Separate and combined psychopharmacological effects of alprazolam and oxycodone in healthy volunteers

Prevalence and correlates of the misuse of z-drugs and benzodiazepines in the National Survey on Drug Use and Health

Background

Benzodiazepines and non-benzodiazepine hypnotics (z-drugs) are commonly prescribed for their anxiolytic and hypnotic properties, though they can also be misused. In studies examining the epidemiology of prescription drug misuse, these medication classes are commonly combined, rendering inadequate knowledge of their patterns of misuse. The objective of this study was to characterize the population prevalence, conditional dependence, and sociodemographic and clinical correlates of the misuse of benzodiazepines and z-drugs.

Methods

Data from the National Survey on Drug Use and Health from 2015 to 2019 were used to estimate population-level prevalence and characteristics of benzodiazepine and z-drug misuse. Groups were derived based on past-year misuse of benzodiazepines alone, z-drugs alone, or both drug types. Unadjusted regression analyses were used to compare groups on characteristics of interest.

Results

Exposure to benzodiazepines and/or z-drugs via prescription or misuse was common; however, only 2% of the population was estimated to have misused a benzodiazepine in the past year, and less than 0.5% misused z-drugs. People who misused only z-drugs were generally older, more likely to have health insurance, more educated, and had less severe psychiatric symptoms. This group was also more likely to report misuse to cope with sleep difficulty. Although concurrent substance use was highly prevalent in all groups, people who misused z-drugs alone generally reported less concurrent substance use than the other groups.

Conclusion

The misuse of z-drugs is less common than benzodiazepines, and people who misuse only z-drugs appear to generally have lower clinical severity. Nonetheless, a substantial subgroup of people exposed to z-drugs report concurrent, past-year use of other substances. Further research on z-drug misuse, including consideration of whether it should be grouped with other anxiolytic/hypnotic drugs, is needed.

A descriptive analysis of drivers under the influence of opioids in Kentucky

Despite the ongoing opioid epidemic and evidence of the increasing prevalence of driving under the influence of opioids, particularly in rural communities, there remains a limited understanding of those who drive under the influence of opioids. The current study aims to fill this gap in the literature by examining drivers under the influence of opioids (DUIOs) using the clinical substance use assessment records of a statewide sample of drivers convicted of driving under the influence (N = 15,917); first identifying differences between DUIOs and drivers under the influence of other, non-opioid substances, followed by an examination of factors associated with driving under the influence of opioids in combination with other substances, and finally, comparing rural and urban DUIOs (N = 1,571). Bivariate analyses were used to compare groups, while a logistic regression model was used to identify correlates of other substance involvement. DUIOs differed from drivers under the influence of other, non-opioid substances, such as being more likely to be convicted in a rural community (65.7% vs 53.6%) and to be under the influence of multiple substances at the time of arrest (42.0% vs 7.1%). Among DUIOs, a rural conviction (p =.016) and meeting DSM criteria for an alcohol (p <.001) and drug use disorder (p <.001) were positively associated with driving under the influence of opioids in combination with other substances. Results also highlighted a number of differences between rural and urban DUIOs, including other substance involvement. Urban DUIOs were more likely to report alcohol involvement in their DUI arrest (16.7% vs 9.1%), and rural DUIOs were more likely to report other, non-opioid drug involvement (36.9% vs 29.1%). Results suggest a possible need for different prevention and treatment approaches depending on rural/urban environment, which is noteworthy given limited treatment availability and other barriers to substance use treatment in rural communities.

Opioid Use and Driving Performance

INTRODUCTION

The USA is in an opioid epidemic, with an increased number of individuals taking psychoactive drugs while executing the tasks of everyday life, including operating a motor vehicle. The pharmacology of opioids has been widely studied, but the effects of opioids on psychomotor function, driving performance, and the risk of motor vehicle collision remain less clear. Clinicians are faced with the challenge of controlling patient pain while also reconciling conflicting messages from the literature about how safe it is for their patients taking opioids to engage in potentially dangerous routine tasks.

DISCUSSION

This review assesses the current literature regarding opioids as they relate to neurocognitive function, driving performance, and accident risk. Manuscripts are categorized by study context and subject matter: controlled experimental administration, illicit use, prescription use, retrospective forensic toxicology, and polydrug consumption.

CONCLUSION

Illicit use, initiation of therapy, and opioid use in combination with other psychoactive medications are contexts most clearly associated with impairment of driving-related functions and/or operation of a motor vehicle. Clinicians should counsel patients on the risk of impairment when initiating therapy, when co-prescribing opioids and other psychoactive drugs, or when a patient is suspected of having an opioid use disorder.

