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      Journal of Pain Research (submit here)

      This international, peer-reviewed Open Access journal by Dove Medical Press focuses on reporting of high-quality laboratory and clinical findings in all fields of pain research and the prevention and management of pain. Sign up for email alerts here.

      52,235 Monthly downloads/views I 2.832 Impact Factor I 4.5 CiteScore I 1.2 Source Normalized Impact per Paper (SNIP) I 0.655 Scimago Journal & Country Rank (SJR)

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      Co-prescription of opioids with benzodiazepine and other co-medications among opioid users: differential in opioid doses

      research-article
      Author(s): ,
      Publication date (Electronic):
      Journal: Journal of Pain Research
      Publisher: Dove Medical Press
      Keywords: co-prescription, opioid, benzodiazepine, co-medication, opioid users, pain

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          Abstract

          Purpose

          This study investigated the patterns of opioid co-prescription with benzodiazepine and other concomitant medications among opioid users. Opioid dose in each type of co-prescription was also examined.

          Patients and methods

          This cross-sectional study was conducted among opioid users receiving concomitant medications at an outpatient tertiary hospital setting in Malaysia. Opioid prescriptions (morphine, fentanyl, oxycodone, dihydrocodeine and tramadol) that were co-prescribed with other medications (opioid + benzodiazepines, opioid + antidepressants, opioid + anticonvulsants, opioid + antipsychotics and opioid + hypnotics) dispensed from January 2013 to December 2014 were identified. The number of patients, number of co-prescriptions and the individual mean opioid daily dose in each type of co-prescription were calculated.

          Results

          A total of 276 patients receiving 1059 co-prescription opioids with benzodiazepine and other co-medications were identified during the study period. Of these, 12.3% of patients received co-prescriptions of opioid + benzodiazepine, 19.3% received opioid + anticonvulsant, 6.3% received opioid + antidepressant and 10.9% received other co-prescriptions, including antipsychotics and hypnotics. The individual mean opioid dose was <100 mg/d of morphine equivalents in all types of co-prescriptions, and the dose ranged from 31 to 66 mg/d in the co-prescriptions of opioid + benzodiazepine.

          Conclusion

          Among the opioid users receiving concomitant medications, the co-prescriptions of opioid with benzodiazepine were prescribed to 12.3% of patients, and the individual opioid dose in this co-prescription was moderate. Other co-medications were also commonly used, and their opioid doses were within the recommended dose. Future studies are warranted to evaluate the adverse effect and clinical outcomes of the co-medications particularly in long-term opioid users with chronic non-cancer pain.

          Most cited references33

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          Association between mental health disorders, problem drug use, and regular prescription opioid use.

          Jürgen Unützer, Thomas D. Sullivan, Gregg B Wells … (2006)
          Use of opioids for chronic noncancer pain is increasing, but standards of care for this practice are poorly defined. Psychiatric disorders are associated with increased physical symptoms such as pain and may be associated with opioid use, but no prospective population-based studies have addressed this issue. Analysis of longitudinal data from 6439 participants in the 1998 and 2001 waves of Healthcare for Communities, a nationally representative telephone community survey. Two hundred thirty-seven subjects (3.6%) reported regular prescription opioid use in 2001. In unadjusted logistic regression models, respondents with a common mental health disorder in 1998 (1165 [12.6%]; major depression, dysthymia, generalized anxiety disorder, or panic disorder) were more likely to report opioid use in 2001 than those without any of these disorders (odds ratio [OR], 4.43; 95% confidence interval [CI], 3.64-5.38; P<.001). Risk was increased for initiation (OR, 3.26; 95% CI, 2.44-4.34; P<.001) and continuation (OR, 2.30; 95% CI, 1.02-5.17; P = .04) of opioids. Respondents reporting problem drug use (136 [2.0%]; OR, 3.57; 95% CI, 2.32-5.50; P<.001) but not problem alcohol use (401 [6.5%]; OR, 0.73; 95% CI, 0.43-1.24; P = .25) reported higher rates of prescribed opioid use than those without problem use. In multivariate logistic regression models controlling for 1998 demographic and clinical variables, common mental health disorder (OR, 1.96; 95% CI, 1.47-2.62; P<.001) and problem drug use (OR, 2.98; 95% CI, 1.68-5.30; P<.001) remained significant predictors of opioid use in 2001. Common mental health disorders and problem drug use are associated with initiation and use of prescribed opioids in the general population. Attention to psychiatric disorders is important when considering opioid therapy.
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            Trends in use of opioids for non-cancer pain conditions 2000-2005 in commercial and Medicaid insurance plans: the TROUP study.

