20-002 Be Aware of Opioid Potentiator Medications
Date: 01/15/20
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.
Health Net* and CalViva Health want to help you and your patients prevent opioid medication misuse. When used in conjunction with opioids, some medications enhance the opiate effect. Please be aware of such potentiator medications, including those listed in the table below.
Although this is not a comprehensive list, it is important to consider these medication classes when prescribing in order to best protect the health and safety of patients and combat misuse. Providers should consider the interaction of an opioid and a potentiator to determine the risks and benefits associated with their combination.
Opioid potentiators
Central Nervous System (CNS) Depressants
| Drug Class | Medication | Significant Considerations |
|---|---|---|
| Benzodiazepines (BZDs) | alprazolam, clonazepam, diazepam, lorazepam | Both opioids and BZDs sedate users, suppress breathing and impair cognitive function |
| Antihistamines | promethazine | Increased risk for respiratory depression, coma and death when used with opioids **The combination of carisoprodol, BZDs and opioids results in a heroin-like high |
| Antipsychotics | quetiapine | Increased risk for respiratory depression, coma and death when used with opioids **The combination of carisoprodol, BZDs and opioids results in a heroin-like high |
| Barbiturates | phenobarbital | Increased risk for respiratory depression, coma and death when used with opioids **The combination of carisoprodol, BZDs and opioids results in a heroin-like high |
| BZD-like hypnotics | zolpidem, zaleplon, eszopiclone | Increased risk for respiratory depression, coma and death when used with opioids **The combination of carisoprodol, BZDs and opioids results in a heroin-like high |
| Gabapentinoids | gabapentin, pregabalin | Increased risk for respiratory depression, coma and death when used with opioids **The combination of carisoprodol, BZDs and opioids results in a heroin-like high |
| Muscle relaxants | tizanidine, cyclobenzaprine, baclofen, carisoprodo** | Increased risk for respiratory depression, coma and death when used with opioids **The combination of carisoprodol, BZDs and opioids results in a heroin-like high |
Pharmacokinetic Enhancers
| Drug Class | Medication | Significant Considerations |
|---|---|---|
| Antibiotics | clarithromycin | CYP450 inhibition leads to increase in serum opioid concentration Ultimately results in strong CNS depression |
| Antifungals | itraconazole, ketoconazole, posaconazole | CYP450 inhibition leads to increase in serum opioid concentration Ultimately results in strong CNS depression |
| HIV drugs | ritonavir, atazanavir, indinavir, cobicistat | CYP450 inhibition leads to increase in serum opioid concentration Ultimately results in strong CNS depression |
Other Potentiators
| Drug Class | Medication | Significant Considerations |
|---|---|---|
| Stimulants | dextroamphetamine, methylphenidate | Extremely high abuse potential Used in combination to combat fatigue and sedation caused by high daily doses of opioids or to increase the analgesic effect |
The chart above was adapted from information provided by the Centers for Medicare & Medicaid Services (CMS).