Co-prescription of opioids and selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) was common in the US from 2013 to 2014, according to a recent study.1 In March 2016 the FDA issued a safety warning about the risk of serotonin syndrome with combined use of opioids and triptans, or SSRIs/SNRIs.2 Whether the FDA warning has resulted in changes in prescribing practices is unknown, though it may be too early to know.
However, what’s clear is that the opioid problem in the US is not going away quickly. Despite recommendations against opioids for acute migraine from the American Academy of Family Physicians (AAFP) and the American Headache Society (AHS) and despite CDC guidelines3 against opioids for chronic non-cancer pain, prescription of opioids in the US tripled between 1999 and 2015.
Serotonin syndrome is a very rare but serious adverse effect of serotonergic antidepressants, caused by excess serotonergic agonism. Symptoms range from mild (diarrhea, shivering) to severe and potentially life-threatening (muscle rigidity, fever, seizures). The opioids most commonly linked to serotonin syndrome include fentanyl, methadone, andoxycodone. Meperidine, methadone and tramadol carry label warnings about the risk of serotonin syndrome.
To provide better epidemiological data about the nationwide prevalence of co-prescription of these medications in the period before the FDA warning, researchers lead by David A. Sclar, PhD, of the Midwestern University College of Pharmacy in Glendale, Arizona, used data from the National Ambulatory Medical Care Survey (NAMCS) database for 2013 to 2014. NAMCS is a cross-sectional nationally representative survey of office-based physician visits run annually by the National Center for Health Statistics (NCHS). The analysis included data from 903.6 million outpatient visits.
Key results and take home points >
1. Molina KC, Fairman KA, Sclar DA, et al. Concomitant use of opioid medications with triptans or serotonergic antidepressants in US office-based physician visits. Drug Healthc Patient Saf. 2018 May 3;10:37-43. doi: 10.2147/DHPS.S151073.
2. US Food and Drug Administration. FDA Drug Safety Communication: FDA warns about several safety issues with opioid pain medicines; requires label changes. March 22, 2016. https://www.fda.gov/downloads/Drugs/DrugSafety/UCM491302.pdf. Accessed June 27, 2018.
3. Centers for Disease Control. Opioid prescribing is still high and varies widely throughout the U.S. https://www.cdc.gov/media/releases/2017/p0706-opioid.html. Accessed June 27, 2018.