165. Pulse Ox, Benzodiazepine, Unhealthy Lifestyle

They say every dog has its day and IT think every drug has its place

Anyone who says ‘that drug is bad’ or that test is bad or that anything is bad is just being closed minded or not aware of the evidence because evidence and medicine comes down to numbers.
The real statement should be I don’t think that drug is beneficial enough for the harm. However that is an opinion statement, it is what you think and that is when shared decision making comes into play because maybe your patient does think it is beneficial
No more clearly see than in this viewpoint in Jama titled

Balancing the Risks and Benefits of Benzodiazepines
https://jamanetwork.com/journals/jama/fullarticle/2775180?guestAccessKey=fe7dd94f-653f-4da0-ad1f-21fb8c60e420&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=olf&utm_term=010821

Which talks about the risk and benefits of benzos. A drug that I often here so many providers dis on with no real evidence to back it up—how do I know there is no real evidence??
Because as the authors point out

To date, no published meta-analyses have compared benzodiazepines with selective serotonin reuptake inhibitors for anxiety
People will often cite data from morbitiy and mortality weekly and say that rates of abuse are on on the rise and as an example-
among US women aged 30 to 64 years, the rate of benzodiazepine-related deaths increased from approximately 0.5 per 100 000 population in 1999 to nearly 5 per 100 000 population in 2017;
BUT BUT “I said benzodiazepine-related deaths”
That is such a tricky number it just means that benzo were on board not that benzo killed them. If I said oxygen related deaths the number would be 100%. Everyone who breaths oxygen dies. and, these data do not distinguish benzodiazepine monotherapy related death from coadministration with other medications.
from 1993 to 2014, the rate of benzodiazepines and opioids combined increased from 9.8 to 62.5,
per 100 000 outpatient visits


Sure benzos can be addictive but so can SSRI!
Have you every tried to take someone off an SSRI?!? You can’t just stop it cold turkey most of the time and lets be honest if you are addicted to drugs you fix isnt coming from benzos.
in 2017 among 2 005 395 admissions to publicly funded substance abuse treatment programs only 1% identified benzodiazepines as their primary drug of abuse.
I am not saying benzos are perfect and give them to everyone. Of course not, and I agree fewer people needs benzos but
Every dog has its day and every drugs has its use
practice guideline from the American Psychiatric Association includes benzodiazepines among first-line pharmacologic treatment strategies for panic disorder
I bring all this up because
https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class

September 2020, the US Food and Drug Administration (FDA) announced an update to the boxed warning on all benzodiazepines to explicitly “address the serious risks of abuse, addiction, physical dependence, and withdrawal reactions”

My fear is most physicians will see this headline, never critically think about it and mimic what they read and it will come off as “benzos are addictive, abusivie, and a terrible drug” with little thought to the limitations of the evidence.

They will likely then go on writing for their SSRI which also has addictive properties with results that are slower for onset and not better than the benzo.

I am not saying these are great drugs but if you are saying they are terrible drugs then you need to remember

Every dog has its day.



https://www.practiceupdate.com/c/111407/2/6/?elsca1=emc_enews_daily-digest&elsca2=email&elsca3=practiceupdate_primary&elsca4=primary-care&elsca5=newsletter&rid=MzU5ODQyMjUwMDM1S0&lid=20849334

Not all things are created equal and not test are created equal. This is no more clearly seen in this article in the New England Journal of Medicine tittled

Racial Bias in Pulse Oximetry Measurement

I often talk about exclusion and inclusion criteria on this podcast and did you know the pulse ox has not been validated in racial diverse populations.
https://www.nejm.org/doi/10.1056/NEJMc2029240

In the study looking at pulse oximetry the author’s were testing for occult hypoxemia which is basically an arterial oxygen saturation of less than 88% despite the pulse oximetry satting 92-96%. This is a big deal, if I walk in the room and I see a pulse oximetry reading 94 or 95% my patients actual oxygen level is certainly above 88%. However, in the study they found that almost 12% of black patient’s had a pulse oximetry between 92-96% but a blood gas oxygen of less than 88% and this only occurred 3-1/2% of the time in white patient’s.
So what you do with this information? Well I think the best way to use it is on the lower end of the pulse oximetry say 92 or 93 or 94% in your black patient’s you should consider increasing their oxygen as the percent of occult hypoxemia at increased as patient’s or approaching 92% pulse oximetry and started 0 cases of occult hypoxemia at 96% pulse oximetry. This may not be the most practice changing article of the year but certainly something I think is important for everyone to be aware of.



1 unhealthy lifestyle begets another unhealthy lifestyle. That is from JAMA network open in a paper titled


Maciejewski ML et al. Association of bariatric surgical procedures with changes in unhealthy alcohol use among US veterans. JAMA Netw Open 2020 Dec 21; 3:e2028117. (https://doi.org/10.1001/jamanetworkopen.2020.28117)


Which propensity matched just over 2000 patients that were getting Roux-en-Y gastric bypass surgery or a laparoscopic sleeve gastrectomy to individuals who were not getting bariatric surgery and after 8 years of follow-up those individuals who had surgery were almost twice as likely to have an healthy alcohol use disorder. Was at that the gastric bariatric surgeries caused alcohol use disorder? not likely. Realistically most people who are obese are eating from something. Most we will run 20 or 30 miles are running from something. And most he will drink in excess or drinking from something. While a simple surgery can fix your ability to eat and consume large amounts of food and can’t fix the underlying damage or trauma or mental state of mind which caused unhealthy consumption of food in the first place, thus 1 unhealthy lifestyle fixed with surgery begets another unhealthy lifestyle.



Less is more or so says this article in jama internal medicine titled -

Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions

Among adults with noncardiac admissions, is treatment of hypertension during the admission or antihypertensive treatment intensification at discharge associated with better outcomes?

We have all had the nurse or the pharmacist call us right before discharge and say this patient was give one or two doses of this bp med during this hospital stay, Do want them to go home with this dose?
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2774562?guestAccessKey=92cef46d-2a66-4714-870f-105561a4041c&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=olf&utm_term=122820
Which sometimes can seem like a confusing question but in this study of almost 23,000 patient’s hospitalized for a non-cardiovascular diagnosis those individuals who were discharged with medications had worse outcomes at 30 days and at one year. What are these outcomes I’m referring to? Really important outcomes that we carry out such as stroke and myocardial infarction. In fact there was no interval in which hypertensive treated patients had better outcomes than those individuals who were left untreated.
The absolute numbers were small such as a myocardial infarction rate from 0.6 up to 1.2% and normally you might be used to me saying this is such a small increase why do we care about it but in this circumstance the reason we care is because we are giving medication in hopes that we are doing a good thing and preventing hypertension but in all actuality we are causing harm by doing more so as this segment states when he comes to the management of the med rec for a hypertensive patient while in the hospital….. Less seems to truly be more