Veterans who were co-prescribed an opioid and benzodiazepine by doctors at the Department of Veterans Affairs faced an increased mortality risk, a new report found.
Opioids are typically prescribed for pain. Benzodiazepines — like Valium, Xanax, and Klonopin — can be prescribed for anxiety, panic disorders, insomnia, and seizures.
A National Academies of Sciences, Engineering, and Medicine study analyzed VA health records from 2007 to 2019 at the request of Congress to “evaluate the effects of prescribed opioid and benzodiazepine pharmacotherapies on all-cause mortality of U.S. veterans, including suicide,” according to the committee report released Thursday.
The risk of death for co-prescriptions of opioids and benzodiazepines has been widely accepted by health experts and federal agencies. According to the National Institutes of Health, the combination of opioids along with “other central nervous system depressants,” such as benzodiazepines, alcohol, or xylazine, increases the risk of an overdose and can cause sedation and suppress breathing.
“We know that opiates are respiratory suppressants. We know that benzos, when given with opiates, may suppress respiration more,” said Brian Strom, chair of the committee that wrote the report and executive vice president for health affairs at Rutgers University in New Jersey. “Our results are consistent with that hypothesis, but we didn’t prove that it was due to respiratory suppression.”
The Department of Veterans Affairs did not immediately respond to a request for comment for this story.
The study also found that veterans were at greater risk if they had received co-opioid and benzodiazepine prescriptions compared to veterans who were co-prescribed alternatives for opioids or benzodiazepines.
The study also found that veterans who received opioids compared to other pain management drugs were more likely to die by suicide, but only “some evidence” linking increased suicide risk among veterans co-prescribed opioid and benzodiazepine pharmacotherapy,” according to the report.
Because the number of suicides included in the data set were relatively small, “it’s imprecise,” Strom said, adding that “it looks like benzos actually blunt the suicide mortality risk.”
The study also cited specific examples of co-prescriptions that occurred before the VA implemented guidelines to limit opioid prescriptions. Between 2004 and 2009, 27% of veterans who received opioids were also given benzodiazepines from VA doctors.
Strom, as well as the report, noted that the committee’s findings are “the effect of care that occurred in the past rather than being indicative of the mortality risks of current practices.”
While clinical guidelines for VA and Department of Defense doctors first highlighted “concerns about prescribing opioids and their interaction with benzodiazepines” in 2010, the report highlighted that the VA updated guidelines for doctors in 2010, 2017 and 2022, in addition to a 2013 Opioid Safety Initiative to increase education and monitoring and promote “safe and effective prescribing.”
The report also highlighted the U.S. Food and Drug Administration’s addition of a black box warning to benzodiazepine medicines to highlight “serious risks and harms” for prescribing and using them inappropriately. “This increases these serious risks, especially when benzodiazepines are used with some other medicines and substances,” according to the FDA.
Across the U.S., opioid prescriptions increased in the early 2000s — this included VA care providers. In 2004, 18.9% of veterans received opioid prescriptions through the VA and by 2013, that increased to more than 33%. But over the last decade, the VA has implemented new pain management care which “focuses on the veteran as a whole person,” looking at factors like nutrition, physical exercise and sleep instead of “relying on one treatment” — pharmaceuticals. The VA reported in 2023 that it had reduced the number of veterans who were prescribed opioids by 67% from nearly 875,000 in 2012 to 289,000 in 2023.
But the role that pharmaceutical drugs play in veteran suicide is still a cause for concern some among lawmakers. One piece of bipartisan legislation aimed at studying “overmedication” practices at the VA has been introduced four times since 2019. In a similar Congressional request that prompted this study, the bill requested an analysis of VA prescription and suicide data to determine “whether there is a relationship between treatment methods and suicide.”
The committee also looked at the impact of opioid dosages and concluded that veterans were more at risk of dying if they had higher opioid dosage levels or “slow or fast opioid dosage escalation compared to stable dosage.” However, because of “the lower number of suicide deaths in the eligible population,” the study was unable to analyze opioid dosage effects on veteran suicide risk.
Derek Blumke, an Air Force veteran and intern who studies overprescription for the Grunt Style Foundation told Task & Purpose that the VA only began referencing veteran benzodiazepine use in its suicide report in 2024. According to the annual suicide report released in December, suicide rates among veterans experiencing “sedative use disorder, often associated with the misuse of substances such as benzodiazepines,” increased by 29.2%, with roughly 237 deaths per 100,000 in 2022.
“There’s never been a mention of a psychiatric drug or psychiatric drug class or even the psychotropic or the term psychiatric drugs a single time in any of the previous reports,” Blumke said.
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