Posts Tagged ‘benzos and methadone’

More about IRETA’s Guidelines for Benzodiazepines in OTPs

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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.

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