Recently, I've received an influx of new patients. It is truly an honor to have patients choose my practice to help guide their journey through recovery. I like to think that my approach is a unique blend of evidence based medicine, individualized treatment, and some tough love. Some of the new patients have come with an old issue that has been diminishing. That is the mixing of opioids, in particularly buprenorphine, and benzodiazepines.
Buprenorphine, commonly known by the brand name Suboxone and Subutex, is a medication used to treat opioid use disorder (OUD). While it can be effective in managing opioid addiction and pain, combining buprenorphine with benzodiazepines can lead to serious health risks. In this article, I want to inform my current and new patients about the potential dangers of mixing these medications and why I will take steps to eliminate these risks.
What are Buprenorphine and Benzodiazepines?
Buprenorphine is a partial opioid agonist used to treat opioid use disorder. It helps reduce cravings and withdrawal symptoms associated with opioid addiction. In my opinion, along with methadone, it provides physicians a powerful tool to treat opioid addiction on an outpatient basis. Benzodiazepines, on the other hand, are a class of medications commonly prescribed for anxiety disorders, panic attacks, and insomnia. They are probably the most effective way of treating those disorders. Examples include alprazolam (Xanax), diazepam (Valium), and clonazepam (Klonopin).
By now, the risk of opioid abuse is well know. However, the risks of benzodiazepine dependency and abuse is "flying under the radar" for most people. Within 6 weeks of daily use, 40% of benzodiazepine users become dependent. Among the highest risks for abuse are alprazolam (Xanax), diazepam (Valium) and lorazepam (Ativan). Clonazepam (Klonopin) is also associated with abuse but might be at a lower risk.
The Risks of Combining Buprenorphine and Benzodiazepines
Research has revealed concerning data about the fatal consequences of combining buprenorphine and benzodiazepines. A study published in the European Journal of Clinical Pharmacology found that benzodiazepines were present in 82% of buprenorphine-related deaths in Finland from 2000 to 2008 among individuals aged 14-44. This statistic highlights the significant role benzodiazepines play in buprenorphine-related fatalities.
Further data from a Massachusetts study showed that 24% of individuals who received buprenorphine also filled at least one benzodiazepine prescription. More alarmingly, 31% of the 183 deaths from opioid overdose occurred when individuals received benzodiazepines during buprenorphine treatment. The adjusted hazard ratio for fatal opioid overdose was 3.02 when benzodiazepines were used together with buprenorphine, indicating a threefold increase in the risk of death.
These statistics are the reasons why prescribing practices have changed and patient education regarding the dangers of combining these medications is so important. The data clearly demonstrates the need for alternative anxiety management strategies in patients receiving buprenorphine treatment for opioid use disorder.
When buprenorphine and benzodiazepines are taken together, the risk of adverse effects increases significantly. Here are some of the potential dangers:
Increased Risk of Overdose
Studies have shown that combining buprenorphine use and benzodiazepines can lead to a higher risk of both fatal and non-fatal opioid overdose. Research indicates that patients receiving buprenorphine who also take benzodiazepines have a significantly increased risk of overdose compared to those who don't use benzodiazepines.
Respiratory Depression
Both buprenorphine and benzodiazepines can cause respiratory depression, which is a slowing of breathing. When used together, this effect can be amplified, potentially leading to severe breathing problems or even death.
Sedation and Impaired Cognitive Function
The combination of these medications can cause excessive drowsiness and impair cognitive function. This can lead to accidents, falls, and other injuries, especially in older adults.
Increased Risk of Relapse
Some studies suggest that benzodiazepine may increase the risk of relapse to illicit opioid use in patients undergoing treatment for opioid use disorder with buprenorphine.
Prevalence of Combined Use
Despite the risks, the concurrent use of buprenorphine and benzodiazepines is relatively common. Research shows that approximately one-third of patients receiving buprenorphine treatment for opioid use disorder are also prescribed benzodiazepines. This highlights the importance of awareness and careful management of these medications.
FDA Warnings and Guidelines
The Food and Drug Administration (FDA) has issued warnings about the risks of combining buprenorphine and benzodiazepines. They recommend that healthcare providers carefully consider the use of these medications together and closely monitor patients for signs of abuse, misuse, and overdose. In reality, the overwhelming majority of physicians no longer combine these drugs. Quite often, you will find that doctors will taper, discontinue or minimize one of these 2 drugs. In other cases, doctors will refuse to accept patients who are taking both drugs.
