Risks, Management, and Monitoring of Combination Opioid, Benzodiazepines, and/or Alcohol Use

Abstract

The concurrent use of opioids, benzodiazepines (BZDs), and/or alcohol poses a formidable challenge for clinicians who manage chronic pain. While the escalating use of opioid analgesics for the treatment of chronic pain and the concomitant rise in opioid-related abuse and misuse are widely recognized trends, the contribution of combination use of BZDs, alcohol, and/or other sedative agents to opioid-related morbidity and mortality is underappreciated, even when these agents are used appropriately. Patients with chronic pain who use opioid analgesics along with BZDs and/or alcohol are at higher risk for fatal/nonfatal overdose and have more aberrant behaviors. Few practice guidelines for BZD treatment are readily available, especially when they are combined clinically with opioid analgesics and other central nervous system–depressant agents. However, coadministration of these agents produces a defined increase in rates of adverse events, overdose, and death, warranting close monitoring and consideration when treating patients with pain. To improve patient outcomes, ongoing screening for aberrant behavior, monitoring of treatment compliance, documentation of medical necessity, and the adjustment of treatment to clinical changes are essential. In this article, we review the prevalence and pharmacologic consequences of BZDs and/or alcohol use among patients with pain on chronic opioid therapy, as well as the importance of urine drug testing, an indispensable tool for therapeutic drug monitoring, which helps to ensure the continued safety of patients. Regardless of risk or known aberrant drug-related behaviors, patients on chronic opioid therapy should periodically undergo urine drug testing to confirm adherence to the treatment plan.

Routes of abuse of prescription opioid analgesics: a review and assessment of the potential impact of abuse-deterrent formulations

“…Abusers may also co-administer prescription opioid analgesics with alcoholic drinks or other substances (e.g., benzodiazepines, barbiturates or antidepressants). [18,19] Furthermore, individual abusers often report utilizing several different routes of abuse.…”

Behind the prescriptions: a snapshot of opioid use across all Ontarians

“…1 In particular, studies have shown that opioids are being increasingly prescribed, and that higher doses and co-prescription with other drugs (such as benzodiazepines) can increase the risk of overdoses. 2 The provincial population-based databases housed at Ontario's Institute for Clinical Evaluative Sciences (ICES) serve as an important resource for studying the utilization and outcomes associated with opioids for the populations covered under the public drug plan. However, due to data limitations, much of the research using these databases has been limited to sub-groups of Ontarians, such as seniors and social assistance recipients.…”

Recomendações para uso de opioides no Brasil: parte I

“…Dose should be maintained or increased if patient, during withdrawal, has withdrawal syndrome, significant pain increase or changes in quality of life. Withdrawal may take from two to three weeks to three to four months and it is necessary to avoid sedatives, especially benzodiazepines 14 . It is important to stress that during pregnancy its acute withdrawal has been associated to premature birth and spontaneous abortion, in addition to risk to mother's health.…”