A little-commented on aspect of the opioid epidemic is the polypharmaceutical nature of the overdoses. For many deaths, it isn’t just morphine or oxycodone found in the drug toxicology report. There can be antidepressants, stimulants, alcohol, and perhaps of most concern, benzodiazepines. If you think opioids are overprescribed, then benzodiazepines, or benzos, are on a whole other level. Used primarily for anxiety, these sedatives can also be used for insomnia, seizures, and as muscle relaxants. We know the drugs in this class through their brand and generic names Xanax, diazepam, Rohypnol, Ativan, and Restoril.
What concerns the medical community about benzos and opioids are their drug-drug interactions. This interaction, or synergistic effect, can increase the rewarding and reinforcing effects of opioids (link), thus increasing the risk of addiction. Additionally, benzos can alter respiratory function just like the opioids and we see the two together among many of the fatalities. Estimates for concomitant use of these drugs is high. In my own studies, I’ve seen prevalence ranging from 50-70% among people who overdosed or had problematic opioid use.
We know that benzos have addictive potential, but its impact hasn’t seeped into the public consciousness. Benzos enhance the effect of the GABA protein, or in vastly simplified terms, the relaxation neurotransmitter. Hence, the use in anxiety. Although they can give a high, it might be more likely that abuse of benzos come from self-medication for undiagnosed anxiety disorders. Like with other addictive drugs, you can develop tolerance and withdrawal symptoms from prolonged use. Benzo withdrawals have been described by addicts as extremely intense and painful. There’s a wide variety of symptoms ranging from anxiety, panic attacks, and seizures, to hallucinations, psychosis, and suicide. These drugs are not to be underestimated.
Guidelines are clear on opioid and benzo polypharmacy. Don’t use them together. Easier said than done. Benzos are probably prescribed at much higher rates than opioids and have cheaper street prices. And like opioids, they require tapering to avoid withdrawal. There’s a further problem. Then what? The patient is safer, but the underlying condition requiring the benzos remain. I’m mainly thinking of the anxiety, insomnia, and panic attacks that threaten the success of addiction treatment. There are alternatives: cognitive therapy, buspirone, the SSRIs, but there needs to be more emphasis on finding ways around benzos.
You don’t have to be a drug abuser to fall prey to the benzo and opioid trap. One of the largest problems in the US healthcare system is its fractured nature. Doctors don’t talk to pharmacists. Psychiatrists don’t talk to primary care physicians. Nurses don’t talk to physician assistants. And who talks to dentists? You can be prescribed an opioid from a pain specialist and a benzodiazepine from a psychiatrist and neither of them may ever know. The general public may be aware of the dangers of opioids, but perhaps not of benzos, and most certainly not their drug interactions. Unless we make some large changes to how we provide care, it will be up to the patient to be aware of the risks. If you take multiple drugs, be crystal clear on what they are for, how much should be taken each day, and how long you’re supposed to use them. Try a “brown bag” approach where you take your medications and consult with a pharmacist or your doctor.
There are still many unanswered questions. Which benzos are problematic? Where do people obtain them? Unfortunately, unlike opioids, we don’t have something akin to morphine milligram equivalents (although the use of that standard is under debate) for benzos. What would be a high dose? What would be long-term use? And what is the risk of relapse?
Summary: Benzos are not safe drugs. More attention needs to be paid to their role in the opioid epidemic.