______________________________________________________ Opioid Safety: Balancing Benefits and Risks
Clinicians should use unexpected results to improve patient safety (e.g., optimize pain management strategy [see Recom- mendation 2], carefully weigh benefits and risks of reducing or continuing opioid dosage [see Recommendation 5], re-evaluate more frequently [see Recommendation 7], offer naloxone [see Recommendation 8], and offer treatment or refer the patient treatment with medications for opioid use disorder [see Rec- ommendation 12], all as appropriate). Recommendation 11 Clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depres- sants (recommendation category: B, evidence type: 3). Implementation Considerations Although in some circumstances it might be appropriate to prescribe opioids to a patient who is also prescribed benzodi- azepines (e.g., severe acute pain in a patient taking long-term, stable low-dose benzodiazepine therapy), clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently. In addition, clinicians should consider whether benefits outweigh risks of concurrent use of opioids with other central nervous system depressants (e.g., muscle relaxants, non-benzodiazepine sedative hypnot- ics, potentially sedating anticonvulsant medications such as gabapentin and pregabalin). Buprenorphine or methadone for opioid use disorder should not be withheld from patients taking benzodiazepines or other medications that depress the central nervous system. Clinicians should check the PDMP for concurrent controlled medications prescribed by other clinicians (see Recommenda- tion 9) and should consider involving pharmacists as part of the management team when opioids are co-prescribed with other central nervous system depressants. In patients receiving opioids and benzodiazepines long-term, clinicians should carefully weigh the benefits and risks of con- tinuing therapy with opioids and benzodiazepines and discuss with patients and other members of the patient’s care team. Risks of concurrent opioid and benzodiazepine use are likely to be greater with unpredictable use of either medication, with use of higher-dosage opioids and higher-dosage benzodiazepines in combination, or with use with other substances including alcohol (compared with long-term stable use of lower-dosage opioids and lower-dosage benzodiazepines without other substances). In specific situations, benzodiazepines can be beneficial, and stopping benzodiazepines can be destabilizing. If risks are determined to outweigh benefits of continuing opioid and benzodiazepine therapy at current dosages and a decision is made to taper, it might be safer and more practical to
taper opioids first. There can be greater risks of benzodiazepine withdrawal relative to opioid withdrawal, and tapering opioids can be associated with anxiety (see Recommendation 5). Clinicians should taper benzodiazepines gradually prior to discontinuation because abrupt withdrawal can be associ- ated with rebound anxiety, hallucinations, seizures, delirium tremens, and, rarely, death. The rate of tapering should be individualized. If benzodiazepines prescribed for anxiety are tapered or dis- continued, or if patients receiving opioids require treatment for anxiety, evidence-based psychotherapies (e.g., CBT) and/or specific antidepressants or other nonbenzodiazepine medica- tions, or both, approved for anxiety should be offered. Clinicians should communicate with other clinicians manag- ing the patient to discuss the patient’s needs, prioritize patient goals, weigh risks of concurrent benzodiazepine and opioid exposure, and coordinate care. Recommendation 12 Clinicians should offer or arrange treatment evidence-based medications to treat patients with opioid use disorder. Detoxi- fication on its own, without medications for opioid use disor- der, is not recommended for opioid use disorder because of increased risks for resuming drug use, overdose, and overdose death (recommendation category: A, evidence type: 1). Implementation Considerations Although stigma can reduce the willingness of individuals with opioid use disorder to seek treatment, opioid use disorder is a chronic, treatable disease from which people can recover and continue to lead healthy lives. If clinicians suspect opioid use disorder, they should discuss their concern with their patient in a nonjudgmental manner and provide an opportunity for the patient to disclose related concerns or problems. Clinicians should assess for the presence of opioid use disor- der using criteria from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders . For patients meeting criteria for opioid use disorder, particu- larly if moderate or severe, clinicians should offer or arrange for patients to receive evidence-based treatment with medications for opioid use disorder. Clinicians should not dismiss patients from their practice because of opioid use disorder because this can adversely affect patient safety. Medication treatment of opioid use disorder has been associ- ated with reduced risk for overdose and overall deaths. Iden- tification of opioid use disorder represents an opportunity for a clinician to initiate potentially life-saving interventions, and should the clinician collaborate with the patient regarding their safety to increase the likelihood of successful treatment.
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