch TV until 2 or so.  When it was time for sleep, I went to bed and he slept in his recliner.

We started sleeping apart after his first surgery in 2007. He was more comfortable sitting up in the chair, but could never sleep more than three hours at a time.  He knew sleeping in bed would just keep me awake. 

A good day always meant it was not cold or raining.  On a good morning, he would be up first and get coffee started.  He would take our two miniature pinchers outside in the yard on their leash for potty time. 

We usually had at least one appointment a week, but if not we could have a nice quiet morning.  That meant coffee in front of the TV.  After a couple of hours of that, he might switch over to playing his computer games, but he was never far from his chair. 

A typical adventure for us would involve going to Walmart.  Jay was not able to walk through the store, but he hated using the handicapped carts. I could always see a look on his face when he had to do it.  After going to the store, we might have lunch or an early dinner at Steak n Shake or Cracker Barrel.  It always needed to be some place familiar and comfortable for him.  More than once we sat, ordered and then took our food home because he was in too much pain. 

In the summer we might walk the dogs after dinner.  Just a quick two block walk, but a lot of times he would have to stop halfway and go back home.  A couple of times I had to go get the car and pick him up because his legs just would not support him anymore. 

A bad day was awful for me to watch, and absolutely horrible for Jay to live. It meant no real sleep, just catnaps in the chair whenever he could.  He always made coffee for us, but on a bad day he would forget to add coffee to the coffee maker and we would just have hot water.  The pain was so much he was just distracted. 

On many bad days, I would look over and see tears just running down his face because he was in so much pain.  It also made Jay’s depression worse.  We spent many cold winter nights talking about how much pain would be too much and would make life not worth living.  It is the most horrible feeling in this whole world to hear the person you love most talk about ending their life. 

In January, 2017 Jay’s pain clinic decided they could no longer prescribe the high doses of morphine he was on.  In addition, they were not going to continue seeing him if he decided to stay on Xanax.  The Xanax was prescribed by another doctor, but they did not care.

I begged the pain doctor -- yes, literally begged -- for some other option. The doctor said that if Jay continued the Xanax he would no longer see him.  He would not give another option for medications, and at one point even said that most of his patients with pain were “making it up.”

The last thing the doctor said to us will stick with me forever.  He said, “My patient’s quality of life is not worth losing my practice over.”

When we left that day, we were barely in the car and I knew what Jay was going to say to me.  I will never forget how sad his voice was when he told me this was it for him. He was not going to continue to live like this.

Through the month of February, as Jay’s medication was decreased, we spent time doing things we did not normally do.  We went out on Valentine’s Day, he bought me the first jewelry he had bought since my engagement ring, and we went out to a fancy restaurant for dinner.  Jay tried to cram in as many good memories as he could into that last month, but I knew it was costing him.

Jay’s next doctor’s appointment was scheduled for March 2, and we knew they were going to decrease his medications again.  The night before, he woke me up to tell me it was time.  I knew what that meant, but I tried to be strong for his sake.  We talked all night long about what it meant, and how it should be.  It was the saddest, strangest, longest night of my life. 

Jay knew he did not have enough pills to kill himself.  He also knew that if he were to try and purchase a gun, they would not sell it to him.  It would have been almost obvious what he was going to use it for. 

In the end, I bought the gun that Jay used -- and yes, we talked about the ramifications of that action.  We went to the park where we had renewed our vows in 2015.  We talked in the car for a while, and then we sat in the same place we had cut our wedding cake.  I was holding his hand when he pulled the trigger. .

Through the shock and horror, my immediate feeling was one of relief for Jay. To know that he was finally out of pain was a weight lifted off both of us.

Because I purchased the gun that Jay used to end his life, I was charged under our state's assisted suicide law.  This charge was later reduced to reckless endangerment, and I am currently on probation. People close to me want me to be quiet about my role in Jay’s death, and I was at first. But I cannot continue that way. 

I know Jay wanted me to put his story out there.  I know he wanted people to know what it was like to live with the pain he lived with daily. When the doctor took away Jay’s medications, they took away his quality of life. That was what led to his decision. Jay fought hard to live with his pain for a long time, but in the end fighting just was not enough. 

