Managing the Relationship Between Chronic Pain and Insomnia

LAS VEGAS – During a well-attended presentation at PAINWeek 2017, held September 5-9, Errol Gould, PhD, senior director of medical and scientific affairs at Pernix Therapeutics in Morristown, New Jersey, covered the risks of co-prescribing benzodiazepines and opioids, particularly for elderly patients, and proposed therapeutic alternatives.¹

Elderly individuals have a higher prevalence of chronic pain than younger adults, with an estimated 30% affected by a chronic pain condition.² Treatment for this population often consists of immediate- and extended-release opioids.² Elderly patients with chronic pain can develop insomnia,³ and conversely, insomnia may exacerbate chronic pain, thus creating a vicious circle.⁴

Benzodiazepines (BZDs) are commonly prescribed for the treatment of insomnia, as well as anxiety, both of which are conditions often comorbid with chronic pain in the elderly. However, older patients have increased sensitivity to BZDs. This phenomenon is thought to be due to age-related downregulation in central nervous system (CNS) BZD receptors leading to, among other effects, increased sedation and memory loss.¹

Acknowledging that opioids and BZDs are often co-prescribed in the United States, the Center for Disease Control and Prevention issued a warning in 2014, which stated that “Overprescribing of opioid pain relievers (OPR) can result in multiple adverse health outcomes, including fatal overdoses. Interstate variation in rates of prescribing OPR and other prescription drugs prone to abuse, such as benzodiazepines, might indicate areas where prescribing patterns need further evaluation.”⁵

A report from the same year by the Substance Abuse and Mental Health Services Administration indicates a steady increase in emergency department visits between 2005 and 2011 for events related to a combined intake of opioids and BZDs in patients aged >12.⁶ In a news release by the US Food and Drug Administration (FDA) dated August 2016, the agency announced that it “requir[ed] class-wide changes to drug labeling, including patient information, to help inform health care providers and patients of the serious risks associated with the combined use of certain opioid medications and a class of central nervous system depressant drugs called benzodiazepines.”⁷

Robert Califf, MD, then FDA Commissioner, stated “It is nothing short of a public health crisis when you see a substantial increase of avoidable overdose and death related to two widely used drug classes being taken together.” The FDA requested that opioid and BZD manufacturers add black box warnings on those drugs to caution against the concomitant use of opioids and BZD (or other CNS depressants), stating that this “may result in profound sedation, respiratory depression, coma, and death.” The warning also added: “Reserve concomitant prescribing of OPIOID and benzodiazepines or other CNS depressants for use in patients for whom alternative treatment options are inadequate.”

In addition, one of the Centers for Disease Control and Prevention’s guidelines for prescribing opioids for chronic pain reads: “Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.”⁸

“Reduc[ing] the risk of preventable overdose deaths by using nonbenzodiazepine treatments, prescribing benzodiazepines judiciously only when clinically indicated, and tapering patients off long-term benzodiazepine treatment,” will help in reducing observed incidents, concluded Dr Gould. “For older patients, sleep aids that do not interact with the GABAA receptor should be considered first,” he added.

Disclosure

Dr Gould is an employee of Pernix Therapeutics.

Read more of Clinical Pain Advisor’s coverage of PAINWeek 2017 by visiting the conference page.

References

1. Gould E. Pain and insomnia in the elderly: Why not to use benzodiazepines? Presented at: PainWeek 2017. Las Vegas, NV; September 5-9, 2017.
2. Byrd L. Managing chronic pain in older adults: a long-term care perspective. Annals of Long-Term Care: Clinical Care and Aging. 2013;21(12):34-40.
3. National Sleep Foundation. Insomnia. Available at: https://sleepfoundation.org/insomnia/content/what-causes-insomnia. Accessed: September 6, 2017.
4. Bolash R, Drerup M. How to beat insomnia when you have chronic pain. Available at: https://health.clevelandclinic.org/2015/12/managing-insomnia-for-those-with-chronic-pain/. Accessed: September 6, 2017.
5. Paulozzi LJ, Mack KA, Hockenberry JM. Vital signs: variation among States in prescribing of opioid pain relievers and benzodiazepines – United States, 2012. MMWR Morb Mortal Wkly Rep. 2014;63(26):563-568.
6. Substance Abuse and Mental Health Services Administration. The DAWN report. Benzodiazepines in combination with opioid pain relievers or alcohol: Greater risk of more serious ED visit outcomes. Available at: https://www.samhsa.gov/data/sites/default/files/DAWN-SR192-BenzoCombos-2014/DAWN-SR192-BenzoCombos-2014.pdf. Accessed: September 6, 2017.
7. U.S. Food and Drug Administration News Release. FDA requires strong warnings for opioid analgesics, prescription opioid cough products, and benzodiazepine labeling related to serious risks and death from combined use. August 31, 2016. Available at: https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm518697.htm. Accessed: September 6, 2017.
8. Centers for disease control and prevention public health service u s department of health and human services. Guideline for prescribing opioids for chronic pain. J Pain Palliat Care Pharmacother. 2016;30(2):138-140.

This article originally appeared on Clinical Pain Advisor