Author: James Anderson

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

Management should be tailored based on whether patients are using their medications safely and appropriately or to address reasons for misuse. Benzodiazepines, such as alprazolam (Xanax®), diazepam (Valium®), clonazepam (Klonopin®), and lorazepam (Ativan®), depress central nervous system (CNS) activity and are used to relieve symptoms of anxiety, panic attacks, and seizures.1,2 They have been deemed safe and effective when taken as prescribed and directed. However, when combined with other drugs that depress CNS activity, such as alcohol or opioid pain relievers like oxycodone (OxyContin®), hydrocodone (Vicodin®), hydromorphone (Dilaudid®), or morphine, benzodiazepines may present serious or even life-threatening problems. Approximately 40% of patients with pain who are undergoing opioid therapy also take BZDs.49,51–53 Recognizing the risks for adverse events when these agents are used in combination, patients on chronic opioid therapy should be screened for BZD use before and throughout the course of treatment. Clinicians should be especially attentive to patient populations who are more likely to concurrently use sedatives (Table 1).

Always ask your doctor if you have questions about the medications you’ve been prescribed. If you think you may be addicted to hydrocodone or Xanax, seek help from a qualified medical professional or rehab facility. Multiple studies have found that people who had received opioids and benzodiazepines at the same time felt higher and more sedated than taking either drug alone, according to a 2012 review in the journal Drug and Alcohol Dependence.

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances. B) Nitrobenzodiazepines and C) triazolobenzodiazepines are metabolized to their corresponding amino or hydroxyl compounds without being converted to oxazepam. Alcohol use disorder and risky drinking behavior were defined by the Alcohol Use Disorders Identification Test–Consumption.

This stresses the need to send the sample to a laboratory for more advanced qualitative or quantitative screening. Overall, 62 percent of visits involving benzodiazepines combined with opioids or alcohol resulted in a less serious outcome, and 38 percent resulted in a more serious outcome. The logistic regression model discussed above was used to predict risk of a visit resulting in a more serious outcome. In this case, risk is simply the proportion of individuals who experience a more serious outcome. For example, Tables 1 and 2 show that in the estimated 174,998 ED visits among patients aged 12 to 34 involving a benzodiazepine alone, patients faced a predicted 28 percent risk of a more serious outcome. In other words, the model predicts that 28 percent of such visits will result in a more serious outcome, and 72 percent will result in a less serious outcome.

Signs That You’re at Risk

Although the utility of these tools is limited because they rely on patient self-report, the sensitivity and specificity of the tests in detecting problematic alcohol use are generally ≥ 80%.56 Even a single-item test asking “How many times in the past year have you had 5 4 for women or more drinks in a day? ” is 82% sensitive and 79% specific for identifying unhealthy alcohol use.63 Screening instruments to assess risks related to BZD use are not readily available. In the next section, we discuss more objective screening and monitoring tools for alcohol, opioid, and BZD use. Combining the drugs is dangerous because each drug can slow breathing.

Interactions between your drugs

If someone experiences these symptoms, call 911 immediately. Administer the opioid reversal medication naloxone if you have access to it. Perform rescue breathing until first responders arrive if the person stops breathing.

  1. You may feel more drowsy, dizzy, or tired if you take ALPRAZolam with alcohol.
  2. That’s why both drugs carry a “black box” warning about the dangers of using them together.
  3. Use of breathalyzer tests is an affordable option for objectively assessing recent alcohol use.
  4. Because distinguishing motives among patients abusing their medications may be difficult, clinicians must use risk-stratification tools as part of every patient’s assessment.
  5. The new requirements for opioid analgesics (which include oxycodone and hydrocodone) and benzodiazepines follow a 41 percent increase in the number of patients prescribed both classes of drugs over the last decade and a resulting increase in overdose deaths in which they were used together.
  6. In this case, risk is simply the proportion of individuals who experience a more serious outcome.

Screening, Brief Intervention, Referral to Treatment

It bothers me that there are non-professionals answering these questions on here. If the answers are coming from a doctor or medical professional person it would be different, but these answers could actually be coming from a 12 year old or a mentally unbalanced person. Ask your doctor questions like this, you’ll stay safer that way.

Save Interactions List

Using narcotic pain or cough medications together with other medications that also cause central nervous system depression can lead to serious side effects including profound sedation, respiratory distress, coma, and even death. Your doctor may be able to prescribe alternatives that do not interact, or you may need a dose adjustment or more frequent monitoring to safely use both medications. Do not drink alcohol or self-medicate with these medications without your doctor’s approval, and do not exceed the doses or frequency and duration of use prescribed by your doctor. Also, because these medications may cause dizziness, drowsiness, difficulty concentrating, and impairment in judgment, reaction speed and motor coordination, you should avoid driving or operating hazardous machinery until you know how they affect you. Do not stop using any medications without first talking to your doctor. In 2021, nearly 14% of overdose deaths involving opioids also involved benzodiazepines, a type of prescription sedative commonly prescribed for anxiety or to help with insomnia.3 Benzodiazepines (sometimes called “benzos”) work to calm or sedate a person, by raising the level of the inhibitory neurotransmitter GABA in the brain.

Clinicians, especially those in primary care and pain management, should consider routine toxicology testing. It is imperative for health care professionals to have objective evidence about the recent substance use of a patient. Urine drug testing and PMPs are 2 indispensible tools that can identify patients who are nonadherent to treatment, have filled multiple prescriptions at multiple pharmacies, and/or are abusing prescription drugs and/or illicit drugs. Whether UDTs and PMPs will affect overdose death rates remains to be seen. Ongoing screening for aberrant behavior, monitoring treatment compliance, documentation of medical necessity, and adjusting treatment to clinical changes are essential for improved patient outcomes.

Benzodiazepines in Combination with Opioid Pain Relievers or Alcohol: Greater Risk of More Serious ED Visit Outcomes

Many offices have adopted POC immunoassay testing for prescribed and illicit agents. Although POC tests offer rapid results, clinicians need to understand the limitations (ie, regarding sensitivity/specificity) of these tests and the clinical utility of laboratory confirmations with GC/MS or LC/MS. Recent advances in testing for alcohol use with biomarkers, such as EtG and EtS, have extended the detection window, allowing for improved/extended monitoring of alcohol use. Clinicians should routinely counsel patients about the dangers of combining opioids with BZDs and/or alcohol and discuss compliance testing as part of a safety monitoring program.

Curves represent data obtained for the major substance of abuse; however, multiple drugs may be involved in each visit. Alcohol combined with other drugs is recorded for all ages and alcohol only for patients aged ≤ 20 years. Treating individuals who are abusing BZDs, opioids, and/or alcohol presents a special challenge owing to additive risk and physical dependence.

Common benzodiazepines include diazepam (Valium), alprazolam (Xanax), and clonazepam (Klonopin), among others. Drug test results should be interpreted with the patient history and risk factors taken into consideration. To best understand and minimize false-positive findings, a thorough history of any potentially cross-reacting substance use should be documented.5,85 Tables for cross-reacting substances are readily available in the literature. In addition, patients should be encouraged to avoid using substances that may interfere with drug testing. When prescribing controlled substances and employing therapeutic drug monitoring, meticulous documentation in the medical record is recommended. Clinicians should document test results, interventions, and any other changes in the patient’s clinical presentation.