Managing Anxiety Without Benzodiazepines
For patients with opioid use disorder who also struggle with anxiety, there are alternatives to benzodiazepines that pose less risk when used with buprenorphine. These include:
Selective Serotonin Reuptake Inhibitors (SSRIs)
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Beta or alpha blockers
Buspirone
Cognitive Behavioral Therapy (CBT)
Mindfulness and meditation techniques
Exercise and physical activity
Herbal supplements (under medical supervision)
These options can effectively manage anxiety symptoms without the risks associated with benzodiazepine use in patients taking buprenorphine. These options are not associated with accidental overdose deaths.
The Importance of Open Communication
Patients receiving buprenorphine treatment must inform their healthcare providers about all medications they are taking, including benzodiazepines. This allows for proper monitoring and adjustment of treatment plans to ensure safety and effectiveness.
My Approach to New Patients
For new patients who are taking both buprenorphine and benzodiazepines, my approach prioritizes safety while ensuring effective treatment. Here's what you can expect:
Comprehensive Evaluation: I conduct a thorough assessment of your medical history, current medications, and specific needs.
Referral to a Psychiatrist: To ensure you receive specialized care for anxiety management, I refer you to a psychiatrist who can provide expert guidance on managing your anxiety.
Gradual Benzodiazepine Taper: Working closely with you, I develop a plan to slowly taper your benzodiazepine use. This gradual approach helps minimize withdrawal symptoms and ensures your comfort throughout the process.
Alternative Anxiety Management: As we taper the benzodiazepines, we work to introduce safer alternatives for managing your anxiety. Preferably this is done by your psychiatrist. This may include medications with lower risk profiles and non-pharmacological approaches like therapy and lifestyle changes.
Ongoing Monitoring: Throughout the process, I closely monitor your progress, adjusting the treatment plan as needed to ensure your safety and well-being.
Patient Education: I provide comprehensive education about the risks of combining buprenorphine and benzodiazepines, empowering you to make informed decisions about your health.
This approach allows us to optimize your safety, comply with the standard of care, and still provide effective management of your anxiety symptoms.
Conclusion
The combination of buprenorphine and benzodiazepines poses significant risks, including an increased chance of fatal opioid overdose and respiratory depression. While these medications can be beneficial when used separately and under proper medical supervision, together they are dangerous.
For patients struggling with both opioid use disorder and anxiety, it's crucial to work closely with healthcare providers to find safe and effective treatment options. By prioritizing open communication, exploring alternatives to benzodiazepines, and following a carefully managed treatment plan, patients can receive the care they need while minimizing potential risks.
Remember, your health and safety are paramount. If you're currently taking both buprenorphine and benzodiazepines, don't stop or change your medications without consulting your healthcare provider. They can guide you through a safe transition to a treatment plan that addresses both your opioid use disorder and anxiety management needs effectively and safely.
For my new patients, I will attempt my best to find you a psychiatrist who will be willing to evaluate and treat your anxiety disorder. I will refer you to counselors who can help with CBT. Lastly, we will start a taper to safely discontinue the benzodiazepines.
Griffin, C. E., III, Kaye, A. M., Bueno, F. R., & Kaye, A. D. (2013). Benzodiazepine pharmacology and central nervous system–mediated effects. Ochsner Journal, 13(2), 214–223. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684331/
Schuman-Olivier, Z., Hoeppner, B. B., Weiss, R. D., Borodovsky, J., Shaffer, H. J., & Albanese, M. J. (2013). Benzodiazepine use during buprenorphine treatment for opioid dependence: Clinical and safety outcomes. Drug and Alcohol Dependence, 132(3), 580–586. https://doi.org/10.1016/j.drugalcdep.2013.04.006
Faroqui, M. H., Cole, M., & Curran, J. (1983). Buprenorphine, benzodiazepines and respiratory depression. Anaesthesia, 38(10), 1002–1003. https://doi.org/10.1111/j.1365-2044.1983.tb12045.x
Park, T. W., Larochelle, M. R., Saitz, R., Wang, N., Bernson, D., & Walley, A. Y. (2020). Associations between prescribed benzodiazepines, overdose death, and buprenorphine discontinuation among people receiving buprenorphine. Addiction, 115(5), 924–932. https://doi.org/10.1111/add.14886
About the author:
Dr. Harold Pierre is a board-certified anesthesiologist and addiction medicine specialist with over 25 years of experience. He is board-certified by the American Board of Anesthesiology and the American Board of Preventive Medicine.
*Disclaimer: This blog post is for informational purposes only and is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of your doctor or other qualified health provider with any questions you may have regarding your health or a medical condition.
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