More about IRETA’s Guidelines for Benzodiazepines in OTPs

aaaapils

This is a continuation of my last blog post about the IRETA (Institute for Research, Education & Training in Addictions) guidelines for management of benzodiazepine use in medication-assisted treatment of opioid addiction. You can read all of the guidelines at: http://ireta.org/sites/ireta.org/files/Best%20Practice%20Guidelines%20for%20BZDs%20in%20MAT%202013_0.pdf

Under the section of recommendations regarding addressing benzodiazepine use is found the following statement:
“Many people presenting to services have an extensive history of multiple substance dependence and all substance abuse, including benzodiazepines, should be actively addressed in treatment. People who have a history of benzodiazepine abuse should not be disallowed from receiving previously prescribed benzodiazepines, provided they are monitored carefully and have stopped the earlier abuse.”

The experts, after reviewing the best data, are saying that if a patient has abused benzos in the past, but isn’t abusing prescribed benzos now, it may be OK to continue benzos, with careful monitoring.

I don’t like this statement. It doesn’t conform to my present thoughts on the topic. I fear that the majority of patients with a history of benzodiazepine abuse or addiction will, sooner or later, revert back to problem use of the medication. That’s my anecdotal experience. Anecdotal experience is worth something, but data from clinical trials trumps anecdotal experience, and IRETA’s guidelines are based on both clinical trials and expert opinion.

So now I need to challenge my previously held views about benzos in the OTP. It’s unpleasant and uncomfortable to change a long-held view. But isn’t that what I ask of my patients? In the interest of science, I will re-consider my present opinion, but I won’t ignore the last part of the statement, which says careful monitoring needs to be done.

Careful monitoring includes, at a minimum, coordination of care between the OTP physician and the provider prescribing benzodiazepines, frequent benzodiazepine pill counts, and consulting the state’s prescription monitoring program regularly.

The IRETA guidelines say coordination of care is essential. The guidelines say that a patient who refuses to allow coordination of care between OTP physician and the physician prescribing sedative drugs may not be appropriate for treatment at an OTP with methadone/buprenorphine. The guidelines recommend the OTP physician get information on the patient’s diagnosis being treated with benzodiazepines and any observed misuse of the medication. The OTP doctor should also ask about the patient’s experience with non-benzo medications for the treatment of the patient’s disorder.

These are great ideas in a perfect world, but problematic in the real world.

Coordination of care is a term that’s batted around by non-physicians like a helium balloon, while in reality it’s as difficult as playing catch with anvils. Doctors, especially primary care doctors, are more pushed for time than ever. Many are at risk of losing their jobs if they don’t see enough patients per hour. (I know this because I was a primary care doctor before I fled the field for the more enjoyable addiction medicine.) Primary care doctors don’t want to spend valuable time on the phone talking to other doctors, especially if the other doctor works at “that clinic.”

I have found a few doctors in my area with whom I work well. I may not always agree with them, but I sense they are trying to do what’s best for their patients, and we can generally come to an agreement about the best plan of care.

And other doctors…not so much.

It’s not rare for my phone calls to prescribers of benzodiazepines to go unanswered. I’ve left up to four messages for one benzo-prescribing doctor at our local mental health clinic and have never received a return call. If we share a patient, I can’t coordinate care.

Even when I do get a call back, the conversation with the other provider is sometimes less than productive. The prescriber often says the patient is on Xanax because she has always been on Xanax, and there’s no clear diagnosis or plan of treatment for the underlying disorder. Prescriptions may be written twice a year with little discussion, with five refills. If non-benzo medications were prescribed in the past, the patient didn’t take them for very long before deciding that benzos were the only thing that worked for them. The doctor took this at face value and enthusiastically prescribed benzos ever since.

Sometimes I’ve suggested the doctor start a slow taper of the patient off benzos, if it’s clear the patient is misusing them. The doctor readily agrees with my suggestion, but month after month, on the prescription monitoring program website, I see the same amount of benzodiazepine being prescribed.

I’m not saying these are necessarily bad prescribers. I won’t call them doctors, because sometimes they’re also nurse practitioners or physician assistants. I do think many of them are pushovers, afraid of making patients angry by saying no. And some aren’t aware of best practice guidelines for prescribing benzodiazepines in general, even if the patient doesn’t have addiction.

Because I’ve worked in primary care, I know what happens. Benzo-seeking patients know which prescribers to go to, and they pester these providers incessantly until they are given the prescription they want. The providers, already pushed for time, give in to patient demands in order to get these patients the hell out of their office.

