Risks, management, and monitoring of combination opioid, benzodiazepines, and/or alcohol use.
The concurrent use of opioids, benzodiazepines (BZDs), and/or alcohol poses a formidable challenge for clinicians who manage chronic pain. While the escalating use of opioid analgesics for the treatment of chronic pain and the concomitant rise in opioid-related abuse and misuse are widely recognized trends, the contribution of combination use of BZDs, alcohol, and/or other sedative agents to opioid-related morbidity and mortality is underappreciated, even when these agents are used appropriately. Patients with chronic pain who use opioid analgesics along with BZDs and/or alcohol are at higher risk for fatal/nonfatal overdose and have more aberrant behaviors. Few practice guidelines for BZD treatment are readily available, especially when they are combined clinically with opioid analgesics and other central nervous system-depressant agents. However, coadministration of these agents produces a defined increase in rates of adverse events, overdose, and death, warranting close monitoring and consideration when treating patients with pain. To improve patient outcomes, ongoing screening for aberrant behavior, monitoring of treatment compliance, documentation of medical necessity, and the adjustment of treatment to clinical changes are essential. In this article, we review the prevalence and pharmacologic consequences of BZDs and/or alcohol use among patients with pain on chronic opioid therapy, as well as the importance of urine drug testing, an indispensable tool for therapeutic drug monitoring, which helps to ensure the continued safety of patients. Regardless of risk or known aberrant drug-related behaviors, patients on chronic opioid therapy should periodically undergo urine drug testing to confirm adherence to the treatment plan.
Pain Management and Wellness Center, Englewood Hospital and Medical Center, Englewood, NJ 07631, USA. healthmd@optonline.net
Jeffrey A
JA
Gudin
Shanthi
S
Mogali
Jermaine D
JD
Jones
Sandra D
SD
Comer
D000428:Alcohol Drinking / Q000009:adverse effects*; D000701:Analgesics, Opioid / Q000009:adverse effects* / Q000627:therapeutic use; D001569:Benzodiazepines / Q000009:adverse effects* / Q000627:therapeutic use; D059350:Chronic Pain / Q000150:complications / Q000188:drug therapy* / Q000523:psychology; D004347:Drug Interactions; D016903:Drug Monitoring; D062787:Drug Overdose / Q000517:prevention & control; D006801:Humans; D006993:Hypnotics and Sedatives / Q000009:adverse effects* / Q000627:therapeutic use; D055118:Medication Adherence; D019964:Mood Disorders / Q000150:complications / Q000188:drug therapy* / Q000523:psychology; D009293:Opioid-Related Disorders / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control / Q000652:urine; D018570:Risk Assessment; D012307:Risk Factors; D012651:Self Medication / Q000009:adverse effects; D019966:Substance-Related Disorders / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control* / Q000652:urine
D000701:Analgesics, Opioid; D006993:Hypnotics and Sedatives; D001569:Benzodiazepines