Reappraising the use of benzodiazepines in chronic pain patients

Abstract

Benzodiazepines are not indicated for pain control, but they are frequently taken by pain patients. Indeed, benzodiazepines are among the most widely prescribed drugs on earth despite the fact that they are known to cause tolerance, dependence, and be associated with side effects [1,2]. Their unfortunate popularity among pain patients is troubling as many pain patients take concomitant opioids and the benzodiazepine-opioid combination can lead to potentially life-threatening respiratory depression. The Centers for Disease Control and Prevention (CDC) in their 12point guidelines to primary care physicians who prescribe opioids specifically advised against the concurrent use of a benzodiazepine with an opioid [3]. About 30% of opioid-associated overdose deaths involve the use of a benzodiazepine. [4] A cohort study found that the risk of death was increased 10-fold for opioid patients who took a benzodiazepine at the same time (7.0 per 10,000 person-years, 95% confidence interval, 6.3-7.8 versus 0.7 per 10,000 person years, 95% confidence interval, 0.6-0-.9) [5]. Benzodiazepines, which first came to market to replace carbamate drugs and the useful but extremely habit-forming drug class of barbiturates, act as positive allosteric modulators of the gamma-aminobutyric acid (GABA) receptor A, producing sedative, anxiolytic, hypnotic, anticonvulsant, and muscle-relaxing effects [6]. GABA is the single most common neurotransmitter in the body and it has an inhibitory effect on excitable neurons, which can result in a calming or dampening effect on cerebral activity [6]. Benzodiazepines are indicated for short-term use to treat acute anxiety and acute insomnia, both of which can occur with acute and chronic painful conditions [7-11]. In addition, benzodiazepines are widely prescribed off-label for a variety of mental health conditions, including depression, posttraumatic stress disorder, schizophrenia, obsessive-compulsive disorder, and others [12-15]. In the case of posttraumatic stress disorder, the use of benzodiazepines is not only contraindicated but it may exacerbate symptoms [12,16]. There is a paucity of evidence in the literature as to why pain patients are prescribed benzodiazepines. One may surmise that many people struggling with pain, particularly chronic pain syndromes, may report distressing symptoms of stress, anxiety, fearfulness, and disordered sleep patterns, any of which might be considered a reasonable indication for a benzodiazepine. Nevertheless, benzodiazepines are intended for short-term use only, typically defined as under four weeks,

The impact of a postoperative multimodal analgesia pathway on opioid use and outcomes after cardiothoracic surgery

“…Additionally, it is worth noting that slightly more patients in the opioid-based group received concomitant psychotropic medications than those in the multimodal group. While the authors were unable to validate the degree to which this concomitant therapy impacted the results of this study, the potential of these agents to directly or indirectly alter responses to painful stimuli should be considered [37,38]. Incidentally, the analgesia groups were not a predictor for ICU LOS in the models however, they can be impacted (i.e., shortened, prolonged) by situations related to patient flow, hospital policy, staffing, or other unknown factors.…”

Polypharmacy in Australian Veterans with Post-traumatic Stress Disorder upon Admission to a Mental Health Facility: A Retrospective Chart Review

“…The increased prescription of benzodiazepines in an inpatient sample is not unexpected given elevated symptom acuity and the drugs’ sedating and short-term anxiolytic effects; however, the above comorbid conditions are prevalent in our inpatient sample, and the cohort had an average age above 60 years, raising questions about prescribing practice. Despite the existing recommendations against their use in PTSD, benzodiazepines are still widely prescribed off-label for PTSD, other mental health conditions and chronic pain [ 35 ]. This common practice has been reported in up to 30–74% of cases of patients with PTSD, with advocates arguing that the effective symptomatic management with benzodiazepines for the anxiety and insomnia associated with PTSD makes them necessary for treatment-resistant patients with severe symptoms.…”

Examination of the clinical factors associated with attendance at emergency departments for chronic pain management and the cost of treatment relative to that of other significant medical conditions

“…Our findings that benzodiazepine or hypnotic use reduced ED attendance for CMP may relate to the central effects of these agents, with a possible decrease in anxiety (or insomnia), although these agents are recommended only for short term use. Furthermore, there are serious risks associated with the concomitant use of opioids and central nervous system depressants, which can ultimately result in premature mortality due to respiratory depression [1419,3041,4057,4361]. There is a need for further studies examining non-pharmaceutical interventions for the treatment of anxiety disorders and insomnia in patients with CMP to ensure safe and effective clinical practice.…”