In my area, two or three prescribers are responsible for the majority of long-term benzodiazepine prescriptions. If I see a patient is on benzodiazepines, particularly alprazolam (Xanax) clonazepam (Klonopin) or diazepam (Valium), I can predict the prescriber. Addicts know who to go to; word gets around on the addict grapevine, an efficient mode for spreading news. I don’t feel I can coordinate care with these providers, even if I can talk to them about my concerns for a specific patient.

I agree with IRETA guidelines, but coordinating care with other prescribers isn’t always workable.

Getting back to the guidelines, later in the document is this important statement:

“Depending on capacity, it may be more appropriate for clinical settings to choose not to induct a person in MAT until benzodiazepine use has ceased and not manage a patient’s taper from benzodiazepines during MAT induction. This person may be more appropriate for inpatient detoxification.”

I heartily agree with this, and that’s what I’m doing at present. It’s much easier to get the taper from benzodiazepines done before MAT is started. Once the patient is on MAT, it’s nearly impossible – in my area – to find an affordable inpatient program that will accept patients on MAT, continue to dose them, and also treat the benzodiazepine or alcohol addiction. I hear from doctors in other states that they have inpatient programs willing to admit MAT patients with co-occurring benzo/alcohol addiction, and buprenorphine or methadone maintenance is continued during the admission. If I had that option available, I would use it.

IRETA guidelines say that patients with significant medical or psychiatric problems should be admitted to a hospital (or, I assume, medical detoxification units) for a benzodiazepines taper. Patients who have had benzodiazepine withdrawal seizures in the past also need to be hospitalized for a benzodiazepine taper, as should pregnant patients.

IRETA guidelines address induction of the dose of maintenance medication for patients taking benzodiazepines. Induction, usually considered to be the first several weeks of treatment, is the most dangerous time of treatment. Most overdose deaths happen during that time. As expected, the guidelines suggest using a lower starting dose of the methadone or buprenorphine in a patient with active benzodiazepine use, and daily observed dosing. The guidelines also say patients taking benzodiazepines who are starting MAT should not drive themselves to the facility each day until they have stabilized, and that they need to give permission for the program to call a relative if they come to the facility impaired. Impaired patients are not to be dosed, of course.

This section also recommends repeated attempts to talk with the patient about dose reduction of benzodiazepines and complete withdrawal from benzodiazepines at some point.

Under the section of IRETA guidelines addressing patient non-compliance with a taper agreement, they recommend trying to retain the patient in treatment if possible, but also say to eliminate take home doses so that the patient doses at the OTP facility each day. If the patient is misusing benzos to the degree that their safety is at risk, despite intensified psychosocial treatments, the patient may need to be referred to a non-MAT treatment for their opioid addiction.

I found interesting statements near the end of the IRETA guidelines, such as:
“Individuals who claim that “nothing else helps” should have a careful evaluation for addiction. Physicians should be aware that the subjective nature of anxiety allows for dishonest presentations of symptoms. The claim that “nothing else helps” is often a direct demand for benzodiazepines from the physician. A reasonable response is a trial of psychotherapy and medications without addictive potential.”

“Benzodiazepines should not be the first-line drug for any disorder.” And “Clinicians are advised not to use benzodiazepines to treat co-occurring psychiatric disorders.”

These statements illustrate the essence of the issue. Benzodiazepines have limited clinical indications. Use for more than three months has little benefit because of the quick development of tolerance to the anti-anxiety effect of the benzodiazepine. For that reason, they aren’t first-line drugs for anxiety disorders. And yet many prescribers take the “nothing else helps” statements at face value and prescribe benzodiazepines for years.

More statements about how to prescribe benzodiazepines from the IRETA guidelines:
“For people receiving methadone, physicians are advised to prescribe a benzodiazepine with a slow onset and long duration of action, at the lowest dose, and for the shortest duration possible.
Document education and treatment decisions during the initiation of benzodiazepines.
Avoid prescribing alprazolam to individuals receiving methadone.
Benzodiazepines with substantially lower abuse potential (e.g. oxazepam, clorazepate) are strongly preferred over benzodiazepines with a rapid onset, such as diazepam and alprazolam, which should be avoided because of their abuse potential.
Initiate short-term benzodiazepines with a prescription for no longer than one week.
For a short-course of treatment, the benzodiazepine prescription should be for less than one month.”
“Long-term maintenance of benzodiazepines is rarely indicated and should be avoided.
Providing a maintenance benzodiazepine dose in the context of MAT is to be considered a last-resort option after other alternatives have been exhausted.
One of the few who may benefit from a maintenance dose of benzodiazepine is a person who has long-term opioid and benzodiazepine abuse and is not able to stabilize on opioid substitution medication alone.”

