Because of several highly-publicized deaths from combining Suboxone with benzodiazepines or ‘benzos,’ a class of sedative medications that includes Xanax and Valium, I am frequently asked about the safety of combining Suboxone with those medications. The risk of life-threatening respiratory depression can be mitigated fairly easily, but that does not mean that benzos are safe or appropriate medications for people with or without addictions. They are commonly-prescribed medications and there are a number of misconceptions among laypeople about their proper use, so they deserve a thorough discussion. Most doctors with a bit of experience have learned to cringe every time a patient says the word ‘anxiety,’ knowing that in all likelihood they are about to be placed in a difficult position. They will either do the right thing and disappoint their patient, or do the wrong thing and struggle with the consequences of their actions for months or years.
The problem is that the non-medical community sees SSRI’s as ‘antidepressants’, and believes that the proper treatments for anxiety disorders are sedatives like Valium or Xanax. While the sedatives are appropriate for acute or short-term anxiety, chronic anxiety disorders are more appropriately treated using SSRI’s or SNRI’s.
Today I saw a new patient who asked for treatment of her addiction to pain medications. When I asked about other psychiatric symptoms she said that she takes alprazolam and clonazepam for anxiety and panic attacks. I explained that those medications are very dangerous for addicts and are intended for short-term use, and the primary treatments for anxiety disorders are SSRIs or SNRIs. I asked her dose and wasn’t surprised to hear that her tolerance was quite high. A milligram of alprazolam doesn’t even do anything, she said—intending to mean that the meds are no potent enough to worry about. I of course took it the opposite way—she has taken benzos to the point that a very large dose has no effect due to her high tolerance. She then said she also has ADD and takes Adderall (i.e. amphetamine). I explained that it makes no sense to take both amphetamines and benzos, particularly a long acting benzo like clonazepam, which has a half-life of around 30 hours. Benzos CAUSE deficient attention; that is how they work! Worry consists of too much attention to a problem or a fear, and benzos prevent the brain from attending, attaching and remembering. In fact, anesthesiologists and dentists use the short-acting benzodiazepine midazolam during uncomfortable procedures to block the patient’s memory. Most adults have had the experience of watching the medication injected into the IV tubing, and next waking up to people saying ‘you’re OK—it’s all done.’ Don’t take a benzodiazepine if you are nervous about an exam the next day! Beyond the amnesia it is simply a bad idea to take two polar-opposite medications as this patient is doing. Stimulants cause wakefulness, attention, tight muscles, and anxiety. Benzos cause drowsiness, amnesia, relaxation, and the inability to remember what you were supposed to worry about. Instead of taking both, take neither.
A related question came to me by e-mail yesterday:
Hello, I found your website and see that you do phone consultations. I have been having anxiety problems and attacks for over a year. It has gotten worse and worse. I’ve been to the doctors in my area but no one wants to treat me for it…they just want to keep giving me Paxil, Zoloft, Prozac, Cymbalta and all these things I’ve tried and nothing seems to be helping me. I have anxiety attacks all the time where my heart beats out of my chest and I can’t breathe and go almost into this blackout stage. I have a lot of things that trigger it; one is my anxiousness all the time. I can’t focus, and any little dilemma sets me off. Everything is a crisis to me. And on top of that, I have the responsibility to take care of a 3 year old all by myself. I’m so scattered and anxious and upset all the time it is affecting me being a good mother. I cannot take it anymore and I am at the end of my rope. I don’t know what to do; no one will treat me with anything to calm me down along with the Paxil because of all the other people in this county that have abused it.. I DO NOT know what else to do. I have no one to talk to or turn to. It’s affecting my job, my personal life and my life in general. If you can’t help me maybe you know someone who will.
The person doesn’t come right out and say it, but her comments about needing to be calmed down and about abuse of the meds by others suggest that she is asking for a benzodiazepine.
Benzodiazepines include long-acting medications like clonazepam (Klonopin) and diazepam (Valium), intermediate-acting medications like lorazepam (Ativan) and alprazolam (Xanax), and the short-acting sleeping pills from my training years like triazolam (Halcion) and temazepam (Restoril). As an anesthesiologist I gave patients midazolam (Versed) more than any other medication. All of these medications are appropriate in certain settings. Most have a street value. Some have active metabolites that accumulate in the body over time. All are sedating, all cause tolerance, and all have the potential to cause significant withdrawal symptoms. The longer-acting medications will self-taper to some extent, but the intermediate-acting agents in particular have the potential to cause withdrawal syndromes that are severe, and even fatal. The first patient I mentioned has been taking an anticonvulsant since presenting to the ER with a grand mal seizure while stopping Xanax ‘cold turkey.’
