When stopping a dangerous prescription drug is dangerous

We all know that opioid painkillers like oxycodone and hydrocodone, and anti-anxiety benzodiazepines like alprazolam (Xanax) and lorazepam (Ativan), can be addictive. Over time, higher doses are required to achieve the same effect, a phenomenon known as tolerance. With tolerance comes dependence, where sufferers are unable to function without the drugs. In addition, these drugs can induce euphoria. Opioids can numb both emotional and physical pain, while benzodiazepines can work a little too well at suppressing anxiety. As a result, people are tempted to take more than prescribed. Abusing either drug carries the risk of a fatal overdose.

Twin epidemics

Decades of unscrupulous prescribing of opioids and benzodiazepines have led to a dual epidemic of addiction and overdose. In the 1990s and 2000s, a national campaign to treat pain as the “fifth vital sign” and aggressive marketing practices by the pharmaceutical industry led to a fourfold increase in opioid prescriptions, as well as an alarming increase in nonmedical use of these drugs. Today, approximately 2.5 million adults in the United States live with opioid use disorder (OUD), while we lose approximately 80,000 lives to opioid overdose each year.

A similar trend was seen with benzodiazepines: Between 1996 and 2013, prescriptions increased by 67% while overdose deaths more than quadrupled. The number of U.S. adults who use prescription sedatives or tranquilizers is not far behind that of OUD: 2.2 million. Taking opioids and benzodiazepines together (compared to opioids alone) increases the risk of overdose by tenfold, yet the number of co-prescriptions of the two drug classes skyrocketed in the 2000s.

These crises may be due to overprescribing, but the solution is not as simple as stopping the prescription. There are serious risks associated with stopping opioids and benzodiazepines, both in the short and long term. Abruptly stopping either class of medication can quickly lead to withdrawal symptoms. Even after a year or more, patients who have been taken off their long-term prescription are at increased risk of death.

retreat

Imagine the worst flu of your life. This is what opioid withdrawal feels like – runny nose, vomiting, diarrhea. Although it is rarely life-threatening, it is associated with increased emergency room use. Benzodiazepine withdrawal, which is similar to alcohol withdrawal, is a more serious syndrome that can lead to seizures and even death. With both classes of drugs, withdrawal can begin within hours of stopping.

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Resort to more dangerous drugs

Even after withdrawal symptoms subside, patients may experience pain or anxiety and turn to alcohol or illicit drugs. One study showed that stopping prescription opioid therapy doubled the risk of heroin use. Some experts have hypothesized that patients who stop taking benzodiazepines may drink to calm their nerves.

Use of nonprescription drugs, including alcohol, can lead to serious poisoning or overdose. Stopping prescription opioids is associated with a nearly threefold risk of fatal overdose. Stopping benzodiazepines was associated with a small but statistically significant risk of overdose, both in patients who were also exposed to opioids and those who were not. This finding was found in a study that followed patients for one year after stopping prescription drugs and contrasts with previous observations in which fewer adverse reactions occurred with shorter follow-up periods. This discrepancy suggests that people who no longer have access to prescription drugs increase their use of nonprescription substances over time, putting themselves at increasing risk. The risk of opioid overdose may persist for up to two years after the drug tapering begins.

Suicidal thoughts

Another frightening potential consequence of stopping opioids or benzodiazepines is suicide. After stopping opioids, data suggest a high-risk window for suicide (as well as overdose) of up to 100 days. For mental health crises, which include depression or anxiety and suicide attempts, this window extends to up to two years. Suicidal thoughts, suicide attempts, and self-inflicted injuries were increased in patients who stopped benzodiazepines at one year of follow-up.

Guidelines give hope

Opioids and benzodiazepines share many similarities, both in terms of the dangers associated with taking these drugs and the dangers associated with stopping them. Fortunately, expert organizations, including the Centers for Disease Control (CDC), the American Academy of Family Physicians (AAFP), and the Veterans Administration (VA), have issued evidence-based recommendations for safely tapering these drugs.

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A patient-centered approach is key to tapering opioids and benzodiazepines. Doctor and patient should decide together whether to taper the dose completely or reduce it to a safer level, as well as how quickly to taper. A rate of 10% per month may be appropriate for both classes of medications. If withdrawal symptoms or severe pain or anxiety occur, patients should be given the option to slow or even interrupt the taper. For patients who have difficulty coming off full opioids such as oxycodone, switching to the safer partial opioid buprenorphine may be considered. Close follow-up allows for adjustment of the plan and maintains the therapeutic alliance, which can be particularly strong when the doctor is the patient's primary caregiver.

During the tapering phase, adjunctive medications should be offered to help with pain, anxiety, and withdrawal symptoms. These include NSAIDs such as ibuprofen for pain and SSRIs for anxiety. Opioid withdrawal can be treated with medications for nausea and diarrhea, while benzodiazepine withdrawal is more likely to require an interruption of the tapering phase and/or a switch to another benzodiazepine or sedative. The opioid overdose antidote naloxone should also be prescribed.

Non-pharmacological interventions also play an important role. Exercise and physical therapy can relieve pain, while talk therapy and especially cognitive behavioural therapy (CBT) can reduce anxiety.

Freedom from addictive substances

Stopping opioids and benzodiazepines poses similar dangers. But the solutions are similar, too. As an addiction medicine specialist, I have seen an evidence-based, patient-centered tapering strategy free people from dependence on a dangerous substance to get through the day. To quote one of my patients, after we completely tapered off the lorazepam she had been prescribed for 40 years, she said, “I feel like I'm finally free.”