Mind Over Matter: Prescription Pain Medications (Opioids)

 

Long-term opioid use changes the way nerve cells work in the brain. This happens even to people who take opioids for a long time to treat pain, as prescribed by their doctor. The nerve cells grow used to having opioids around, so that when they are taken away suddenly, the person can have lots of unpleasant feelings and reactions. These are known as withdrawal symptoms.

Have you ever had the flu? You probably had aching, fever, sweating, shaking, or chills. These are similar to withdrawal symptoms, but withdrawal symptoms are much worse.

That is why use of opioids should be carefully watched by a doctor—so that a person knows how much to take and when, as well as how to stop taking them to lessen the chances of withdrawal symptoms. Eventually, the cells will work normally again, but that takes time.

Someone who is addicted to opioids has other problems as well. For example, they keep taking the drug even though it may be having harmful effects on their life and their health. They have strong urges to take the drug—called cravings—and they no longer feel satisfied by natural rewards (like chocolate, TV, or a walk on the beach).

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Benzodiazepines and Opioids | National Institute on Drug Abuse (NIDA)

 

More than 30 percent of overdoses involving opioids also involve benzodiazepines, a type of prescription sedative commonly prescribed for anxiety or to help with insomnia. Benzodiazepines (sometimes called “benzos”) work to calm or sedate a person, by raising the level of the inhibitory neurotransmitter GABA in the brain. Common benzodiazepines include diazepam (Valium), alprazolam (Xanax), and clonazepam (Klonopin), among others.

Every day, more than 115 Americans die after overdosing on opioids.1 However, between 1996 and 2013, the number of adults who filled a benzodiazepine prescription increased by 67%, from 8.1 million to 13.5 million.2 The quantity obtained also increased from 1.1 kg to 3.6 kg lorazepam-equivalents per 100,000 adults. Combining opioids and benzodiazepines can be unsafe because both types of drug sedate users and suppress breathing—the cause of overdose fatality—in addition to impairing cognitive functions. In 2015, 23 percent of people who died of an opioid overdose also tested positive for benzodiazepines (see graph).3 Unfortunately, many people are prescribed both drugs simultaneously. In a study of over 300,000 continuously insured patients receiving opioid prescriptions between 2001 and 2013, the percentage of persons also prescribed benzodiazepines rose to 17 percent in 2013 from nine percent in 2001.4 The study showed that people concurrently using both drugs are at higher risk of visiting the emergency department or being admitted to a hospital for a drug-related emergency.

Previous studies have also highlighted the dangers of co-prescribing opioids and benzodiazepines. A cohort study in North Carolina found that the overdose death rate among patients receiving both types of medications was 10 times higher than among those only receiving opioids.5 In a study of overdose deaths in people prescribed opioids for noncancer pain in Canada, 60 percent also tested positive for benzodiazepines.6 A study among U.S. veterans with an opioid prescription found that receiving a benzodiazepine prescription was associated with increased risk of drug overdose death in a dose-response fashion.7

In 2016, the Centers for Disease Control and Prevention (CDC) issued new guidelines for the prescribing of opioids.8 They recommend that clinicians avoid prescribing benzodiazepines concurrently with opioids whenever possible. Both prescription opioids and benzodiazepines now carry FDA “black box” warnings on the label highlighting the dangers of using these drugs together. People being prescribed any medications should inform their doctors about all of the other drugs and medications they use, and patients should consult with their doctors about the potential dangers of using various medications and substances together, including the use of alcohol.

Line graph showing causes of death from opioids, benzodiazepines and opioids, and opioids without benzodiazepines between 1999 and 2015Source: Centers for Disease Control and Prevention (CDC). Multiple Cause of Death, 1999-2015.

