REVIEW OF: Chua KP et al, JAMA Netw Open 2021;4(8):e2120353

STUDY TYPE: Retrospective cohort study

When a patient on an opioid needs a benzodiazepine, should the two medications be handled by one prescriber or multiple prescribers? Among patients on opioids, one in five are also prescribed a benzodiazepine, but the combination raises the risk of opioid overdose fatalities four-fold. This study is the first to look at safety outcomes for single vs multiple prescribers. 

Using a database of medical and pharmacy claims, researchers performed a retrospective cohort analysis, identifying patients who had one or more days of opioid-benzodiazepine overlap between January 1, 2017, and December 31, 2018. Ultimately, the cohort included 529,053 patients, ages 12 years and older, with an average age of 61. Researchers determined whether the opioids and benzodiazepines were prescribed by a single clinician or by two or more clinicians. The primary outcome measure was the occurrence of an overdose.

The relative overdose risk, adjusted for prescribing patterns, demographics, and comorbidities, was 1.2 times greater when the opioid-benzodiazepine overlap involved multiple prescribers vs a single prescriber (unadjusted overdose risk was 1.8 times greater), which translates to a 20% increased risk of overdose. 

The main limitation is the study’s design, which cannot prove causation. Also, the cohort was restricted to insured patients, and overdose deaths may have been underreported.

CARLAT TAKE

Opioid and benzodiazepine combinations are risky, but the risk goes down when one clinician monitors both scripts. It’s easier to detect problematic use with that arrangement, particularly when the prescriber is a pain specialist, as they require a higher level of scrutiny, including urine drug screens and pill counts. If you’re concerned about the overdose risk in a patient taking both an opioid and a benzo, arranging for them to get both prescriptions from the same physician is a reasonable option.