The Food and Drug Administration came out with a new warning this week, stating that mixing drugs that are opioids and either benzodiazepines or barbituates (anti-anxiety) can be especially dangerous and may result in coma or death. The recognition of the dangers of mixing these two classes of drugs is becoming increasingly evident. Both types of drugs – opioids and anti-anxiety drugs – have addictive natures. The use of these drugs is additive, and both can suppress the respiratory drive. When used together, one could easily “pass out” and stop breathing.

The FDA is ordering that some 400 products now carry a “black box warning.” This is one of the most severe categories of risk, indicating that these products have serious health risks and are potentially fatal. The products of concern are anxiety medications such as Valium (diazepam), Ativan (lorezepam), Xanax (alprazolam), Klonipin (clonazepam), Restoril (temazepam), Soma (carisoprodol), and phenobarbital. All these drugs make one relax and often fall asleep. Drugs in this class are also used as part of anesthesia to control anxiety during procedures. All these medications can decrease the ability to breathe. However, in a medical setting, they can be reversed with an IV medication flumazenil, but they can not be easily reversed often when taken orally or outside of medical settings. These are the same type of medications that are part of the cocktail used for putting a person to death with drugs for the death penalty.

Why Mixing Medications Is Dangerous

Opioid addiction and abuse has been a major problem, becoming worse over the last ten years. Death rates have skyrocketed and now are about 30,000 people each year in the US, putting it in the same range as the number of people killed in motor vehicle accidents. A person can die just from overdosing on an opioid. The illegal use of narcotics makes death especially easy since the dose of drug is often uncontrolled. Prince died due to such an illegal mixture of oxycodone and fentanyl. The only good thing is that the drug naloxone (Narcan) can reverse most opioids rapidly and prevent death. Examination of those dying from opioid overdoses has found a disturbing trend that many of those people have had both opioids and benzodiazepines in their bodies. Furthermore, just giving naloxone may not rescue an overdose victim.

Patients with chronic pain are often dependent on medications to control symptoms. When pain is not well managed, and there is no successful treatment, many doctors resort to the use of opioid medications. For select patients, these drugs may be very helpful to manage symptoms. With chronic pain, the brain also tends to show changes, and the central receptors for painful sensations become overly active. These regions in the brain are right next to the same regions responsible for depression and anxiety. Patients with chronic pain often develop depression and anxiety, possibly related to the fact that the centers in the brain involved in pain and anxiety are next to each other. Treating chronic pain patients who have anxiety with both opioids and benzodiazepines now has become especially dangerous, and potentially fatal.

The bottom line for chronic pain patients is that if you have pain and anxiety, do not mix opioids and anxiety medications. If as a patient, opioids are felt to be necessary, try to find an alternative treatment. Long-term management with opioids for pain is often unsuccessful, and using other options may be more beneficial. Anxiety is a form of depression. If you also have pain, do not use an anxiety drug. Instead, work with a professional to treat the symptoms and the depression. There are many anti-depressant medications that may help along with working with a psychology management team.

The mixing of medications when one has pain can be highly dangerous. A good pain provider will want to know all the medications a patient is taking such that they can reduce the risks of serious interactions.