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An Examination of Concurrent Opioid and Benzodiazepine Prescribing in 9 States, 2015

  • Gery P. Guy Jr.
    Correspondence
    Address correspondence to: Gery P. Guy Jr., PhD, MPH, Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway, MS-F62, Atlanta GA 30341.
    Affiliations
    Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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  • Kun Zhang
    Affiliations
    Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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  • John Halpin
    Affiliations
    Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
    Search for articles by this author
  • Wesley Sargent
    Affiliations
    Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
    Search for articles by this author
Published:September 27, 2019DOI:https://doi.org/10.1016/j.amepre.2019.06.007

      Introduction

      Concurrent prescribing of opioids and benzodiazepines is discouraged by evidence-based clinical guidelines because of the known risks of taking these medications in combination.

      Methods

      This study analyzed concurrent opioid and benzodiazepine prescribing in 9 states using the 2015 Prescription Behavior Surveillance System, a multistate database of de-identified prescription drug monitoring program data. Concurrent prescribing rates were examined among individuals with both an opioid and a benzodiazepine prescription. Among patients with concurrent prescribing, total days of opioid supply, daily dosage of opioids, and total days of concurrent prescriptions were examined. Analyses were stratified by whether concurrent prescribing was from a single prescriber or multiple prescribers. Opioid prescribing and concurrent opioid and benzodiazepine prescribing rates were examined by age and sex. Analyses were conducted in 2018.

      Results

      Among 19,977,642 patients that were prescribed an opioid, 21.6% (4,324,092) were also prescribed a benzodiazepine, of which 54.9% (2,375,219) had concurrent prescriptions. More than half of patients with concurrent opioids and benzodiazepines received prescriptions from 2 or more distinct prescribers. Mean total opioid days, daily opioid dosage, and days of concurrent prescribing were higher among patients when multiple prescribers were involved compared with concurrent prescriptions from the same prescriber. Concurrent prescribing was more common among adults aged ≥50 years and female patients.

      Conclusions

      Public health interventions are needed to reduce concurrent prescribing of opioids and benzodiazepines. Evidence-based guidelines can help reduce concurrent prescribing when one prescriber is involved, and utilization of prescription drug monitoring programs and improved care coordination could help address concurrent prescribing when multiple prescribers are involved.
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      REFERENCES

