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We all know that opioid pain medications, such as oxycodone and hydrocodone, and anxiety-suppressing benzodiazepines like alprazolam (Xanax) and lorazepam (Ativan), can be addictive. Over time, higher doses are needed to produce the same effects, a phenomenon known as tolerance. Dovetailing with tolerance is dependence, whereby people experience an inability to function without the medications. Moreover, these drugs can cause euphoria. Opioids may numb emotional as well as physical pain, while benzodiazepines can work a little too well to eliminate anxiety. As a result, people become tempted to take more than prescribed. Misuse of either drug poses a risk of fatal overdose.
Twin Epidemics
Decades of overprescribing of opioids and benzodiazepines has led to twin epidemics of addiction and overdose. In the 1990s and 2000s, a nationwide campaign to treat pain as “the fifth vital sign” and aggressive marketing practices pharmaceutical companies brought a four-fold increase in opioid prescriptions as well as an alarming rise in nonmedical use of these drugs. Now, approximately 2.5 million adults in the U.S. are living with opioid use disorder (OUD), while we are losing about 80,000 lives per year to opioid overdose.
A similar trend occurred with benzodiazepines: Between 1996 and 2013, prescriptions climbed 67%, while the overdose death rate more than quadrupled. The number of U.S. adults with a prescription sedative or tranquilizer use disorder does not lag far behind that of OUD: 2.2 million. Taking opioids and benzodiazepines together (vs opioids alone) raises the overdose risk 10-fold, yet coprescribing of the two classes of drugs soared in the 2000s.
Overprescribing may have gotten us into these crises, but the path out is not as straightforward as deprescribing. In both the short- and long-term, cessation of opioids and benzodiazepines carries serious risks. Abrupt discontinuation of either class of drug can rapidly cause withdrawal. Even after a year or more, patients cut off from a long-term prescription face an increased chance of death.
Withdrawal
Imagine the worst flu of your life. That’s what opioid withdrawal feels like: runny nose, vomiting, diarrhea. While rarely life-threatening, it is associated with increased emergency department utilization. Benzodiazepine withdrawal, which mirrors alcohol withdrawal, is a more serious syndrome that can include seizures and even death. With both classes of drug, withdrawal can set in within several hours of discontinuation.
Turning to More Dangerous Drugs
Even after withdrawal symptoms resolve, patients may suffer from underlying pain or anxiety and self-medicate with alcohol or illicit drugs. One study showed that discontinuing prescription opioid therapy doubled the risk of heroin use. Some experts have hypothesized that patients cut off benzodiazepines may drink to calm their nerves.
Use of non-prescribed drugs, including alcohol, can cause serious intoxication or overdose. Stopping prescription opioids is associated with a nearly threefold risk of fatal overdose. Benzodiazepine discontinuation has been linked with a small but statistically significant chance of overdose, both in patients who were also exposed to opioids and those who were not. This finding was noted in a study that followed patients for a year after they stopped their prescription, contrasting with previous observations of fewer adverse events over shorter follow-up intervals. The discrepancy suggests that after losing access to a prescription, people may engage in escalating use of non-prescribed substances over time, placing themselves in growing danger. Opioid overdose risk can persist up to two years beyond the start of tapering the prescription.
Suicidal Ideation
Another frightening potential consequence of stopping opioids or benzodiazepines is suicide. After opioid discontinuation, data points to a high-risk window for suicide (as well as overdose) of up to 100 days. For mental health crises, which include depression or anxiety as well as suicide attempts, that window expands to up to two years. Suicidal thoughts, attempts, and self-inflicted injury were all increased in patients taken off benzodiazepines at one-year follow-up.
Guidelines Offer Hope
Opioids and benzodiazepines have numerous parallels, both in the perils of using these drugs and the dangers associated with stopping them. Thankfully, organizations including the Centers for Disease Control (CDC), the American Academy of Family Physicians (AAFP), and the Veterans Administration (VA), have issued evidence-based recommendations to safely taper these medications.
Addiction Essential Reads
A patient-centered approach is key to tapering opioids and benzodiazepines. Clinician and patient should share in the process of deciding whether to taper off completely or reduce the dose to a safer level, as well as the speed of the taper. A rate of 10% per month may be appropriate for both classes of drugs. Should withdrawal or severe pain or anxiety occur, patients should have the option to slow down or even pause the taper. For patients who struggle to come off full opioids like oxycodone, switching to the safer partial opioid buprenorphine can be considered. Close follow-up allows for the plan to be adjusted and maintains the therapeutic alliance, which may be particularly strong if the clinician is the patient’s primary care provider.
Adjunctive medications to alleviate pain, anxiety, and withdrawal should be offered during tapers. These include NSAIDs like ibuprofen for pain and SSRIs for anxiety. Opioid withdrawal can be managed with anti-nausea medications and antidiarrheals, while benzodiazepine withdrawal is more likely to require pausing the taper and/or switching to a different type of benzodiazepine or sedative. The opioid-overdose reversal agent naloxone should also be prescribed.
Nonpharmacologic supports play a key role as well. Exercise and physical therapy can mitigate pain, while talk therapy, and in particular cognitive behavioral therapy (CBT), addresses anxiety.
Freedom From Addictive Substances
Opioid and benzodiazepine discontinuation are fraught with similar hazards. Yet, the solutions are also similar. As an addiction medicine specialist, I have seen that utilizing an evidence-based, patient-centered taper strategy liberates people from relying on a dangerous substance to get through their day. To quote one of my patients, exhilarated after we completed a taper of the lorazepam she had been prescribed for 40 years: “I feel like I am finally free.”