Greater Conditioned Pain Modulation Is Associated With Enhanced Morphine Analgesia in Healthy Individuals and Patients With Chronic Low Back Pain

OBJECTIVES

Conditioned pain modulation (CPM) protocols index magnitude of descending pain inhibition. This study evaluated whether the degree of CPM, controlling for CPM expectancy confounds, was associated with analgesic and subjective responses to morphine and whether chronic pain status or sex moderated these effects.

MATERIALS AND METHODS

Participants included 92 individuals with chronic low back pain and 99 healthy controls, none using daily opioid analgesics. In a cross-over design, participants attended 2 identical laboratory sessions during which they received either intravenous morphine (0.08 mg/kg) or saline placebo before undergoing evoked pain assessment. In each session, participants engaged in ischemic forearm and heat pain tasks, and a CPM protocol combining ischemic pain (conditioning stimulus) and heat pain (test stimulus). Placebo-controlled morphine outcomes were derived as differences in pain and subjective effects across drug conditions.

RESULTS

In hierarchical regressions controlling for CPM expectancies, greater placebo-condition CPM was associated with less subjective morphine unpleasantness (P=0.001) and greater morphine analgesia (P's<0.05) on both the ischemic pain task (Visual Analog Scale Pain Intensity and Unpleasantness) and heat pain task (Visual Analog Scale Pain Intensity, McGill Pain Questionnaire-Sensory, and Present Pain Intensity subscales). There was no moderation by sex or chronic low back pain status, except for the ischemic Present Pain Intensity outcome for which a significant 2-way interaction (P<0.05) was noted, with men showing a stronger positive relationship between CPM and morphine analgesia than women.

DISCUSSION

Results suggest that CPM might predict analgesic and subjective responses to opioid administration. Further evaluation of CPM as an element of precision pain medicine algorithms may be warranted.

The association between endogenous opioid function and morphine responsiveness: a moderating role for endocannabinoids

We sought to replicate previous findings that low endogenous opioid (EO) function predicts greater morphine analgesia and extended these findings by examining whether circulating endocannabinoids and related lipids moderate EO-related predictive effects. Individuals with chronic low-back pain (n = 46) provided blood samples for endocannabinoid analyses, then underwent separate identical laboratory sessions under 3 drug conditions: saline placebo, intravenous (i.v.) naloxone (opioid antagonist; 12-mg total), and i.v. morphine (0.09-mg/kg total). During each session, participants rated low-back pain intensity, evoked heat pain intensity, and nonpain subjective effects 4 times in sequence after incremental drug dosing. Mean morphine effects (morphine-placebo difference) and opioid blockade effects (naloxone-placebo difference; to index EO function) for each primary outcome (low-back pain intensity, evoked heat pain intensity, and nonpain subjective effects) were derived by averaging across the 4 incremental doses. The association between EO function and morphine-induced back pain relief was significantly moderated by endocannabinoids [2-arachidonoylglycerol (2-AG) and N-arachidonoylethanolamine (AEA)]. Lower EO function predicted greater morphine analgesia only for those with relatively lower endocannabinoids. Endocannabinoids also significantly moderated EO effects on morphine-related changes in visual analog scale-evoked pain intensity (2-AG), drug liking (AEA and 2-AG), and desire to take again (AEA and 2-AG). In the absence of significant interactions, lower EO function predicted significantly greater morphine analgesia (as in past work) and euphoria. Results indicate that EO effects on analgesic and subjective responses to opioid medications are greatest when endocannabinoid levels are low. These findings may help guide development of mechanism-based predictors for personalized pain medicine algorithms.

Self-reported cumulative medical opioid exposure and subjective responses on first use of opioids predict analgesic and subjective responses to placebo-controlled opioid administration

BACKGROUND AND OBJECTIVES

To expand the evidence base needed to enable personalized pain medicine, we evaluated whether self-reported cumulative exposure to medical opioids and subjective responses on first opioid use predicted responses to placebo-controlled opioid administration.

METHODS

In study 1, a survey assessing cumulative medical opioid exposure and subjective responses on first opioid use was created (History of Opioid Medical Exposure (HOME)) and psychometric features documented in a general sample of 307 working adults. In study 2, 49 patients with chronic low back pain completed the HOME and subsequently rated back pain intensity and subjective opioid effects four times after receiving saline placebo or intravenous morphine (four incremental doses) in two separate double-blinded laboratory sessions. Placebo-controlled morphine effects were derived for all outcomes.

