Both the popular media and scientific publications have recently closely covered the problem of overdoses of prescription opioids. However, some issues that are important corollaries to this are still largely overlooked.
Over the past year, a bit more attention has been paid to the frequent co-prescription of opioids and benzodiazepines, both of which heighten the risk of emergency department (ED) overdose visits and death.
A new study highlights another substance that can play a significant role in overdoses of both opioids and benzodiazepines: alcohol.1
Using the federal government’s Substance Abuse and Mental Health Services Administration’s Drug Abuse Warning Network (DAWN) data for 2010, this study examined the role alcohol plays in ED visits for prescription opioid and benzodiazepine overdoses for the entire United States and drug-related deaths in 13 states.
The results indicated that alcohol use is a factor in a significant number of ED visits and in deaths related to prescription opioids and benzodiazepines. Alcohol was involved in 18.5% of opioid- and 27.2% of benzodiazepine-related ED visits, and in 22.1% of opioid-related deaths and 21.4% of benzodiazepine-related deaths.
ED visits and deaths related to what are considered the “stronger” opioids, including fentanyl, methadone, and hydromorphone, were found to be less likely to involve alcohol than when the opioid hydrocodone was involved.
Why stronger opioids are less likely to be encountered in combination with alcohol in ED visits and deaths is unclear. A possible explanation is that a smaller number of physicians may be prescribing these drugs, and those who do may be more aware of the potential problematic interactions with alcohol and other substances and be more likely to discuss this with patients. Also, until the recent change in scheduling of hydrocodone-containing products, prescribers were not required to monitor their patients as frequently, compared with patients taking one of the stronger opioids.
The study does not mention the number of patients for whom the drugs were prescribed for a legitimate medical reason vs those who obtained them from physicians under false pretenses or illicitly. We must do our best to make sure that our prescribing doesn’t place our patients at risk.
So, how should we advise our patients in whom we initiate opioid or benzodiazepine therapy regarding alcohol use?
Certainly if we believe that our patients are abusing alcohol, then the use of benzodiazepines (unless they are used to treat alcohol withdrawal) and opioids (with the exception of their use for severe acute pain under close monitoring for a brief period, such as postoperative pain) are generally contraindicated.
With regard to benzodiazepines, readers of my column are aware that I strongly recommend against prescribing them for patients with pain for a variety of reasons. If you are treating a patient without pain or one with pain for whom a benzodiazepine is felt to be indicated on a regular basis, I believe that patients should be advised not to drink at all. It is very difficult to die of an overdose of a benzodiazepine when it is taken alone. It was this safety profile that allowed benzodiazepines at their introduction to rapidly replace barbiturates as the primary drug for anxiety and sleep problems. What makes benzodiazepines lethal is their combination with other drugs; alcohol is probably the most frequent culprit.
As for prescription opioids, ideally patients would not consume alcohol at the same time, and I tell my patients this. However, for those who tell me that they like to have an occasional drink, I find it better to accept this and advise them on the best way to do this safely.
I warn them that while having one drink a day when also using opioids is unlikely to do them any harm, I can’t guarantee this, since just as with benzodiazepines and alcohol, there is no way to predict what the combination will do. If they feel they need to drink more than this, I usually tell them that they have to make a choice between the drink and the opioid.
If they are taking a short-acting opioid, I advise them to separate the alcohol and a dose of the drug by 3 to 4 hours, since this reduces the risk that the two will interact.
However, things become much more uncertain for those taking a long-acting opioid. In this situation, the level of the drug in the body will be fairly consistent over the course of the day, so that even if the alcohol is consumed hours after taking the drug, there is little reduction in risk. If the patient feels that having a drink is more important than any possible benefits of a long-acting opioid, I usually prefer to prescribe a short-acting one for them instead.
It is important to remember that some patients see alcohol as an analgesic, so health care providers need to disabuse them of the idea that it has a role in controlling pain. There is also the vital issue that alcohol, benzodiazepines, and opioids each impair cognitive function, making it difficult for those using them to keep track of how much they are putting into their bodies.
A study published earlier this year indicated that health care providers do a pretty poor job overall of discussing alcohol use with their patients.2 In a survey of patients, fewer than 16% said that they had an interaction with a health care professional that involved a discussion of alcohol use. Even among those who would appear to be at high risk for alcohol-related problems—those who engaged in 10 or more episodes of binge drinking during the previous year—fewer than 40% reported that they had discussed their alcohol use with a health care professional.
Obviously, opioids are not the only analgesics that when combined with alcohol can create serious problems. Those who abuse alcohol are at increased risk for hepatic toxicity from acetaminophen and bleeds related to the use of NSAIDs. It is also risky to combine alcohol with analgesic drugs that act on the CNS, such as anticonvulsants and serotonin–norepinephrine reuptake inhibitors.
If you are considering prescribing benzodiazepines, opioids, or a wide variety of other medications, you cannot assume that the patient has been asked about alcohol use, much less evaluated for the impact of alcohol on their treatment plan. It is incumbent on you to make sure this is done.
1. Jones CM, Paulozzi LJ, Mack KA. Alcohol involvement in opioid pain reliever and benzodiazepine drug abuse-related emergency department visits and drug-related deaths - United States, 2010. MMWR Morb Mortal Wkly Rep. 2014;63:881-5.
2. McKnight-Eily LR, Liu Y, Brewer RD, et al. enters for Disease Control and Prevention (CDC). Vital signs: communication between health professionals and their patients about alcohol use - 44 states and the District of Columbia, 2011. MMWR Morb Mortal Wkly Rep. 2014;63:16-22.