ATTC Messenger April 2014: Management of Benzodiazepines in Medication-Assisted Treatment
Management of Benzodiazepines in Medication-Assisted Treatment: The creation and dissemination of new practice guidelines
National Screening, Brief Intervention & Referral to Treatment ATTC
A compelling and ever-growing body of research supports the use of medications as a component of addiction treatment. Considerable efforts have been made, at both a federal and grassroots level, to move this research into practice by expanding access to medication-assisted treatment (MAT). These efforts have seen success: in 2011, 306,000 clients were enrolled in methadone programs, 32,767 clients were undergoing buprenorphine treatment from OTPs or substance use treatment facilities, and over 640,000 were receiving buprenorphine from waivered physicians. In contrast, in 2004, there were just 227,000 clients in methadone and between 20,000 and 96,000 people receiving buprenorphine.1,2
Especially given the sharp nationwide increase in prescription opioid abuse, the number of patients seeking and receiving MAT is likely to continue to rise.
Inevitably, broader use of these medications has been accompanied by questions about their implementation in clinical settings. Some of our most urgent questions revolve around client use and abuse of benzodiazepines during MAT…and it’s a messy issue, to be sure. Research shows that benzodiazepines (a family of central nervous system depressants often used to treat anxiety, known to many by brand names like Xanax and Valium) can have severe acute consequences for MAT clients and, in the longer-term, can compromise an individual’s recovery and adversely impact physical and mental health.3, 4, 5, 6
As such, the risks of benzodiazepine use are of great concern to treatment providers, who may be liable for acute outcomes like overdose deaths or accidents caused by impairment and whose work may be hindered by longer-term effects that interfere with clients’ access to recovery.
Treatment providers are also heavily invested in the proper management of benzodiazepine use in medication-assisted treatment because of the sheer numbers of users. Estimates of methadone maintenance patients who abuse or are dependent on benzodiazepines range from 18-50% 7, 8, 9, and lifetime users of benzodiazepines are estimated to be 66-100% of the global methadone maintenance population.10
The popularity of workshops on this topic at the American Association for the Treatment of Opioid Dependence (AATOD) conference in both 2012 and 2013 is one illustration of the avid interest and rampant confusion that surrounds the management of benzodiazepines in MAT.
Need for treatment guidelines
One reason for this interest and confusion is that existing treatment guidelines (SAMHSA TIPs and TAPs, VA guidelines, WHO guidelines, and others) haven’t thoroughly examined the practicalities of managing benzodiazepine use in MAT, which has left clinicians to fill in the gaps.
The sorts of dilemmas that providers encounter were wonderfully articulated at a 2012 conference in Philadelphia, “Management of Benzodiazepines in Medication-Assisted Treatment,” when public servants, payors, epidemiologists, some of the foremost researchers and clinicians in the field, and MAT clients explored the issue more deeply.
An often-cited issue was that published research does not offer clear instructions for providers to follow. “How can we address this issue in the absence of strong empirical support for what to do?” asked Arthur Evans, Jr., PhD, Commissioner of Philadelphia’s Department of Behavioral Health and disAbility Services (DBHIDS).
Another theme at the conference was the difficulty of untangling co-occurring anxiety from opioid addiction, which makes clients’ need for benzodiazepines is difficult to determine in the context of MAT. “Addiction is an anxiety provoking disease,” presenter Peter DiMaria, Jr., MD, FASAM, DFAPA reminded the attendees.
And, frustratingly: “There are legal and clinical issues associated with taking someone off and with keeping them on benzodiazepines,” said Louis Baxter, Sr., MD, FASAM. Abrupt discontinuation of benzodiazepines can be life-threatening. On the other hand, MAT induction in the context of uncontrolled benzodiazepine use is ill-advised as it can lead to impairment and overdose.
Video recordings and slideshow presentations from the 2012 conference in Philadelphia are available online. They are highly recommended.
Building treatment guidelines
The conference kicked off a project to build updated treatment guidelines for Philadelphia DBHIDS. With support from Community Care Behavioral Health, the Institute for Research, Education and Training in Addictions (IRETA) coordinated the development of the guidelines using a well-researched method known as the RAND/UCLA Appropriateness Method (RAM).