RESULTS

Two HOME subscales were supported: cumulative opioid exposure and euphoric response, both demonstrating high test-retest reliability (Intraclass Correlation Coefficients > 0.93) and adequate internal consistency (Revelle's Omega Total = 0.73-0.77). In study 2, higher cumulative opioid exposure scores were associated with significantly greater morphine-related reductions in back pain intensity (p=0.02), but not with subjective drug effects. Higher euphoric response subscale scores were associated with significantly lower overall perceived morphine effect (p=0.003), less sedation (p=0.04), greater euphoria (p=0.03) and greater desire to take morphine again (p=0.02).

DISCUSSION

Self-reports of past exposure and responses to medical opioid analgesics may have utility for predicting subsequent analgesic responses and subjective effects. Further research is needed to establish the potential clinical and research utility of the HOME.

TRIAL REGISTRATION NUMBER

NCT02469077.

Characterizing the Interrelationships of Prescription Opioid and Benzodiazepine Drugs With Worker Health and Workplace Hazards

OBJECTIVE

Prescription opioid and benzodiazepine drug use, which has risen significantly, can affect worker health. Exploration of the scientific literature assessed (1) interrelationships of such drug use, occupational risk factors, and illness and injury, and (2) occupational and personal risk factor combinations that can affect their use.

METHODS

The scientific literature from 2000 to 2015 was searched to determine any interrelationships.

RESULTS

Evidence for eight conceptual models emerged based on the search yield of 133 articles. These models summarize interrelationships among prescription opioid and benzodiazepine use with occupational injury and illness. Factors associated with the use of these drugs included fatigue, impaired cognition, falls, motor vehicle crashes, and the use of multiple providers.

CONCLUSION

Prescription opioid and benzodiazepine drugs may be both a personal risk factor for work-related injury and a consequence of workplace exposures.

The impact of therapeutic opioid agonists on driving-related psychomotor skills assessed by a driving simulator or an on-road driving task: A systematic review

BACKGROUND

Driving cessation is associated with poor health-related outcomes. People with chronic diseases are often prescribed long-term opioid agonists that have the potential to impair driving. Studies evaluating the impact of opioids on driving-related psychomotor skills report contradictory results likely due to heterogeneous designs, assessment tools and study populations. A better understanding of the effects of regular therapeutic opioid agonists on driving can help to inform the balance between individual's independence and community safety.

AIM

To identify the literature assessing the impact of regular therapeutic opioid agonists on driving-related psychomotor skills for people with chronic pain or chronic breathlessness.

DESIGN

Systematic review reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis statement; PROSPERO Registration CRD42017055909.

DATA SOURCES

Six electronic databases and grey literature were systematically searched up to January, 2017. Inclusion criteria were as follows: (1) empirical studies reporting data on driving simulation, on-the-road driving tasks or driving outcomes; (2) people with chronic pain or chronic breathlessness; and (3) taking regular therapeutic opioid agonists. Critical appraisal used the National Institutes of Health's quality assessment tools.

RESULTS

From 3809 records screened, three studies matched the inclusion criteria. All reported data on people with chronic non-malignant pain. No significant impact of regular therapeutic opioid agonists on people's driving-related psychomotor skills was reported. One study reported more intense pain significantly worsened driving performance.

CONCLUSION

This systematic review does not identify impaired simulated driving performance when people take regular therapeutic opioid agonists for symptom control, although more prospective studies are needed.

Opioid Analgesic Use in Patients with Ankylosing Spondylitis: An Analysis of the Prospective Study of Outcomes in an Ankylosing Spondylitis Cohort

OBJECTIVE

Opioid analgesics may be prescribed to ankylosing spondylitis (AS) patients with pain that is unresponsive to antirheumatic treatment. Our study assessed factors associated with opioid usage in AS.

METHODS

A prospective cohort of 706 patients with AS meeting modified New York criteria followed at least 2 years underwent comprehensive clinical evaluation of disease activity and functional impairment. These were assessed by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Functional Index (BASFI). Radiographic severity was assessed by the Bath Ankylosing Spondylitis Radiology Index and modified Stokes Ankylosing Spondylitis Scoring System. Medications taken concurrently with opioids, as well as C-reactive protein (CRP) levels and erythrocyte sedimentation rate (ESR), were determined at each study visit, performed every 6 months. Analyses were carried out at baseline, and longitudinal multivariable models were developed to identify factors independently associated with chronic and intermittent opioid usage over time.

