Fatal Anti-Anxiety and Pain Drug Overdoses in Veterans

Veterans taking two kinds of prescription drugs risk a fatal overdose. Doctors are navigating a puzzle.

Combining opioids with benzodiazepines is dangerous. So is buprenorphine and benzos.

Veterans are twice as likely to die from an opioid overdose than civilians. That put the U.S. Department of Veterans Affairs (VA) on the hot seat to devise successful treatment, relying on opioid agonists.  (Agonists undo the effect).

Benzos, a family of anti-anxiety drugs, are part of the challenge.

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What the VA has accomplished

It’s not surprising that many military veterans have injuries and conditions that cause pain, and common opioids (Vicodin, Percocet, OxyContin, and Opana) were frequently prescribed to treat their discomfort.

As the opioid epidemic became national news, the VA cut the use of opioids for patients within its system by 64 percent between 2012 and 2020, and the number of patients on high doses by 80 percent.

Many veterans were also taking benzodiazepines (Xanax, Valium, and Klonopin) to manage anxiety, insomnia, and alcohol withdrawal symptoms. The agency reduced usage in that group by 87 percent.

It became much harder to get and keep the two prescriptions simultaneously. The combination of opioids and benzos previously increased the chances of a fatal opioid overdose by nearly four times, according to one large study.

As part of their program, the VA is pushing to make medications that treat opioid addiction more available. Methadone, buprenorphine, and naltrexone are considered the gold-standard.

For vets in rural areas, the best hope may be to receive an anti-addiction prescription through telemedicine. That approach has more than tripled in recent years.

How benzos fit in

Benzos are still very much in the picture and still dangerous. In fact, some 20 to 43 percent of people (not just vets) getting anti-addiction meds also have a benzo prescription.  

For example, in a study of more than 63,000 Massachusetts patients, a quarter filled at least one benzo prescription while under treatment with buprenorphine. That group had triple the chance of a fatal opioid overdose and were twice as likely to die for any reason, compared to those who didn’t.

This phenomenon won’t be a big surprise to doctors. They face a puzzle. The Food and Drug Administration has advised them not to withhold the anti-addiction medicine from people taking benzos, saying that the risk of untreated opioid use disorder is greater than the risk of combining drugs like buprenorphine with benzos. Patients also can get benzos illegally and often do.

The goal is to help patients taper off

Doctors hope to nudge their patients off benzos over time, believing they’ll lose the patient if they push too hard, according to other research. There’s truth to that idea. In the big Massachusetts study, the patients who took benzos were 13 percent less likely to stop taking their buprenorphine.

The problem is that benzos, like opioids, backfire. They can make you more anxious, not less.

As one doctor put it, “That conversation is a really tough one, like telling a patient, ‘look, you’ve been on Xanax for like 30 years, but I feel like that’s contributing negatively to your anxiety, insomnia’ and nobody wants to come off. And nobody has programs that focus on getting people off benzos. So, you essentially end up with these patients on benzos. And the easiest thing is for us to just keep writing this prescription.”

Some would say doctors are fueling yet another addiction. It’s true that patients tend to abuse benzos early in treatment.

“I’d mix Xanax and Klonopins and take them on a high dose of methadone so I would be pretty much high all day,” one patient said.

Patients tend to focus on the benefits of benzos. “It could potentially be dangerous… but nothing else has seemed to help me,” one said.

Others don’t think that the risk of benzos applies to them. As one example, a patient who bought benzos illegally said: “Most people in my life don’t agree with taking them. They think that it’s close to using… but I think that if it’s helping me with my anxiety attacks… that’s fine.”    

While the opioid agonist drugs are substituting one medicine for another, allowing people to break their addiction, they may also need to taper off their benzos.

“A combination of increased monitoring of patients taking benzodiazepines, limiting benzodiazepine doses, and undergoing slow, patient-guided dose reduction when necessary, may be a way to navigate this difficult, but not uncommon, clinical scenario,” wrote a team at Boston University, led by Tae Woo Park, MD, assistant professor of psychiatry.

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