Something has to be done to wake up the doctors, insurers and regulators to make them see pain patients as real people. People with husbands, wives and children that love them.  People that are suffering and just barely holding on. 

Pain News Network invites other readers to share their stories with us.  Send them to:  editor@PainNewsNetwork.org. 

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Utah Raid Uncovered Large Fentanyl Pill Ring

By Pat Anson, Editor

A drug bust in a Utah home last November has uncovered one of the largest counterfeit pill operations in U.S. history.

This week a federal grand jury in Salt Lake City indicted six individuals for manufacturing nearly 500,000 pills laced with illicit fentanyl that were disguised to look like the painkiller oxycodone and the anti-anxiety drug alprazolam (Xanax). The counterfeit pills were distributed throughout Utah and the United States to customers who ordered them online.

Fentanyl is a powerful synthetic opioid that it is 100 times more potent than morphine and 50 times more potent than heroin. In recent years, illicit fentanyl has been blamed for thousands of overdose deaths in the U.S. and Canada.

“What we feared and hoped somehow would stay away has arrived in spades,” said Brian Besser, the DEA’s agent in charge in Utah. “Fentanyl is as dangerous as it gets.”

According to documents filed in federal court, the pill ring was created by Aaron Shamo and Drew Crandall, both Utah residents who worked together at eBay, but quickly grew to include the other conspirators. Prosecutors say the defendants purchased pill presses, dies and stamps so the counterfeit pill markings would match those of legitimate pharmaceutical drugs. Some items were purchased legally and others, such as fentanyl and alprazolam, were illegally imported from China

The fake pills were sold on a “dark net online store” at a significant profit. Once sold, Shamo and Crandall used their co-conspirators to package the pills and ship them to customers. In less than a year, the operation mailed 5,606 drug orders totaling $2.8 million, according to court documents.

“Shamo’s customer base was extremely comprehensive and widespread, touching every corner of the United States,” Besser said. “It touched large cities and rural communities.”

The round blue tablets manufactured by the pill ring were offered for sale online as oxycodone 30mg tablets. The tablets were debossed with “A 215” on the bisected side, with an “M” on one side and a “30” above the bisect on the other side. The indictment alleges the defendants did not use oxycodone at all in the manufacturing process, but instead used illicit fentanyl.

Federal agents arrested Shamo last November. During a raid on Shamo’s suburban Salt Lake City home, agents discovered a pill press capable of manufacturing several thousand pills an hour. Agents also seized 70,000 pills and $1.2 million in cash stuffed in garbage bags.

Crandall fled to Australia with his girlfriend and was in Laos when agents raided Shamo’s house. He was arrested last month in Hawaii. A summons will be issued for the other four conspirators for their initial appearances in federal court.

Anti-Anxiety Meds Raise Risk of Opioid Overdose

By Pat Anson, Editor

Taking opioid painkillers with benzodiazepines – a class of anti-anxiety medication that includes Xanax and Valium – significantly raises the risk of an emergency room visit or hospital admission for an overdose, according to a large new study.

Opioids and benzodiazepines are both central nervous system depressants that can cause sleepiness, respiratory depression, coma and death. Nearly 30% of fatal overdoses in the U.S. linked to opioids also involve benzodiazepines.

Researchers at Stanford University School of Medicine analyzed private insurance claims for over 315,000 people prescribed opioids from 2001 to 2013.

In 2001, they found that 9 percent of opioid users also received a prescription for a benzodiazepine. By 2013, the co-prescribing rate nearly doubled to 17 percent.

Their study, published in The BMJ, found that use of both drugs was associated with a substantially higher risk of an emergency room visit or inpatient admission for opioid overdose.

“We found that opioid users who concurrently used benzodiazepines were at an increased risk of opioid overdose and that eliminating concurrent benzodiazepine/opioid use could reduce the risk of opioid overdose by 15%,” wrote lead author Eric Sun, MD, an assistant professor at Stanford University School of Medicine.

“Providers should exercise caution in prescribing opioids for patients who are already using benzodiazepines (or vice versa), even in a non-chronic setting. Indeed, we note that the association between concurrent benzodiazepine/opioid use and the risk of opioid overdose was broadly similar for both intermittent and chronic opioid users.”

The Food and Drug Administration recently expanded the warning labels on opioids and sedatives because of the risk of overdose. Insurance companies are also actively discouraging doctors from prescribing the two together..

