Alcohol and Benzodiazepines Commonly Co-Involved in U.S. Opioid Overdose Deaths, Study Finds

Opioids are a class of drugs that includes three main types.[1] The first type is natural or semisynthetic prescription opioids, such as codeine (generic only), hydrocodone (HYSINGLA ER, ZOHYDRO ER), morphine (KADIAN, MS CONTIN) and oxycodone (OXAYDO, OXYCONTIN, ROXICODONE, XTAMPZA ER). The second type is the more potent synthetic opioids, such as fentanyl (ACTIQ, DURAGESIC, FENTORA, LAZANDA, SUBSYS), which is approved for treating severe cancer pain but often made and sold unlawfully as well. The third type is the illegal drug heroin.

Prescription opioids are generally safe and effective when taken for a short time for relief of acute pain as directed by a doctor, but they have not been shown to be safe or effective for relief of chronic noncancer pain.

Opioids often are misused because they produce temporary euphoria (a state of intense happiness), resulting in abuse disorder, debilitating addiction, overdose and death.[2]

When taken in high doses, all opioids can depress or stop breathing, potentially leading to brain damage or death (for signs and symptoms of opioid overdose, see Text Box, below). In fact, opioid-related overdose accounted for two-thirds of the total U.S. drug overdose deaths in 2016.[3]

The Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) have cautioned that combining opioids with other central nervous system depressants, mainly alcoholic beverages or benzodiazepines — sedative medications used to treat anxiety, insomnia and other conditions (examples include alprazolam [XANAX], diazepam [VALIUM] and lorazepam [ATIVAN]) — greatly increases the risk of opioid overdose and death.[4],[5] In fact, the product labeling for prescription opioids and benzodiazepines have black-box warnings (the strongest warnings the FDA can require) highlighting the dangers of using these drugs together.[6]

A new study showed that alcohol and benzodiazepines were commonly co-involved in U.S. opioid overdose deaths in recent years. The study was conducted by researchers at Boston University and was published in the April 2020 issue of the Journal of the American Medical Association (JAMA) Network Open.

The JAMA Network Open study[8]

The study researchers analyzed opioid poisoning deaths and assessed the extent of alcohol or benzodiazepine co-involvements in those deaths using CDC data. They also incorporated state-level data for benzodiazepineprescribing and self-reported bingedrinking rates.

Overall, there were over 399,000 reported opioid-poisoning deaths from 1999 to 2017. Sixty-six percent of the deceased were men and 51% were between the ages of 35 and 54.

Alcohol co-involvement in opioid overdose deaths was common and has increased over time. Specifically, its co-involvement in overall opioidoverdose deaths increased from 12% in 1999 to 15% in 2017. This increase also occurred across opioid types. For example, alcohol co-involvement in prescription and illicit synthetic opioid overdose deaths increased from 9% and 12%, respectively, earlier in the study period to 15% in 2017. Alcohol’s co-involvement in heroin overdose deaths increased from 10% to 20% during the study period.

Similarly, benzodiazepine co-involvement in overall opioid overdose deaths increased from 9% in 1999 to 21% in 2017, peaking distinctively at 26% in 2010. Its co-involvement in overdose deaths for each type of opioid overdose death also increased during the study period. Specifically, benzodiazepine co-involvement in prescription opioid overdose deaths increased from 16% in 2000 to 33% in 2017. Benzodiazepine co-involvement in opioid overdose deaths during the study period also increased from 15% to 26% for deaths involving illicit synthetic opioids and increased from 4% to 17% for deaths involving heroin.

Alcohol co-involvement in opioid overdose deaths was more common in men, whereas benzodiazepine coinvolvement was more common in women.

Across states, there was a statistically significant positive correlation between state-level alcohol binge-drinking and the extent of alcohol co-involvement in overall opioid-overdose deaths. An even stronger correlation was present between state-level benzodiazepine prescribing rates and benzodiazepine co-involvement in overall opioid-overdose deaths.

