The Benzo Conversation

Glass head full of pills

Not all of my patient interactions are easy. One of my colleagues, after reading my blog, remarked, “It sounds like you have really easy patients.” While that’s true for the most part, of course there are more difficult patients, as in any practice. Some patients, eager to get into treatment to stop opioid addiction, may not be at all ready to stop other drugs of addiction. That’s not a deal-breaker for me, unless those drugs could be fatal when mixed with methadone or buprenorphine. This means the use of alcohol, benzodiazepines, and sedatives of other kinds must be discussed in detail.

I’ve noticed a conversational merry-go-round that I call “the benzo conversation.” I’ve had versions of this conversation more times than I can remember.

This conversation occurs during my initial assessment of a new patient presenting for medication-assisted treatment. I always look on my state’s prescription monitoring program for each new patient on the day of admission. If they have prescriptions for benzodiazepines (like Xanax, Valium, or clonazepam), or other sedatives (Soma, Ambien, etc.) I need information about the pattern of use. Is my patient taking his prescribed daily dose? Is he then physically dependent on benzodiazepines? Is he selling them? Is he giving part of the prescription away, and taking the rest? Does he binge on benzos for the first few weeks of the month, and then run out for several weeks? Or is he bartering the benzos for opioids, and not taking any of them, despite filling a large prescription each month?

I really don’t care if the patient is breaking the law or not; I just want to get the complete picture of my patient’s health status.

Following is a typical conversation with a new patient whom I will call “Bob.”

Bob sought admission to our methadone maintenance treatment program for his opioid addiction. He had snorted pain pills for six years, and wanted help. He had little if any denial about his opioid addiction. He denied taking any prescription medications, saying he got all his opioids off the street, used no other drugs or medications, and had no other medical problems.

However, when I checked his name on my state’s controlled prescription monitoring program, he was filling a prescription for Xanax 2mg, ninety per month, from a local Dr. Feelgood. This prescription had been filled every month for the last four years. My patient’s admission urine drug screen also tested positive for benzodiazepines.

As part of my initial history and physical, I asked him about the Xanax prescription. I explained to Bob that benzos have the potential to cause a fatal overdose when mixed with opioids. I told him that benzos are especially risky with methadone, and I was concerned about his use of them.

Bob said, “Oh, I don’t use benzos now. I haven’t used Xanax for years.
“But you’ve been prescribed it every month and picked up the last prescription of ninety pills just two weeks ago.”
“Yes, but I don’t take them. I quit them long ago.”
“And you do have benzos in the urine sample you gave us.”
“Well, that’s probably from a little piece of Valium I used four days ago.”
“Ummm…, Valium’s also a benzo, in the same family as Xanax, so when you say you’ve stopped, that doesn’t make sense to me.…”
“As I told you, I don’t take benzos anymore.”
“But four days ago is pretty recent.”
“No,” he said, getting a little worked up. “As I’ve already told you, I stopped benzos years ago!”
“So what do you do with the Xanax pills you pick up at the pharmacy every month?”
“I don’t know. They’re in the house somewhere. But I don’t take them.”
“So you have…how many bottles do you have at home?”
“Bunches, I don’t know.”
I could tell I was annoying him, but this as an important clinical issue, so I pushed on.
“Would you be willing to bring all those bottles in tomorrow so the nurse can watch you dispose of them?”
He sighed deeply, annoyed by my questions. “Yes. I suppose I can. Now can I get my dose?”
“No, I’ll leave an order for you to be able to start tomorrow after you bring in the medication to dispose, since you tell me you haven’t taken them. I worry about a fatal overdose if methadone were combined with all that Xanax you have at home.”
Now he was mad. “I don’t have any Xanax at home! I’m not going to overdose! I know what I’m doing.”
“Will you give me permission to call the doctor prescribing the Xanax, so we can talk about your entry into treatment here? Maybe your doctor would be willing to taper your dose so that we can make it safer for you to be in treatment with us.”
“No! I don’t want everybody to know my business. My doctor is friends with my ex-wife and if she finds out I’m being treated for addiction, she’ll cause trouble. He can’t find out.”
“I’m sorry, but that’s a deal-breaker for me. I’m not going to prescribe methadone for you unless I can talk to your other doctor. It’s just too risky. All of your doctors need to know all medications that you’re on.”
“So you’re telling me to go back out there and use drugs? That I can’t get help unless my ex-wife finds out I’m an addict?” The veins in his neck were standing out.
“No. I’m not telling you to use drugs. I’m telling you…
“I want my money back, since I’m gonna have to go buy dope again ‘cause you won’t help me. It’s just not right. I came here to get help.” He stalked off toward the receptionist, where I heard him demanding his money back, despite the hour he spent with a counselor and the time spent with me in an evaluation. (For some reason, patients who don’t get admitted to the program don’t feel they should have to pay for their evaluation)

This was a difficult, tense conversation, and one I’ve had too many times to count. This patient wasn’t a bad guy, but he was not ready to address his benzodiazepine use. The outcome wasn’t what I’d hoped, and this patient didn’t come into treatment.

