Should an 81‑year‑old woman who is taking oxycodone be started on diazepam 2 mg with a 30‑tablet supply, or is this unsafe and the benzodiazepine should be reconsidered/tapered?

Diazepam 2 mg Should Not Be Initiated in This 81-Year-Old Woman on Oxycodone

You should contact the prescriber immediately to recommend against starting diazepam in this patient, as the combination of opioids and benzodiazepines significantly increases the risk of respiratory depression and death, particularly in elderly patients. 1, 2, 3

Critical Safety Concerns

Respiratory Depression Risk

• The CDC explicitly warns that clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible due to increased risk for respiratory depression and overdose 1
• The FDA drug label for diazepam carries a boxed warning about potentially fatal respiratory depression when combined with opioids 3
• Animal studies demonstrate that co-administration of oxycodone and diazepam causes dose-dependent exacerbation of respiratory depression, with significant decreases in arterial oxygen and increases in carbon dioxide 4

Heightened Vulnerability in the Elderly

• Elderly patients face particular risks from benzodiazepines including cognitive impairment, reduced mobility, falls, fractures, and loss of functional independence 2
• In debilitated elderly patients, the FDA recommends limiting diazepam to the smallest effective amount (2–2.5 mg once or twice daily initially) to preclude ataxia or oversedation 3
• Long-acting benzodiazepines like diazepam pose particular concerns in the elderly due to sedation, cognitive impairment, and fall risk with injuries 2
• Observational data demonstrates that benzodiazepines with prolonged use are associated with dementia, with the effect being greatest for higher-dose agents 2

Immediate Action Steps

Before the First Visit

1. Check the Prescription Drug Monitoring Program (PDMP) to identify all controlled substances this patient is receiving and determine total opioid dosage 1
2. Contact the prescribing clinician to discuss safety concerns and coordinate care, as the CDC recommends communicating with others managing the patient to weigh risks of concurrent benzodiazepine and opioid exposure 1
3. Do not fill the diazepam prescription until you have evaluated the patient and confirmed the indication justifies the substantial risk 1, 2

At the First Visit

• Document the specific indication for diazepam—benzodiazepines should be used only for narrow indications (acute stress reactions, episodic anxiety, short-term insomnia) and ideally for courses not exceeding 2–4 weeks 5
• Assess for substance use disorder, as the FDA warns that benzodiazepines should be used with extreme caution in patients with a history of alcohol or drug abuse 3
• Screen for respiratory disease, as benzodiazepines can cause respiratory depression, particularly when combined with opioids 6
• Evaluate fall risk and cognitive function, as these are the primary adverse outcomes in elderly patients on benzodiazepines 2

Safer Alternative Approaches

Non-Pharmacologic First-Line Treatment

• Cognitive-behavioral therapy (CBT) is the first-line treatment for anxiety and insomnia and does not carry dementia-related or respiratory depression risks 2
• Offer evidence-based psychological therapies as alternatives to benzodiazepines during any treatment planning 2

Pharmacologic Alternatives (If Medication Is Necessary)

• For anxiety: Consider buspirone (requires 2–4 weeks to become effective but has no dependence risk) or SSRIs such as citalopram 10–40 mg/day or sertraline 25–200 mg/day 2
• For insomnia: Trazodone 25–200 mg can be used for short-term management without abuse potential 2
• For acute agitation: Hydroxyzine or other non-benzodiazepine anxiolytics should be considered first 2

If Diazepam Must Be Prescribed

Absolute Requirements

• Start at the lowest possible dose (2 mg once daily, not 2 mg multiple times daily) and use for the shortest duration possible 3, 5
• Limit prescription to a few days or maximum 2–4 weeks, as prescriptions beyond 4 weeks dramatically increase dependence risk 2, 5
• Provide naloxone to the patient given the high-risk combination of opioids and benzodiazepines 1
• Schedule close follow-up within 1 week to monitor for excessive sedation, dizziness, confusion, and respiratory depression 2

Critical Monitoring

• At every clinical encounter, assess for signs of respiratory depression, falls, cognitive impairment, and functional decline 2, 6
• Educate the patient and caregivers about the risks of potentially fatal respiratory depression with this drug combination 3
• Advise the patient not to drive or operate machinery until the effects of the combination have been determined 3

Common Pitfalls to Avoid

• Never assume a 30-tablet supply is appropriate—this quantity suggests chronic use, which is contraindicated in the elderly 2, 5
• Never add benzodiazepines to manage opioid-related anxiety—this creates a dangerous cycle of polypharmacy 1, 2
• Never prescribe without a clear, time-limited indication—about 50% of patients prescribed benzodiazepines continuously for 12 months develop dependence 2
• Never ignore the PDMP—failure to check may miss dangerous combinations or multiple prescribers 1

If the Patient Is Already Taking Both Medications

If you discover at the visit that she has already started both medications, do not abruptly discontinue the diazepam, as abrupt cessation can cause seizures and death 2, 6, 3. Instead:

• Initiate a gradual benzodiazepine taper using a reduction of 25% of the current dose every 1–2 weeks, or 10% per month for long-term users 2, 6
• When both medications need adjustment, taper the benzodiazepine first due to higher risks associated with benzodiazepine withdrawal compared to opioid withdrawal 2
• Integrate CBT during the taper to significantly increase success rates 2, 6
• Follow up at least monthly during the taper, with more frequent contact during difficult phases 2