Veterans who simultaneously take opioids for chronic pain and benzodiazepines for anxiety and insomnia are at an increased risk of unintentional overdose and death as well as suicide.
Nearly 20 veterans kill themselves each day in the United States, a statistic that has led the Department of Veterans Affairs to make suicide prevention its highest priority and to recognize the risks from the simultaneous use of opioids and benzodiazepines. To tackle the issue, the VA asked the National Academies of Sciences, Engineering and Medicine to develop protocols for a study that would use existing records to evaluate the best approaches to opioid treatment in veterans taking benzodiazepines.
"These records might reveal important insights that could inform the use of opioid treatment as part of chronic pain management," said Brian Strom, chancellor of Rutgers Biomedical and Health Sciences and chair of the committee that developed the study protocol. "The committee's report gives the VA guidelines on how to research the effects of starting veterans on an opioid for chronic pain while they are taking benzodiazepines and the effects of tapering patients off opioids and the relationship to any subsequent death by suicide or other causes."
Strom discusses the study design and how it can help the VA improve care for veterans:
Why are veterans at a higher risk of overdose and death?
Compared to civilians, veterans have higher rates of chronic pain, traumatic brain injury, post-traumatic stress disorder, depression and other mental health conditions. This makes it more likely they will be on concurrent opioid and benzodiazepine treatment, a combination that has been linked to potentially fatal health risks, such as respiratory depression and suicide.
Discuss the proposed study.
Investigations using existing data are an excellent opportunity to use VA medical records to clarify the connections between important clinical conditions, changes in opioid and benzodiazepine prescribing practices over the years 2010 to 2017, and outcomes.
In the proposed hypothetical trial, the veterans would be randomly assigned to one of two treatment strategies and followed for 18 months. One group would start opioid treatment and the other would be treated with a non-aspirin nonsteroidal anti-inflammatory drug, such as ibuprofen or naproxen. Both groups would be followed for a year. The committee then recommended how the VA data could be used to simulate this trial.
What are the risks to introducing opioids to a person who is already taking benzodiazepines?
There are always risks from all medications, certainly including opioids, but people on benzodiazepines are thought to be at higher risk of the opiate's side effects. Future studies of interest could examine how the combination of the two affects measures of pain, social and emotional functioning, depression and anxiety.
What are the risks to tapering patients from opioids?
Providers usually decide to taper opioids to prevent long-term opioid-related risks or medication misuse. However, tapering a patient who is tolerant to opioids may actually contribute to adverse consequences, including suicide.
In the hypothetical trial, veterans would be eligible for tapering after their prescribed daily opioid dosage reaches a level that would be likely to induce opioid dependence. They then would randomly be assigned different reduction strategies that providers use - slow dosage reduction, moderate to fast dosage reduction and abrupt discontinuation of the opioid - and be followed for six months. The study would explore whether the different tapering methods are safe and effective. The committee then recommended how the VA data could be used to simulate this trial.