Benzodiazepines Pose Threat to People Using Opioid Painkillers

Discussion in 'FIbromyalgia and Pain Research' started by Cort, Apr 9, 2017.

  1. Cort

    Cort Founder of Health Rising and Phoenix Rising Staff Member

    The dangers opioid painkillers pose to those who abuse them or improperly use them is well known. Deaths from opioid painkillers, for instance, have increased fourfold in the past 15 years and the FDA has produced stern warnings about their misuse.

    Opioid painkillers aren't the only drugs, though, that play a role in opioid issues. A recent study suggests that benzodiazepine drugs that are commonly used in the fibromyalgia and chronic fatigue syndrome communities such as klonopin (clonazepam) play a significant role in deaths associated with opioid painkillers.

    Benzodiazepines pose a risk to those using opioid painkillers because their similar sedating effects can potentiate the problem of "respiratory depression". Respiratory depression occurs when a central nervous system inhibiting drug depresses breathing activity. A victim of respiration depression simply goes to sleep and doesn't wake up. It's a common way to die from opioid painkiller misuse.

    Studies suggest that nearly 30% of deaths associated with opioid painkillers involve benzodiazepines. The CDC recently warned physicians about the dangers of combining both classes of drugs and the FDA requires "black box" warnings be put on the drug labels, but some evidence suggests that concurrent use of these two drugs is still common. Nearly 30% of veterans prescribed opioids at a Veterans Administration hospital, for instance, were also taking benzodiazepines.

    The actor Heath Ledger died from using a mixture of prescription opioid and benzodiazepine drugs.

    The Study

    Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis Eric C Sun,1 Anjali Dixit,2 Keith Humphreys,3 Beth D Darnall,1 Laurence C Baker,4 Sean Mackey. BMJ 2017;356:j760

    Essentially the study asked if benzodiaezpine use in people taking opioid painkillers was increasing over time, and if it was, what effects it was having. It examined trends in benzodiazepine/opioid use over more than a decade to see: a) how many people were using both; b) if benzodiazepines were being prescribed more frequently than before and; c) it determined what impact combining those two drugs had on the incidence of opioid overdose emergency room visits over the past 13 years. This large study combed through the records of almost 600,000 patients to identify over 300,000 patients who at some time had had an opioid painkiller prescription filled.

    • Opioids: fentanyl (patch or oral form), hydrocodone, hydromorphone (oral form), methadone, morphine, oxymorphone, oxycodone. (Note: Tramadol not assessed)
    • Benzodiazepines: alprazolam (Xanax), chlordiazepoxide, clonazepam (Klonopin), clorazepate, diazepam (Valium), estazolam (ProSom), flurazepam, halazepam, lorazepam (Ativan), midazolam, oxazepam, prazepam, quazepam, temazepam, triazolam.

    The study found that the percentage of patients using both benzodiazepines and opioids almost doubled (9-17%) over 13 years. Most of the increase came from intermittent users of opioids; those who used opioids once or for time to time but did not use them chronically.

    The percentage of opioid painkiller users visiting the emergency room or who became hospitalized because of issues with their painkillers rose by about thirty percent from 2001 to 2013. Overall, the risk was relatively low: about 1% of those using opioid pain-killers visited the emergency room or became hospitalized in 2001 and 1.35% of those did in 2013.

    Chronic opioid users exhibited a much higher rate of emergency room visitation/hospitalization than intermittent users (chronic - 3.5%; intermittent - 1.15%).

    Using benzodiazepines in combination with opioids almost tripled one's chances of landing in the emergency room or being hospitalized (@4% for the entire population.). That risk zoomed up to 5.6% for chronic opioid users. Intermittent opioid users who also used benzodiazepines were at much less risk (1.5% in 2013), but using benzodiazepines increased their odds of visiting the emergency room by about 50%.

    Overall the study found that not using benzodiazepines in conjunction with opioids would reduce emergency room visits/hospitalizations because of opioid painkillers by about 15%. Because it did not include people who visited the emergency room and then died from the opioid-painkiller abuse it underestimated the true risk of using these two drugs together.

    Tramadol Not Assessed

    Because Tramadol - a weaker opioid often used in fibromyalgia - was not included in the survey, it's impossible to assess the effects concurrent benzodiazepines have on it. Tramadol is a weaker opioid drug that poses less risk of abuse and misuse than other opioid drugs. The FDA included Tramadol in the list of opioid drugs in its Safety Announcement regarding benzodiazepines and opioids.