What You Can Do

To manage noncancer pain, talk to your doctor about nondrug (such as exercise or physical or behavioral therapy) and non-opioid drug (such as acetaminophen [TYLENOL] or ibuprofen [ADVIL, IBU-TAB, MIDOL LIQUID GELS, MOTRIN IB, TAB-PROFEN]) options.[9] If such options are not possible (for example, after surgery) or they have not provided adequate pain relief and your doctor recommends an opioid medication, ask him or her to prescribe the lowest effective dose of an immediate-release (instead of an extended-release or long-acting) opioid and discuss with him or her how long you need to take this medication and when you can stop it. Tell your doctor about any other medications you take. Follow up with your doctor periodically while you are taking any opioid to avoid complications.[10]

Never drink alcohol or take benzodiazepines or other central nervous system depressants when you are using opioids. Note that Public Citizen’s Health Research Group has long designated all benzodiazepines as Do Not Use except for alprazolam when used for panic disorder.

Learn about the signs and symptoms of opioid overdose (see Text Box, above) and seek medical attention immediately if you experience any of them.

Ask your doctor about naloxone (EVZIO [AUTOINJECTOR], NARCAN) — a lifesaving medication that can rapidly reverse the breathing depression effects of opioid overdoses.[11] You should especially do so if you are taking opioids for extended periods of time or at very high doses, or if you are taking any other medication that depresses the central nervous system; have a history of or risk factors for overdose; have opioid use disorder; or have household members, including children, or other close contacts who are at risk of accidental ingestion or opioid overdose.

Store opioid medications in a locked medicine cabinet or drawer to keep them away from children and others. Remove unused prescription opioids from your home as soon as possible to reduce the chances of misuse and accidental overdose (see the October 2019 issue of Worst Pills, Best Pills News for details).[12]

References

[1] Centers for Disease Control and Prevention. Opioid basics. March 19, 2020. https://www.cdc.gov/drugoverdose/opioids/index.html. Accessed October 1, 2020.

[2] National Institute on Drug Abuse. Opioids. Summary of issue. https://www.drugabuse.gov/drug-topics/opioids. Accessed October 1, 2020.

[3] Seth P, Scholl L, Rudd RA, Bacon S. Overdose deaths involving opioids, cocaine, and psychostimulants. MMWR Morb Mortal Wkly Rep. 2018;67(12):349-358.

[4] Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain-United States, 2016. JAMA. 2016;315(15):1624-1645.

[5] Food and Drug Administration. FDA drug safety communication: FDA warns about serious risks and death when combining opioid pain or cough medicines with benzodiazepines; requires its strongest warning. August 31, 2016. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-warns-about-serious-risks-and-death-when-combining-opioid-pain-or. Accessed October 1, 2020.

[6] Ibid.

[7] Centers for Disease Control and Prevention. Preventing an opioid overdose tip card. https://www.cdc.gov/drugoverdose/pdf/patients/Preventing-an-Opioid-Overdose-Tip-Card-a.pdf. Accessed October 1, 2020.

[8] Tori ME, Larochelle MR, Naimi TS. Alcohol or benzodiazepine co-involvement with opioid overdose deaths in the United States, 1999-2017. JAMA Netw Open. 2020;3(4):e202361.

[9] Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain-United States, 2016. JAMA. 2016;315(15):1624-1645.

[10] Centers for Disease Control and Prevention. Injury prevention and control. Injury and prevention. Talk to your doctor about managing your pain. March 3, 2020. https://www.cdc.gov/injury/features/manage-your-pain/index.html. Accessed October 1, 2020.

[11] Food and Drug Administration. FDA drug safety communication: FDA recommends health care professionals discuss naloxone with all patients when prescribing opioid pain relievers or medicines to treat opioid use disorder. July 23, 2020. https://www.fda.gov/media/140360/download. Accessed October 1, 2020.

[12] How to dispose of unused opioids and other high-risk drugs safely. Worst Pills, Best Pills News. October 2019. https://www.worstpills.org/member/newsletter.cfm?n_id=1288. Accessed October 1, 2020.