Should patients in opioid treatment programs ever be approved to take benzodiazepines? Even addiction medicine doctors hold widely varying opinions on this issue.
In my state, all of the doctors who work in opioid treatment programs are invited to participate in a conference call once per month. The people who head the state’s methadone authority and the Governor’s Institute on Substance Abuse are also usually on the call. We discuss difficult issues we’re facing, and discuss difficult cases. Last month, the question was asked pointedly by one of the doctors: “Is zero-tolerance for benzodiazepines now the standard of care for opioid treatment programs in our state?” For the people on this call, the consensus was that the ideal was zero tolerance or at least a restricted policy regarding benzodiazepine use.
I’m about as anti-benzo as any doctor can get. However, the term, “zero tolerance” troubles me when used to describe anything. Is any issue ever that absolute?
Some opioid treatment programs and their medical director doctors have no problem with benzodiazepine use by their patients, as long as it is by prescription. These programs recognize the dangers of high-dose benzodiazepine abuse in their methadone patients, but have permitted patients with prescribed benzodiazepines to remain in treatment, believing stable patients can take benzodiazepines safely and as prescribed. Some of the programs in my state have this approach.
Others programs, after seeing the increase in the number of methadone overdose deaths in our state, have the zero tolerance approach mentioned above, meaning they feel the ideal is that no benzodiazepine use ever be approved for a patient on methadone in an opioid treatment program. North Carolina had one of the highest overdose death rates in the nation in 2005. Of the patients who died with methadone detected in their system, the majority also had benzodiazepines in their toxicology report at autopsy. 
We know opioids and benzos have synergy when used together. Both types of drugs affect the part of the brain that tells humans to breath while we are asleep. If used together in sufficiently large doses, the patient can fall asleep, stop breathing, and die after the heart and brain are deprived of oxygen for more than a few minutes. How much is a sufficiently high dose? That can be unpredictable. Methadone, as a full opioid that gives more effect with higher doses, is more dangerous when mixed with benzodiazepines than is buprenorphine (Suboxone, Subutex), which is a partial opioid, but overdose can still occur with benzos and buprenorphine.
In my state, benzos are massively overprescribed. I’m convinced we have just as big of a problem with benzos as we do with opioids. The NC DETECT program shows that in 2012, benzodiazepines were the most frequently cited drugs seen in the emergency department for unintentional poisonings, followed closely by opioids. 
There are large variations in prescribing rates for benzodiazepines, by county. Counties in my state that have teaching hospitals, and urban areas have the lowest per-capita rates, while Western mountain counties and scattered others have the highest rates. Probably not coincidentally, the counties with the highest rates of benzodiazepine prescribing are almost the same counties with the highest rates of unintentional poisonings from controlled substances and the highest rates of mortality from unintentional overdoses with controlled substances. 
This state is awash with benzos because doctors and their physician extenders don’t pay any attention to safe prescribing guidelines. Evidence-based guidelines for the prescribing of benzodiazepines already exist. Other nations such as Great Britain, Canada, and Australia, concerned about the mis-prescribing and overprescribing of benzodiazepines within their borders, have all produced documents meant to guide their physicians so they can prescribe benzodiazepines in such a way that assures better patient care and outcomes. [3, 4]
Similarly, Maine and Kentucky have issued guidelines for physicians in their states. It’s useful to review what these guidelines say regarding evidence-based indications for the prescribing of benzodiazepines. 
There’s presently no evidence to support the indefinite prescribing of benzodiazepines for the treatment of any mental illness. That’s right…no evidence.
Here are evidence-based indications for benzodiazepine use:
- Acute alcohol withdrawal syndrome
- Acute anxiety disorders, for up to six weeks, until a more definitive treatment is effective. Nearly all the guidelines emphasize that benzodiazepines are best used short-term, until another medication like an SSRI becomes effective. Alternatively, CBT or other counseling techniques are often helpful. Benzodiazepines are not a first line treatment for any anxiety disorder since their use for more than four months leads to tolerance and loss of efficacy.