    According to several sites, however, Tramadol is considered to pose a smaller risk of respiratory depression than other opioid drugs. ehealthme states tramadol can cause respiratory depression although the risks appear to be quite low, and eMeD Expert states that:

    Warning Signs

    From the FDA's Safety Announcement:


    Benzodiazepines taken in combination with most opioid painkillers substantially increase the risk patients might need to visit an emergency room or be hospitalized due to the effects of opioids.

    Intermittent opioid users appear to be at much lower risk of landing in an emergency room or becoming hospitalized because of benzodiazepine/opioid associated problems than chronic opioid users (intermittent users - 1.5%; chronic users - 5.6%).

    Because the study did not assess people who visited the emergency room or who were hospitalized and later died, it probably underestimated the risks of concurrent drug use. The study also did not assess the effects of dose - presumably an important factor in respiratory depression.

    Because the effects of Tramadol - perhaps the most frequently used opioid painkiller in fibromyalgia and ME/CFS - were not assessed, it's impossible to determine the effects of benzodiazepines on it. The FDA included Tramadol in its Safety Warning. Several other websites, however, state that Tramadol poses a considerably lower risk of respiratory depression than other opioids.
    Last edited by a moderator: Apr 10, 2017
    nibs likes this.
  2. Issie

    Issie Well-Known Member

    I have used Tramadol for years and find it to be one of my best helps for not only pain but POTS. I was told to take much more than I do. I find that I have to cycle it or it quits working. When it starts to be less effective, I go off for 2 or more weeks. I haven't had a problem cycling this and coming off it. I find it will work in small doses doing it this way. It resets it. I usually take 1 a day sometimes more if necessary. And they are the lowest strength available..
    I was using Bentyl with it. Im trying to not use that any more. It is a mild muscle relaxer but can work similar to a benzo in the fact that it is a suppressant of the sympathetic system. It can also cause depression if you aren't careful as can benzos. (I couldn't tolerate benzos.)
    I'm using Frankincense, Myrrh and Turmeric oil and this is seeming to help my pain. I also find certain foods make my pain worse.
  3. tearydawn

    tearydawn Active Member

    What do you mean by cycling it? Stopping the meds to let your body rest? I plan on doing that with oxycodone during 2 weeks this summer so I can reset my dose and make sure it's not contributing to my pain in any way. I would hate to find out my pain is made worse by pain pills which someone told me once. I rather know and correct it if so. But so far, oxycodone is the only way I have had muscle pain relief and energy relief and it works quite well for me. Takes the heavy sandbags off each limb! How do you use your oils? Humidifier, massage?? I have two of your three but have not tried it for pain. I know for menstrual pain, I use peppermint, lavender, and ginger root. Works well most times unless it's a really bad cycle.

  4. tearydawn

    tearydawn Active Member

    I use both opioids and benzo's. I only use 1mg Xanax each day and only at night so I can sleep. I don't take it with my pain pills as my pain pills keep me up so my last dose is usually no later than 3:30 and my pain usually comes back after 4 hours. I'm going to be getting an early evening dose soon though so I can stay up longer on the weekends. My primary doc refuse to fill it except once though I've been on it for over a year and it works quite well for me to sleep. I've exhausted all other sleep drugs. He sent me to a councilor just to get sleep meds and she finally agreed to fill it yet sent me home with the name of a new prescription she wanted me to think about. When I looked it up, it's a controlled substance as well!!!! WTH? Why is one ok and not the other? Didn't get that. Sigh.

  5. Issie

    Issie Well-Known Member

    Yes, I stop using it for 2 or more weeks and then go back on at lowest dose. It seems to reset it and make it work again. Tramadol is different than other pain med. It was only in the last year that it was put into a controlled substance catagory. It used to be said to be opioid-like but not really put in that catagory. They were uncertain as to why it worked completely.

    They also know it works on all the neurotransmittors. It has been used off label for some who are not good responders to SSRI or SNRI. I know it works on NMDR channels and that can calm the sympathetic system down. It also has mild calcium channel blocking affects and vasodilates and that can help blood flow. There are so many possible reasons why it may help. Some claim it is addictive. But, in my case - I don't really have withdrawals when I come off it. Maybe because I cycle it and keep it so low a dose. For me, doesn't appear to have caused an addiction. But it does calm my autonomic nervous system down. It helps my pain, but doesn't completely get rid of it. It's a small bandaid. But helps me get out of pain enough to sleep a little.

