The Benzodiazepine Dilemma: New Guidelines for Opioid Treatment Programs from IRETA

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I’ve written about benzodiazepines before in this blog (See my post of November 3, 2012). I worry about overdose deaths and other complications in patients for whom I prescribe methadone who are also taking benzodiazepines, prescribed or illicit.

Now doctors at OTPs have help from the Institute for Research, Education and Training in Addiction (IRETA). This well-respected organization located in Pittsburgh, Pennsylvania just issued an evidence-based document titled, “Management of Benzodiazepines in Medication-Assisted Treatment.” You can access this document at IRETA’s website: http://ireta.org/

I love IRETA for tackling this subject. There’s much misinformation about the use of benzodiazepines, even for patients without addiction. But for patients with addiction, benzodiazepines can be deadly when combined with opioids including methadone and buprenorphine.

IRETA’s document first describes how and why these guidelines were created. Opioid treatment programs often have patients who also use benzodiazepines, both by prescription and illicitly. Physicians at OTPs have widely varying responses to these patients. Some programs have zero tolerance, meaning they won’t allow anyone on benzodiazepines to be in their opioid treatment program. Other physicians at OTPs actually prescribe benzodiazepines for their patients when they feel it’s clinically indicated. IRETA wanted to delve into actual scientific literature and consult a panel of experts for interpretation of that data. This IRETA document describes in detail how the literature search was done. It also goes into exhaustive detail about how each statement in the set of guidelines was vetted by experts.

This paper’s guidelines fall into seven categories:

General guidelines
Assessment for MAT
Addressing benzodiazepine use
MAT for patients with concurrent benzodiazepine use
Noncompliance with treatment agreement
Risk management/Impairment assessment
Special circumstances

Here are the general guidelines, taken directly from the document:

CNS depressant use is not an absolute contraindication for either methadone or buprenorphine, but is a reason for caution because of potential respiratory depression. Serious overdose and death may occur if MAT is administered in conjunction with benzodiazepines, sedatives, tranquilizers, anti-depressants, or alcohol.
People who use benzodiazepines, even if used as a part of long-term therapy, should be considered at risk for adverse drug reactions including overdose and death.
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. MAT should not generally be discontinued for persistent benzodiazepine abuse, but requires the implementation of risk management strategies.
Clinicians should ensure that every step of decision-making is clearly documented.
Clinicians would benefit from the development of a toolkit about the management of benzodiazepines in methadone treatment that includes videos and written materials for individuals in MAT.

Please note that under the third point of the general guidelines, it says patients shouldn’t be taken off MAT because of repeated benzo use, but need “risk management strategies.” That’s a little vague, but IRETA guidelines go into more detail later in the document.

IRETA’s second section of guidelines is about assessment for MAT. The guidelines say all of the usual things; for example, they say a doctor should do a complete evaluation of a patient presenting for treatment, as described in SAMHSA’s TIP (Treatment Improvement Protocol) 40 and 43. The evaluation should include the patient’s history of medical problems and history of all drug use, even over the counter medication. A mental status assessment and a drug screen should also be included.

Also under the assessment section, IRETA suggests adding patient education about the dangers of mixing benzos with methadone or buprenorphine. I like this idea, and I do something similar. When I ask about past drug use, I always warn patients about the potential bad outcome of mixing benzos and alcohol with the medication I’m going to prescribe, and I repeat the warning at the end of our interaction.

IRETA suggest doctors go farther, and give patients information not only about overdose risk, but also about the other problems benzodiazepines can cause. Benzodiazepines are associated with a greater risk of depression and suicide. Having a prescription for benzodiazepines doubles a patient’s risk for an auto accident, and increases the risk for other accidents, like falls. Taking a benzodiazepine prescription is associated with an increased risk for hip fracture.

The IRETA guidelines remind us that there is “Substantial and growing literature that suggests long term use of benzodiazepines (especially in large doses) leads to cognitive decline.” (page 16 of the report) the guidelines also say that benzodiazepines are associated with emotional blunting, and long-term sleep and mood disturbances. Even more relevant, studies show that patients on benzodiazepines have worse outcomes in medication-assisted treatment.