There’s no way I could know what this patient was doing with his benzodiazepine prescription. I couldn’t tell if this patient was telling the truth, in denial, or lying. Without being able to talk to his prescribing doctor, I wasn’t willing to start medication-assisted treatment. This didn’t mean he didn’t need treatment, only that perhaps a different form of treatment will be safer for him. I wish I could have given him information about other treatments, but he left too quickly and too angrily.

Sometimes patients tell me I’m violating their privacy by looking at their information on the prescription monitoring database. I tell them I don’t see it that was at all, since they are asking me to prescribe a medication that could have a fatal interaction with other medications. Not only is it my business, it’s my responsibility.

Some doctors would fault me for not admitting this patient despite his refusal to allow me to talk to his prescribing doctor, given the increased risk of death for patients in active opioid addiction who are not in any treatment. But I would feel terrible if I’d admitted this patient and he died during the first few weeks of a methadone/benzodiazepine overdose. Either way, there’s a lot at stake, and I feel stress about these decisions.

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16 responses to this post.

  1. Posted by dbcaae10218aajz998 on July 26, 2015 at 1:58 pm

    LOL, getting 90 2mg xanax a *month* (which is a HUGE dose) and claiming to have not used them in years, further claiming to have ‘bottles and bottles’ of them at his house. You correctly deduced he was a liar, and not a very good one. No doubt he was selling those Xanax.

    Now, what is the name of this Dr. Feelgood? I’d like to make an appointment ;). Just kidding ;p.

    Reply

  2. Posted by Pat Bowman on July 26, 2015 at 2:15 pm

    I had to chuckle a bit–but only in the way one does when does when one has had the same conversation in many treatment settings. How very true “Bob” is–and in all probabity, based on my experince, “Dr. Feelgood” who likely does not review current prescriptions or drug screen.

    Reply

  3. Posted by Andrew angelos on July 26, 2015 at 2:25 pm

    First I would like to say that your blog is interesting and I always wonder what you will be talking about when I see the email in my inbox. I have been in two different suboxone programs. One was a monthly hour or so in a group setting but with a therapist and the prescribing doctor sat in almost every meeting. You would give a urin sample and get your prescription. This program did not allow and use of benzos unless they were preclscribed outside the program. I’m not sure what contact the prescribing doc had with this outside person. It was looked down on to say the least. The other was a weekly group setting for an hour or so with a therapist and a weekly urin screen. Every urin sample went to a lab and was tested for anything you can think of and the electrolyte for that substance. This program gave benzo scripts from the pa that was basically a scribe. Who we would do our Med check with every week also. I never saw the actual prescribing doc in this program ever. It seems as if programs are different. I believe we need uniformity on this issue. As far as privacy my privacy seems pleanty violated by the urin test more that looking at my script history. The program I was in up until June just stopped providing care. Siteing insurance problems as the reason why. There are no other programs in my area and I would be happy to have whatever privacys violated just to have access to treatment. For someone to say that you should just take every addict without some due diligence because there an addict is the reason I can’t get into another program cause they are tied up with people who get chance after chance and never get kicked out. I think you have to want to recover. Since my experience with suboxone I now know the difference between addiction and dependence. I would rather be dependent any day of the week. Here’s to the next step of formerly dependent. Have a good day and thank you for what you do for people.

    Reply

  4. Your patient is certainly not rare, but is not the typical (legal) benzo patient, who (in my experience) has been prescribed the medication for a long time, and has no objection to coordination of care. But I agree that even those patients require close scrutiny and coordination. I am curious about how much success you have had in discussing the issue(s) with their PCP? Alas, I have found it to be difficult and unsuccessful, but that may be just me.

    Reply

  5. Posted by nspunx4 on July 26, 2015 at 3:46 pm

    I can’t imagine how tough these decisions must be. As a serious question how would you feel of you found out Bob overdosed on Heroin after leaving that day? It must be very complex.

    Reply

  6. Posted by Icecutter on July 26, 2015 at 4:21 pm

    I think what’s important here is that Bob and new intakes using benzos need to somehow understand that “benzos are not always absolutely off limits”, but that the doctor must know exactly what someone is using so as to make sure the patient is safe. I have used prescribed benzos occasionally while on MMT safely. Dr. Burson, you acted appropriately in this case. I wish I had the magic words you could use to convey to the intakes that every patient is unique and to help them safely, you must know about their drug usage to help them as individuals. In this case, either by tapering Bob down to a safe level of Xanax ( if there is one) or by tapering him off Xanax completely, or working with his other physician to find if a different benzo or substitute is appropriate. Perhaps some conversation in this direction might help with some patients. You did offer this, but Bob was not willing to be honest with you or listen. I hope he gets help somewhere.

    Reply

    • Posted by nspunx4 on July 26, 2015 at 4:27 pm

      Some doctors opinion is that any benzo use is not appropriate which imo is not individualized treatment.

      Reply

  7. You did the right thing. If he died from the combined effects of benzos/opioids, it would be a terrible strain on your heart and possibly be a liability. His loved ones would most likely be coming to point the finger at you, asking why you gave him the opioids.