These statements assure me that long-term benzodiazepine prescriptions are a bad idea for the majority of patients on medication-assisted treatment, but there may be some rare patients for whom it may be of benefit, though close monitoring is essential.

This is a controversial area. I appreciate IRETA’s time and effort in formulating these guidelines. I think they will be helpful as OTP doctors struggle to define a standard of treatment that is safe, yet not unduly restrictive for patients with serious mental health issues.

About these ads

4 responses to this post.

  1. Posted by Icecutter on February 3, 2014 at 7:41 pm

    I want to commend you for deciding to reconsider the use of benzodiazepines in some patients in OTPs. Not every opiate addict is also benzodiazepine-addicted. For patients with panic attacks or generalized anxiety, benzodiazepines offer significant relief. I agree that which benzodiazepine to prescribe for MMT patients is an important consideration. Low doses of long-acting benzodiazepines can work for some carefully selected patients. Clinic policies on benzodiazepines go back and forth on this issue and understandably so, since benzodiazepines and methadone can be dangerous and for someone who abuses benzodiazepines it can be deadly. I am a 13 year stabilized MMT patient. I was prescribed two 0.25 mg doses of lorazepam daily for generalized anxiety when I started on MMT. After about five years, II tapered off the lorazepam and remained off it for about eight years. However, recently, I began experiencing severe flare-ups of Irritable Bowel Syndrome (IBS) and have resumed taking an occasional 0.5 mg dose of lorazepam for it. The critical difference here is that I have never abused benzodiazepines,and I am above board with the clinic and my prescribing doctor about this. I have gotten some good benefits from periodic lorazepam use.
    To compare this experience, I went through intake at another MMT clinic in my city some years ago because that clinic was less costly, and when I mentioned I was on benzodiazepines, the treatment director told me that I would have to detox off it before I could be treated with methadone. Hearing that, I continued with my original clinic. Interestingly, I have never tested positive for benzos at either clinic, since my dose is low. I suppose I could have remained quiet about it, but I am not attending a MMT clinic to get something over on them. i am attending it to treat my opiate addiction. So in conclusion, I want to say that although having a blanket policy against benzo usage might be easier for a clinic, such a policy could prevent an addict needing both MMT treatment. and carefully prescribed, supervised benzodiazepine treatment from getting MMT treatment. And that can most certainly be deadly.

    Thanks, Dr. Burson and keep up the good work!

    Reply

  2. I am going to my dr tomoro and going to discuss with him about my Xanax.
    I take subutex and was prescribed 4 (1mg) Xanax by my last dr for anxiety attacks and PTSD, and fast heart beat.

    I got down to 2 a day with my current dr and today I counted them to see if I made any progress and I had 36 1mg Xanax left out of 60. I was tickled bc that means I did not even take a whole xanax every day in a 30 day period.

    My question to him tomoro is going to be why do I keep having attacks. For example today I was working on a wreath, nothing bad had happened and then I felt like my throat was closing and couldn’t breathe. I took a 1/2 a Xanax and 20 minutes later- i felt like I could breathe. It is the craziest thing!

    I have said from day one- I hate benzodiazepines! I hate any kind of downer. And I truly truly do hate them however it is the only thing I have found so far to make my throat feel like it isn’t closing.

    I only take 1/2 of one when this occurs. I just wished I could figure out what is making it occur!

    I have come along way from 4mg a day!
    That was what the dr started me on- on the first day – on top of 40mg of subutex per day. We went back in my chart and discovered this. To anyone out there reading this- that is a HUGE dose!! If you must take it- be smart enough to take .25s bc your body will build a tolerance quickly.

    I can say I have never abused them bc I don’t like them but I would like to not need them at all anymore.

    I can say that the overprescribing dr of mine had tried me on Ativan 1mg 4/day before Xanax- and I couldn’t even tell I took those ( which is weird bc I was told that they were stronger), and he also tried me on Valium 10mg (again- no affect). So I don’t know why Xanax worked for the throat closing issue- all I know is I want off the junk! Progress has been made- but I want off completely.

    I gotta get to the root of the attacks!
    Thanks for all of your post!
    God Bless! Nacole

    Reply

  3. […]  http://janaburson.wordpress.com/2014/02/02/more-about-iretas-guidelines-for-benzodiazepines-in-otp… […]

    Reply

  4. […] about benzodiazepine use on suboxone prescriber Jana Burson’s outstanding blog (Part I and Part II), including the comment section where patients weigh in on anxiety and […]

    Reply

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Follow

Get every new post delivered to your Inbox.

Join 470 other followers

%d bloggers like this: