Opioids and Benzos: A Risky Mix

Two in five people seeking detoxification for heroin or other opioid addictions reported taking benzodiazepines (BZDs), usually obtained illegally. This finding suggests a need for better education about the risks of the potentially dangerous drug combination, according to a new study led by a Boston University School of Public Health (SPH) researcher.

The study, based at a Massachusetts drug-treatment program, found that just 23 percent of dual users obtained the BZDs (sedatives such as Xanax) from a prescriber, while 48 percent reported getting them from “the street” and 28 percent from a friend or family member. And while those who got the drugs legally reported that “managing anxiety” was their primary reason for using them, those who bought them on the street were far more likely to report using the drugs to “get high or enhance a high.”

The study, published in September 2016 in the Journal of Substance Abuse Treatment and led by Michael Stein, chair of the SPH health law, policy, and management department, urges more education—for both clinicians and patients—on the risks and alternatives to BZDs.

“Prescribers continue to need education on the risks of combining opioids and benzodiazepines, but another important target audience is drug users themselves,” Stein says. Some opioid users “may never cross paths with a health care provider in their pursuit of opioids and benzodiazepines, and therefore may be missing out on the diagnosis of psychiatric symptoms and alternative treatments for anxiety or depression,” he says.

Forty percent of the study group—176 out of 438 people seeking opioid detoxification—reported taking Xanax or other benzodiazepines, or had them in their systems during toxicological testing within the month prior to admission; 25 percent met the criteria for BZD dependence. The vast majority (70 percent) of those who obtained the benzodiazepines through a prescription reported anxiety as their primary reason. In contrast, only 3 percent of those who used the drugs to “get high” obtained them legally.

Interestingly, the study group of BZD users had much higher rates of anxiety than other reported samples of opioid-addicted people receiving treatment. The authors recommend that clinicians should educate patients that “although in the short term they may experience subjective relief of anxiety with BZDs, long-term use is likely to have limited effectiveness.”

Research has shown that concurrent use of opioids and benzodiazepines can slow the heart rate and breathing and increase the risk of accidental overdose.

Stein says there is debate about whether the benefits of even short-term BZD prescriptions—for reasons such as help with sleep, withdrawal, and depression—outweigh the risks for opioid users.

“Either way, there is likely to be a fine line between therapeutic use and misuse, and the risk of developing a BZD-use disorder may be high,” he says. In addition, many long-term opioid-treatment programs insist on participants halting all benzodiazepine use.

“Having non-prescribed benzos identified may lead to program discharge and, in many cases, even preclude treatment receipt of methadone or suboxone,” Stein says.

Nationally, the number of patients admitted to addiction-treatment programs who reported combined use of opioids and BZDs increased five-fold between 2000 and 2010, the authors note. Opioid overdose deaths nearly quadrupled from 1999 to 2011, with an estimated 31 percent of opioid-related deaths associated with concurrent BZD use.

Co-authors on the study were from Butler Hospital in Providence, Rhode Island, Brown University’s Warren Alpert Medical School, Stanford University School of Medicine, and Stanley Street Treatment and Resources, Inc., in Fall River, Massachusetts.