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Keys to Prescribing Opioids Properly to Reduce Concurrent Benzodiazepine Use
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    By: Dr. Carolyn Rodríguez, PharmD
    Executive Vice President of Pharmacy at MCS


    The overuse of opioid drugs has been a topic of conversation in the medical and public health fields for several years. Various sectors have implemented efforts to address this health situation that puts the lives of thousands who take opioids for pain management at risk. However, it’s also important to talk about benzodiazepines – one of the most prescribed drug groups in Puerto Rico, and also one that has the potential for abuse.

    According to statistical data and since the COVID-19 pandemic, the number of people using these prescription drugs has increased substantially, from fewer than 7,000 people per year in 2019 to more than 9,500 as of the first quarter of 2020. In addition, according to the Prescription Drug Monitoring Program (PDMP), from 2020 to 2022, 2,045,861 opioid and 8,784,869 benzodiazepine prescriptions were issued in Puerto Rico. Given the increase in use, there’s a need to educate patients regarding the danger associated with the simultaneous use of these drugs. Opioids, when combined with benzodiazepines, can depress the central nervous system and cause serious side effects, such as dizziness, confusion, excessive sleep, breathing problems or very slow breathing, which can lead to a coma, overdose or death.

    Although the use of benzodiazepines on the island is much higher than that of opioids (contrary to the scenario in the U.S.), it’s essential to know how to optimize the prescription of these pain drugs, and thus reduce concurrent use and related complications. The clinical practice guideline1 established by the Centers for Disease Control and Prevention (CDC) for prescribing opioids for pain is a tool that helps physicians, healthcare professionals and patients work together to make informed and focused decisions regarding a patient’s pain treatment. This guideline, which was updated in 2022, highlights 12 recommendations to support healthcare professionals in treating ambulatory patients age 18 and older for:

    • Acute pain: duration of less than one (1) month
    • Subacute pain: duration of one (1) to three (3) months
    • Chronic pain: duration of more than three (3) months

    The following are 12 recommendations and additional details to facilitate their implementation in one’s practice:

    1. Non-opioid therapies are as effective as opioids for many common types of acute pain. These therapies include:
      • Non-opioid drugs: acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), selected anti-depressants and anti-convulsants
      • Physical treatments: heat therapy, acupressure, spinal manipulation, remote electrical neuromodulation, massage, exercise therapy and weight loss, among others
      • Behavioral treatments: cognitive behavioral therapy, stress reduction and mindfulness, among others
    2. Because non-opioid therapy is preferred for subacute and chronic pain, physicians should maximize the use of pharmacological and non-pharmacological therapies, and only consider initiating opioid therapy if the benefits to the patient are expected to outweigh the risks. Patients must also be informed that their opioid therapy will be discontinued if the benefits do not outweigh the risks.
    3. When starting opioid therapy for acute, subacute, or chronic pain, consider immediate-release instead of long-acting opioids (ER/LA).
    4. When starting opioid treatment for those patients with acute, subacute or chronic pain who have never received opioids (naïve), physicians should prescribe the lowest effective dose
    5. For patients already receiving opioid therapy, physicians should carefully evaluate the benefits, risks and dose changes. Unless there’s evidence of a life-threatening problem, opioid therapy should not be stopped abruptly, and the dose should not be reduced quickly
    6. In the case of treatment for acute pain, and according to the expected duration and intensity, patients should not be prescribed more opioids than necessary.
    7. Doctors must weigh the benefits and risks with patients within the first and fourth week after initiating opioid therapy for subacute or chronic pain. This evaluation also applies when there’s a dose increase.
    8. Before starting and during opioid therapy, physicians should evaluate the risks related to opioids, and discuss them with the patient. A plan should also be made with the patient to establish strategies to mitigate risk, including offering naloxone.
    9. When prescribing initial opioid therapy and during the therapy, physicians should review the patient’s controlled substance prescription history using the state’s prescription drug monitoring program (PDMP) data to determine whether the patient is receiving doses or combinations of opioids that may increase the person’s risk of overdose.
    10. When prescribing opioids for subacute or chronic pain, physicians should consider the benefits and risks of toxicology testing to evaluate prescription drugs, as well as other prescription and non-prescription substances.
    11. Physicians should take special precautions when prescribing opioid analgesics and benzodiazepines at the same time, and consider whether the benefits outweigh the risks of the simultaneous prescription of opioids and other central nervous system depressants.

      Opioids and benzodiazepines with the highest use in Puerto Rico include:

      Opioids Benzodiazepines
      tramadol (Ultram®)
      oxicodona (OxyContin®, Percocet®)
      fentanyl      		 clonazepam (Klonopin®)
      temazepam (Restoril®)
      lorazepam (Ativan®)
      alprazolam (Xanax®)
      diazepam (Valium®) 
    12. Physicians should offer or arrange for evidence-based drug treatments for those patients with opioid-use disorders. Given the increased risks of resuming drug use, overdose and death by overdose, detoxification alone is not recommended.

    Optimizing the prescription of drug therapies with high abuse potential is essential for improving treatment effectiveness and promoting patient safety. These recommendations, as well as your knowledge regarding a patient’s medical history of pain treatments, will allow you to improve communication about the risks and benefits, as well as work as a team to make decisions focused on the person’s well-being.

    The opioid prescription guideline does not apply to pain management for patients with sickle cell disease, cancer and palliative care.


    References:

    1. Alza en el Uso de Fármacos para Ansiedad.” ENDI, http://www.cfpr.org/files/endi-news.pdf Accessed 30 June 2023.
    2. ASSMCA Brinda Adiestramiento Esencial a Profesionales de La Salud En Puerto Rico.” WIPR, 24 Feb. 2023, https://wipr.pr/assmca-brinda-adiestramiento-esencial-a-profesionales-de-la-salud-en-puerto-rico/
    3. Puerto Rico Opioids Dashboard. Programa de Opioides de la Secretaría Auxiliar de Planificación y Desarrollo (SAPD) del Departamento de Salud de Puerto Rico (DSPR): Puerto Rico Opioids Dashboard pr.gov
    4. Puerto Rico PDMP. Administración de Servicios de Salud Mental y Contra la Adicción (ASSMCA). https://www.pdmpassist.org/pdf/resources/South-East-Regional-Meeting/19-C_Epidemiology_Puerto_Rico.pdf
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