    I have to turn and readjust a lot in the night. I also find beaded pillows to be very necessary. I put them under my whole back and neck and sleep semi-reclined. I can have my body better supported by them.

    As for oils. I use a humidifier / diffuser and use it transdermal.
  6. tearydawn

    tearydawn Active Member

    I too plan on the two week rest. I have to wait till summer as my husband has summers off and he can help me. I wouldn't be able to get up or function otherwise. Tramadol did nothing to help me. My doctor also prescribed it both for pain and off label for anxiety as I don't respond to SSRI's. I believe it made me agitated though.

    I wonder if oxycodone works in that same way as it does seem a bit relaxing and not in the high kind of way, I don't respond to it like that. It gives me energy, or more likely removes the heavy feeling so I feel more like myself. My issue is that I get adapted to it quite quickly and have increased the dose several times which makes me nervous but worth the risk as it's my life saver in quality of living.

    I'm not sure if I will have withdrawals when I stop it. They put me on OxyContin last month to help with break through pain and to see if will last longer than the typical 4 hours for me and I think that drug is the devil! I had to quit the night dose so I could sleep and was only taking the morning dose. My pain seemed to increase significantly at night as well as chest heaviness and digestive issues. Today is the first day I haven't taken a dose of that stuff and I feel like I have my brain back! I'm not irritable or dumpy feeling like I was. Woohoo! Fatigue is much more significant today though. It will be interesting to see if I feel as bad tonight or not. It's all one big experiment really.

    Take care!
  7. Tammie Page

    Tammie Page Member

  8. Tammie Page

    Tammie Page Member

    There is something very important to note re this statement: "A victim of respiration depression simply goes to sleep and doesn't wake up. It's a common way to die from opioid painkiller misuse." This paints a picture that is not exactly accurate. It's very important to know this, because our population has a high percentage of suicidal people, and this statement makes this sound like a very enticing and peaceful way to go. Many years ago I tried to commit suicide this way. (I was dealing with PTSD, severe depression, and some other problems, not these illnesses, at that time. However, I can totally understand why suicide seems inviting to many with these illnesses. Had I not tried before, had a horrible experience, and ultimately been happy that I failed, I probably would have tried at some point since getting so sick.) The truth is that with this combo of drugs, you can absolutely feel yourself suffocating, and it is terrifying. There are some other symptoms that go along with it that are very hard to describe, but they are also scary. It is not anything close to peacefully laying down to sleep and then simply not waking up. I am writing this in the hope that it will deter anyone who is contemplating suicide. I'm also writing as a reminder that this is a population that has a high rate of suicide, and as such, we need to be very careful about what we write.
  9. tearydawn

    tearydawn Active Member

    Thanks for sharing. My kids keep me going!
    Tammie Page likes this.
  10. Tammie Page

    Tammie Page Member

    I'm glad you have them. :)
  11. tearydawn

    tearydawn Active Member

    Thank you!! :) I as well!! It definitely gets difficult at times. :)
  12. VLynx

    VLynx Member

    This is another facet of the anti-opioid hysteria sweeping the country. Most pain doctors will tell you that a high percentage of intractable pain patients need both opioids and benzodiazepines. I believe that if real studies were done of the causes of these overdoses, they would be largely found to be: a. suicides, b. people who are abusing medications (taking higher doses than needed or, especially, taking medications that are not prescribed), or people who have comorbidities, especially sleep apnea. In the latter case, the doctor should have screened the patient for sleep apnea prior to prescribing, and in any case, the two types of drugs should not be started at the same time. However, pain medicine doctors have been prescribing these two types of drugs together for decades. The current hysteria is causing enormous suffering among patients.
    GinnyMH, tearydawn and Martinigal like this.
  13. Martinigal

    Martinigal Active Member

    Ugh, I saw the title of this episode and I'm not even going to read it.

    By the time I tried Methadone, I had suffered from Fibromyalgia for 8 years. I tried EVERYTHING, but nothing helped. I also have a fairly severe medical background. For example, I went to an evaluation for an elective surgery a month ago and the surgeon told me, not only would he not work on me but that if I found someone who would, I shouldn't let them touch me. I was heart broken. I wanted to fix the disfigurement that occurred during my surgery for Breast Cancer. I couldn't do it back when I had breast cancer because right after my radiation I found out I had 4 Pulmonary Embolisms and once that was cleared up I had open heart surgery. Now I'll never get rid of the damage.