            Mark Sullivan, Mark Edlund, Ming-Yu Fan … (2008)
            Opioids are widely prescribed for non-cancer pain conditions (NCPC), but there have been no large observational studies in actual clinical practice assessing patterns of opioid use over extended periods of time. The TROUP (Trends and Risks of Opioid Use for Pain) study reports on trends in opioid therapy for NCPC in two disparate populations, one national and commercially insured population (HealthCore plan data) and one state-based and publicly-insured (Arkansas Medicaid) population over a six year period (2000-2005). We track enrollees with the four most common NCPC conditions: arthritis/joint pain, back pain, neck pain, headaches, as well as HIV/AIDS. Rates of NCPC diagnosis and opioid use increased linearly during this period in both groups, with the Medicaid group starting at higher rates and the HealthCore group increasing more rapidly. The proportion of enrollees receiving NCPC diagnoses increased (HealthCore 33%, Medicaid 9%), as did the proportion of enrollees with NCPC diagnoses who received opioids (HealthCore 58%, Medicaid 29%). Cumulative yearly opioid dose (in mg. morphine equivalents) received by NCPC patients treated with opioids increased (HealthCore 38%, Medicaid 37%) due to increases in number of days supplied rather than dose per day supplied. Use of short-acting Drug Enforcement Administration Schedule II opioids increased most rapidly, both in proportion of NCPC patients treated (HealthCore 54%, Medicaid 38%) and in cumulative yearly dose (HealthCore 95%, Medicaid 191%). These trends have occurred without any significant change in the underlying population prevalence of NCPC or new evidence of the efficacy of long-term opioid therapy and thus likely represent a broad-based shift in opioid treatment philosophy.
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              National trends in pharmaceutical opioid related overdose deaths compared to other substance related overdose deaths: 1999-2009.

              Jason Glanz, Ingrid Binswanger, S Calcaterra (2013)
              Pharmaceutical opioid related deaths have increased. This study aimed to place pharmaceutical opioid overdose deaths within the context of heroin, cocaine, psychostimulants, and pharmaceutical sedative hypnotics examine demographic trends, and describe common combinations of substances involved in opioid related deaths. We reviewed deaths among 15-64 year olds in the US from 1999-2009 using death certificate data available through the CDC Wide-Ranging Online Data for Epidemiologic Research (WONDER) Database. We identified International Classification of Disease-10 codes describing accidental overdose deaths, including poisonings related to stimulants, pharmaceutical drugs, and heroin. We used crude and age adjusted death rates (deaths/100,000 person years [p-y] and 95% confidence interval [CI] and multivariable Poisson regression models, yielding incident rate ratios; IRRs), for analysis. The age adjusted death rate related to pharmaceutical opioids increased almost 4-fold from 1999 to 2009 (1.54/100,000 p-y [95% CI 1.49-1.60] to 6.05/100,000 p-y [95% CI 5.95-6.16; p<0.001). From 1999 to 2009, pharmaceutical opioids were responsible for the highest relative increase in overdose death rates (IRR 4.22, 95% CI 3.03-5.87) followed by sedative hypnotics (IRR 3.53, 95% CI 2.11-5.90). Heroin related overdose death rates increased from 2007 to 2009 (1.05/100,000 persons [95% CI 1.00-1.09] to 1.43/100,000 persons [95% CI 1.38-1.48; p<0.001). From 2005-2009 the combination of pharmaceutical opioids and benzodiazepines was the most common cause of polysubstance overdose deaths (1.27/100,000 p-y (95% CI 1.25-1.30). Strategies, such as wider implementation of naloxone, expanded access to treatment, and development of new interventions are needed to curb the pharmaceutical opioid overdose epidemic. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Pain Res
                Journal ID (iso-abbrev): J Pain Res
                Journal ID (publisher-id): Journal of Pain Research
                Title: Journal of Pain Research
                Publisher: Dove Medical Press
                ISSN (Electronic): 1178-7090
                Publication date Collection: 2017
                Publication date (Electronic): 25 January 2017
                Volume: 10
                Pages: 249-257
                Affiliations
                Kulliyyah of Pharmacy, International Islamic University Malaysia, Bandar Indera Mahkota, Kuantan, Pahang, Malaysia
                Author notes
                Correspondence: Che Suraya Zin, Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan Campus, Jalan Sultan Ahmad Shah, Bandar Indera Mahkota, 25200 Kuantan, Pahang, Malaysia, Tel +60 9 570 4909, Fax +60 9 571 6775, Email chesuraya@ 123456iium.edu.my
                Article
                Publisher ID: jpr-10-249
                DOI: 10.2147/JPR.S122853
                PMC ID: 5279838
                PubMed ID: 28182128
                SO-VID: b0706fd1-2495-4ca8-8083-78f7d6f03990
                Copyright © © 2017 Zin and Ismail. This work is published and licensed by Dove Medical Press Limited
                License:

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                History
                Categories
                Subject: Original Research

                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: co-prescription,opioid,benzodiazepine,co-medication,opioid users,pain
                Data availability:
                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: co-prescription, opioid, benzodiazepine, co-medication, opioid users, pain

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