Winter 2017

Claims Q&A: RX Drugs of Abuse: Which Non-Opioid Drugs Present Concern?


Just as physical injury claims that rely heavily on pharmacological modalities to address the symptoms of pain without active therapies to promote functional recovery should raise flags, mental–only claims that fail to incorporate a psychotherapy component should raise concerns that the patient’s PTSD is not being adequately or effectively treated.

Common benzodiazepines: alprazolam, diazepam, and lorazepam


Benzodiazepines are not meant to be taken chronically. Long-term adverse effects associated with benzodiazepines include cognitive impairment, physical dependence and withdraw, an increase in anxiety and depression, overdose, and death.

Additionally, even though evidence-based guidelines warn against combining benzodiazepines and prescription pain medications, benzodiazepines are almost always prescribed in combination with opioids in workers’ comp, despite significant risks.2

  • Benzodiazepines are involved in 31% of opioid overdose deaths3
  • Benzodiazepine overdoses are 75% likely to involve opioids4


Muscle relaxants are frequently used in workers’ comp to alleviate muscle spasms, pain, and overresponsive reflexes. While muscle relaxants can help with pain, they are not meant to be taken chronically as overreliance can lead to dependence and withdrawal, fueling abuse.

Common muscle relaxants: cyclobenzaprine, carisoprodol, methocarbamol, and tizanidine


Muscle relaxants should be used with caution, as they present the risk of adverse effects such as mood changes, impaired thinking, paralysis, CNS depression, respiratory depression, and heart failure.

Risk varies among products. Carisoprodol (Soma®) is known for having more severe withdrawal symptoms than cyclobenzaprine, increasing its risk for abuse. From 2004-2009, emergency department visits involving carisoprodol doubled from 16,000 to 32,000.5

While muscle relaxants can be abused by themselves, as depressants they can be more dangerous when combined with other depressants, such as alcohol, benzodiazepines, and opioids, increasing the likelihood of potentially fatal adverse effects.


Gabapentin and pregabalin are anticonvulsants (anti-seizure drugs) often used off-label for the treatment of certain types of neuropathic pain. While these drugs are considered very safe by themselves, they do have mood-altering properties and can be abused to boost the high of other drugs of abuse.

Abuse-Related Concerns

The excessive ingestion of gabapentin or pregabalin significantly increases risk for suicidal thoughts and overdose, a cause for concern as these drugs are seeing rising levels of abuse to boost the euphoric high of opioids.

  • Law enforcement-derived data has found that gabapentin diversion is closely tied to the opioid epidemic and has slowly been on the rise6
  • A systematic review of various databases found that increasingly, people are self-administering higher-than-recommended doses of pregabalin and gabapentin to achieve a high, particularly among opioid users7
  • Of nearly 12,000 reported cases of abuse since 2004, 75% of those cases have occurred since 20127

The state of Kentucky recently classified gabapentin as a Schedule V drug,8 while Ohio and Massachusetts now require the dispensing of gabapentin to be reported to their respective prescription drug monitoring programs.9-10

In the event assistance is required analyzing a patient’s drug regimen, Healthesystems’ clinical pharmacists are available to answer questions for our customers and pharmacists within our network. Please contact our Ask a Pharmacist Drug Line at 866.646.2828. Questions can also be submitted online at, or emailed to


  1. Bachhuber MA, et al. Increasing Benzodiazepine Prescriptions and Overdose Mortality in the United States, 1996-2013. American Journal of Public Health. April 2016. 106:686–688. doi:10.2105/AJPH.2016.303061
  2. Lavin RA, et al. Impact of the combined use of benzodiazepines and opioids on workers’ compensation claim cost. Journal of Occupational & Environmental Medicine. September 2014. doi: 10.1097/JOM.0000000000000203
  3. CDC. Vital Signs: Variation Among States in Prescribing of Opioid Pain Relievers and Benzodiazepines — United States, 2012. July 2014.
  4. Jones CM, McAninch JK. Emergency department visits and overdose deaths from combined use of opioids and benzodiazepines. American Journal of Preventive Medicine. October 2015. 49(4):493-501. doi: 10.1016/j.amepre.2015.03.040. Epub 2015 Jul 3.
  5. Hospital emergency department visits involving the misuse of the muscle relaxant drug carisoprodol have doubled over five years, study shows. SAMHSA. Nov 3, 2011. Accessed Oct 3, 2017.
  6. Buttram ME, Kurtz SP, Dart RC, Margolin ZR. Law enforcement-derived data on gabapentin diversion and misuse, 2002-2015: diversion rates and qualitative research findings. Pharmacoepidemiol Drug Saf. May 2017. DOI: 10.1002/pds.4230
  7. Evoy KE, Morrison MD, Sakld SR. Abuse and misuse of pregabalin and gabapentin. Drugs. March 2017 ;77(4):403-426. doi: 10.1007/s40265-017-0700-x
  8. Important notice: gabapentin becomes a schedule 5 controlled substance in Kentucky. Kentucky Board of Pharmacy website. Published March 3, 2017. Accessed Oct 2, 2017.
  9. Reporting gabapentin products to OARRS – effective 12-1-2016. State of Ohio Board of Pharmacy website. Published July 13, 2017. | Accessed Oct 2, 2017.
  10. Changes to the prescription monitoring program (PMP) reporting requirements. The Commonwealth of Massachusetts website. Published May 10, 2017. | Accessed Oct 2, 2017.


Since 2010, the semi-annual RxInformer clinical journal has been a trusted source of timely information and guidance for workers’ comp payers on how best to manage the care of injured worker claimants and plan for the challenges that lay ahead. The publication is an important part of Healthesystems’ proactive approach to advocating for quality care of injured workers while managing the costs associated with treatment.