Category Archives: Benzodiazepine

Methadone and Other Medications

doc66Methadone is FDA-approved for pain management and the treatment of opioid addiction. Methadone is a relatively safe and highly effective medication when used exactly as prescribed. It is currently in use in the United States and around the world following years of conclusive research on methadone’s efficacy and safety.

It is important for patients receiving methadone to know that it can interact with other central nervous system depressants like alcohol and benzodiazepines such as xanax, klonopin, valium, and librium as well as similarly acting non-benzodiazepine agents like ambien (a popular sleep aid). When methadone is mixed with these other medications, there is an increased risk of sedation and loss of consciousness. In extreme cases, individuals mixing methadone and other CNS depressants have gone into respiratory failure.

For those who have chosen to receive methadone in an opioid treatment program, they will discover that a proper dose of methadone not only eliminates opiate withdrawal & cravings, but will also block the euphoric effects of any other opiates. This is typically a positive side effect in that it discourages illicit opiate use or supplementing with street drugs like heroin. Since methadone binds so well to the brain’s opiate receptor sites, any other opiates that are ingested have no means of creating a euphoria or a high since the body’s opiate receptors are occupied by methadone. This removes the incentive to misuse other opiates and can facilitate the process of recovery.

There are instances in which a patient’s physician has prescribed a benzodiazepine for anxiety management while also prescribing methadone. Such decisions should always be accompanied by a thorough discussion with one’s doctor of the potential risks & complications. There are other, safer alternatives for treating anxiety such as Buspar and cognitive therapy. These other options should be considered when a patient is already receiving methadone. In addiction treatment, the use of benzodiazepines for anxiety is typically monitored carefully through increased random urinalysis testing and medication counts.

Benzodiazepines in the Methadone Program

factsBenzodiazepines are a classification of drugs primarily prescribed to treat anxiety and panic attacks. They have been in use for over thirty years and are typically utilized for short term periods from several days to three months maximum.

Benzodiazepines are sometimes administered just prior to medical procedures or surgery to help calm a patient. Common examples include valium, ativan, klonopin, librium, and xanax. These medications have also been used successfully on a short-term basis to help reduce alcohol withdrawal as patients undergo alcohol detoxification.

For opioid treatment programs, benzos present a particular risk due to the higher probability of abuse and overdose death when mixed with methadone, other opioids, or alcohol. Benzodiazepines depress the central nervous system and can shut down respiration when combined with other CNS depressants. This lethal drug combination has resulted in numerous accidental deaths – even among experienced drug users.

While limited and carefully monitored benzodiazepine use can be clinically justified in some cases, prescribing physicians (and methadone clinics) must be vigilant and cautious in their use of these medications due to their risk of abuse and overdose with opioid dependent patients.

Many opioid treatment programs around the country have adopted a no benzodiazepine policy and will not induct a patient with methadone until the patient has successfully detoxed off of any benz medications, and is able to test negative for the drug.

Some prospective patients have been on benzodiazepines for many years – long past any justifiable therapeutic or medical necessity. Several years ago, an OTP was approached by a client seeking admission who had been taking klonopin by prescription for 25 years. She had experienced several overdose episodes during that time period. The prospective patient voluntarily completed a successful detox off the klonopin, and she demonstrated incredible courage in pursuing this goal. She remained benz free and has tested negative for illicit substances for 3 years now. While she was afraid and doubtful that she could complete the benz detox, she surprised herself and the clinic staff in what can only be described as an incredible commitment to change and a new life.

For those patients diagnosed with a severe anxiety disorder, benzodiazepines may be indicated in select cases. Cognitive-behavioral therapy can also be effective in helping individuals learn to cope successfully with anxiety although it will require strong commitment to the therapy process and a considerable degree of work. With benzodiazepine treatment alone, the medication only manages the symptoms … but does not treat the underlying cause of the anxiety. For that reason, treating anxiety exclusively with benzodiazepines (at the exclusion of therapy) can be a disservice to a patient.

Physical dependency on benzodiazepines can be quite powerful and withdrawal from them dangerous. No one should ever try to self-detox from a benzodiazepine addiction due to the risk of seizure and possibly death.

Methadone Programs and Prohibited Medications

rx-medication-abuseMany clients in methadone programs have co-occurring disorders like depression, anxiety, or adult attention deficit disorder (ADD). Historically, clinics have attempted to treat psychiatric symptoms with established, FDA-approved psychotropic medications which have proven useful across many settings in managing symptoms.

In the past decade, it became very apparent that benzodiazepines (commonly prescribed to treat anxiety) had become a popular alternative drug of abuse for individuals with an opioid addiction. “Benzos” are a particularly dangerous medication when used in conjunction with methadone, and the combination of these two contributed to a number of overdose deaths in recent years.

For this reason, many safety-oriented, reputable methadone clinics (and independent physicians) either discontinued or noticeably restricted their use of benzodiazepine medications with patients on methadone. Common benzodiazepines include prescription meds like klonopin, valium, xanax, and ativan. As an alternative to these high risk medications, non-addictive options like Buspar are utilized to help clients better manage their anxiety symptoms as well as cognitive therapies for teaching stress reduction and anxiety management skills.

