Benzodiazepines significantly enhance the action of other Central Nervous System (CNS) depressant medications including methadone and buprenorphine. On their own, benzodiazepines have a broad safety profile but in combination with opioids in particular, the risk of sedation and respiratory depression increases significantly. Patients with a history of addiction are at much higher risk for benzodiazepine misuse and dependence; therefore, benzodiazepines are not the ideal treatment for insomnia or anxiety in most cases. Tolerance to benzodiazepine-induced euphoria and sedation develops quickly, and withdrawal can be life threatening. Abuse liability of specific benzodiazepines varies depending on pharmacokinetic properties, rate of absorption, metabolism, intrinsic activity and elimination half-life. There are few clinical situations where benzodiazepines may be appropriate for short-term use in methadone or buprenorphine treated patients. Despite the known increased risks of overdose and misuse, opioid dependent patients often access these prescriptions.
Worldwide, 18-50% of patients receiving methadone in Opioid Treatment programs (OTPs) are dependent on benzodiazepines. [i] Benzodiazepine use among patients in opioid agonist medication assisted therapy is linked to poorer outcomes; the combination with opioid agonists poses significant risks for morbidity and mortality. There are few published articles that offer useful guidance for management of benzodiazepines in OTPs. As a result, treatment protocols and clinical practice vary. In spite of the gap in the literature, care should be taken with patients admitted to opioid agonist treatment with either licit or illicit benzodiazepine use. Treatment of opioid use disorder with medications should not be discouraged or delayed, but the risks of ongoing benzodiazepine use should be taken seriously and interventions guided accordingly.
The purpose of this document is to offer guidance instead of restrictive procedures to assist programs in treating patients in OTPs who use benzodiazepines. [ii] [iii] [iv] [v] [vi] [vii] [viii] [ix] [x] [xi]
There is strong evidence that the use of benzodiazepines and other sedating medications combined with methadone or buprenorphine pose safety risks. OTPs should work to ensure that patients considering controlled substances have had quality diagnostic evaluations to optimize diagnostic accuracy, and ensure that safer medication options have been considered. Careful monitoring and coordination of care that is respectful but not capricious or punitive is essential to ensure access to safe, effective and individualized care for patients in OTPs.
[i] Williams, J. Management of Benzodiazepines in Medication-Assisted Treatment. The creation and dissemination of new practice guidelines. ATTC Messenger. April 2014.
[ii] IRETA, Management of Benzodiazepines in Medication-Assisted Treatment. Report to Philadelphia Department of behavioral health and Disability Services. November 2013.
[iii] Baltimore Substance Abuse Systems, Inc. Clinical Guidelines for the Use of benzodiazepines Among Patients Receiving Medication-Assisted Treatment for Opioid Dependence. May 2013.
[iv] Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 08-4214. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005, reprinted 2006 and 2008.
[v] Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 07-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004.
[vi] Renner, JA. Management of psychiatric medications in patients receiving buprenorphine/naloxone. PCSS-B Training. April 17, 2006. Available at: http://pcssb.org/wp-content/uploads/2010/09/PCSS-BManagement- of-psychiatric-medications-in-patients-receiving-buprenorphine-naloxone.pdf. Last accessed 3/9/13.
[vii] Kenneth Minkoff, M.D., Developing Standards of Care for Individuals With Co-occurring Psychiatric and Substance Use Disorders,’ Psychiatric Services. May 2001 Vol. 52 No. 5. http://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.52.5.597
[viii] Methadone Safety: A Clinical Practice Guideline: the American Pain Society and College on Problems of Drug Dependence, in Collaboration With the Heart Rhythm Society. The Journal of Pain: official journal of the Pain Society 15(4):321–337 · March 2014.
[x] Clinical Guidelines for the Use of Benzodiazepines Among Patients Receiving Medication-Assisted Treatment for Opioid Dependence – Behavioral Health System Baltimore, May, 2013.
[xi] Paulozzi, L. J. et al., (2012). Vital signs: Risk for overdose from methadone used for pain relief-united states, 1999-2010. Morbidity and Mortality Weekly Report, Atlanta: U.S. Center for Disease Control.