All of these medications have appropriate uses, almost always for short-term conditions. When given long-term they cause problems. In fact, from the top of my head I can think of 12 reasons to avoid prescribing benzos for ‘anxiety.’
Many anxious patients aren’t truly anxious. When a patient complains of ‘anxiety’ he/she is often complaining of something else. If I ask a patient to describe the symptoms without using the word ‘anxiety’, I often find that the patient is bored, restless, angry, depressed, overwhelmed, or appropriately frightened. Take a look at the second patient—the one who is ‘scattered,’ ‘at the end of her rope,’ and ‘caring for a 3-year-old boy all by herself,’ Do you really think she will be a ‘better mom’ if she is taking alprazolam or clonazepam? She is feeling overwhelmed, angry, tired, afraid, hopeless, depressed—feelings that when added together become ‘anxiety.’ Do we really want to give a person in this condition a medication that will make her sleepier, more forgetful, more scattered, and more disinhibited?
Even if we get it right, her relief will be short-lived due to tolerance. Patients often escalate their dose at some point—no matter how many times they promise that they won’t. Dose escalation is not the patient’s fault—it is simply what these meds do. Once a pattern of dose escalation begins, it is difficult to control; patients will call after two weeks reporting that they are out of alprazolam, and the doctor feels pressured to issue a refill to prevent withdrawal.
Benzos turn manageable anxiety into an anxiety disorder. Patients get a calming effect from the medication, but as the medication wears off the anxiety returns, including extra anxiety from a ‘rebound effect’—a miniature form of withdrawal. Patients do not usually attribute that anxiety to rebound, but instead believe they have a horrible anxiety condition that appears as soon as the medication wears off. When I worked in a maximum security prison for women in Wisconsin many inmates were taking benzos upon arrival; several months after the benzos were discontinued the most amazing thing happened: the anxiety disorders went away!
A problem specific to addicts is that they don’t take sedative medications to achieve the ‘absence of anxiety,’ but rather they take them until they feel ‘relaxed.’ They are not seeking normalcy—they are seeking relaxation. There is a difference between the two states; one is feeling normal without feeling excessive worry or panic; the other is feeling ‘relaxed,’ something other than feeling ‘normal.’ This doesn’t make addicts bad people; it is simply a consequence of the conditioning process during addiction. Addicts are not aware that they are seeking a ‘fuzziness’ that non-addicts often find to be uncomfortable!
Again specific to addicts, benzos (like other medications that have an immediate psychotropic effect) direct the person’s attention inward. An addict become obsessed with ‘how I feel;’ a goal in treatment is to get the addict out of his or her own head to experience life on life’s terms. Benzodiazepines encourage the opposite effect, encouraging the addict to focus on internal feelings and sensations.
Addicts with one favored class of drugs, for example opiates, will often move to a different substance when the first drug of choice is removed, for example using Suboxone. This phenomenon is called ‘cross addiction.’
A final concern for addicts is that benzos help preserve the mistaken thought that the person cannot function without ‘taking something.’
Benzos impair driving and have the potential to impair a person working with dangerous machinery. After all, patients get anxious at work too. They also make a person appear intoxicated by causing slurred speech, forgetfulness, and sometimes ‘loopy behavior’, risking the person’s job and having other unforeseen consequences. Some people have completely different personalities when disinhibited by benzos.
Benzos have been linked to fetal anomalies and early miscarriage.
They destroy sleep in the long run through tolerance and through rebound effects. If the patient takes the benzo during the day, he/she will be trying to sleep just as the sedation is wearing off. The alternative is to take the medication at bedtime, defeating the goal of finding relief for daytime anxiety. If the person takes benzos both day and night, tolerance increases even more quickly.
I have already mentioned the need to taper off benzodiazepines and the risk of seizures and worse during withdrawal.
Benzodiazepines may calm a truly anxious patient, but they do not generally increase the patient’s function. A person who can’t get out of bed becomes less likely to get out of bed. Bills that are unpaid become even less likely to be paid. Relationships do not generally improve when one partner is nodding off as the other talks about feelings.