Stimulant therapy is the use of stimulant-based medications to aid adults struggling with attention deficit disorder. Popular medications in this class include adderall, ritalin, and concerta. Unfortunately, these medicines are also widely abused and often illegally sold by patients thus forcing treatment providers to reconsider the use of these medications in their programs.

Positively, there are several medications which can help ADD and which have a low abuse potential. Some psychotropic medications can also be used off label to help reduce attention deficit problems. Off label means the drug was not designed specifically to treat a symptom, but has been found to have a beneficial effect on reducing that symptom.

In the end, methadone programs must employ the safest protocols to insure that clients receive treatment that genuinely helps them and will not place them at risk. There are instances in which benzodiazepines and stimulant therapies are appropriate and in the best interest of the client. However, medical and clinical staff must utilize a careful sense of discretion and evaluate the merits of a particular high risk medication against its potential for harm.

Clients can help this process by being open, honest, and direct with their treatment staff. Clients should report to management any person who is known to sell prescription medications to other clients. While this type of behavior typically occurs among a minority, it can have an extremely negative impact on other clients and the clinic itself.

Prescription Monitoring Helps Suboxone and Methadone Treatment

methadone40Dr. Jana Burson, in her opioid treatment blog, has written two important and interesting entries on the value of prescription monitoring programs (entry 1, entry 2). Prescription monitoring allows approved physicians to review a database listing controlled substances a patient receives (like opioids or benzodiazepines), the prescribing physician, and the pharmacy that filled the prescription.

This information is extremely useful for monitoring patient behavior in opioid treatment and helping to provide a measure of patient accountability. Some patients have a pattern of doctor shopping and abusing prescription medications even after entering opioid treatment. This monitoring program allows doctors to identify doctor shopping activities and to intervene with their patients who may be abusing prescription meds or selling them.

Dr. Burson writes that 42 states have approved a prescription monitoring program, and a majority of them already have the program up and running in their state. One notable exception is the state of Florida. Dr. Burson writes that Florida’s Governor Scott has blocked the implementation of the prescription monitoring program. This is detrimental to identifying & managing prescription abuses across the state. It is reported that Governor Scott has been contacted by other State Governors urging him to reconsider.

Methadone and suboxone treatment programs aim to help their clients change their lifestyle & behavior, and to make choices rooted in healthy recovery. Prescription monitoring enables treatment professionals to assist their clients in examining negative behaviors and correcting them.

Some individuals who doctor shop find themselves in legal trouble and facing possible incarceration. This can derail a client’s opioid treatment, as well as compromise the integrity and reputation of the methadone treatment program trying to serve addicted people. It is much better to identify prescription abuses early on and to intervene quickly.

Prescription monitoring programs are ideal for the safety and security of clients and the welfare of communities. The over-prescribing of opioids and benzodiazepines has become a major problem in the United States, and prescription monitoring is a huge forward step in rectifying this troubling issue.

Benzodiazepine and Methadone Considerations

safetyAnxiolytics are a frequently prescribed classification of drugs that are utilized to reduce anxiety and which may provide some anticonvulsant benefits for those at risk of seizure. The most common of this class are benzodiazepines such as Xanax, Ativan, Valium, Klonopin, or Librium. These medications have helped many people who suffer with generalized anxiety or panic disorder.

However, there is some consensus that benzodiazepines are over-prescribed. They are typically provided on a short-term basis only since tolerance & dependency can develop with prolonged use. Of particular concern to opioid treatment providers is the potential for fatal overdose when "benz" medications are taken in conjunction with methadone.

This is a delicate issue in that many methadone clinics have adopted a policy that disallows any use of benzodiazepines while a client is receiving methadone. This decision came about several years ago, as a safety measure, when a number of client deaths occurred tied specifically to benzodiazepine and methadone use combined.

It must be said that there are methadone patients who have received & taken benzodiazepine medication responsibly and experienced no problem. But the medical and addiction treatment community have recognized a significant risk associated with the mixture of these two potent medications. Ultimately, a program's physician is the one who bears responsibility for which medications can be safely administered. When benzodiazepines are determined to be "too risky", this can leave a methadone patient feeling defenseless & concerned about their ability to manage their chronic anxiety. No doubt, unmanaged co-occurring disorders (and uncomfortable associated symptoms) can put clients at increased risk of drug relapse.

It is very important that treatment providers (opioid programs) give their clients ample support & alternative options for coping with their anxiety. There are non-addictive medications-of-choice for treating anxiety such as Buspar, and also a variety of cognitive-behavioral approaches that help clients learn to moderate their anxiety symptoms using newly developed skills.

In the end, opioid program clients put their trust in the expertise of the clinic physicians & staff who aim to help them. Sometimes, there is no perfect answer. And clinic staff must base a treatment decision on maximum client safety as well as factoring in liability concerns that could even jeopardize the clinic's existence. Benzodiazepines will remain a high priority topic for some time to come. They too, like methadone, are helpful medications. They too, like methadone, must be closely monitored and used appropriately.