The Danger of Mixing Benzos With Methadone

MastHead Outline
February 5, 2020

Methadone and all the different types of benzodiazepines are medications prescribed by doctors for legitimate reasons, yet they can be dangerous, both individually and especially if taken simultaneously. Methadone is the cornerstone of many successful medication-assisted treatment (MAT) programs, and many people credit the medicine with helping them overcome addiction to opioid drugs. Doctors prescribe benzodiazepines to help treat anxiety and some other conditions, and they work well for their intended purpose.

However, benzodiazepines have a huge potential for misuse, as their dispensation is not as controlled as methadone. Taking benzodiazepines while participating in methadone treatment is highly dangerous in terms of physical health and the potential for developing an addiction to one or both medications. Learning the symptoms and side effects of each drug will help you understand just how dangerous it is to combine them when undergoing addiction treatment.

What Are Benzodiazepines?

Benzodiazepines, or “benzos,” are a class of psychoactive medications prescribed to manage the symptoms of a variety of conditions. There are more than a dozen benzodiazepines on the market, which all have a similar basic structure and act on specific neurotransmitters called GABA. By influencing activity at the GABA receptors, benzodiazepines create dramatic changes in the central nervous system (CNS). The CNS regulates heart rate, breathing, blood pressure and core temperature of the body. Benzos work to slow all these functions down.

Doctors prescribe benzos to manage very severe or sudden effects of anxiety caused by stress and over-stimulation. They work very quickly and quite literally calm a person’s nerves within minutes, they also cause a feeling of euphoria as other drugs of abuse do. As a short-term medication, they are relatively safe. However, benzos are so powerful and interfere with the brain and body on such a significant level that they can cause dependence very quickly.

In a state of dependence, a person’s neurons adapt to frequent exposure to benzos. These adaptations result in a series of physiological reactions that make stopping the drug without medical assistance almost impossible. Some of the symptoms, like seizures, can be life-threatening. If a person doesn’t get help and continues to use benzos, their use becomes more about avoiding withdrawal than it is about deriving a “high” from the medication.

Side Effects of Benzodiazepines

Benzodiazepines can be dangerous even when taken according to a doctor’s prescription. The side effects of benzodiazepine usage may include:

  • Tiredness and drowsiness
  • Confusion
  • Dizziness
  • Trembling or shaking
  • Impaired coordination
  • Impaired vision
  • Grogginess
  • Depression
  • Headaches

These symptoms are often mild at first, then increase with the dosage a person is taking. The symptoms are clearly indicative of how much benzos affect the nervous system, and if a person’s use continues to escalate, damage to the CNS can become long-term.

How Methadone Works

Methadone has been an effective weapon for decades in the fight against opioid addiction. As long as users take it as prescribed, methadone is highly effective and a safe option for treatment. Methadone is itself an opioid medication, which is active on the same receptors as drugs like heroin and prescription painkillers. However, methadone’s window of action is longer and its effects are far more subdued than those of more powerful opioids when taken at a therapeutic dose, as prescribed.

For a person already dependent on opioids, methadone does not produce a high in prescribed doses. Instead, methadone creates just enough of an opioid effect to reduce cravings and prevent withdrawal symptoms from setting in. This drug allows people to stabilize and feel normal enough to participate fully in the other components of their treatment program and navigate life without returning to drug abuse.

Methadone is highly controlled, so people taking it must visit a clinic daily and consume their doses under supervision for several months before becoming eligible to take doses home. That’s because methadone can be addictive, and users must take it exactly as prescribed by a physician to remain safe. Side effects of methadone include:

  • Headaches
  • Weight gain
  • Stomach pain and cramps
  • Dry mouth
  • Tongue pain
  • Flushed skin
  • Difficulty with urination
  • Changes in mood
  • Vision problems
  • Insomnia or disordered sleep

Why Do People Mix Benzos With Methadone?

Despite the severe side effects that can occur with either medication, a surprising number of people mix methadone with benzos. Between 18 and 50% of patients receiving methadone in opioid treatment programs meet the criteria for dependence on benzodiazepines. Combining the two drugs can lead to worse outcomes from treatment, and the combination also increases the risk of mortality. So why do people do it? These are three of the reasons a person might mix methadone and benzos.