I do prescribe benzodiazepines, usually for the short-term or while recommending they be taken no more than every other day. Some patients do fine with them, but for others, benzos are a Pandora’s Box that should never be opened. As a psychiatrist I often resent the treatment that led to the mess that I try my best to clean up— such as the case with the first patient I mentioned. I think most doctors who read this will understand what I am saying, and many will have similar thoughts about benzodiazepines. Perhaps others will find the use of benzodiazepine much more beneficial than harmful. Comments anyone?
JJ
{ 14 comments… read them below or add one }
I was given huge amounts of Midazolam for no apparent reason when I went in for a simple surgery. The effects of this medication haven’t left me yet, 3 years later. I now have PTSD. Doctors keep telling me that Versed just couldn’t have caused this! I must have been insane to start with. Well, I sure wish I could get back to that “insanity” now. I have tried Prozac, amitriptiline, and now Lexapro. the Lexapro had me feeling more anxious than ever worrying about running out of the pills. I don’t want to be “relaxed” I want to stop obsessing over the Versed. Now I think I should ask my Dr. for Adderall. Maybe that would do the trick.
Hey what’s up doc! To start off, I was addicted to opiates and I started taking suboxone to recover. I was also suffering from a long term depression and that was probably why I was self medicating. When I started the SNRI’s my anxiety went through the roof, and it was a battle to get my doctor to believe me. I started off on cymbalta ativan and doxepin. Ativan basically did nothing for the anxiety and doxepin was for sleep. then she wanted to try wellbutrin and trazodone. The combo did not have the anticipated effect that most people have. In fact it through my concentration off and it was difficult for me to do my school work, I’m 29. Oh, and by the time I was put on wellbutrin she finally prescribed clonazepam. So clonazepam has been a constant. So after about a month and a half of the new combo i decided to switch back, but it seemed like I lost the edge that the cymbalta and doxepin gave me. So i suggested effexor and trazodone, because effexor worked for me one time and trazodone doesnt cause weight gain like doxepin. So now i am taking effexor, clonazepam, and trazodone. I do not take clonazepam to get high. I take it every morning or afternoon to keep the anxiety away, and its been like this for a year. I am actually starting to meet new people and make 15 minute friends in places like the grocery store line. Now i would not mind coming off the clonazepam. In fact I think i would like to try the effexor wellbutrin and trazodone combo. Do you think that I can keep my anxiety down with this combo? Maybe adding something that is stronger than wellbutrin because like i said, it had no effect. so what do you know of that is a potent reuptake inhibtor of dopamine that i can ask for without looking crazy? I dont mind the clonazepam, its just that i need to get active and do something. My wife says i am lazy, but i wouldnt relate that the benzo. i just need something to motivate me and wellbutrin was supposedly suppose to do that. Would a stimulant be bad to ask for? I have my own ideas, but i dont want to sound crazy when i go to my next appt. give me an idea of what might work. please
A few thoughts in random order…. Wellbutrin is indeed a dopamine reuptake blocker. It has NO benefit or anxiety, and often makes the anxiety worse. In fact, if a person tells me that he/she has ‘less nxiety’ on wellbutrin, then I don’t think they are really having ‘anxiety’– maybe something else that they are mistaking for anxiety, but not anxiety. Dopamine is released by amphetamines as well– which is one reason that stimulants like adderall cause anxiety as well. If you are truly having any anxiety, a stimulant is NOT the right medication, as it will make the anxiety worse.
In my experience, I would disagree with many of your perceptions about clonazepam. That medication has a half-life over 24 hours, meaning that it accumulates in the body over time, causing a general loss of energy and drive– making a person appear more ‘lazy’. I almost never meet a person who takes clonazepam and who also exercises. I’m not saying nobody does, but it is not very common, because clonazepam makes a person feel tired.
The effects of clonazepam are subject to tolerance and withdrawal. The withdrawal is essentially anxiety, eventually becoming so severe as to cause a seizure. People do not take it to get ‘high’; they take it because they feel anxious and uncomfortable when it wears off. When I worked at the womens’ prison it seemed that almost every new inmate was on xanax, and had become convinced that they had anxiety disorders; the women screamed bloody murder as the benzos were tapered off, but three months later they discovered that they had no anxiety anymore! Plus, they were surprised to find that they no longer had sleep problems, and they had more energy during the day.
