McMaster University

Michael G. DeGroote
National Pain Centre

Scope of Search

Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

Cluster 1: Deciding to Initiate Opioid Therapy

R06. Recommendation Statement

No. Recommendation Keyword
R06 For patients taking benzodiazepines, particularly for elderly patients, consider a trial of tapering (Grade B). If a trial of tapering is not indicated or is unsuccessful, opioids should be titrated more slowly and at lower doses. (Grade C). Benzodiazepine tapering
  • R06. Discussion
  • R06. Summary of Peer-Reviewed Evidence

R06. Discussion

The combination of opioids and benzodiazepines increases the risk of sedation, overdose, and diminished function in all patients, especially as age advances. (See also Recommendation 17 for prescribing cautions for the elderly). Opioids should be prescribed more slowly and at lower doses for patients on benzodiazepine treatment.

A successful trial of benzodiazepine tapering can mean either a dose reduction or elimination of benzodiazepines. (See Appendix B-6 for a description of benzodiazepine tapering approach.) Benzodiazepine tapering is feasible in a primary-care setting, and it is associated with improved health outcomes. Tapering benzodiazepines may not be indicated in situations such as moderate to severe anxiety, panic disorder, seizures, and spasticity.

R06. Summary of Peer-Reviewed Evidence

1. There is evidence that benzodiazepines increase opioid toxicity and risk of overdose.

Concurrent prescribing of opioids and benzodiazepines is common. Cross-sectional studies suggest that pain patients may be more likely to be prescribed opioids and to receive higher doses if they abuse alcohol, are on benzodiazepines, or are depressed (Hermos 2004, Sullivan 2005). Most opioid overdoses involve multiple drugs in addition to opioids (Mirakbari 2003); benzodiazepines and alcohol are most commonly implicated. The serum concentration of opioids is lower in mixed overdoses than in pure overdoses, suggesting that other drugs significantly lower the lethal opioid dose (Cone 2004).

2. There is evidence that benzodiazepines can be successfully tapered in a primary-care setting, with improved health outcomes.

Several controlled trials have demonstrated that benzodiazepine tapering can be done in a primary-care setting. Tapering has been shown to be successful both in patients with anxiety disorders and with insomnia (Baillargeon 2003, Gosselin 2006). An observational study documented reduced symptoms of depression in methadone patients who were tapered off benzodiazepines and started on antidepressant therapy (Schreiber 2008). Tapering is more effective when combined with cognitive-behavioural therapy, but can be successful without formal CBT (Baillargeon 2003, Gosselin 2006, Vicens 2006). A significant number of older patients are willing to attempt benzodiazepine tapering (Cook 2007). Patients being tapered for insomnia have decreased sleep time but improved quality of sleep post-taper (Morin 2004). Controlled trials have found that psychiatric symptoms (panic disorder, GAD) do not worsen with tapering, and may improve (Moroz 1999, Gosselin 2006). For an approach to benzodiazepine tapering, see Appendix B-6.