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Concomitant Opioid Benzodiazepine Prescribing Common

Last August, CHPSO warned of the frequent appearance of opioids and benzodiazepines (BZD) in medication events in the CHPSO events database. Coincidentally, several weeks later the FDA initiated black-box warnings advising against using BZDs with opioids, based on the increased risk of death with the combination. Additionally, BZD-like sedative hypnotics (BZD-SH) such as eszopiclone, zaleplon and zolpidem should pose a similar risk given their similar mechanism of action.

Two recent studies measured the prevalence of this potentially dangerous prescribing combination. One, a review of Medicare Part D beneficiaries found that 28 percent of non-hospice non-cancer outpatients receiving opioids were also receiving BZDs or BZD-SHs. Another, looking at patients in one tertiary care hospital, found that 25 percent of patients receiving BZDs or BZD-SHs were receiving opioids. Since BZDs/BZD-SHs were frequently prescribed in the hospital (approximately 50 percent of all patients) the total number in that study at risk was very high.

The Pharmacy Quality Alliance now has a measure for concurrent use of opioids and benzodiazepines, focused on outpatient use. “This measure examines the percentage of individuals 18 years and older with concurrent use of prescription opioids and benzodiazepines. The denominator includes individuals 18 years and older by the first day of the measurement year with 2 or more prescription claims for opioids filled on 2 or more separate days, for which the sum of the days’ supply is 15 or more days during the measurement period. Patients in hospice care and those with a cancer diagnosis are excluded. The numerator includes individuals from the denominator with 2 or more prescription claims for benzodiazepines filled on 2 or more separate days, and concurrent use of opioids and benzodiazepines for 30 or more cumulative days.”

CMS has a measure under development (CMIT ID 3341) for hospital quality reporting: “Safe use of opioids—concurrent prescribing” that would measure the percentage of patients discharged with concurrent opioid prescriptions or with concurrent opioid and BZD prescriptions, excluding cancer and palliative care patients.

CHPSO recommends that organizations review their approach to the black box warning for combined BZD/BZD-SH and opioid use and consider measuring concomitant usage. Excluding patients on ventilatory support or undergoing monitored sedation, caution is definitely required when combining the two and the rationale for benzodiazepine use should be clearly identified.

References

Benzodiazepine Use During Hospitalization: Automated Identification of Potential Medication Errors and Systematic Assessment of Preventable Adverse Events. PloS One 11 (10): e0163224. October 6, 2016.

CMS Measures Inventory. August 2, 2016.

Concurrent Use of Opioids and Benzodiazepines in a Medicare Part D Population. CMS. May 12, 2016.

FDA requires strong warnings for opioid analgesics, prescription opioid cough products, and benzodiazepine labeling related to serious risks and death from combined use. FDA. August 31, 2016.

Opioids’ Dangerous Sidekick: Benzodiazepines. CHPSO. August 11, 2016.

PQA Performance Measures. August 2, 2016.