Benzodiazepines and Opioid Medicines

Opioid pain medicine and a benzodiazepine can be prescribed for two different problems and still be dangerous in the same body. On August 31, 2016, the FDA said it was requiring class-wide label changes so clinicians and patients would see that risk. The changes include boxed warnings, the agency's most prominent warning, and patient Medication Guides. They cover prescription opioid analgesics, opioid-containing cough products, and benzodiazepines, nearly 400 products in all. The risks of using those medicines at the same time include extreme sleepiness, respiratory depression, coma, and death.

This page is that warning. It does not list doses, and it does not tell you which of the two medicines to drop tonight. SmarterRecovery is a referral helpline. It is not SMART Recovery, the peer program with a similar name, and a call to (800) 653-9376 is not a prescriber's order.

If someone is extremely sleepy and you cannot wake them, if breathing is slow or difficult, or if they are unresponsive, call 911. The FDA tells patients and caregivers to seek medical help immediately for unusual dizziness or lightheadedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness. Do not wait for every sign on the list.

Why the combination is the warning

The FDA's explanation is plain. Opioids and benzodiazepines both affect the central nervous system, which controls most of the functions of the brain and body. Used together, they can slow the system enough to stop safe breathing. The same patient notice folds in other central nervous system depressants, including alcohol. A drink on top of the two medicines is part of the warning, not a separate hobby.

Opioids, in that notice, are powerful prescription medicines that can help manage pain when other treatments cannot be taken or do not relieve enough pain. Some are approved with other medicines to reduce coughing. Common side effects include drowsiness, dizziness, nausea, vomiting, constipation, and slowed or difficult breathing. The FDA also names misuse, abuse, addiction, overdose, and death. Examples it gives are oxycodone, hydrocodone, codeine, and morphine. Those four names are examples. They are not the whole class, and they are not a signal that a cough syrup is harmless because it came from a pharmacy.

Benzodiazepines, in the same notice, are prescribed for conditions such as anxiety, insomnia, and seizures. Examples include alprazolam, clonazepam, and lorazepam. Common side effects include drowsiness, dizziness, weakness, and physical dependence. Dependence means the body has adapted. It is a reason the medicine cannot be dropped overnight. It is not, by itself, the boxed warning about the combination. The benzodiazepine withdrawal guide is where the FDA's later class warning on stopping too fast is explained, including seizures and the statement that no standard taper fits every patient. Read that page before you skip a benzodiazepine dose to "get off the combination."

If you are already taking both, the 2016 notice says to consult your health care provider about whether continued combined use is still needed. That is a clinical question. A family member's fear, however well founded, is not a new prescription.

The label change was not a recall. The FDA described it as one step in its Opioids Action Plan: inform prescribers, and still leave room for patients in pain to get care that is effective and appropriate. A boxed warning is how the agency marks a risk it wants at the front of the labeling. It does not, by itself, mean every person on both medicines must stop today. It means the reason for using them together has to be a clinician's reason, revisited, not a habit that survived because nobody looked at both bottles.

Respiratory depression is the phrase on the warning for breathing that has become too slow or too shallow to be safe. Extreme sleepiness is the companion sign, because a person can slide from drowsy to unable to wake. Coma and death are the far end of that slide, which is why the FDA tells caregivers not to wait the night out. Unusual dizziness or lightheadedness belongs on the same list. You do not need all of them before you call 911.

The patient notice also required Medication Guides, which are the handouts meant for the person taking the drug, not only the paragraph written for clinicians. If you were not given one, ask the pharmacist or the prescriber for the guide that matches what you are actually taking. The existence of nearly 400 products is why a blog list of brand names would be incomplete and why your own labels matter more than the four opioid examples and three benzodiazepine examples printed above.

Physical dependence is listed among common benzodiazepine effects in that 2016 patient section. Dependence is the body adapting to the medicine. The later FDA update on the benzodiazepine class, which the withdrawal guide explains, says patients should not stop suddenly, and that no standard taper fits everyone. Ending a dangerous combination by throwing out the benzodiazepine tonight can trade one emergency for another. The consult the 2016 notice asks for is the place where both facts have to be held at once: the combination can stop breathing, and a sudden benzodiazepine stop can cause seizures. A clinician who knows the doses is the person who can sequence that. This page cannot.

Opioid cough products are inside the 2016 action, not a footnote. The FDA grouped them with prescription opioid pain medicines and with benzodiazepines when it required the boxed warning. A syrup can be the opioid half of the combination. Tell the prescriber about cough medicine by name, including one bought because a different clinician wrote it, and about alcohol, which the same notice puts with other drugs that slow the central nervous system.

What this page will not turn into a chart

The polysubstance guide is the wider problem of two or more drugs, on purpose or mixed without the person knowing. The naloxone guide is how reversal medicine fits an opioid overdose. The opioid withdrawal guide is the timetable after opioids stop, which is a different emergency from slowed breathing while the drugs are still on board. The fentanyl guide is the potency and overdose context for that drug. None of those pages replaces the 2016 label change, and this page will not repeat their instructions as if they were one protocol.

Medication treatment for opioid use disorder is its own subject. The medication guide is where methadone, buprenorphine, and naltrexone are explained as treatment, not as a cough-and-anxiety combination. Do not decide from this paragraph that a prescribed opioid treatment medicine is the same thing as the pain pill in the FDA examples. Ask the prescriber what you are actually taking, and tell them about every benzodiazepine, including one that was prescribed by someone else.

Alcohol belongs in the same sentence you give that clinician. The FDA included it with other drugs that depress the central nervous system. The alcohol withdrawal guide is what happens if heavy drinking stops suddenly. Do not add a plan to quit drinking tonight on top of a plan to quit a benzodiazepine tonight. Each of those stops can be medically dangerous on its own.

What to do with a bottle you already have

1. If breathing is slow, the person will not wake, or they have collapsed, call 911. Tell the dispatcher both medicines if you know the names.
2. If you are awake and worried, and nobody is in that emergency, call the prescriber before you change a dose. Ask whether the two medicines still need to be taken together, and what warning signs should send you to an emergency department.
3. Bring both bottles, or a written list, to that conversation. The FDA's examples are not a full inventory of your nightstand.
4. If the benzodiazepine is the one you want to stop, ask for a patient-specific plan. The FDA has said no single taper suits everyone. This website will not invent one.

FindTreatment.gov lists treatment programs. SmarterRecovery's about page describes a free referral service paid for by treatment providers. Call or text (800) 653-9376 if you need help finding care and both an opioid and a benzodiazepine are in the house. Say that plainly. The person on the phone cannot change your prescription.

The 2016 warning exists because the combination can kill, including when each medicine was prescribed for a real condition. Stopping either one overnight can create a different medical emergency. Get a clinician between you and that choice, and use 911 if breathing has already slowed.

Additional Resources

Sources cited on this page:

• FDA: New safety measures for opioid analgesics, opioid cough products, and benzodiazepines (August 31, 2016)
• FDA: Boxed warning to improve safe use of benzodiazepines
• SAMHSA FindTreatment.gov
• 988 Suicide & Crisis Lifeline
• SmarterRecovery about page (referral disclosure)

Common Questions