By: Dr. Carolyn Rodríguez Rivera, PharmD
MCS Executive Vice President of Pharmacy

In recent years, opioid overdose deaths have increased significantly. An estimated 1 in 3 of these deaths involves a benzodiazepine. In Puerto Rico, there’s an overuse of both drugs, and in 2018 alone, around 500,000 opioid and more than one million benzodiazepine prescriptions were issued.

The concurrent use of opioids and benzodiazepines can lead to serious health complications. These include cognitive impairment, extreme drowsiness, respiratory depression, falls, coma, and even death, and are more common in patients age 65 or older. This population commonly takes multiple drugs prescribed by various providers, making it difficult to identify overuse and adverse effects.¹.

Benzodiazepines, even when taken in the recommended dosages, can lead to abuse and addiction. Therefore, the Food and Drug Administration (FDA) required adding a boxed warning to promote their safe use.² In addition, the Centers for Disease Control and Prevention (CDC) has published guidelines to prevent the overuse of opioids, and thus reduce their simultaneous use with benzodiazepines.³

Recommendations include:

1. Using non-pharmacological and/or non-opioid pharmacological therapies

2. Setting realistic goals and educating patients about opioids

3. Using immediate-acting instead of long-acting opioids

4. Frequently evaluating the benefits and risks of opioid therapy

5. Not prescribing opioids and benzodiazepines simultaneously

There are therapeutic alternatives that can be considered to replace the use of opioids and benzodiazepines.^{1, 4}

Drug Therapy	Therapeutic Alternative
Analgesic drugs (OTC): acetaminophen, ibuprofen, naproxen Serotonin-norepinephrine reuptake inhibitors SSRI: sertraline, escitalopram, fluoxetine SNRI: venlafaxine, duloxetine, milnacipran Topical medications: Diclofenac (gel) Localized injections Transcutaneous electrical nerve stimulation	Selective serotonin reuptake inhibitor drugs (SSRI, SNRI) Buspirone

The Centers for Medicare and Medicaid Services (CMS) has implemented programs to review the use of opioids and benzodiazepines.5 These can help identify at-risk patients, and properly manage their therapy. Therefore, as healthcare professionals we can comply with providing a safe and effective treatment for our patients.

Clinical guidelines recommend limiting the dosage and duration of benzodiazepines, either alone or in combination, to the minimum necessary to achieve the desired clinical effect. The dosage of one or both should be gradually decreased to minimize withdrawal symptoms.6 To reduce anxiety associated with the process, it’s recommended to gradually reduce opioids before benzodiazepines.⁶

It’s important to talk with patients about the controlled drugs they use, especially when they are prescribed by multiple providers. In addition, treatment progress must be reassessed, with safe alternatives considered, and unnecessary drugs discontinued. These clinical practices help control the use of these therapies to avoid overuse and adverse effects, helping to keep patients safe.

Referencias:

1. Reduce Risk of Opioid Overdose Deaths by Avoiding and Reducing Co-Prescribing Benzodiazepines, 2019. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19011.pdf

2. Concurrent Use of Opioids with Other Central Nervous System-Active Medications Among Older Adults. Population Health Management 2020; 23(4): 286-296.

3. CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. JAMA. 2016 April 19; 315(15): 1624–1645.

4. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. BMJ 2017;356: j760.

5. Concurrent Use of Opioids and Benzodiazepines (COB-AD). Measure Details, cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=5887

6. Opioids and Benzodiazepines Just Don’t Mix. Timely Information for Providers in South Carolina, South Caroline Healthy Connections, cme-opioids-benzodiazepines-dont-mix, 2018.

https://msp.scdhhs.gov/tipsc/sites/default/files/tipsc_mailer_v3_23%20final%204-13-18%20(003).pdf