On the subject of Benzo's within the OTP

Subject: On the subject of Benzo's within the OTP Mon 05 Nov 2012, 7:45 pm

I'd like to apologize in advance for the length of this post. Although long it is quite worth the read. Comments are welcome.

From the blog of Jana Burson:

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.

North Carolina Disease Event Tracking and Epidemiologic Collection Tool,
http://www.ncdetect.org
Data from NC CSRS, provided by Mr. Bill Bronson, November, 2011

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

http://janaburson.wordpress.com/2012/11/03/benzos-at-the-opioid-treatment-program/

Guest

This is a great Dee! My doc absolutely will not prescribe benzos! How do you feel about them? Do you think it's ok if they are closely monitored?

Subject: Re: On the subject of Benzo's within the OTP Tue 15 Jan 2013, 11:00 am

Good question Jasmine!
There was a time when a woman would or could walk into a doctors office with an ailment and the doctors answer would be to place her on a Benzo.
A case of the "Nerves" would warrant a prescription. I have a sister in law who has bad nerves and is on 2 different Benzos and I hate it. I can't understand anything she says half the time because she slurs. Doesn't her doctor notice this? Probably but, she again has a case of bad nerves.
Nerves? She shakes, her nervous system. Something like a person when you see their head shaking but it is her hands that shake. It runs in the family. I've noticed it in others related to her.
But she tells the doctor that her nerves are bad so they prescribe. She has been on them for years. Would it help to take her off of them? Who knows. She's been on them for so long she probably wouldn't be able to function without them.
My mom had "bad nerves" and took Benzos.

I won't take them. I've seen too many people on them long term and when they stop, they are not the same if they can even stop.

Short term, I think they have their place.
Recently a friend of my son was having severe anxiety and panic attacks. It was getting so bad that she was afraid to leave her home. She is 17 and has had a bad growing up. Alcoholic mom who never paid her any attention and had been abused several times by boyfriends of the mom.
She wanted to get better but couldn't even get out of the car to make it into the exam room of a doctor. Her mom would yell at her and tell her to just "get over it", Last week she made a doctor's appointment but when it came time to go into the office she was paralyzed. Could not get out of the car. The doctor came out to the car to talk to her but couldn't treat her outside like that so the appointment was cancelled.
I spent most of last week trying to find someone who could go to her home to at least talk to her. Do you know how hard that is? To know someone needs help and wants help but can't get it. It is frustrating to say the least. Mental Health in my area sucks.
Finally her boyfriend was able to talk to her old childhood doctor who agreed to give her a couple of Benzos, just enough to help relax her so she could try the appointment again.
This morning she had her appointment. Took her medication about an hour before the appointment, she was not only able to go but when the doctor came out to the car to get her, she went inside the exam room. A huge step for her. And I am so proud of her for it.

She will be starting therapy at some point but for now, she will be on a Benzo short term to allow her to try getting out a little bit each day. It is going to take some time but I have faith that she can do it.
That was a long explanation I know, But it is my opinion.

Sometimes Benzos are necessary but if you can find an alternative that works for the person, then I would say that would be the route to go. Benzo dependence is hard to get over. Much harder that opiate dependence. It takes time and most certainly medical supervision. No one should ever ever stop on their own.

Guest

That's a great story Dee! I am happy that the medication was able to help her to get the help that she needed. I'm sure if it was an extreme case like that, my doc would prescribe it. But he absolutely will not prescribe it to anybody in his treatment program. No matter what they are in treatment for, opiates, crack/cocaine or even meth. He believe that you're not only at risk of becoming addicted to your drug of choice. Sure you can kick that drug of choice and become addicted to a whole new thing!
He wants to try every non-addictive possibility first before he will try anything that can become habit forming.

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