1. Lack of Knowledge

Many people don’t know combining methadone with benzos is dangerous in the first place. They may receive a prescription from a primary care physician who doesn’t realize the patient is on methadone and therefore can’t give appropriate guidance on possible repercussions.

2. Desire to Get High

The mixture of benzodiazepines and methadone can produce a range of effects some people enjoy and seek out on purpose. Around 45% of methadone patients with a history of benzodiazepine use reported in a study that they use benzos to “get high,” “have a good time” or “produce an intense, exciting experience.”

Respondents also said that benzodiazepines enhance the effects of their daily dose of methadone. Heroin users reported that benzodiazepines extended the duration and intensity of the drug’s effect.

3. Physician Prescription

In very limited cases, a doctor overseeing methadone treatment will prescribe a benzodiazepine to address anxiety symptoms in a patient. If it does happen, the patient receives only one or two doses in case of emergencies like a panic attack. However, taking a benzodiazepine in combination with methadone even once can incite a persistent desire to abuse benzos, methadone or both.

Many individuals who struggle with a substance use disorder have co-occurring mental health disorders or issues. Depression and anxiety are among the most common, and are often a part of the reason that a person used drugs in the first place. Those individuals may have been prescribed a benzodiazepine as a part of their treatment for anxiety or other mental health issues, and are now beginning treatment for substance use disorder and will have to address the conflict between these medications with their physicians.

The Dangers of Mixing Benzos and Methadone

Surprisingly, there is little research on exactly how methadone and benzos interact. However, we see the danger of the combination in the number of associated overdoses. More than 30% of the people who died from an opioid overdose also tested positive for benzodiazepines. People taking both drugs are also at significantly higher risk of being admitted to the emergency room for drug-related care.

An overdose resulting in death is the worst possible outcome for someone taking both benzos and methadone. The risk worsens dramatically if a person is taking either or both medications outside of prescribed dosages. The symptoms of an overdose involving benzodiazepines and opioids mostly come from the sedative effects of both drugs and their impact on the respiratory function of an individual. The symptoms are the same as those experienced when abusing either drug, but taken to their furthest extreme:

  • Blurry vision
  • Bluish color in nails and lips
  • Confusion and disorientation
  • Dizziness and light-headedness
  • Impaired coordination
  • Nausea
  • Constricted pupils
  • Slowed or stopped breathing
  • Slurred speech
  • Weakness

Without the proper intervention from emergency medical services, overdoses including benzodiazepines and opioids such as methadone can be fatal. While it’s possible to reverse an opioid overdose using naloxone, this medication does not affect the component caused by benzodiazepines, and may not be able to save a person’s life if they have combined benzos and methadone.

How Benzos Affect Methadone Retention

Another concern about mixing benzos and methadone is how the combination affects treatment retention. Do those who take benzos have a lesser chance of completing treatment? According to a study published in the Journal of Addiction Medicine, the combination of medicines might not affect treatment retention as long as users take both as prescribed.

The study followed patients in 52 different opioid treatment clinics who were starting MAT with methadone and taking prescription benzodiazepines, non-prescribed benzodiazepines or no benzodiazepines at all. The study followed patients through their discontinuation of treatment, death or one-year follow-up. The researchers used the results of urine drug screens and prescribing information from health records.

The primary outcome of the study showed patients who were using non-prescribed benzodiazepines were much more likely to discontinue their methadone treatment, as compared to the participants not taking benzodiazepines or taking benzodiazepines as prescribed.

Can People on Benzos Start Methadone Treatment?

Given the known and unknown risks of combining benzos with methadone, what should people on benzodiazepines do if they need treatment for opioid addiction? In 2017, the Food and Drug Administration (FDA) clarified its guidelines on benzos and opioid addiction medications such as methadone. Their additional review led to a recommendation that treatment professionals shouldn’t withhold methadone from patients who are taking benzos or other CNS depressants.

While the combined use of the drugs does increase the risk of severe side effects, the damage done by an untreated opioid addiction outweighs the risk. If a doctor co-prescribes MAT with methadone and benzodiazepines, that physician can better control and adjust dosages to reduce the risk as much as possible.

