Sedated We Stand: Medicare Paid for Nearly 40 Million Tranquilizer Prescriptions in 2013

In 2012, Medicare’s massive prescription drug program didn’t spend a penny on popular tranquilizers such as Valium, Xanax and Ativan.

The following year, it doled out morexanax than $377 million for the drugs.

While it might appear that an epidemic of anxiety swept the nation’s Medicare enrollees, the spike actually reflects a failed policy initiative by Congress.

More than a decade ago, when lawmakers created Medicare’s drug program, known as Part D, they decided not to pay for anti-anxiety medications. Some of these drugs, known as benzodiazepines, had been linked to abuse and an increased risk of falls and fractures among the elderly, who make up most of the Medicare population.

But doctors didn’t stop prescribing the drugs to Medicare enrollees. Patients just found other ways to pay for them. When Congress later reversed the payment policy under pressure from patient groups and medical societies,it swiftly became clear that a huge swath of Medicare’s patients were already using the drugs despite the lack of coverage.

In 2013, the year Medicare started covering benzodiazepines, it paid for nearly 40 million prescriptions, a ProPublica analysis of recently released federal data shows. Generic versions of the drugs—alprazolam (Xanax), lorazepam (Ativan) and clonazepam (Klonopin)—were among the top 32 most-prescribed medications in Medicare Part D that year.

Florida, and particularly Miami-Dade County, had more doctors who prescribed large amounts of benzodiazepines than anywhere else in the country. Some 144 Florida doctors wrote at least 2,000 prescriptions for them to Medicare patients, compared to 98 in Puerto Rico and 27 in Alabama, the next highest state.

And it appears these were not new prescriptions.

IMS Health, a healthcare analytics company that tracks drug sales nationwide, logged only a tiny increase in all benzodiazepine prescriptions, including those covered by Medicare, from 2012 to 2013. That probably means Medicare paid mostly for refills of existing prescriptions, not new ones, said Michael Kleinrock, director of research for the IMS Institute.

That millions of seniors are taking Xanax, Ativan and other tranquilizers represents a very real safety concern, said Dr. Brent Forester, a geriatric psychiatrist at Harvard-affiliated McLean Hospital in Belmont, Mass.

The drugs are popular because they are fast-acting—working quickly, for example, to quell debilitating panic attacks. But they can be habit-forming and disorienting and their effects last longer in older patients. For that reason, the American Geriatrics Society discourages their use in seniors for agitation, insomnia or delirium. The group says they may be appropriate to treat seizure disorders, severe anxiety, withdrawal and in end-of-life care.

Forester said he and others who specialize in geriatric psychiatry don’t use benzodiazepines as a “first-, second- or third-line treatment because we see more of the downside than the good side.”

Some of the Florida doctors who ranked among Medicare’s top prescribers of the drugs said any risks were outweighed by their benefits.

Miami psychiatrist Rigoberto Rodriguez ranked high among Medicare prescribers of benzodiazepines, writing 9,900 prescriptions in 2013, and most of his patients were seniors.

Many, he said, are Cuban immigrants who experienced traumas that left them with lingering anxiety, and they have been taking the drugs for years.

Rodriguez readily acknowledged the risks of the drugs for elderly users – recently, researchers found that the longer a person took benzodiazepines, the higher his or her risk of being diagnosed with Alzheimer’s Disease. The drugs’ labels say they are generally for short-term use but many patients take them for years

He said he has been working to reduce his benzodiazepine prescriptions in light of emerging research. He expects that when Medicare releases data for 2014 and 2015, his totals will be lower.

“This is fresh information coming out in the last couple years that are telling us that benzos are probably not good and you should try to avoid them,” Rodriguez said. “I totally agree with that.”

Roberto Hernando, another Miami psychiatrist who wrote high numbers of benzodiazepine prescriptions in 2013, said he intends to review his prescribing after a reporter told him his totals.

“Some people may need it; some people may not,” he said. “You’re bringing to my attention something that I wasn’t even aware of.”

