MentalHealth+

Sun EC, Dixit A, Humphreys K, et al. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. BMJ. 2017 Mar 14;356:j760. doi: 10.1136/bmj.j760.
Discipline Area Score
Physician 5 / 7
Abstract

Objectives To identify trends in concurrent use of a benzodiazepine and an opioid and to identify the impact of these trends on admissions to hospital and emergency room visits for opioid overdose.Design Retrospective analysis of claims data, 2001-13.Setting Administrative health claims database.Participants 315?428 privately insured people aged 18-64 who were continuously enrolled in a health plan with medical and pharmacy benefits during the study period and who also filled at least one prescription for an opioid.Interventions Concurrent benzodiazepine/opioid use, defined as an overlap of at least one day in the time periods covered by prescriptions for each drug. Main outcome measures Annual percentage of opioid users with concurrent benzodiazepine use; annual incidence of visits to emergency room and inpatient admissions for opioid overdose.Results 9% of opioid users also used a benzodiazepine in 2001, increasing to 17% in 2013 (80% relative increase). This increase was driven mainly by increases among intermittent, as opposed to chronic, opioid users. Compared with opioid users who did not use benzodiazepines, concurrent use of both drugs was associated with an increased risk of an emergency room visit or inpatient admission for opioid overdose (adjusted odds ratio 2.14, 95% confidence interval 2.05 to 2.24; P<0.001) among all opioid users. The adjusted odds ratio for an emergency room visit or inpatient admission for opioid overdose was 1.42 (1.33 to 1.51; P<0.001) for intermittent opioid users and 1.81 (1.67 to 1.96; P<0.001) chronic opioid users. If this association is causal, elimination of concurrent benzodiazepine/opioid use could reduce the risk of emergency room visits related to opioid use and inpatient admissions for opioid overdose by an estimated 15% (95% confidence interval 14 to 16).Conclusions From 2001 to 2013, concurrent benzodiazepine/opioid use sharply increased in a large sample of privately insured patients in the US and significantly contributed to the overall population risk of opioid overdose.

Comments from MORE raters

Physician rater

This study contributes to the rapidly growing literature on the high risk associated with opioid prescriptions, with or without concomitant use of other drugs. Although it is very unlikely that many of the included patients received both opioid and benzo prescriptions in a single ED visit, it is nonetheless useful for ED physicians to be aware of the many facets that increase risk with respect to these medications.

Physician rater

I have little experience with this type of drug use. Unfortunately the study fails to describe drug levels in blood in order to differentiate which change is more important. It is logical that a combined use or abuse will have more consequences for health. What the study does not show is why the combination was taken or given, i.e. how can side effects be prevented.

Physician rater

Quite unsurprisingly, this large cohort study found that adding a potent sedative (benzodiazepines) to opioids is associated with an increased risk of ED visits and overdoses. While the study does not prove causation, this would seem to be common sense. Unfortunately, many providers, emergency physicians and others, continue to co-prescribe theses meds or add one to the other. Not using these meds for conditions that clearly don't benefit from them (benzodiazepines for muscle strains for example) would be low hanging fruit to decrease this likely dangerous practice.

Physician rater

As a hospitalist, I find this well done retrospective analysis looking at a robust data base, raises further alarms anytime we admit and/or DC someone on opioids and a benzo. Appropriate cautions and alternatives must be sought. While we must stay alert to the pitfalls of the methodologies used here (confounding and selection bias always a concern), this is aligned with other reports and makes clinical sense.

Physician rater

I have some qualms about the way the information is presented. The title says "association," and the discussion comments on the problems with the study, but the conclusion makes recommendations as if there was a "cause and effect." They acknowledge the problems and biases inherent in a retrospective chart review but try to explain away those issues with statistical manipulation, which may or should encourage physicians to carefully consider co-prescribing these may not be correct. Certainly, this study as well as the prior VA study medications and to monitor those patients carefully in whom they have decided to prescribe them, but I am afraid that those policy analysts who do not understand the limitations of the study will make a rule which will only complicate the care of these patients.