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Dangerous Duo: Understanding Risks Associated with Concurrent Opioid and Benzodiazepine Use

While benzodiazepines have received less public attention than opioids over the past year, it’s estimated that nearly 30 percent of fatal opioid overdoses also involved benzodiazepines. According to the Food and Drug Administration, combined use of these two medications increased by 41 percent between 2002 and 2014.

Benzodiazepines are a class of medications that work in the central nervous system to treat a variety of conditions, including anxiety (short-term use), panic disorders, alcohol withdrawal and seizures. Well-known “benzos”, as they’re sometimes called, include Xanax®, Klonopin® and Valium®.

Benzodiazepines may be co-prescribed with opioids due to their anxiety-reducing and skeletal muscle relaxant effects, but combining these medications can be dangerous. Benzodiazepines intensify the respiratory depressant effects of opioids, which means breathing can be slowed down or stopped altogether. This drug class also carries similar risks of tolerance and dependence that opioids have. Another concern is that benzodiazepines can enhance the euphoric effects of opioids, making them a prime candidate for misuse or abuse.

When benzodiazepines are combined with opioids, it nearly quadruples the risk of an overdose-related death compared to opioid use alone.

Due to the rise in prevalence and potentially fatal consequences of concurrent use, the FDA and Centers for Disease Control and Prevention have taken firm action. Both drug classes now carry “boxed warnings” and revisions to labeling to caution patients and providers about the concurrent use of these medications, which may result in extreme sedation, respiratory depression, coma and death. The CDC recommends clinicians avoid prescribing opioids and benzodiazepines concurrently whenever possible.

Patients suffering from anxiety may be prescribed benzodiazepines due to their fast-acting sedative effects. However, clinical guidelines recommend against their use for treatment of generalized anxiety disorder except in limited circumstances on a short-term basis. Antidepressants, specifically selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs), are first-line treatments when medications are needed for anxiety.

For physicians

If benzodiazepines are co-prescribed with opioids, limit dosages and durations to the minimum required, monitor patients for signs and symptoms of respiratory depression and extreme sedation, and provide education about the increased risks of overdose, death and addiction. If you have questions or need additional information, email RxOpioidTaskForce@bcbsm.com.

For patients

It’s important to let your primary care physician know about all the medications you’ve been prescribed and that you’re currently taking. If your doctor wants to prescribe benzodiazepines in addition to opioids you’re already taking, or vice versa, talk to them about the risks and work together to come up with an action plan you and they are comfortable with.

Sources:
CDC Morbidity and Mortality Report
FDA Drug Safety Communication

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