Benzos at the Opioid Treatment Program

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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. [1]

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. [1]

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. [2]

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. [5]

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.

  1. North Carolina Disease Event Tracking and Epidemiologic Collection Tool, http://www.ncdetect.org
  2. Data from NC CSRS, provided by Mr. Bill Bronson, November, 2011
  3. The Royal Australian College of General Practitioners ABN 34 000 223 807      www.racgp.org.au/guidelines/benzodiazepines/

4. http://guidance.nice.org.uk/CG113

5. Guidelines for the use of Benzodiazepines in Office Practice in the state of Maine

http://www.benzos.une.edu/documents/prescribingguidelines3-26-08.pdf

 

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9 responses to this post.

  1. Posted by Dave M> on November 7, 2012 at 11:41 pm

    I couldn’t agree more. Thank you for the article. please note the RACGP link is broken.

    Reply

  2. Posted by shocbomb on November 29, 2012 at 8:59 am

    I can’t comment at all on medical necessity for methadone patients when it comes to taking Benzo’s becasue there are patients who probably do need them at a clinic I just don’t see it ? All I can do is comment on what I see at my methaodne clinic at Hudson Valley Hospital and its not good at all.

    When it comes to Benzo’s I can’t put a percentage on it but I would say most patients who get them prescribed if not close to all are abusing them and selling or getting them just to sell to other petients. Most are getting them prescribed from dirty doctors that addicts pass on my word of mouth.They will hand out a RX for Xanxex with out asking any questions or look into medical history. It’s commom knowledge amonst most addicts and patients at my clinic who and were the dirty doctors are who will give out Benzo and opioid scripts.

    The clinic has stated time and time again how much of a serious problem Benzo’s are now and how its just getting worse and worse. As a patient what I see when it comes to patients taking Benzo’s mostly it being Xanex is just abuse. From people standing in line looking like they just walked of the casting as a zombie extra on the walking dead, to others selling them in the parking lot to there fellow patients. I just can’t see how it is a good thinkg for any Doctor who heads a clinic to let there patients be prescribed Benzo’s.

    Reply

  3. Posted by reply_to_shocbomb on December 13, 2012 at 12:21 pm

    “… would say most patients who get them prescribed if not close to all are abusing them and selling or getting them just to sell to other petients.”Ignorance exposed. Never say “close to all” about anything you don’t have evidence-based research and statistics on. You have exposed your ignorance; thank you.

    Reply

    • Posted by shocbomb aka Eric VT on December 14, 2012 at 12:59 pm

      Actually I will rephrase my statment. wait no sorry I would still say “cough,cough” exposing all my ignorance that close to all patients/addicts at the methadone clinic a large good % who are prescribed benzo’s abuse or sell them it just the truth sorry.There is actually alot of evidence for that at most clinics its clear as day to the
      workers,counsolers,nurses and doctors who work there and other patients. There is a ton of evidence to support this just go do a simple google search about how bad this problem is at clinics.

      Actually since the last time I wrote my statement above the Doctor at the Methadone clinic Dr.Rosenbaum is now putting a all out ban on all benzo’s prescribed or not for patients. Just way to many problems with them, the abuse and sales to other patients not to mention the crazy amount of Deaths the last few years.Like I said above Yeah sure a few patients probably need them but the vast majority are getting them for the wrong reason and thats abuse or to sell them.

      Reply

  4. Posted by Chris kelly on January 15, 2013 at 2:52 pm

    One thing you dont mention is have the OTP doctor prescribe the benzo’s if they are needed. We did that for quite a few years here in Washington DC with good results, however once our funding source changed we had to discontinue this practice.

    Another issue that leads to benzo misuse, in my experience here in Washington DC, is chronic underdosing. When patients believe that methadone doses above 80mgs are “too high” this leads to benzo misuse to “boost my dose”. When our average dose was 40mgs….lots of patients had this problem. Thankfully, both doctors and patients in Our Nations Capitol are learning the benefits of therapeutic dosing, there is no low dose or high dose just the RIGHT DOSE.

    Reply

  5. I wish the school systems would teach their students how to determine a valid, statistically sound and carefully controlled scientific outcome, using a randomized, double blind clinical trial to determine the efficacy of treatment. Another much needed
    skill is the ability to make decisions using publications utilizing peer reviewed scientific journals such as JAMA, Archives of General Psychiatry, and so on.
    Sadly, because science and statistics are under-represented fields in our nations’ schools, the majority of people seem to believe that if something is in writing, it has to be true.
    Mixing CNS depressants can result in respiratory depression, a fact with scientifically, replicated results. This seems to be where good sense leaves the “dilemma” of mixing CNS depressants. It appears that someone has decided that if an addiction evolves from one drug with addiction potential, then that person is addicted to all drugs with addiction potential. Some people do.
    On the other hand, can anyone say with certainly that an opiate addiction arose from a need to self- medicate to help eliminate the sometimes paralyzing effects that panic and anxiety produce. Few drugs are free from side effects, ranging from dry skin to death. This is where the risk vs. benefit decision comes in.
    The current fervor over opiate abuse and prescribing controlled substances has led to a rising tendency for MD’s to avoid prescribing these meds. If workers from these methadone clinics begin calling MDs,” to make them aware of a possible fatal reaction,
    this comes across much like a threat. The DR must decide if he should risk losing his livelihood, or treating a patient, with an invisible mental health disorder. I think it takes pure ignorance on the part of these clinic workers to question what another specialist
    deems appropriate.

    Reply

    • But what if the “clinic workers” are also medical doctors, much better educated about the dangers of mixing benzos and opioids than the specialists?

      Reply

      • Beth Rawlings-my son died of an overdose (respiratory depression) from heroin and Xanax. His MD, a family practice doctor with a suboxone practice, gave him suboxone, Xanax, Geodon and Remeron for two years. This doctor never asked or required him to see a mental health provider or attend outpatient treatment. Twice in the two years my son had prolonged relapses of four and five months when he didn’t see this doctor at all. Both times he went back to the doctor like nothing happened, and received all the scripts with no questions about his absence.

        Before this MD, my son had two other suboxone doctors (he had a 15 year addiction) who refused to Rx him benzos. My son found this doctor through “friends” who doctor shopped until they found one willing to prescribe both subox and Xanax. The first time he got his benzo script, I heard him telling another addict to go there, and what to say.

        At the time of his death, my son was addicted to the Xanax, and was buying extra off the street. His autopsy revealed recent track marks on his hand, in addition to the one fresh track mark on his arm from the shot that killed him. The track marks on his hand indicate he was shooting either suboxone or Xanax, as a drug test days before his death was negative for heroin.

        I don’t blame the MD. Through intensive work on myself I don’t blame anyone. Addiction and mental illness is multi layered.Genetic, environmental, and psychological factors created the perfect storm in our family. On the other hand, benzos are suicide for someone with substance use dependence. I don’t mean “problem using” or “substance disorder”. Maybe those addicts can take benzos. My son was a hard core, polysubstance abuser with a 15 year history of IV heroin use. He could not take anything “responsibly”. There is huge difference between substance abuse and substance dependence. Dr Burson understand this, she sees it every day. She has heard every story about panic/anxiety/insomnia any addict can concoct. She does not describe psychiatric drugs without consulting a psychiatrist.

        I applaud the “rising tendency for MD’s to avoid prescribing these meds.” That means they are educating themselves about the true nature of addiction.

      • Thank you and I am very sorry for your loss.

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