    Reply

  8. Posted by neil goldberg on July 26, 2015 at 5:39 pm

    Jana,Nice honest post.We had a patient in Hickory who was not engaged in treatment and was a benzo mess with prescriptions. Young woman in her 20’s. We felt she needed a higher level of care and called one of her MD’s who apparently did some pain work. He told us he had recently given her METHADONE!!! Those calls are critical and enlightening. I am surprised to find more of the docs are open to my calls than I expected. CMG centers, like Hickory, tolerate prescriptions for benzos. This is a big problem I face in MMT. I address it by switching as many as I can to Gabapentin. I have been confronting more of the patients with the clinical reality of benzos: memory loss, cognitive decline (“it makes you stupid—-I am not stupid , doc….”) potential for dementia and general risk of trauma like car accidents. I do think it helps. The more I learn about benzos AND alcohol, the more I dislike them. Increased anxiety and glutamate spikes—horrible.I’m taking my Substance Boards in October. This is the most fun I’ve had in Medicine in 25 years. Neil Goldberg.

    Reply

  9. Posted by Kristy t on July 30, 2015 at 5:59 am

    As an mmt patient I see benzo abuse is rampant, the clinic I go to is based on the harm reduction model, in many ways this is a good thing however when it comes to benzos it doesn’t work well, people are constantly buying and selling Benzos at my clinic but the other thing I’ve seen get bad there is the abuse of Phenergan and Clonidine which can’t be tested for

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  10. Wow, how ridiculous. If this Appointment DID INDEED go as this Physician has written, I say BLESS YOU…These Days, Patients seeking Suboxone therapy and the Prescribing Physician checks KASPAR, or the State’s equivalent, and finds out that Benzo’s are ALSO among the Use, the Doctor will act as un-moving and along the lines of how this particular PATIENT acted. I’ve been on Suboxone BID now for Years. I also am Prescribed a small Script of Klonopin 0.5mg BID. My tolerance is absolutely ridiculous…I was told from the beginning to join the Methadone Clinic, as Suboxone just wouldn’t cut it for Someone like Me. Of course as an Addict, I know all about Methadone. I know how adding CNS Depressants to Opioids is INDEED a very dangerous thing…This was further exclamated 2 Months ago, when My Cousin…She was basically My Sister OD’ed on Her Monthly Scripts of Methadone and Xanax. It hurt like Hell to lose Her…I thought She knew more about Her tolerance than that. But, it again goes to show that You can talk all Day long to an Addict, and ONLY when THEY DECIDE to start listening, did ANY of it make a difference whatsoever. I AM a Polysubstance addict, and I realize this. The Cosmos and the Universe (My “Higher Power(s)” knows that I wish I could speak to THIS Doctor, as She seems kind, CARING beyond the lines of Her duty, and seeks only to potentially be able to help Out the Addict in need…BUT,only IF She is able…If the Patient is HONEST and forthright with the Information regarding Other key things; I.E: About You and Your Medicine intake…Again, Bless You, Doctor Burson. We DEFINITELY need more Buprenorphine Physicians out there like You!

    – Kudos from Kentucky

    Reply

  11. Posted by John S. Dittmann on October 27, 2015 at 7:10 pm

    Thank you for addressing this. As a person in long term recovery, who has been on methadone maintenance for 8 years, and also ativan then xanax for 7 and 5 years,respectively, it is so refreshing to hear this approach. I take my medication responsibly, and actually take 2/3 of my allowable dose of xanax most of the time. It seems like the illegal actions of a few are making it virtually impossible for those of us who truly need both medications to be treated. Why should I be forced to choose between which disease to treat? Would you force someone to choose between treating their diabetes and their coronary artery disease? Of course not. There need to be stiffer repercussions for those taking one of these medications illegally in combination with the other. I find many of these people are not ready for sobriety, much less recovery. Thank you
    J. Dittmann, NREMT-P

    Reply

  12. Posted by Aaron on November 15, 2015 at 8:31 pm

    I used to do the same thing Bob would do. I started at the methadone clinic and went every day like clockwork because the dr their told me it was my best way to come off Roxie’s. He told me they would get me up to the dose that I was comfortable with and continue maintenance program. I asked about the downside and was told there were none. It didn’t take long that I was having to go to clinic and buy off street because my tolerance grew so quickly. Before I knew it, I was using needles to get a “quicker fix”. I also would take Xanax, not excessive but as prescribed. I tried to quit the done several times but after 3-4 days of feeling so bad, I would go to a”friends” and buy more. It wasn’t until my wife and parents had me baker acted and then a month in rehab that I realized how stupid I was. I died in detox and was given the atropine shot even after 4 days of nothing. I have been off opiates for 5 months now and feel so much better. I do take a monthly shot of Vivitrol that is supposed to take away 98% of cravings. However, all 3 of my doctors said to get back on Xanax as soon as I got out because of my panic attacks but to take as prescribed. I do that now and feel like a new man.

    Reply

    • Posted by nspunx4 on November 17, 2015 at 4:08 am

      Vivitrol does NOTHING for cravings pharmacologically. It is simply a naloxone shot an opioid blocker. Some patients report depression and other unpleasant side effects because it also blocks your natural endogenous opioids.

      Reply

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