Workers Using Prescription Opioids and/or Benzodiazepines Can Face Safety and Health Risks

The opioid crisis that faces the nation has a great impact on workers and NIOSH has a comprehensive program to address opioids in workers. One issue of concern is workers who use prescription opioids and/or benzodiazepines for medically appropriate reasons.

Workers who use either prescription opioids or benzodiazepines or a combination of prescriptions for both of these drugs, for medical reasons, can face safety and health risks in U.S. workplaces, which employ 160 million people across all occupations [1].

Opioids treat moderate-to-severe pain, and benzodiazepine medications (sometimes called “benzos”, including diazepam and alprazolam) are sedatives often used to treat anxiety, insomnia, and other conditions [2]. In particular, patients with combined prescription use of both drugs may be more likely to become addicted or to die from an overdose [3].

Facts about prescription opioid and benzodiazepine medications, whether each drug is used alone or if they are used together

• Patients prescribed opioids are more likely to become addicted or to die from an overdose even if they start out using prescribed opioids for a medically appropriate reason [1–9].
• Co-abuse, where both prescribed opioids and benzodiazepines are abused, can happen [7, 10–11].
• Overlapping prescriptions, where a prescription for an opioid and one for a benzodiazepine cover at least some of the same dates, often are a sign of inappropriate prescription drug use and/or inappropriate prescribing practices [12–14].
• More than 6 of every 10 overdose deaths involve opioids [15].

In 2016, the Centers for Disease Control and Prevention published the CDC Guideline for Prescribing Opioids for Chronic Pain [16]. This guideline focuses on how clinicians can carefully prescribe opioids, so fewer patients become addicted and placed at risk for overdose. The guideline also calls for doctors to first consider other treatment options that can safely manage chronic pain.

How might the use of prescription opioids and/or benzodiazepines be important for workplace issues?

A review of scientific research published in 2017 examined prescription opioid and/or benzodiazepine medication use and workplace issues [4]. The review authors suggested models to describe how workplace and personal risk factors that involve prescription drugs might affect illness and injury [4], using information from published scientific studies. Evidence reviewed from these scientific studies suggests that if prescription opioid and/or benzodiazepine medications are medically appropriate, workplace issues to be aware of for health and safety reasons include

• Workplace psychosocial stress, which is linked to increased prescription benzodiazepine use;
• Prescription use of both opioids and benzodiazepines (using either one alone), which is linked to
  • Decreased psychomotor performance,
  • Falls, and
  • Motor vehicle crashes; and
• The combined use of prescription opioids and benzodiazepines (together), which is associated with
  • More use of multiple healthcare providers,
  • More disabilities, and
  • Higher healthcare costs.

These factors can lead to health and safety problems in such areas as shift work, ladder use, and transporting and moving of materials; as well as for workers who have job-related low back pain. For example, when patients who use ladders at work take a prescription opioid or a prescription benzodiazepine, they may be more likely to fall. The review also noted the following about increased use of opioids in workplaces:

• Risks can increase for ergonomic challenges, musculoskeletal disorders that continue without relief, and/or job-related injuries can cause more workers to use prescription opioids
• Workplace psychological and social stress may cause more workers to use prescription benzodiazepines.
• Drug-free workplace policies may lower the use of prescription drugs in the workplace.

This review extended previous work that examined the importance of occupational and personal risk factors for illness and injury [17, 18].

How can this review help workers?

This analysis helps workers by raising awareness of risks that involve prescription opioid and benzodiazepine use for employers and doctors.

For example, evidence supports that workers who do shift work while using prescription opioid and benzodiazepines can perform worse in skills involving psychomotor functioning. If a doctor knows a patient works a night shift, then the doctor could consider the shift work when counseling the patient or prescribing medications. As another example, evidence supports that workers who take prescription opioids and benzodiazepines are more likely to be involved in motor vehicle crashes. Patients who work in transporting or moving materials, for example, may need medication counseling and more nuanced prescriptions.

Why do doctors need to know about a patient’s work?

Everyone involved in promoting healthy and safe workplaces can benefit from knowing how prescription opioids and benzodiazepines interact with workplace roles and tasks. This includes workplace safety and health professionals, those who make policies, workplace managers, and workers.

Doctors who understand a patient’s responsibilities at work can support informed clinical decision making, improved communication between patients and providers, and appropriate prescribing..

Sudha P. Pandalai, MD, PhD, is a physician (public health) in the Risk Evaluation Branch of NIOSH’s Education and Information Division.

Paul A. Schulte, PhD, is director of the NIOSH Education and Information Division.

References

1. BLS [2017]. Databases, tables & calculators by subject.
2. CDC [2017]. Opioid overdose.
3. Park TW, et al. [2015]. Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study.
4. Kowalski-McGraw M, et al. [2017]. Characterizing the Interrelationships of Prescription Opioid and Benzodiazepine Drugs with Worker Health and Workplace Hazards.
5. CDC [2017]. Understanding the epidemic.
6. CDC [2015]. NVSS mortality data.
7. Substance Abuse and Mental Health Services Administration [2010]. Results from the 2010 National Survey on Drug Use and Health.
8. Hall AJ, et al. [2008]. Patterns of abuse among unintentional pharmaceutical overdose fatalities.
9. Hausken AM, et al. [2007]. Use of anxiolytic or hypnotic drugs and total mortality in a general middle-aged population.
10. Manchikanti L, Singh A [2008]. Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids.
11. Jones JM, et al. [2012]. Polydrug abuse: A review of opioid and benzodiazepine combination use.
12. Paulozzi LJ, et al. [2012]. A history of being prescribed controlled substances and risk of drug overdose death.
13. Paulozzi LJ, et al. [2011]. Prescription drug monitoring programs and death rates from drug overdose.
14. Weisberg DF, et al. [2014]. Prescription opioid misuse in the United States and the United Kingdom: cautionary lessons.
15. Seth, et al. [2018]. Overdose deaths involving opioids, cocaine, and psychostimulants – United States, 2015-2016.
16. CDC [2016]. Guideline resources.
17. Schulte PA, et al. [2012]. Interaction of occupational and personal risk factors in workforce health and safety.
18. Pandalai SP, et al. [2013]. Conceptual heuristic models of the interrelationships between obesity and the occupational environment.