Per the RAM, multidisciplinary experts (many of them presenters at the 2012 conference), comprised an expert panel that rated the appropriateness of proposed guideline statements based on existing research, clinical experience, and consultation with one another. The guidelines were grounded in Philadelphia DBHID’s existing Practice Guidelines for Recovery and Resilience Oriented Treatment and the premise that recovery and risk management are compatible and mutually reinforcing. That is to say, a clinician can better offer each patient recovery when comfortable with risk management practices throughout the organization.
After the expert panel assembled a set of draft guidelines, Philadelphia DBHIDS issued a call for public comment to incorporate additional viewpoints into the guidelines. And in December 2013, “Management of Benzodiazepines in Medication-Assisted Treatment” practice guidelines were published and disseminated.
They are free for download and can be used by providers, consumers, and systems.
Some of the primary takeaways from the practice guidelines include:
- Central Nervous System (CNS) depressant use is not an absolute contraindication for the use of either methadone or buprenorphine in MAT, but is a reason for caution because of potential respiratory depression. Serious overdose and death may occur if MAT is administered in conjunction with benzodiazepines, sedatives, tranquilizers, antidepressants, or alcohol.
- Individuals who use benzodiazepines, even if used as a part of long-term therapy, should be considered at risk for adverse drug reactions including overdose and death.
- 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.
- MAT should not generally be discontinued for persistent benzodiazepine abuse, but requires the implementation of risk management strategies.
- Clinicians should ensure that every step of decision-making is clearly documented.
- Clinicians would benefit from the development of a toolkit about the management of benzodiazepines in methadone treatment that includes videos and written materials for individuals in MAT.
The final recommendation, to develop a toolkit with materials designed for clients, is consistent with the overarching theme of patient education, which was discussed at the February 2012 conference and emerged as a significant issue in the final practice guidelines.
In the spirit of patient education, IRETA has created an infographic about combining benzodiazepines and opioid agonists targeted at MAT clients. Feel free to share it, print it, post it, and distribute it to others in the field.
1. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (April 23, 2013). The N-SSATS Report: Trends in the Use of Methadone and Buprenorphine at Substance Abuse Treatment Facilities: 2003 to 2011. Rockville, MD.
2. Clark, H. (2010, May). The state of buprenorphine treatment. PowerPoint presentation delivered at: Buprenorphine in the treatment of opioid addiction: Reassessment 2010. Retrieved from http://buprenorphine.samhsa.gov/bwns/2010_presentations_pdf/01_Clark_508.pdf
3. Lintzeris, N., & Nielsen, S. (2010). Benzodiazepines, methadone and buprenorphine: interactions and clinical management. The American Journal on Addictions, 19(1), 59-72.
4. Barker, M. J., Greenwood, K. M., Jackson, M., & Crowe, S. F. (2004). Cognitive effects of long-term benzodiazepine use. CNS drugs, 18(1), 37-48.
5. Lavie, E., Fatséas, M., Denis, C., & Auriacombe, M. (2009). Benzodiazepine use among opiate-dependent subjects in buprenorphine maintenance treatment: correlates of use, abuse and dependence. Drug and alcohol dependence, 99(1), 338-344.
6. Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No. 43.) Available from: http://www.ncbi.nlm.nih.gov/books/NBK64164/
7. Gelkopf, M., Bleich, A., Hayward, R., Bodner, G., & Adelson, M. (1999). Characteristics of benzodiazepine abuse in methadone maintenance treatment patients: a 1 year prospective study in an Israeli clinic. Drug and alcohol dependence, 55(1), 63-68.
8. San, L., Tato, J., Torrens, M., Castillo, C., Farré, M., & Camí, J. (1993). Flunitrazepam consumption among heroin addicts admitted for in-patient detoxification. Drug and alcohol dependence, 32(3), 281-286.
9. Miller, N. S., & Gold, M. S. (1991). Abuse, addiction, tolerance, and dependence to benzodiazepines in medical and nonmedical populations. The American journal of drug and alcohol abuse, 17(1), 27-37.
10. Lintzeris, N., & Nielsen, S. (2010). Benzodiazepines, methadone and buprenorphine: interactions and clinical management. The American Journal on Addictions, 19(1), 59-72.