Eight principles for safer opioid prescribing and cautions with benzodiazepines

Abstract

The provision of long-term opioid analgesic therapy for chronic pain requires a careful risk/benefit analysis followed by clinical safety measures to identify and reduce misuse, abuse, and addiction and their associated morbidity and mortality. Multiple data sources show that benzodiazepines, prescribed for comorbid insomnia, anxiety, and mood disorders, heighten the risk of respiratory depression and other adverse outcomes when combined with opioid therapy. Evidence is presented for hazards associated with coadministration of opioids and benzodiazepines and the need for caution when initiating opioid therapy for chronic pain. Clinical recommendations follow, as drawn from 2 previously published literature reviews, one of which proffers 8 principles for safer opioid prescribing; the other review presents risks associated with benzodiazepines, suggests alternatives for co-prescribing benzodiazepines and opioids, and outlines recommendations regarding co-prescribing if alternative therapies are ineffective.

Keywords:

• opioid analgesics
• benzodiazepines
• chronic pain
• mortality
• drug overdose
• therapeutic use

Acknowledgments

Special thanks to Nabarun Dasgupta, PhD, for providing portions of his dissertation, which was approved by the faculty of the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Department of Epidemiology. Beth Dove of Dove Medical Communications, LLC, Salt Lake City, Utah, provided technical writing and editorial assistance for this manuscript.

Declaration of interest: Lynn R. Webster has disclosed a relevant financial relationship with Acura Pharmaceuticals, AstraZeneca, BioDelivery Sciences International, Bristol-Myers Squibb, CVS Caremark, Depomed, Egalet, Grunenthal USA, Inspirion Pharmaceuticals, Insys Therapeutics, Jazz Pharmaceuticals, Kaleo, Mallinckrodt Pharmaceuticals, Nektar Therapeutics, Nevro Corporation, Orexo Pharmaceuticals, Signature Therapeutics, Synchrony Healthcare, Teva Pharmaceuticals and Travena. Gary M. Reisfield and Nabarun Dasgupta have no conflicts of interest to declare.