Opioid and Benzodiazepine Co-prescribing With Aberrant Behavior
Mr. D is a 61-year-old man with chronic low back pain on oxycodone 20 mg three times daily and alprazolam 1 mg three times daily. The opioid is prescribed by his primary care physician and the benzodiazepine by a psychiatrist. A state prescription drug monitoring program query shows fills from two pharmacies and an early refill 10 days ago. Urine drug testing is negative for oxycodone and benzodiazepines but positive for cannabis. He admits to taking extra oxycodone on bad days and borrowing alprazolam from a friend when anxious. He denies injection use, has no prior overdose, and lives alone. He asks for a dose increase because pain is 8/10.
1. How do the PDMP and urine drug test results change your risk assessment? Explain the limitations of each data source.
Read the worked answer
The combination of opioid plus benzodiazepine is already high risk for sedation and respiratory depression. Early refills, two pharmacies, taking extra oxycodone, and borrowing alprazolam suggest misuse and possibly diversion. A negative urine test for prescribed oxycodone and benzodiazepines is concerning for nonadherence, diversion, or rapid metabolism, but it is not proof: immunoassays can miss oxycodone, benzodiazepine metabolites vary, and dilute urine can produce false negatives. The PDMP documents fills, not ingestion, and may miss cash payments or out-of-state prescriptions. Cannabis adds impairment risk but does not explain the negative opioid result. I would verify with a definitive liquid chromatography-tandem mass spectrometry test, review all prescribers, and assess for opioid use disorder rather than immediately discharging him.
2. What immediate actions would you take regarding the opioid and benzodiazepine prescriptions? Include withdrawal and safety considerations.
Read the worked answer
Do not abruptly stop both medicines; abrupt benzodiazepine cessation can cause seizures, and abrupt opioid cessation can cause withdrawal and crisis. Coordinate care so one prescriber manages both, or set a clear written agreement. Prescribe naloxone and counsel him and a household contact. Stop early refills and require a single pharmacy. Begin a gradual benzodiazepine taper, often 10% to 25% every 2 to 4 weeks, after coordination with psychiatry. For opioids, stop dose escalation and begin a slow taper or transition to buprenorphine if he meets criteria for opioid use disorder. Use frequent visits and urine testing. Document the risk-benefit discussion. If diversion is confirmed, address it directly and follow legal and regulatory requirements without abandoning him.
3. How would you determine whether he meets criteria for opioid use disorder, and what treatment options would you offer if he does?
Read the worked answer
Apply DSM-5 criteria, remembering that tolerance and withdrawal do not count when the opioid is taken as prescribed. I would ask about taking more than prescribed, craving, unsuccessful efforts to cut down, time spent obtaining or using, continued use despite harm, role failure, risky use, and social problems. His extra oxycodone and borrowing benzodiazepines suggest misuse but do not alone establish opioid use disorder. If criteria are met, offer buprenorphine or methadone maintenance rather than punishment or rapid taper. If criteria are not met, provide a structured taper, multimodal pain care, and close monitoring. Either way, treat the anxiety, involve behavioral health, and avoid returning to high-dose opioid plus benzodiazepine. Document the diagnosis and rationale.