From the Guidelines
For patients taking opioids who experience panic attacks, selective serotonin reuptake inhibitors (SSRIs) such as sertraline (50-200 mg daily) or escitalopram (10-20 mg daily) are recommended as first-line treatments due to their efficacy and relatively safer profile compared to benzodiazepines when used with opioids. When considering medication options, it's crucial to weigh the benefits against the risks, especially in patients already on opioids, given the potential for increased respiratory depression with certain combinations 1. The following options can be considered:
- SSRIs like sertraline or escitalopram, which are effective for both panic disorder and anxiety symptoms.
- Serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine (75-225 mg daily) or duloxetine (60-120 mg daily), which are also good options.
- For acute management, while benzodiazepines like lorazepam can provide rapid relief, their use with opioids should be cautious due to the increased risk of respiratory depression, as highlighted in studies 1. Non-benzodiazepine alternatives such as hydroxyzine (25-50 mg as needed) or buspirone (5-10 mg three times daily) can be considered for managing anxiety without the significant risk of dependence and respiratory depression associated with benzodiazepines when used with opioids. It's also important to consider cognitive behavioral therapy alongside medication for a comprehensive treatment approach. Given the risks associated with benzodiazepines and opioids, the safest approach is to avoid concurrent use of these medications whenever possible, opting for alternatives like SSRIs or SNRIs as first-line treatments for panic attacks in patients taking opioids 1.
From the Research
Medications for Panic Attacks in Patients Taking Opioids
- Selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines are among the most frequently prescribed drugs for panic disorder 2.
- Benzodiazepines, such as clonazepam, alprazolam, and lorazepam, are effective in treating panic disorder and can be considered for patients taking opioids 3, 4.
- Serotonergic antidepressants, including SSRIs, are also indicated for the treatment of panic disorder and can be used in conjunction with opioids 5.
- Clonazepam, in particular, has been shown to be effective in the treatment of panic disorder, both alone and in combination with SSRIs and/or behavioral therapy 3.
Considerations for Medication Use
- Benzodiazepines can cause tolerance and dependence, and their chronic use is associated with risks such as cognitive disorders, dependence, and withdrawal syndromes 2, 5.
- SSRIs may have a delayed onset of therapeutic effect and can exacerbate anxiety and panic early in the treatment course 2.
- Combining cognitive behavior therapy (CBT) with pharmacotherapy may be beneficial in treating panic disorder, but more research is needed to determine the additive effects of these treatments 6.