- Short-term treatment of insomnia.
- Sedation during a medical procedure, during which the patient is appropriately monitored.
- Treatment of acute psychosis and acute severe mania, in a monitored setting
- Acute stimulant intoxication (cocaine or methamphetamine), in monitored setting
- Acute treatment of seizures.
- Short-term treatment for muscle relaxation.
- Treatment of severe dementia, in place of antipsychotics
- Palliation of anxiety in the terminally ill.
- Some neurologic disorders that cause severe muscle stiffness.
These guidelines also say that benzodiazepine should be used with great caution, if at all, in the following situations:
- Depression, apart from short-term (one to two weeks) of treatment of anxiety that can be seen in some depressed patients. Benzodiazepines, since they have sedative properties, have the potential to worsen depression.
- Grief reaction – some literature says benzodiazepines can suppress and prolong the grieving process, though use at nighttime for insomnia for one or two weeks can be helpful.
- Treatment of anxiety in a patient with a history of alcohol or drug addiction, except for the treatment of acute withdrawal for alcohol or sedatives. These patients are at very high risk for abuse and addiction to benzodiazepines.
- Benzodiazepines are not recommended in patients who are on long-term opioids or stimulant medications.
- Benzodiazepines are contraindicated in pregnancy (category D)
- Benzodiazepines are associated with falls, cognitive impairment, and medication interactions in the elderly. Benzodiazepines should be used with great caution in this age group, and starting doses should be lower than for younger patients. Older patients who have been prescribed benzodiazepines on a long-term basis may benefit from gradually reducing their dose.
If physicians were heeding these prescribing guidelines, physicians at opioid treatment programs wouldn’t be seeing so many patients addicted to both opioids and benzos. In other words, the solution starts with appropriate prescribing, just as it does for opioids.
The benzodiazepine prescribing guidelines make clear that benzos are rarely the treatment of choice for anxiety disorders. Other medications should be used first and second line, and cognitive behavioral therapy is important as well. These other medications and counseling both take longer to have an effect, so are often less desirable for someone who wants quick (though temporary) relief of anxiety.
So back to the original question…is zero tolerance the ideal? Yes, I think it is; however, there may always be exceptions. In the interest of full disclosure, out of the nearly 500 patients I see at two opioid treatment programs, I’ve approved two patients to take prescription benzodiazepines. In my defense, I’ve known both patients for more than five years, have seen them on and off benzodiazepines, and see that they function better with a benzodiazepine prescription. Their prescribing doctors are accessible, and know the patients have addiction histories. They are both actively getting mental health counseling.
In my Suboxone practice, out of the ninety-some patients, four are approved to take benzos. Two take very low doses of Ambien (yes, I count this as a benzo) at bedtime for chronic insomnia. Both have been in stable recovery for more than four years, and have good doctors who watch them closely. The third takes alprazolam (Xanax) maybe four times a year before getting on an airplane, to treat her flying phobia. The fourth takes low-dose alprazolam (Xanax) before public speaking events, which he must do for his job every two years or so.
To summarize my feelings about benzos in I’d like to make clear these points:
- Benzodiazepines are massively overused, and most prescriptions can be replaced with safer and more effective medications.
- Use of a medication with the potential to cause addiction is always riskier in patients with a history of addiction to other drugs, including alcohol.
- Benzodiazepines can be fatal when mixed with opioids.
While I can’t claim zero-tolerance to benzos…I’m pretty close.
- North Carolina Disease Event Tracking and Epidemiologic Collection Tool, http://www.ncdetect.org
- Data from NC CSRS, provided by Mr. Bill Bronson, November, 2011
- The Royal Australian College of General Practitioners ABN 34 000 223 807 www.racgp.org.au/guidelines/benzodiazepines/
5. Guidelines for the use of Benzodiazepines in Office Practice in the state of Maine