References

  1. Centers for Disease Control and Prevention (CDC). National Vital Statistics System, Mortality. CDC WONDER Online Database. https://wonder.cdc.gov/. Published 2017. Accessed April 4, 2017.
  2. Bachhuber MA, Hennessy S, Cunningham CO, Starrels JL. Increasing Benzodiazepine Prescriptions and Overdose Mortality in the United States, 1996-2013. Am J Public Health. 2016;106(4):686-688. doi:10.2105/AJPH.2016.303061
  3. Centers for Disease Control and Prevention (CDC). Multiple Cause of Death, 1999-2015. CDC WONDER Online Database. https://wonder.cdc.gov/mcd-icd10.html. Accessed April 4, 2017.
  4. Sun EC, Dixit A, Humphreys K, Darnall BD, Baker LC, Mackey S. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. BMJ. 2017;356:j760.
  5. Dasgupta N, Funk MJ, Proescholdbell S, Hirsch A, Ribisl KM, Marshall S. Cohort Study of the Impact of High-Dose Opioid Analgesics on Overdose Mortality. Pain Med Malden Mass. 2016;17(1):85-98. doi:10.1111/pme.12907.
  6. Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011;171(7):686-691. doi:10.1001/archinternmed.2011.117.
  7. Park TW, Saitz R, Ganoczy D, Ilgen MA, Bohnert ASB. Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study. BMJ. 2015;350:h2698. doi:10.1136/bmj.h2698.
  8. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016;65. doi:10.15585/mmwr.rr6501e1er.

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Fentanyl and Other Synthetic Opioids Drug Overdose Deaths

 

Figure 1: Recent Trends

In 2016, synthetic opioids (primarily illegal fentanyl) passed prescription opioids as the most common drugs involved in overdose deaths in the United States.

In 2016, synthetic opioids were involved in nearly 50% (19,413) of opioid-related deaths, up from 14% (3,007) in 2010.

*This infographic summarizes mortality data from 2010-2016. Please note, 15 to 25 percent of death certificates analyzed did not indicate the type of drug involved in the overdose. This was because drug tests were not conducted or there was a failure to record test results on death certificates.

Figure 2: Synthetic Opioids Linked to Overdose Deaths with Other Substances

In 2016, 42,249 drug overdose deaths involved opioids. Of those, 45.9% involved synthetic opioids. 17,087 overdose deaths involved prescription opioids. Of those, 23.7% involved synthetic opioids. 15,469 overdose deaths heroin. Of those, 37.4% involved synthetic opioids. 10,375 overdose deaths involved cocaine. Of those, 40.3% involved synthetic opioids. 7,542 overdose deaths involved psychostimulants. Of those, 13.8% involved synthetic opioids. 10,684 overdose deaths involved benzodiazepines. Of those, 31.0% involved synthetic opioids. 4,812 overdose deaths involved antidepressants. Of those, 20.8% involved synthetic opioids. 1,877 overdose deaths involved antipsychotics and neuroleptics. Of those, 20.5% involved synthetic opioids. 409 overdose deaths involved barbiturates. Of those, 21.5% involved synthetic opioids. 543 overdose deaths involved other illicit drugs. Of those, 26.5% involved synthetic opioids.

*Deaths are not mutually exclusive. Deaths involving more than one drug or drug class are counted multiple times.

Figure 3: Type of Opioid Involved in Opioid-Related Overdose Deaths

Among the 42,249 opioid-related overdose deaths in 2016, 19,413 involved synthetic opioids, 17,087 involved prescription opioids, and 15,469 involved heroin.

*Deaths are not mutually exclusive. Deaths involving more than one drug or drug class are counted multiple times.

Figure 4: HHS Response to the Opioid Crisis

HHS is committed to:

  1. improving access to treatment and recovery services
  2. promoting use of overdose-reversing drugs
  3. strengthening our understanding of the epidemic through better public health surveillance
  4. providing supporting for cutting-edge research on pain and addiction
  5. advancing better practices for pain management

For more information about finding treatment for yourself or a loved one, visit drugabuse.gov/related-topics/treatment.

References:

Jones CM, Einstein EB, Compton WM. Changes in Synthetic Opioid Involvement in Drug Overdose Deaths in the United States, 2010-2016. JAMA. 2018;319(17):1819-1821.

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