Benzos are useful for a week or two, but for longer periods of time they often do more harm than good.
ok doc…Im going to cut my dose in half and see how that goes. My anxiety or panic attacks were a thing of the past though. I would sweat in public, especially in my back and head and the underwear area. I would find the most remote spot in dept stores and I couldn’t ever stop shaking when around people, this was clear when i had a cup in my hand. I would have to sit on them basically, and twitching occured also. But now i think that i am over the social anxiety if i can come off clonazepam. If cutting it by half is too drastic then i’ll only cut it by a quarter. How long would you say a person should wait before going to the next step in tapering off the drug?
Carlos Cardenas
Hello! I am currently writing a case study of a young woman who went into respiratory failure after taking multiple home doses of her suboxone in the ED and the ED gave her ativan to treat her “anxiety”. You note many high publicized cases regarding deaths in relation to suboxone and benzos. Where could I find out more info on these deaths? Do you know of any literature realted to this topic? I have some, but always looking for more leads. thanks,
If the clonazepam Carlos is taking for a year has a half life of 24 hours he is in deep shit trying to come off of that. He sounds like he has a true anxiety disorder or a phobea of being in public places. If the clonazepam is working for him don’t you think he should stay on?
As for the women with the 3 year old, what should she do? She has been on all the popular ssri already. What if she is telling the truth and has paic attacks anxiety eyc. She she just keep taking anti deppressants until she finds one that works?
Just exhausted myself with a 500 word comment that was totally lost after pressing submit…what a loss to the pantheon of psychiatric literature!!
I was reading your article while doing research as to why doctors avoid benzos and benzos in particular, and for the most part you are right, but that is for the general populations, you go by what you are taught and by generalizing people in one category of all drugs affects everyone the same with slight variances, I have found through self administration observing others prescribed these two medications together , research, and a few other facts, that I am a complete and utter exception to most of the things you are taught and contradict everybody elses reactions to these medications, I have add which used to be adhd as a kid but i realized how annoying i was with it and just decided better to say nothing at all than something stupid, so i went through high school as very antisocial , unmotivated slacking not doing any homework not paying any attention in class and simply just doing extremely well on tests and exams alone without studying, I will state how both medications affect me and how they affect me taken together, when i take xanax i feel a rush of just relief from all the anxiety and racing thoughts that have been consuming my mind and can have clarity in my thought, INCREASED energy, INCREASED motor skills concentration, basically the opposite of everyone else, xanax makes me better at EVERYTHING i do , from lifting weights( on xanax i can lift a decent amount more than not) , basketball, just everything, i am very glad that i can use xanax as a only partial substitute for amphetamines for my add because i despise that medication the the fullest, it is the only medication that I just have to have to reach my full potential, but taking amphetamines without benzos for me, is worse than not taking them, all i feel is increased anxiety, uncomfortability with the way im feeling, racings thoughts, and my breathing turns into so many sighs im almost breathing with them, and yes i have tried ssri srid and other non stimulant and less stimulating add meds. They dont work. I absolutely refuse to have anything to do with anti depressants due to theyre dependability and the nature or them and the fact of if you miss your dose for the day you feel like absolute hell, i miss any of my doses for benzos or amphet, I just feel like my normal self unmedicated. I have at one point used benzos recreationally younger and they affected me to a certain degree like everyone else but me and the other highly intelligent people prescribed amphet and benzos, it had no impact on memory like everyone else , I have taken 5-10 bars about 3 times a week at my peak of usage, taken ten bars with ten non light beers, have taken 8 bars with half a liter of hennessy, still walking, still functioning, but by what you are taught, i should have been dead from about half of that. Your next is thought is have fun getting off of those with that dosage you are going to have terrible withdrawal and damge to your brain and body, guess what? Cold turkey i could stop taking them whenever i pleased with not a single symptom, off of up to ten bars in one dosing, No need to take them just for fun. I have never been dependent or addicted to anything in my entire life, I quit cigarrettes cold turkey after a year and half without feeling a single craving for another cigarrette, can stop taking benzos on demand due to budgetting and accesibility and not feel any craving for them, I go back to exactly how i was before starting anything have always had bad anxiety it runs heavily in my family i am just a very self controlling individual who learned to deal with it, and i would get the occasional panic attack, and believe me it was a panic attack but unrelated to stopping cold turkey. the ONLY time i absolutely must have benzos is when i take amphetamines i cannot take them without benzos, caffiene does nothing to me i can take two 5 hour energies and go to sleep, on adderall i cannot touch caffiene, over