Opioids and Tranquilizers/Sedatives Don’t Mix

“Sedative-hypnotic use compared with nonuse was associated with 6.4 times the risk of opioid overdose death. … Even at opioid doses 1-19 mg/d, patients using sedative-hypnotics concurrently had 5.6 times the risk than patients without sedative-hypnotics”. I must admit I have found clonazepam helpful for restless legs and sleep but cannot bring myself to allow sedative use with these sort of statistics.

Garg, Renu K., Deborah Fulton-Kehoe, and Gary M. Franklin. “Patterns of Opioid Use and Risk of Opioid Overdose Death Among Medicaid Patients.” Medical Care 55.7 (2017): 661-668.

  • 150,821 noncancer pain patients aged 18-64 years with ≥1 opioid prescription, April 2006 to December 2010
  • Use sedative/hypnotic with opioid – 6.4 times the risk of opioid overdose death.
  • as quoted above, low opioid users had a 5.6 times risk of death if on combo

Comment – problem stems from the relatively high risk of major mood disorder in chronic pain patients. Bipolar rates in fibromyalgia for example were 20% according to meta-analysis. In neuropathic pain in the neck they found 80% had major mood disorder. In my ketamine study I was amazed to find those that continued therapy were 80% likely to have major mood issues.

Seen not infrequently is  when one of these mood patients develop agitation where can’t sleep, can’t concentrate, can’t be still and often irritable. When bad this is called a mixed state. In this state, pain will be much worse. I treat it with quetiapine, risperidone or olanzapine. This state is worse than their pain and they will tell you they would take the pain over it. They can easily sop up large quantities of tranquilizers to ease this “pain” until atypicals mentioned above kick in. – Then try to get them off them later…This group can have huge fluctuations in their pain and unless you have more than opioids to treat their pain, they could up their dose and kill themselves.

I had one case that, out of desperation, started clonazepam 0.5 mg bid. Without my consent, she quickly upper her dose to 2 mg bid and then had the pharmacist to fax me to continue with that dose. I could not see myself giving her that dose and opioids so she never came back.

Bottom line, is that it will not be easy to limit tranquillizers among people with chronic pain, but look like it will be necessary.

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