    So, back to Fibromyalgia. I started taking Methadone about 4 years ago and have been a long time clonopin user. Methadone was my first miracle in the fight against Fibromyalgia. I didn't take it lightly, much to the contrary, but my life had become so small, so painful and lonely that I had contemplated suicide seriously on more than one occasion. So I took the dive, with Methadone instead of suicide.

    My Fibromyalgia wasn't completely relieved, due to that severe medical history of mine I had lots of pain that wasn't related to Fibromyalgia. But the more annoying symptoms like those darn flu like aches and the absence of motivation and energy were helped tremendously. I no longer felt sick, I was just in pain. Not ideal but a vast improvement. And pain from some diagnosed conditions which I could now parse out and treat. Also pain from, what I suspect is, a problem with my tendons. But that's another story.

    It's also important to note that after I began Methadone, I became more active again and was able to cut down drastically on my clonopin use. I went from 2 mg/day down to .5 mg/day. If I know I'm going to have a particularly stressful day, like a job interview, I may take 1mg, but that has become more the exception than the rule.

    And yes, I did say "job interview"! The job interview didn't come from Methadone alone, but from Methadone and Ketamine infusions which I heard about here on Health Risings. A man named Stephen Corte had commented on the dangers of benzo use and some where Ketamine came up, he welcomed questions and so I e-mailed him. And that seemed to be the missing link to me getting back to a more full life.

    I am working, very part time, but continue to look for something in the 20 hr/week category. So if taking opiods and benzos pose a threat to me, it's a risk I'm willing to take. I've not been fortunate to have good health and when I was hit with Fibroyalgia, things looked so dark for so long and I was so weary. I do not mean one should take this information lightly. I know the risks, my doctors put me through a lot before they would prescribe this. Rarely do they help and they allow this. So in order not to panic, I no longer read this kind of information. And really, with all due respect, is there anyone one of us who doesn't know this is risky? I'm not going through life with blinders on, I'm simply chosing what makes my life worth living and accepting the risk that comes with it.

    If anyone has any questions about any of this, please feel free to e-mail me at I'll get back to you just as soon as I can.
    Cort and tearydawn like this.
  14. Martinigal

    Martinigal Active Member

    I couldn't agree more! If anyone is interested in why there is such a rise in the use of Heroin in this country, watch a story Vice did on the reason. Vice is a sort of 60 Minutes like news series produced by HBO but can also be watched on youtube...excellent, not restrained like the big networks. I just tried to search for the link but Vice has done so many on Heroin and I don't have time to find it right now. Basically when the DEA started coming down hard on Opioids, the Mexican drug cartels were estatic because they knew Herion use would increase. They found bedroom communities where there was a high amount of prescription opioid use and they set up shop. President Obama was warned about this, but he told the DEA to go ahead anyway (I'm a huge Obama fan, not knocking him at all) and now, as predicted Heroin use is out of control. Opioid abuse is not the same as taking opiods for pain control. The abusers, many of them abuse by perscription, cause the problem and those of us who use them properly are just caught up in the hysteria. Mark my words, give it some time and this will no longer be in the spotlight.
  15. Martinigal

    Martinigal Active Member

    Isn't it interesting how these opioids tend to give energy to those of us who have Fibromyalgia? Now that deserves looking in to!
    JillyMc likes this.
  16. Issie

    Issie Well-Known Member

    This made me think of my late departed dad. He had terrible pain and cancer all over. He was on massive pain med. The patches he wore had to be applied with gloves and we were told not to get it on us. A normal person a tiny amount would kill. But for those in massive amounts of pain - it doesn't. In fact as he got sicker the dose went up. But it didn't kill him.

    Another doc told me there is a difference with those who truly need pain meds. He said it's not an addiction that happens with them. In fact, most are really concerned to use them from that fear. But it's given when a true cause can't be "fixed". It's a bandaid to give a little more quality to life. It's not so much quantity as quality with chronic illness. But the key is lowest dose possible, to not get addicted (then require more and more) and not zone out and lose quality.

    Despite my dad getting the cancer in his brain and having a sort of dementia in the end - he still knew us, had a level of joy and could still laugh and enjoy things. He wouldn't had lasted so long in his state without the pain meds. It's a crutch - not a "fix" - a purple bandaid.

