Prior to recovery, addictive disease is like a roaring, out-of-control fire that no one in their right mind would want to be near. During the treatment process, if all goes well, the roaring fire is subdued to the point where it is no longer a danger to self or others. However, as my good friend and colleague Bob DuPont states so eloquently, “Once the addiction switch is thrown on, it never goes off.” Dr. DuPont would know. After all, he is the original Drug Czar and the first director of the National Institute of Drug Abuse (NIDA). Back to my fire analogy. Recovery, then, is no longer a roaring, out of control fire, but the embers remain indefinitely. So it doesn’t take much to fan them into a roaring fire once again.
Why Does This Matter?
The concomitant use of opioids and benzodiazepines is associated with high mortality. Additionally, Dr. DuPont argues, the pharmacology doesn’t make sense. Benzodiazepines are FDA-approved for anxiety and have also been prescribed as a muscle relaxant for short-term use. For a non-addicted person, short-term use of a benzodiazepine for post-surgical spasms or acute, episodic anxiety is within the realm of what the FDA had in mind. Yet benzodiazepines are often referred to as “freeze-dried alcohol,” namely because they are both GABA inhibitors and work in the same way on the same part of the brain. Xanax, for example, is called Zannies, Xanbars, Handlebars, Bars, Z-bars, Totem Poles or Zanbars. They have street value of $2 per 1 mg. Yet many prescribers do not realize this and do not see the cases of alcoholics abusing benzodiazepines. Psychiatrists are often ambivalent and believe the efficacy of benzos for anxiety, even for addicts, outweighs the potential for harm.
TW Park, MD (2016) wrote:
“Benzodiazepines are among the most effective and well-tolerated treatments for anxiety, and are safe for the majority of patients who take them. Though not appropriate for all cases, particularly in those with an active opioid use disorder, benzodiazepines should be considered as a treatment for patients with substance use disorders after careful weighing of benefits and harms.”
So the debate rages on.
Benzodiazepines for Addicts on Opioids
The use of benzodiazepines has increased as opioid use continues to rise. To wit, benzodiazepines are increasingly prescribed for insomnia resulting from daily stress, or to mediate the side effects of opioid use such as insomnia, agitation, mood swings, etc. In 2016, the U.S. Food and Drug Administration put a black box warning on all benzodiazepines and opioid analgesics regarding the serious risks associated with their concomitant use—primarily, respiratory distress and failure, resulting in death.
Lastly, giving a drug that produces euphoria and addiction, similar to addicts’ preferred drug of abuse, can be like pouring gasoline on the red hot embers of a fading fire. Someone is bound to get hurt.
What has been lost in this debate is the fact that there are many non-benzo treatments available for recovering addicts with anxiety, including mindfulness training and Mindfulness Relapse Prevention Training Program (MRTP), relaxation, CBT, National Alliance for Mental Illness (NAMI) support groups as well as 12-step programs. There are other types of non-benzodiazepine medications that can be effective under the direction of a well-trained addiction psychiatrist or professional.