Certain factors associated with opioid, benzodiazepine coprescription
Patients on long-term opioid therapy were more likely to also get a benzodiazepine prescription if they were on more than 150 mg of morphine equivalents daily, if they started buprenorphine, or if they had anxiety not treated with a serotonergic medication, a retrospective study found.
Four factors were associated with increased likelihood of coprescription of opioids and benzodiazepines, a study found, while two other factors were negatively associated with coprescription.
Researchers conducted two retrospective cohort studies using California's prescription drug monitoring program (PDMP) from July 2016 to December 2018 and a national sample of commercial and Medicare Advantage enrollees during the same time span. The outcome was recorded incident benzodiazepine and opioid coprescription of 20 days or longer during any 30-day period. All patients were prescribed long-term opioids. The Medicare cohort excluded patients without continuous enrollment, with cancer diagnoses, or with use of hospice or prolonged inpatient skilled nursing care. Results were published online July 16 by the Journal of General Internal Medicine.
Among the 617,946 patients in the PDMP cohort and 223,885 in the Medicare cohort, incidence rates of coprescription were 4.6 and 3.9 cases per 1,000 patient-months, respectively. Important predictors included receiving more than 150 mg of morphine equivalents daily during baseline (adjusted hazard ratios [HRs], 1.74 [95% CI, 1.67 to 1.81] in the PDMP cohort and 2.66 [95% CI, 2.47 to 2.86] in the Medicare cohort) and starting buprenorphine to treat opioid use disorder, with continued treatment (HRs, 1.68 [95% CI, 1.49 to 1.89] and 2.10 [95% CI, 1.71 to 2.59], respectively) or without (HRs, 1.35 [95% CI, 1.18 to 1.56] and 1.64 [95% CI, 1.27 to 2.11], respectively).
Coprescription was also associated with short-term (60-day) decreases in opioid dose (HRs, 1.07 [95% CI, 1.04 to 1.10] in the PDMP cohort and 1.06 [95% CI, 1.01 to 1.12] in the Medicare cohort) but negatively associated with long-term (180-day) decreases (HRs, 0.81 [95% CI, 0.78 to 0.85] and 0.78 [95% CI, 0.73 to 0.84], respectively). Patients with anxiety diagnoses were at higher risk for coprescription, although risk was lower if accompanied by treatment with serotonergic anxiolytics.
Although the study did not test causation, the findings have implications for clinical care, the study authors wrote. To prevent coprescription of benzodiazepines among patients with long-term opioid therapy, strategies to reduce pain-associated anxiety and distress are critical, including cognitive behavioral therapy, relaxation techniques, and alternative treatments such as acupuncture. Additionally, lifestyle changes, specifically avoiding alcohol and caffeine, will improve sleep quality and reduce need for insomnia-related benzodiazepine use, the authors said.
“For patients undergoing opioid tapers, following best practices can reduce subsequent anxiety; such as initiating tapers in a slow, deliberative, and patient-centered manner, coordinating tapers with adjuvant treatments to mitigate withdrawal symptoms, and multidisciplinary coordinated care to ensure psychosocial support to reduce spikes in patient anxiety and pain,” the authors wrote.