Author: Charles Frank

Hospitalization and Combined Use of Opioids, Benzodiazepines, and Muscle Relaxants in the United States PMC

Separate analyses were performed to measure the association via odds ratio (OR) between exposures of opioids, benzodiazepines, muscle relaxants, double-threat, and triple-threat using a reference group of nonusers of these medications with the outcome of hospitalization. To evaluate the relationship within the same year of exposure and outcome, we completed an analysis of 2013 exposure and 2013 outcome and performed a separate analysis of 2014 exposure and 2014 outcome. Finally, to examine the relationship of prior year exposure of the study medications to hospitalization in the succeeding year, the association was measured of 2013 medication exposure with hospitalization in 2014. Benzodiazepines are central nervous system depressants that cause drowsiness and are used to treat insomnia, seizures, anxiety disorders, nervousness, panic disorders, muscle spasms, alcohol withdrawal, status epilepticus, premenstrual syndrome, and as sedation during surgery. Both benzodiazepines and narcotics (opioids) are common drugs of abuse. Only use benzos and opioids if you really need them and your doctor decides that the benefits outweigh the risks.

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Oxycodone is the type of opioid found in the prescription drugs Percocet and OxyContin. Doctors prescribe them to treat anxiety, muscle spasms, sleep problems, and seizures. These medicines work by increasing the level of GABA (gamma aminobutyric acid), a chemical that calms your brain.

Implications for Health Care Professionals

The phenomenon of learning to use benzodiazepines as prescribed was so common among patients that it led to a conceptual framework of benzodiazepine use in individuals with opioid use disorder (Figure 1). This framework posits that how patients take or use benzodiazepines is highly dependent on where they are in the recovery process. The recovery process for a person with opioid use disorder might be defined as starting with illicit opioid use, then moving to an initial treatment phase involving OAT, then to a later OAT treatment phase with less substance use.

Similar to our findings, patients with opioid use disorder are well aware of the risks of benzodiazepine use including the risk of overdose (Stein et al., 2017). Review and identification of existing medications should be undertaken prior to the initiation of a new opioid, benzodiazepine, or muscle relaxant for any patient. This may involve usage of a PDMP or review of available administrative claims data to detect potentially offending medications. Within the electronic medical record, an automated alter would inform the prescriber or their care team of the synergistic risk of adding the agent to the current regimen.

What conditions do benzodiazepines treat?

Poorly controlled or untreated anxiety or insomnia may increase the risk of alcohol relapse.58 Evidence-based pharmacotherapy and use of agents without abuse potential should be prescribed first-line and when appropriate, but BZDs may be indicated for some patients at elevated risk for abuse. When this occurs, provide thorough education on the risk of combining these drugs with alcohol or other substances, discuss diversion, prescribe a BZD with lower abuse potential, monitor for adverse effects, and monitor for inappropriate use. In this first qualitative study focused on benzodiazepine use in people treated with OAT, we found similar reasons for benzodiazepine use as have been found in quantitative survey studies. This qualitative study goes further than these earlier surveys in describing more of the nuance and context of the functional benefits and symptom relief reported by patients who take benzodiazepines. Reasons for benzodiazepine use in quantitative studies most commonly include treatment of anxiety and insomnia and to get high in OAT patients (Chen et al., 2011; Gelkopf et al., 1999) and patients with opioid use disorder (Fatséas et al., 2009; Stein et al., 2016).

1. Benzodiazepines (benzos) are strong sedatives that are prescribed for anxiety or sleep problems.
2. When clinicians mandate benzodiazepine discontinuation, clinicians report that patients often disengage with that clinician.
3. Narcotic analgesics have a high potential for misuse, abuse, and diversion (to addicted persons).
4. Doctors write millions of prescriptions for each of these drugs every year.

Three members of the research team (T.P., J.S., V.D.) reviewed transcripts line-by-line and coded for conceptual categories. After agreeing on a final coding scheme through consensus coding, we double-coded all of the transcripts. After coding was complete, the research team discussed transcripts to analyze themes, triangulate impressions, and completed the final analyses developing overall themes and selected representative quotations. We completed coding and analysis using NVivo 12 qualitative software (QSR International). One of two interviewers (T.P. and J.S) conducted interviews in private research offices away from where participants received or clinicians delivered OAT.

Food and Drug Administration boxed warnings on their labels highlighting the potential dangers of using these drugs together. These risks are even greater if benzodiazepines are used in older people who have a history of falls or who are already receiving two or more other CNS drugs (such as opioids, muscle relaxants, sleeping pills, or barbiturates, among others). Past measures to reduce and restrict benzodiazepines were implemented in New York in 1989 in the form of triplicate prescriptions.

When To Call the Doctor

Even then, use these medicines for the shortest amount of time and lowest dose possible to manage your symptoms. Avoid alcohol because it can intensify the effects of benzos and opioids. And make sure that your doctor checks on you often while you take these medicines. Alcohol is involved in 1 in 4 ED visits resulting from BZD abuse and is involved in 1 in 5 BZD-related deaths.18 Both alcohol and BZDs bind to distinct binding sites on the GABAA receptor, ultimately leading to synergistic drug actions. In addition, health care professionals should make necessary interventions and referrals when problematic alcohol consumption is suspected or identified.

The CDC developed and published the CDC Guideline for Prescribing Opioids for Chronic Pain to provide recommendations for the prescribing of opioid pain medication for patients 18 and older in primary care settings in 2016. That’s why both drugs carry a “black box” warning about the dangers of using them together. Speak with your healthcare provider about first trying safer, evidence-based alternatives such as cognitive behavioral therapy and other medications like antidepressants. Benzodiazepines are a powerful medication class with a wide variety of indications and off-label uses, such as anxiety disorders, epileptic seizures, and insomnia, and for initiating anesthesia. In cases in which benzodiazepines are necessary in an older individual, the most favored options are known as the “LOT drugs” (lorazepam, oxazepam, and temazepam). This is because they are shorter-acting and do not have active metabolites, making them less likely to cause residual or longer-term side effects.

Together, these four drugs make up 99% of benzodiazepine prescriptions. The strength and duration of action of benzodiazepines are important in what conditions they treat. Short-term or emergency conditions usually merit the use of stronger, short-acting benzodiazepines.

GABA reduces the activity of nerves in the brain that may cause seizures, anxiety, and other conditions. People being prescribed any medication should disclose all other substances and medications they use and consult with their health care teams about avoiding or managing the risks of using certain medications and substances in combination. The best way to prevent side effects and an overdose is to avoid combining opioids and benzos. Use one drug or the other, or try other treatments to manage your symptoms. Benzodiazepines are often prescribed for conditions like anxiety and insomnia, even though other treatments exist that show equal or better results with fewer risks and side effects. In a 12-month period spanning 2014 and 2015, experts estimate that at least 30.5 million people in the U.S. took benzodiazepines prescribed by a healthcare provider.

Taking both drugs together increases your risk of overdosing and of dying from an overdose. Even low doses of these two drugs can be risky when they’re combined. Benzodiazepines (benzos) are strong sedatives that are prescribed for anxiety or sleep problems. Benzodiazepines are a class of drugs (commonly referred to as “benzos”) prescribed to treat anxiety, panic disorder, seizures, insomnia, and alcohol withdrawal. Your healthcare provider will schedule follow-up visits after prescribing benzodiazepines.