RESULTS

Factors significantly associated with opioid usage, especially chronic opioid use, included longer disease duration, smoking, lack of exercise, higher disease activity (BASDAI) and functional impairment (BASFI), depression, radiographic severity, and cardiovascular disease. Patients taking opioids were more likely to be using anxiolytic, hypnotic, antidepressant, and muscle relaxant medications. Multivariable analysis underscored the association with smoking, older age, antitumor necrosis factor agent use, and psychoactive drugs, as well as with subjective but not objective determinants of disease activity.

CONCLUSION

Opioid usage was more likely to be associated with subjective measures (depression, BASDAI, BASFI) than objective measures (CRP, ESR), suggesting that pain in AS may derive from sources other than spinal inflammation alone.

Gender difference in prescription opioid abuse: A focus on oxycodone and hydrocodone

Several data gathered in the last decade indicate an increase of abuse of prescription opioid drugs oxycodone (OXY) and hydrocodone (HYDRO) in women. However, to date there are no conclusive evidences investigating the gender-dependent abuse liability of prescription opioids. This study aims to supply a specific focus on women's data through a selective summary of the literature analyzing gender differences in the pharmacokinetic and pharmacodynamic dimension of OXY and HYDRO. Findings from this study suggest that the majority of OXY and HYDRO pharmacokinetic and pharmacodynamic effects do not differ according to gender, though confirming a significant difference in the incidence of adverse effects as demonstrated by the increased gastrointestinal adverse reactions in female subjects. Although the majority of recent clinical studies include an equal number of female and male subjects, the main outcome parameters do not relate specifically to gender differences. Due to the gender influence in activity of CYP3A4 and its crucial role in metabolism of both OXY than HYDRO, we suggest that assessing pharmacokinetic and pharmacodynamic interactions in clinical studies may be useful to clarify the effect of the higher CYP3A4 activity in female in relation to CYP2D6 genotype. Overall, considering the paucity of data regarding gender differences in European Union, this work highlights that impact of new abuse deterrent formulations should be assessed with a special focus on data concerning female subjects.

Parent and Metabolite Opioid Drug Concentrations in Unintentional Deaths Involving Opioid and Benzodiazepine Combinations

Effects of benzodiazepines on postmortem opioid parent and parent/metabolite blood concentration ratios were determined for fentanyl-, hydrocodone-, methadone-, or oxycodone-related accidental deaths. These opioids are partially metabolized by the CYP3A4 enzyme system, which is also affected by diazepam and alprazolam. Opioid/metabolite combinations examined were as follows: fentanyl/norfentanyl, hydrocodone/dihydrocodeine, methadone/EDDP, and oxycodone/oxymorphone. Parent opioid concentrations were analyzed for 877 deaths. Parent/metabolite concentration ratios were analyzed for 349 deaths, excluding cases with co-intoxicants present known to interfere with opioid elimination. Alprazolam in combination with diazepam significantly decreased median hydrocodone concentrations by 48% (p = 0.01) compared to hydrocodone alone. The methadone parent/metabolite concentration ratio was reduced by 35% in the presence of diazepam compared to methadone alone (p = 0.03). Benzodiazepines did not statistically significantly affect fentanyl or oxycodone concentrations. Possible factors affecting opioid concentrations and possible toxicity development, including any differential effects on specific opioids, should continue to be explored.

Polydrug abuse: a review of opioid and benzodiazepine combination use

This paper reviews studies examining the pharmacological interactions and epidemiology of the combined use of opioids and benzodiazepines (BZDs). A search of English language publications from 1970 to 2012 was conducted using PubMed and PsycINFO(®). Our search found approximately 200 articles appropriate for inclusion in this paper. While numerous reports indicate that the co-abuse of opioids and BZDs is ubiquitous around the world, the reasons for the co-abuse of these medications are not entirely clear. Though the possibility remains that opioid abusers are using BZDs therapeutically to self-medicate anxiety, mania or insomnia, the data reviewed in this paper suggest that BZD use is primarily recreational. For example, co-users report seeking BZD prescriptions for the purpose of enhancing opioid intoxication or "high," and use doses that exceed the therapeutic range. Since there are few clinical studies investigating the pharmacological interaction and abuse liability of their combined use, this hypothesis has not been extensively evaluated in clinical settings. As such, our analysis encourages further systematic investigation of BZD abuse among opioid abusers. The co-abuse of BZDs and opioids is substantial and has negative consequences for general health, overdose lethality, and treatment outcome. Physicians should address this important and underappreciated problem with more cautious prescribing practices, and increased vigilance for abusive patterns of use.