A recent study by the Centers for Disease Control and Prevention ranked Xanax (alprazolam) as the fourth deadliest drug in the United States, while Valium (diazepam) was ranked tenth. Xanax was involved in about a quarter of the overdoses involving opioid pain medication.  

Fentanyl ‘Death Pills’ Spreading Coast-to-Coast

By Pat Anson, Editor

Law enforcement officials are warning that counterfeit pain and anxiety medications laced with illicit fentanyl have started appearing in Florida, where they are blamed for at least one overdose death.

The pills in Florida are disguised to look like oxycodone, Percocet or Xanax, but are actually made with fentanyl, a powerful and dangerous drug 50 times more potent than morphine. Similar counterfeit pills, made to look like Norco hydrocodone medication, are blamed for at least ten deaths and dozens of overdoses in the Sacramento, California area in recent weeks.

“I've had one of these so called super Norco’s,” said David, a 25-year old father of two, who started using street drugs for back pain.  “I only took a half just in case because of the news from the day and luckily I did. It was unlike any high I've had. It made me dizzy.  I couldn't see straight or sleep.”

As Pain News Network has reported, some of the victims in California are pain patients like David who sought opioid medication on the street because they can no longer get it prescribed legally.

"The people who have overdosed are not typically drug addicts," Olivia Kasirye of the Sacramento County health department told Agency France-Presse. “Many of the individuals said at one time or another they had a prescription and either they didn't get it refilled or the doctor said they didn't need it anymore."

Florida "Death Pills"

fake fentanyl pills disguised as norco

"It is here, it is deadly and it will continue to grow in our community,” said Danny Banks of the Florida Department of Law Enforcement in the Orlando Sentinel.

“If you are dependent upon or if you are experimenting with prescription painkillers, please make sure you are getting those painkillers from a licensed pharmacy. I cannot assure you right now, if you are buying prescription painkillers from either the black market or on the street, I cannot assure that they will not be laced with a deadly concoction that contains fentanyl. And it will kill you.”

In many cases, Banks said, neither buyers or sellers know the so-called “death pills” contain fentanyl.  He said fentanyl-laced pain pills have been seized in Osceola and Brevard counties, and have been linked to at least one fatality.

Florida’s Pinellas County Sheriff's Office has attributed nine recent fentanyl deaths to a batch of fake Xanax, an anxiety medication.

DEA Sees No Link to CDC Guidelines

In recent years, Illicit fentanyl has been blamed for thousands of overdose deaths. It is usually produced in China and then imported by Mexican drug cartels, which often mix fentanyl with heroin or cocaine before smuggling it into the U.S. The recent appearance of fentanyl in counterfeit pills is an ominous sign that drug dealers could now be targeting patients as customers, not just addicts.

But a DEA spokesman in Washington, DC disputes that notion.

“I don’t think you’re seeing that at all,” says the DEA’s Rusty Payne. “They’re going after anybody who will buy the product. By and large they are reaching hard-core addicts.”

Payne also sees no connection between the fake fentanyl pills and the recent adoption of the CDC’s opioid guidelines, which discourage primary care physicians from prescribing opioids for chronic pain. Many patients fear losing access to opioids because of the guidelines.

“These CDC guidelines are brand spanking new. I think it’s hard to draw any sort of conclusions from that,” Payne told PNN. “I don’t think the Mexican cartels are paying one lick of attention to what the CDC guidelines are. What they see are thousands and thousands of addicts that they can push a product on, whether it be heroin or now fentanyl. And introducing it in pill form is just another way to make a lot of money."

In a survey of over 2,000 pain patients last fall by Pain News Network and the International Pain Foundation, 60 percent predicted patients would get opioids off the street or through other sources if the CDC guidelines were adopted. Another 70% said use of heroin and illegal drugs would increase.

According to a story in STAT, drug cartels are now shipping machinery into the U.S. that can manufacture pills, allowing dealers to mass produce fentanyl in pill form. In March, the DEA arrested four men in southern California who were operating four large presses to make counterfeit hydrocodone and Xanax pills.

Recently the Royal Canadian Mounted Police arrested 14 people in British Columbia, seizing firearms, diamonds, cash and about a thousand fentanyl pills.