Some geriatric psychiatrists worry that doctors may have turned to the drugs in place of antipsychotic medications to sedate patients with conditions such as dementia. In the past several years, Medicare has pushed to reduce the use of antipsychotics, particularly in nursing homes, because of strong warnings about their risks.

In 2013, Medicare covered more prescriptions for benzodiazepines than for antipsychotics.

“At the end of the day,” Forester said, “in terms of risk, the risk with benzodiazepines seems so much worse to me….There’s significant danger and there’s no spotlight.”

A spokeswoman at the Centers for Medicare and Medicaid Services declined to answer questions about Medicare’s suddenly soaring tab for benzodiazepines.

Psychiatrist Claude Curran of Fall River, Mass. wrote more than 11,700 prescriptions for benzodiazepines (including refills) in 2013, behind only four doctors in Puerto Rico.

He said the drugs worked well for his patients, many of whom are trying to kick addictions to narcotics but struggle with anxiety and depression.

“First of all, they’re reliable,” he said. “Second of all, they’re cheap because they’re all generic…They tickle the brain in the same way alcohol does.”

Without benzodiazepines, he added, patients in recovery often need higher doses of methadone, which carries significant risks of its own.

The vast majority of Curran’s Medicare patients were younger than 65 and qualified for coverage based on a disability. Disabled patients made up about a quarter of Part D’s 35 million enrollees in 2013, but used benzodiazepines disproportionately, accounting for about half of all prescriptions.

A worrisome aspect of the newly released data is that some doctors appear to be prescribing benzodiazepines and narcotic painkillers to the same patients, increasing the risk of misuse and overdose. The drugs, paired together, can depress breathing.

ProPublica also found that this pattern was most common in southeastern states, which struggle with opioid abuse and overdoses. In 2013, 158 doctors in Florida wrote at least 1,000 prescriptions each for opioids and for benzodiazepines, tops in the nation.

Alabama, Kentucky and Tennessee also had unusually high numbers of doctors who often prescribed both narcotics and benzodiazepines. The data does not indicate if the prescriptions were given to the same patients.

Dr. Leonard J. Paulozzi, a medical epidemiologist at the Centers for Disease Control and Prevention, co-authored an analysis showing that benzodiazepines were involved in about 30 percent of the fatal narcotic overdoses that occurred nationwide in 2010.

He expressed concern that doctors could be pairing these types of drugs because of their  “cumulative depressive effect.”

“It increases the possibility of overdoses,” he said.

When Congress created Medicare’s drug program in 2003, there wasn’t much discussion about whether it should cover benzodiazepines.

They were on a larger list of drugs excluded for coverage, along with barbiturates, fertility drugs, drugs for weight loss and cosmetic purposes. The list mirrored one from a law years earlier allowing states to voluntarily exclude certain drugs from Medicaid programs for the poor. (Medicare now also pays for barbiturates.)

Andrew Sperling, director of federal legislative advocacy for National Alliance on Mental Illness, said it’s unclear why Congress made the exclusions mandatory for Medicare when they had only been voluntary for Medicaid. He believes it was a drafting error.

IMS Health data suggests that while the Medicare ban was in effect, seniors and disabled patients paid for benzodiazepines in other ways. Many paid out of pocket for the relatively inexpensive drugs—some cost less than $10 for a 30-day supply. Some, particularly those with disabilities, qualified for Medicaid, which covers the drugs. Another set of patients chose Medicare Advantage plans that offered the drugs as an added benefit.

Dr. Michael Ong, an associate professor at UCLA, co-authored a 2012 paper concluding that many patients continued using benzodiazepines after Congress banned coverage in Medicare Part D and that some turned to more powerful psychiatric drugs.

“Just mandating something and saying we’re not going to pay for the benzodiazepines is probably not the right type of policy solution to change the behaviors of both the providers who are providing these medications and also the patients who are using them,” Ong said.

–Charles Ornstein and Ryann Grochowski Jones, ProPublica

This story was co-published with the Boston Globe, the Miami Herald and Health News Florida.