        • Jones CM
        • McAninch JK.
        Emergency department visits and overdose deaths from combined use of opioids and benzodiazepines.
        Am J Prev Med. 2015; 49: 493-501
        • Park TW
        • Saitz R
        • Ganoczy D
        • Ilgen MA
        • Bohnert ASB
        Benzodiazepine prescribing patterns and deaths from drug overdose among U.S. veterans receiving opioid analgesics: case-cohort study.
        BMJ. 2015; 350: h2698
        • Dasgupta N
        • Funk MJ
        • Proescholdbell S
        • et al.
        Cohort study of the impact of high-dose opioid analgesics on overdose mortality.
        Pain Med. 2016; 17: 85-98
        • Sun EC
        • Dixit A
        • Humphreys K
        • et al.
        Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis.
        BMJ. 2017; 356: j760
        • Jones JD
        • Mogali S
        • Comer SD
        Polydrug abuse: a review of opioid and benzodiazepine combination use.
        Drug Alcohol Depend. 2012; 125: 8-18
        • FDA Drug Safety Communication
        FDA warns about serious risks and death when combining opioid pain or cough medicines with benzodiazepines; requires its strongest warning.
        U.S. Food and Drug Administration, Silver Spring, MD2016
        www.fda.gov/drugs/drugsafety/ucm518473.htm
        Date accessed: June 20, 2019
        • Guy Jr., GP
        • Zhang K
        • Bohm MK
        • et al.
        Vital Signs: changes in opioid prescribing in the United States, 2006–2015.
        MMWR Morb Mortal Wkly Rep. 2017; 66: 697-704
        • Hwang CS
        • Kang EM
        • Kornegay CJ
        • et al.
        Trends in the concomitant prescribing of opioids and benzodiaepines, 2002–2014.
        Am J Prev Med. 2016; 51: 151-160
        • Hirshtritt ME
        • Delucchi KL
        • Olfson M
        Outpatient, combined use of opioid and benzodiazepine medications in the United States, 1993–2014.
        Prev Med Rep. 2017; 9: 49-54
        • Kim HS
        • McCarthy DM
        • Hoppe JA
        • Mark Courtney D
        • Lambert BL
        Emergency department provider perspectives on benzodiazepine-opioid coprescribing: a qualitative study.
        Acad Emerg Med. 2018; 25: 15-24
        • McClure FL
        • Niles JK
        • Kaufman HW
        • Gudin J
        Concurrent use of opioids and benzodiazepines: evaluation of prescription drug monitoring by a United States laboratory.
        J Addict Med. 2017; 11: 420-426
        • Hernandez I
        • He M
        • Brooks MM
        • Zhang Y
        Exposure–response association between concurrent opioid and benzodiazepine use and risk of opioid-related overdose in Medicare part D beneficiaries.
        JAMA Netw Open. 2018; 1e180919
        • Dowell D
        • Haegerich TM
        • Chou R
        CDC guideline for prescribing opioids for chronic pain–United States, 2016.
        MMWR Recomm Rep. 2016; 65: 1-49
        • National Center for Injury Prevention and Control
        CDC compilation of benzodiazepines, muscle relaxants, stimulants, zolpidem, and opioid analgesics with oral morphine milligram equivalent conversion factors, 2017 version.
        CDC, Atlanta, GA2017
        • Zhu Y
        • Coyle DT
        • Mohamoud M
        • et al.
        Concomitant use of buprenorphine for medication-assisted treatment of opioid use disorder and benzodiazepines: using the prescription behavior surveillance system.
        Drug Alcohol Depend. 2018; 187: 221-226
        • Strickler GK
        • Zhang K
        • Halpin JF
        • et al.
        Effects of mandatory prescription drug monitoring program (PDMP) use laws on prescriber registration and use on risky prescribing.
        Drug Alcohol Depend. 2019; 199: 1-9
        • Liu Y
        • Logan JE
        • Paulozzi LJ
        • Zhang K
        • Jones CM
        Potential misuse and inappropriate prescription practices involving opioid analgesics.
        Am J Manag Care. 2013; 19: 648-658
        • Bohnert ASB
        • Guy Jr., GP
        • Losby JL
        Opioid prescribing in the United States before and after the Centers for Disease Control and Prevention's 2016 Opioid Guideline.
        Ann Intern Med. 2018; 169: 367-375
        • Dowell D
        • Haegerich CR
        • Chou R
        No shortcuts to safer opioid prescribing.
        N Engl J Med. 2019; 380: 2285-2287
        • Dunn KM
        • Saunders KW
        • Rutter CM
        Opioid prescriptions for chronic pain and overdose: a cohort study.
        Ann Intern Med. 2010; 152: 85-92
        • Bohnert ASB
        • Valenstein M
        • Bair MJ
        Association between opioid prescribing patterns and opioid overdose-related deaths.
        JAMA. 2011; 305: 1315-1321
        • 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: 886-891
        • Shah A
        • Hayes CJ
        • Martin BC
        Characteristics of initial prescription episodes and likelihood of long-term opioid use - United States, 2006–2015.
        MMWR Morb Mortal Wkly Rep. 2017; 66: 265-269
        • Martin BC
        • Fan MY
        • Edlund MJ
        • et al.
        Long-term chronic opioid therapy discontinuation rates from the TROUP study.
        J Gen Intern Med. 2011; 26: 1450-1457
        • Dowell D
        • Zhang K
        • Noonan RK
        • Hockenberry JM
        Mandatory provider review and pain clinic laws reduce the amounts of opioids prescribed and overdose death rates.
        Health Aff (Millwood). 2016; 35: 1876-1883
        • Winstanley EL
        • Zhang Y
        • Mashni R
        • et al.
        Mandatory review of a prescription drug monitoring program and impact on opioid and benzodiazepine dispensing.
        Drug Alcohol Depend. 2018; 188: 169-174
        • Brandeis University Prescription Drug Monitoring Program Center of Excellence
        PDMP prescriber use mandates: characteristics, current status, and outcomes in selected states.
        Published 2016
        • O'Brien PL
        • Karnell LH
        • Gokhale M
        • et al.
        Prescribing of benzodiazepines and opioids to individuals with substance use disorders.
        Drug Alcohol Depend. 2017; 178: 223-230
        • Stein MD
        • Anderson BJ
        • Kenney SR
        • Bailey GL
        Beliefs about the consequences of using benzodiazepines among persons with opioid use disorder.
        J Subst Abus Treat. 2017; 77: 67-71
        • Paulozzi LJ
        • Strickler GK
        • Kreiner PW
        • Koris CM
        Controlled substance prescribing patterns–Prescription Behavior Surveillance System, eight states, 2013.
        MMWR Surveill Summ. 2015; 64: 1-14
        • Kessler RC
        • McGonagle KA
        • Zhao S
        Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National comorbidity Survey.
        Arch Gen Psychiatry. 1994; 51: 8-19
        • Olfson M
        • King M
        • Schoenbaum M
        Benzodiazepine use in the United States.
        JAMA Psychiatry. 2015; 72: 136-142
        • Huang AR
        • Mallet L
        • Rochefort CM
        • et al.
        Medication-related falls in the elderly: causative factors and preventive strategies.
        Drugs Aging. 2012; 29: 359-376
        • Woolcott JC
        • Richardson KJ
        • Wiens MO
        Meta-analysis of the impact of 9 medication classes on falls in elderly persons.
        Arch Intern Med. 2009; 169: 1952-1960
        • Hampton LM
        • Daubresse M
        • Chang HY
        • Alexander GC
        • Budnitz DS
        Emergency department visits by adults for psychiatric medication adverse events.
        JAMA Psychiatry. 2014; 71: 1006-1014
        • Zint K
        • Haefeli WE
        • Glynn RJ
        • et al.
        Impact of drug interactions, dosage, and duration of therapy on the risk of hip fracture associated with benzodiazepine use in older adults.
        Pharmacoepidemiol Drug Saf. 2010; 19: 1248-1255