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Dangerous Drug Combinations to Treat Chronic Pain
and Mental Health Conditions

Study finds that the rate of prescribing for pain medications has slowed while dangerous multidrug use has not.

Although the United States may have passed the peak in the use and abuse of prescription opioids, recent studies show no decline in the coprescribing of opioid pain medications and sedatives, whose interaction can slow breathing and dramatically raise the risk of overdose death.

"Multidrug use is the trailing edge of the opioid epidemic," says Mark Sullivan, MD, PhD, a University of Washington (UW) professor of psychiatry and behavioral sciences and the executive director of COPE (Collaborative Opioid Prescribing Education) for Chronic Pain CME at the UW School of Medicine. "We are making progress on decreasing opioid prescribing, but coprescribing of opioids and sedatives has not decreased."

This is important, he says, because most prescription opioid deaths commonly involve alcohol, sedatives, and/or illicit drugs such as heroin. But the most fatal combination is opioids and common benzodiazepines, which are medications prescribed for depression, anxiety, and sleep. A leading pain research specialist, Sullivan provided commentary, "What are we treating with opioid and sedative-hypnotic combination therapy?" in the August 2015 issue of the journal Pharmacoepidemiology and Drug Safety.

It is estimated that as many as 80% of unintentional overdose deaths related to opioids may involve benzodiazepines. Prescription opioids, benzodiazepines, and muscle relaxants are all central nervous system depressants, and their combination can slow breathing to the point of death. According to the Centers for Disease Control and Prevention, in 2013 more than 16,000 people in the United States died from overdoses involving opioid painkillers, and nearly 7,000 died from overdoses involving benzodiazepines.

The extent to which opioids and sedatives are coprescribed is detailed in new research by Marc LaRochelle, MD, MPH, an assistant professor of medicine at the Boston University School of Medicine, and colleagues, and published in the same issue of the journal. The authors found that prescribing benzodiazepines is three to four times more likely when opioids are prescribed. Their review of more than 30,000 patient visits from 2001 to 2010 found that when these patients were prescribed opioids for acute musculoskeletal pain, 33% also received a prescription for a sedative. Among patients who were prescribed opioids for chronic musculoskeletal pain, 36% of patients also received a prescription for a sedative. Persons with psychiatric and substance abuse disorders were more likely to be coprescribed high dose opioids and sedatives. For example, veterans with posttraumatic stress disorder (PTSD) were more likely to be coprescribed opioids and sedatives than veterans without PTSD.

"Patients who are on long-term combined opioid and benzodiazepine therapy are often on a treadmill," Sullivan says. "They feel relief when they take their medications and withdrawal when they stop, so they continue this combined therapy, even though many function poorly and some will die as a result."

Sullivan points out that solutions include improved prescriber education to help clinicians better understand the risks and benefits associated with prescription opioids. He notes that it is crucial to adopt more effective and integrated approaches to treating patients with chronic pain, and improve access to and insurance coverage for evidence-based substance abuse treatment, including medication-assisted treatment for opioid use disorders with buprenorphine and other medications.

— Source: University of Washington