Concurrent Use of Benzodiazepines and Opioids in Elderly Patients

Introduction to Risks

The Centers for Disease Control and Prevention (CDC) explicitly recommends avoiding prescribing opioids and benzodiazepines concurrently whenever possible, due to the high risk of respiratory depression, overdose, and death 1, 2

The American Academy of Family Physicians recommends that diazepam 10mg 3-4 times daily is an extremely high dose, especially for a geriatric patient, and may lead to increased risk of tolerance, dependence, and addiction 3, 4
The CDC recommends that Percocet 4-6 times daily represents frequent dosing that increases risk, and both medications have significant risk of tolerance, dependence, and addiction 5, 6

Elderly patients have decreased drug clearance and metabolism, increased sensitivity to central nervous system depressants, and higher risk of falls, cognitive impairment, and respiratory depression 4, 7
The Mayo Clinic recommends that benzodiazepines are considered high-risk medications in older adults according to Beers Criteria 7

The CDC recommends reviewing prescription drug monitoring program (PDMP) data to verify all current prescriptions, performing urine drug testing to confirm medication use and check for other substances, and assessing for signs of opioid use disorder or benzodiazepine dependence 1, 2, 5, 8
The CDC also recommends evaluating the patient's pain condition and anxiety/indication for benzodiazepine use, and considering a gradual tapering plan for both medications 6, 8

The CDC recommends implementing a gradual tapering plan, with a decrease of 10% of the original dose per week for benzodiazepines, and a slower taper of 10% per month for opioids if the patient has been on long-term therapy 8
The American Academy of Family Physicians recommends considering transitioning to safer alternatives, such as non-benzodiazepine options like buspirone for anxiety, and maximizing non-opioid and non-pharmacological pain management 3, 5, 6

The CDC recommends more frequent follow-up, monitoring for withdrawal symptoms, and considering naloxone prescription and education for overdose prevention 5, 6, 8