What are the risks of co-prescribing opioids and stimulants?

From the Guidelines

Coprescribing opioids and stimulants is a high-risk combination that should be avoided whenever possible due to the potential for dangerous drug interactions, increased risk of cardiovascular complications, and enhanced abuse potential 1.

Risks Associated with Coprescription

The combination of opioids and stimulants can lead to:

• Increased risk of cardiovascular complications such as irregular heartbeat, elevated blood pressure, and potential heart attack or stroke
• Masking of sedative effects of opioids by stimulants, potentially leading to higher opioid doses and increased overdose risk
• Intensified side effects such as anxiety, agitation, and insomnia
• Increased addiction risk or complication of existing substance use disorders due to the abuse potential of both medication classes
• Unpredictable effects that can confuse clinical assessment due to the opposing pharmacological actions of stimulants and opioids

Recommendations for Healthcare Providers

If coprescription is deemed necessary, healthcare providers should:

• Implement enhanced monitoring, including more frequent office visits and urine drug screening 1
• Use prescription drug monitoring program checks to minimize the risk of overdose and addiction 1
• Start with lower doses and shorter prescription durations to reduce the risk of adverse effects 1
• Provide clear patient education about the risks and proper use of the medications 1
• Consider alternative treatment options that do not involve the use of opioids and stimulants together 1

Key Considerations

• The use of opioids and stimulants together should be carefully considered and monitored due to the potential risks and complications 1
• Healthcare providers should prioritize patient safety and well-being when making decisions about coprescription 1
• The benefits of coprescription should be weighed against the potential risks, and alternative treatment options should be considered whenever possible 1

From the Research

Risks of Coprescribing Opiates and Stimulants

• There is limited direct evidence on the risks of coprescribing opiates and stimulants, as the provided studies primarily focus on the use of stimulants and atomoxetine in the treatment of ADHD, as well as the coprescription of opioids and benzodiazepines 2.
• However, it is known that coprescribing opioids and other central nervous system depressants, such as benzodiazepines, can increase the risk of adverse effects, including respiratory depression and overdose 2.
• The use of stimulants, such as those used to treat ADHD, can also have potential risks, including increased heart rate and blood pressure, as well as the potential for abuse and dependence 3, 4, 5, 6.
• In adults with comorbid ADHD and bipolar disorder, the use of stimulants and atomoxetine may be problematic, and a hierarchical approach to treatment is recommended, with mood stabilization preceding the treatment of ADHD symptoms 5.
• Long-term efficacy and safety of treatment with stimulants and atomoxetine in adult ADHD have been studied, and the results suggest that these medications can be effective and well-tolerated, but more longitudinal studies are needed to fully understand their long-term effects 6.

Potential Interactions and Consequences

• The coprescription of opioids and stimulants may increase the risk of adverse effects, including increased heart rate and blood pressure, as well as the potential for abuse and dependence.
• The use of stimulants and atomoxetine in adults with comorbid ADHD and bipolar disorder requires careful consideration and monitoring, as the potential for mood destabilization and other adverse effects is increased 5.
• The intensity of coprescribing opioids and benzodiazepines was found to be high, with a significant proportion of opioid prescription days overlapping with benzodiazepines, highlighting the need for careful consideration and monitoring of coprescription practices 2.