Benzodiazepine use and abuse by patients on methadone is a pressing concern for opioid treatment programs (OTPs) because of potentially dangerous drug interactions, especially during induction, so it was a natural selection for a “hot-topic” meeting at the American Association for the Treatment of Opioid Dependence (AATOD) conference in April. Ron Jackson, MSW, LICSW, moderated the session.
“We decided to have this hot topic because everybody talks about the problems of benzodiazepine use, so we wanted to figure out what treatment providers were doing and why they were doing it,” said Mr. Jackson, who is executive director of Evergreen Treatment Services in Seattle.
Some patients are prescribed benzodiazepines with the knowledge of the OTP. There was a large degree of difference in program policies about approving such prescriptions as described by participants in the roundtable discussion, ranging from “If it’s being prescribed by a psychiatrist it’s OK” to “Our clinic has a discussion with the prescriber to coordinate care.” But of bigger concern are patients who are taking benzodiazepines but do not have valid prescriptions—they may be doctor-shopping or buying benzodiazepines on the street. For these patients, there is no consensus, at least not one Mr. Jackson detected during the AATOD session. “Program policies are all over the place,” he told AT Forum. Some refuse to admit anyone who says they use benzodiazepines. Some will admit these people but require them to self-taper during the first month—a risk, because the patient could have seizures. One OTP said patients are sent to a local facility for detoxification—but that could be a problem, because they are detoxified from opioids, too.
Some OTPs simply decrease methadone doses for patients whose urine drug tests are positive for benzodiazepines, but Mr. Jackson said there’s no science to support this, as the tests do not measure how much the patient is taking.
In fact, there aren’t many tools for patients who are abusing benzodiazepines, said Mr. Jackson. “I wish there were some sort of benzodiazepine antagonist. Other than cognitive-behavioral therapy to resist cravings, there isn’t anything.”
Evergreen’s PMP Experience
A combination of checking with the prescription monitoring program (PMP) and asking patients what they are taking helps identify which people are on benzodiazepines before they are admitted. The PMP will not tell whether patients have bought them on the street or obtained them in some other way without a prescription, which is why it’s important to also ask them, said Mr. Jackson.
Evergreen’s patients are required to register their prescriptions with the OTP, so the clinicians know about possible drug interactions and are able to coordinate care. Recently Evergreen queried the PMP about all of its patients in the Seattle clinic. It found that 31 percent (350 patients) in the clinic showed up on the PMP. Of these 350 patients, about 20 percent were taking exactly what they had registered they were taking. “I was happy with that,” he said. But of the other 80 percent, 45 percent were prescribed benzodiazepines. Some were taking them but did not inform the OTP, and some were selling them. The number of current benzodiazepine prescriptions per patient ranged from 1 to 19.
Evergreen worked closely with these doctor-shopping patients by trying to get them to quit. “We wanted to continue their OTP treatment while safely tapering them from benzodiazepines,” said Mr. Jackson. “But if patients cannot cooperate, and every drug test is positive for benzodiazepines, and the patient has been to the ER with overdoses, we say, ‘You may need a higher level of care. We can no longer safely give you the medications you need.’”
Many more patients—88 percent of the 350—were getting prescribed opioids, but some were not taking them – this was clear because the medications never appeared in urinalysis tests. Some were selling all of them, which was also true of those receiving prescriptions for benzodiazepines. “One patient said, ‘This is my way of making a living,’” said Mr. Jackson. That patient left treatment. Some were getting prescriptions for Suboxone and selling or giving away the pills.
For patients who had prescriptions for trivial amounts of drugs—for example, a prescription for 6 acetaminophen/ hydrocodone (Vicodin) after a root canal procedure– Evergreen didn’t take any action other than reminding such patients to register their medications. About 25 percent of the patients had prescriptions for these “trivial” amounts.
Seeking a High
The reality is that some people come to methadone treatment but aren’t interested in treatment, according to Mr. Jackson. “They’re interested in the medication. That way they can continue to live the life they want—without craving opioids—and instead can get high from other drugs, like benzodiazepines.” OTPs must face this reality, especially OTPs with limited capacity or waiting lists, noted Mr. Jackson. Patients come to OTPs with a history of seeking euphoria from drugs. “You end up with this difficult triage decision: who is appropriate, who gets these slots?”