Education is Key to Prevent Dangerous Opioid Drug Combinations

There is good news on the opioid front in the workers’ compensation system. According to the latest Workers’ Compensation Drug Trend Report from myMatrixx, an Express Scripts company,


  • Average spending on the drugs declined 11.9 percent
  • The percentage of injured workers using opioids for at least 30 days decreased by a couple of percentage points
  • The morphine-equivalent dose (MED) declined — with a 33.7 percent reduction in cumulative MED greater-than 100 and a 26.9 percent decrease in cumulative MED overall.


But the good news is tempered by the persistent problem of opioids prescribed in conjunction with other medications that together form a dangerous interaction. While the numbers were somewhat better in 2017 than the previous year, there are still too many injured workers being put at risk for overdoses and death. Education and outreach are needed to address the problem.



The Facts


According to the Drug Trend report, 74.2 percent of payers spent less on opioids in 2017 than in 2016. The average amount per claim declined to $342.57, compared to $388.80 in 2016. Opioids continued to be the most expensive and highly used class of drugs among injured workers and accounted for 24.1 percent of total pharmacy spend in 2017.


“While a decrease in the utilization of opioids is a positive sign for the workers’ compensation industry, there is still work to be done,” according to the report. “Nearly 40 percent of injured workers took an opioid along with a muscle relaxant, while 9 percent took an opioid and benzodiazepine. Taking these medications together can increase the risk of side effects and death from respiratory depression.”


The report showed that in 2017


  • 7 percent of injured workers took an opioid and a muscle relaxant, compared to 31.1 percent in 2016.
  • 3 percent took an opioid and a benzodiazepine last year, compared to 7.3 percent the previous year.
  • 5 percent took an opioid, a muscle relaxant and a benzodiazepine in 2016, compared to 3.1 percent in 2016.
  • Among injured workers using opioids for a short-term (less than a 30 days’ supply), 79.6 percent used opioids only, and4 percent used an opioid and a muscle relaxant.
  • For injured workers using opioids for more than 30 days, 36.1 percent filled both an opioid and a muscle relaxant.


Despite the slightly better news, there is still much to be done to curb the problem of combining opioids with certain other drugs. The federal government reports more than 30 percent of overdoses involving opioids also involve benzodiazepines or ‘benzos.’ These drugs are used to help anxiety, insomnia, muscle tension, seizures, and alcohol withdrawal. Both benzos and opioids suppress breathing, sedate users and impair cognitive functions.


Benzos are commonly sold under the names Valium, Xanax, and Klonopin. Additionally, some benzos, have muscle relaxant properties and are often prescribed for injured workers with muscle spasms.


The Centers for Disease Control and Prevention issued new guidelines in 2016 that recommend clinicians avoid prescribing benzos concurrently with opioids whenever possible. Both opioids and benzo medications now carry warnings from the Food and Drug Administration (FDA) highlighting the dangers of using the drugs together.


Research clearly shows the dangers of combining opioids with benzos. In a North Carolina study, for example, researchers found the overdose death rate among patients receiving both types of medications was 10 times higher than among those who only received opioids.


Part of the problem is that physicians may prescribe opioids on a long-term basis to treat acute or chronic pain, along with Valium to treat muscle spasms. Injured workers may also receive a Xanax prescription from a therapist if they suffer from anxiety.



Additional Medication Dangers


In addition to muscle relaxants and benzos, many other medications can be harmful when taken in combination with opioids. The FDA has issued warnings for physicians to limit their prescribing of the following for patients on opioids:


  • Antidepressants
  • Migraine medications
  • Antipsychotic drugs
  • Sleep medications
  • Serotonergic drugs, such as St. John’s wort.


There’s also evidence that antihistamines, which can cause drowsiness and sedation, may be problematic when combined with opioids. Finally, mixing alcohol with opioids can be deadly.





Over sedation and depressed breathing are two of the biggest problems resulting from a mix of opioids with other medications. Over sedation renders the person unable to wake up or respond to stimuli, creating risks for falling or slipping into a coma. Depressed breathing leads to a lack of oxygen to the brain and eventually shuts down vital organ systems, causing brain damage or death.


There are additional risks as well.


  • Serotonin Syndrome, a serious central nervous system reaction occurs when high levels of the chemical serotonin build up in the brain and cause toxicity. Symptoms may include agitation, hallucinations, rapid heart rate, excessive sweating, shivering, muscle twitching and trouble with coordination.


  • Adrenal insufficiency is a rare but serious condition in which adequate amounts of the hormone cortisol cannot be produced. Cortisol helps the body respond to stress. Symptoms of adrenal insufficiency include nausea, vomiting, loss of appetite, fatigue, weakness, dizziness or low blood pressure.


  • Decreased sex hormone levels are associated with long-term use of opioids and can reduce the person’s interest in sex, or lead to impotence or infertility.


Knowing the symptoms of an overdose is important, and may include


  • Pinpoint pupils
  • Unconsciousness
  • Dizziness or lightheadedness
  • Extreme sleepiness
  • Slowed, irregular breathing
  • Confusion
  • Unresponsiveness
  • Blue lips
  • Snoring or gurgling sound in the throat


Educating patients and physicians about the dangers of combining opioids with many other medications is the first step to reduce the problem. Those managing claims should reach out to prescribers to ensure they understand the risks of interaction.




The combination of opioids with other medications should only be prescribed to patients who do not respond adequately to other treatments. If they do, the dosages and duration of each medication should be the lowest amount possible.




Michael Stack - AmaxxAuthor Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center .



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