The third section of IRETA’s guidelines is about addressing benzodiazepine use. They say that a patient should be willing to address their benzo addiction. IRETA says that uncontrolled use of benzodiazepines is a contraindication to treatment with methadone or buprenorphine because of the “extremely high risk for adverse drug reaction involving overdose and/or death during the induction process.”

I’m in the “amen” corner for that one! But it’s hard for me to know which patients use benzos occasionally to help opioid withdrawal, and which patients use benzos heavily in an uncontrolled manner. Most patients, seeing me for admission to MAT, minimize their use of benzodiazepines, knowing it’s a big issue. If they’re getting benzodiazepine prescriptions in large amount from multiple doctors, I can see that on our state’s prescription monitoring program. If the patient is taking benzos illicitly, I may not have a way to know this. Information from family members and friends can sometimes help, if the patient will allow. Or family members and friends may be as heavily involved in addiction as the patient presenting for treatment.

The IRETA guidelines remind us that patients on long-term benzodiazepine therapy are at risk for adverse drug reactions which can include overdose and death. The guidelines say that central nervous system depressants are not absolutely contraindicated with methadone, but also put patients at risk for overdose and death. I assume at this point in the document, its authors are referring to other non-benzo central nervous system depressants like carisopradol (Soma), zolpidem (Ambien), and the other “z” sleep medications, and perhaps pregabalin (Lyrica).

IRETA’s benzodiazepine guidelines for OTPs are extensive, so I’m going to split my review of the contents over two blog entries. Stay tuned…or even better, go read them for yourself:
http://ireta.org/sites/ireta.org/files/Best%20Practice%20Guidelines%20for%20BZDs%20in%20MAT%202013_0.pdf

1. Thomas et al, “Benzodiazepine use and motor vehicle accidents. Systematic review of reported association.” Canadian Family Physician, 1998 April;44:799-808.
2. Smink et al, “The relationship between benzodiazepine use and traffic accidents: A systematic literature review.” CNS Drugs, 2010 Aug.24(8)6390653.

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9 responses to this post.

  1. Posted by kevin on January 27, 2014 at 1:54 am

    What about trazadone? My family doctor put me on trazadone 50mg for sleep and Lamotrigine for mood 25 mg at bedtime for a week then 50 after. Well I called my clinic. Waited before talking for approval. Knowing they were gonna say no cause there both sedating. And to my surprise my counselor called back and said those can be taken with methadone. I couldn’t believe it. I thought anything sedating could not be taken. My question is a yr and a half in treatment 140 mg a day of methadone. Waiting on blood work for a peek and trough for an increase. Would you have aloud this if I was you patient? If yes why are these ok but not benzos how are they different

    Reply

  2. Posted by Vicki on January 29, 2014 at 1:53 pm

    Dr. B, have you ever written on sleep problems with MMT before? If so, could you reference where in your blog. I am have great difficulty with sleep. What can be used for sleep (safely) while on MMT? I have NOT slept all night in the last year since starting MMT. My dose has been stable at 68mg for 9 months. I wake up every 2 hrs 10 min. Weird.. I know. Please advise, the cumulative effect of disruptive sleep cycle is catching up with me. Thank you for all you do!

    Reply

    • I don’t think I have – great idea for a future blog entry. I have used trazadone in the past but a recent study showed it’s no better than placebo…tough issue.

      Reply

  3. Posted by Kandie on February 5, 2014 at 11:10 pm

    I live in Maine. If you watch the news I am sure you have heard comments about our governor. Along with not accepting the medical expansion, he also cut Mainecare funding for many. This action tossed many out of the system who were getting help with methadone clinics. This is not something I have personal experience in but from others and from reading, I know these people are in trouble. Because of cuts in funding they have only been providing a watered down version of what is needed to help people so it takes longer for recovery, if at all. Do you have statistics for me on how successful this treatment is, if following the evidenced based research? Any ideas how I can help educate others how in the long run this will save our state money? Common sense seems to elude so many these days. and I am afraid too many are like the doctor you tried to speak with about his pregnant patient.

    Reply

  4. Posted by Kandie on February 9, 2014 at 1:08 am

    The amount of 1 on 1 with a councilor has been cut back as well as the drug testing. The supports basically being taken from what helps make it work from my understanding.

    Reply

  5. […] Read more 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 insomnia […]

    Reply

  6. […] Read more 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 insomnia […]

    Reply

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