Honest Coordinated Care Results in Safe Treatment

Health care providers can and should take a variety of other actions and precautions when developing a treatment plan with methadone for a patient also taking benzodiazepines or other nervous system depressants. Some of the most critical include:

  • Giving patients thorough education about the risk of combination use, including the potential for overdose and death when taking benzodiazepines
  • Developing new strategies that help manage the use of benzodiazepines and other CNS depressants, whether prescribed or used illicitly
  • Verifying the patient’s diagnosis if they are receiving benzodiazepines for anxiety or insomnia, and introducing considerations for other treatment options for the diagnosed conditions
  • Acknowledging that some people may need MAT indefinitely, and that use of methadone or another MAT medication should continue as long as the person is benefiting
  • Coordinating care with the patient’s other health care providers to ensure all parties are aware of the patient’s prescriptions for methadone, benzodiazepines and any other medications
  • Monitoring the patient for illicit drug use through blood or urine screenings
  • Tapering benzodiazepine use with the intention of discontinuation whenever possible

With proper management on the part of health care providers, patients taking benzodiazepines stand a better chance of success in MAT with methadone while minimizing the risk of overdose and other adverse outcomes.

Is Suboxone® a Better Option?

While methadone treatment has been successful for many people over many decades, the problem of its potential for abuse remains, and makes concurrent benzodiazepine use more dangerous in terms of developing an addiction to either medication. For patients currently prescribed benzos, Suboxone® may be a more appropriate option. Suboxone® is a prescription medication approved for use in MAT in 2002. It contains two active ingredients.

  • Buprenorphine: A partial opioid antagonist that helps relieve cravings and withdrawal symptoms by blocking the brain’s opioid receptors
  • Naloxone: An opioid antagonist that blocks the effects of the opioid itself

Suboxone® can address the potential for addiction by incorporating naloxone as a deterrent. The naloxone only activates when someone attempts to abuse the medication by injecting it. Upon injection, the naloxone in Suboxone® produces immediate withdrawal symptoms, including headache, sweating, restlessness, nausea and vomiting. Additionally, the naloxone makes it impossible for the individual to stop the withdrawal symptoms using another opioid drug.

This powerful deterrent makes it almost impossible for someone to abuse Suboxone®, which is a crucial feature for those taking another potentially addictive medication like benzodiazepines.   

Tapering Benzos for Opioid Treatment Success

No matter which FDA-approved medication someone takes as part of a MAT program, it is in their best interest to discontinue benzodiazepines whenever possible. The way physicians facilitate this discontinuation is through tapering, where they gradually reduce the patient’s prescription over time until the person stops taking the medication altogether. This approach gives the brain time to readjust to functioning without benzos, and minimizes withdrawal symptoms for better management. When a doctor opts for a slow taper over three to six months, they will usually:

  • Switch the patient from a short-acting benzo such as lorazepam to the equivalent dose of a longer-acting benzo like diazepam
  • Reduce total dosage by 5 to 10% each week
  • Decrease total dosage once per month after the patient reaches half of the original dose
  • Educate the patient about non-drug options for managing symptoms

The physician may prescribe other, less dangerous medications to help with symptoms like anxiety or inability to sleep well, and will encourage the use of strategies like deep breathing, exercise and counseling to help curb unwanted symptoms without the use of medication. Each patient, however, is evaluated and advised based on their unique needs, dosage and in collaboration with the medical provider prescribing the benzodiazepine medication.

Opioid Addiction Treatment at AppleGate

If you or someone important in your life are struggling with opioid addiction as well as dependence on benzodiazepines, you may be wondering what your treatment options are. The good news is that benzos will not get in the way of your opioid treatment if you work with a network of physicians that coordinate your care, prescribe appropriate amounts of benzodiazepines and potentially taper you off the medication altogether.

AppleGate Recovery is proud to provide medication-assisted treatment with Suboxone® and other buprenorphine compounds. Our dedicated team of physicians and other addiction treatment professionals provides individualized treatment plans to give you or your loved one the tools and support necessary to overcome opioid addiction. To learn more about the next steps, where we’re located and what AppleGate Recovery can do for you, call us at 888-488-5337 or contact us online.

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