the past year i have realized that i NEED to be prescribed amphetamines for my add i simply cannot live up to my potential in life and be all i can be without it im just lazy un motivated slacking and procrastinating and never paying attention in things im not interested in for example class. You are probably thinking, this guy needs to get bloodwork done, a physical, he has damage. I got bloodwork done, with beautiful results, im in top physical shape weighing 150 lbs and being able to bench 100 lbs above my weight. My reason for sharing this with you is STOP generalizing everybody into one category , our doctor/prescribing system is FUCKED UP. I got in for an appointment and immediately profiled as drug seeking behavior just based on my anti social quiet simply stated dimeanor and you know why? because non properly medicated, i cannot explain to him fully what i am going through i lack the mental focus and thought process and motivation to explain to him fully why he is wrong and how fucked up it is for him to do that, i cant get my proper medication legally without first being on my proper medication going into the appointment and then what, when you are openly honest and truthful? ( as i doctor i cannot just ignore the fact that your taking controlled subtances, we will try alternative routes and if you are looking for controlled substances id see another doctor) . So, the only thing im left to do is play actor and liar due to your fucked up system to legally obtain what i absolutely must have to feel NORMAL
Also to follow up that post, I am not a drug addict , I take what i should be prescribed, every single one of my friends almost have tried percocet, painkillers, cocaine, ecstacy, I have done NONE. There is no reason for me too, they are retarted and dumb, I typed up my previous post on a dose of 20mg aderrall and half a xanax bar and was actually able to explain reasoning in detail, my ideal dose needs to be 70mg of vyvanse and 4mg of xanax a day when i am on that, I feel like i should i have no problem in trying to explain things, communicate my thoughts, think my thoughts through , accomplish my goals, this dose is just the bare minimum i manage to feel partly normal, when i take xanax it does not last long whatsoever i will only feel that relief while i am dissolving it under my tongue and depending on the mg depends on how long after its dissolved i feel it for, If you have any questions dont hesitate because i am itching to have these conversations with people who have your attitude towards medicine and how I, and 18 year old self educated person with no college education can point out every flaw in your program. Also, most doctors believe amphet. and benzos. are a dangerous combination on your health due to upper and downer, if you did your research and were more educated, as the very high educated prominent doctors who believe that they are made for each other due to one taking out every single negative effect of the other, and it being perfectly safe as any of them alone you would know this instead of biasing everything on what you think and what you have been taught, my goal in posting these responses is, YOU HAVE TO KEEP AN OPEN MIND, this does not just refer to medicine and doctors, this refers to being succesful to the fullest extent in life, if you are not open minded, you have a cap on your intelligence, your enlightenment, and your success.
That was my thought process on bare minimum dosage, now if you can imagine how much deeper into it and how much better i would be able to communicate it on my full dosage , thats enough said
also by nature i tend to start out with a high tolerance and resilience to drugs, not just accumulated, I have had syrup when i was going thru the worst contagious cough, and my tolerance to the opiod codeine was higher than peopl who have used it before by never using it, i was also prescribed vic 5/500 for my thorough broken wrist which did absolutely nothing taken at maximum possible dosage per 24 hr without acetaminophen liver overtoxicity they need to ban acetaminophen period. It is a legal medicine and yet one of the most toxic for your liver and terrible for you. Our whole medicine system is extremely flawed, I would take a xanax bar instead of the vicodin, and i would feel like my wrist was normal and not broken. I am interested to hear your response to my posts.
I’ll get straight to the point, I am a 25 year old student at The Ohio State University. I take 8mg’s of Suboxone two times a day, we well as a 30mg Serax. This medication combonation is crutial to my life, without it, I may be begging you for quarters at any local street corner. The point is, these pills help me feel as “normal” as I’ve ever felt. I
have taken no less than five non-benzodiazapines (not ambien) including Buspar, Lexapro, Paxil. . . etc. . . The only drug I have taken that has worked on a regular basis, and did not cause a variety of side effects. The Serax is built up in my system to the point where I can take exactly what I’m prescribed, and feel exremely level. The reason I mention all of this is that I have been diagnosed with ADHD since the 4th grade, I have taken Adderall, Concerta and Ritalin. Now, because I find it difficult, feeling normal and comfortable from my other medications, to pay attention to anything for longer than 5 minutes. Needless to say, this won’t fly in college, so my Suboxone doctor said it would be fine if I went back to my old dose of 20mgs two times a day. This may seem like a lot of drugs, and I know you people don’t know me, but from the bottom of my heart I am honestly doing good in my life, no more constant all night drug deals, no more being a walking felony. . I have goals. . .
. . . So please email me if you have any advice, as that would be SO MUCH appreciated. . .