    I personally, can't take a true opioid or benzo - (just don't tolerate them and have paradox reactions). Pain, sadly, is my worst symptom and I have a "ton" of things wrong.
  17. JillyMc

    JillyMc New Member

    Hi Dianne,
    I recently stopped opioid use after 8yrs. First, I'll caution you about the physical withdrawals. I don't consider myself an addict and was willing to try different meds as my doctor insisted some of my pain was induced by long term pain meds. I had full body "restless legs" feeling for 3 weeks which kept me from sleeping, which in turn caused a bad crash. Please consider talking with your doc about the best way to calm the physical dependency.
    Next, I found some of my pain was increased by the drug itself. I still have pain but found I can usually manage it. There are days tho that make me cry and I wish I had something that worked. I tried tramadol and it caused an I'll effect on my urine output, which caused infections. Also, my precious energy level has severly decreased. I miss the bump of energy opioids gave me. Of course this could affect you completely different but thought I would chime in on my experience. Thanks.
  18. FAB

    FAB New Member

    Dear Cort and folks:
    As many of the other responders to this article, I know the dangers of mixing drugs. I think we FM/CFS people are more aware than the "un-sick" people since we are already mixing so many drugs, including gabapentin/Lyrica, statins, NSAIDS, etc.
    All this article does is give more people the idea that ANYONE taking opioids is automatically a drug addict. And now with Trump being our new president, he has promised to make it even harder for those of us who are in REAL pain to get effective treatment, i.e. opioids...
    I developed (genetic) diabetes about 2 yrs. ago and the pain I am experiencing now is out of control. My A1c is very good. Doc say that is the key to keep neuropathy away but obviously, its not working for me. I believe I have automatic neuropathy on top of peripheral neuropathy. There is no treatment or drug for automatic neuropathy; Doctors tell me to take B12 and B6-GREAT. Been taking multiple B's for years now and it doesn't help.
    My poor brother has FM and diabetes as well; can you believe that? Two siblings in the family! He just saw a pain specialist that took 6 months to see. Got a shot of something in his spine and it didn't help. The pain Doc is now recommending he goes to a rheumatologist and he doesn't have RA. What the hell are you supposed to do if a pain specialist can't help?! So they will try to push methotrexate (chemo-drug) or a TNF alpha inhibitor like Humera or Enbrel, which by the way, insurance covers only one month. Plus a simple cold could kill him. The cost is $30K-$60K/yr!
    As Martinigal stated, my life has become so small, so painful and so lonely, even my boyfriend is at the end of his rope with me and I don't blame him. A person in pain is not a lot of fun to be around. And since I am a Medicaid/disability patient, PCP doesn't have the time of day for me and won't authorize any specialists! I'm sure my Medicare Adv. Plan penalizes him if he does.
    So, in closing, please be more careful with articles like this-it sends a negative message to those who aren't in pain and uneducated about the entire subject, yet feel the need to control our lives, i.e.-Congress, etc...
    Any advice would be appreciated-I can't live rolled up in a fetal position for the rest of my life!
    God bless us all.
    JillyMc likes this.
  19. Issie

    Issie Well-Known Member

    FYI, too much B6 can cause neuropathy. Make sure you aren't creating a deficiency of folate with too high B 12. Methyl forms usually better metabolized.
    Have you tried Turmeric, ginger, cinnamon in coffee or tea? I use the spices and put in stevia and coconut milk. Taste yummy. Also Frankensinse, myrrh oils topically. There are many essential oils that may help. Addressing allergies - important.
    I found eliminating all grains, dairy and nightshades to be very helpful. There is a book - "No grains - no pain" - I found helpful.
    Farmgirl likes this.
  20. Cort

    Cort Founder of Health Rising and Phoenix Rising Staff Member

    There are lots of issues with opioids: two of them are that opioids, when used incorrectly, can be very dangerous and another is that people who need opioids are having more and more trouble getting them.

    I understand your concern but each blog cannot take on every issue. This blog was specifically targeted to warn people about the dangers of combining opioids with benzodiazepines. It was not at all meant to suggest that people taking opioid pain-killers are addicts. (In a recent fibromyalgia survey we did opioids were the number one drug used by people with FM.)

    Other blogs will take on the issue that the opioid restrictions are preventing some people from getting the help they need. I hope that helps!
    GLORIA GARRINGER likes this.