Benzodiazepines in Long-Term Opioid Therapy

The prescribing of long-term opioid therapy (LtOT) for chronic noncancer pain (CNCP) gained wide clinical acceptance over the past quarter century. The practice has become increasingly controversial in recent years, however, due both to questions about long-term efficacy and the potential for opioid-related morbidity and mortality [1–3]. Recently, several pain medicine thought leaders have retreated from long-held positions about the wisdom of prescribing LtOT for patients with CNCP [4]. The prescribing of long-term benzodiazepine therapy for anxiety and mood disorders, insomnia, and other indications is also both prevalent and controversial. Advocates for their use point to their rapidity of onset, efficacy, and tolerability, while opponents highlight concerns about sedation, cognitive and psychomotor impairment, abuse and addiction, physical dependence, and the sometimes enormous difficulties in tapering and discontinuing these medications [5–7]. It has been argued that the availability of psychological therapies and selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine uptake inhibitors (SNRIs) for anxiety disorders, and sleep hygiene and melatonin for insomnia have made the long-term administration of benzodiazepines largely avoidable [7–9]. Although a detailed discussion of the safety and efficacy of benzodiazepine therapy is beyond the scope of this commentary, a recent critical appraisal of these agents offered the following conclusions [10]: