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PostPosted: Sat Apr 30, 2016 6:45 pm 
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Hi, my name is Mike and I was interested in getting feedback from folks who had to do battle with benzo dependency concurrently with opiates or even by themselves. I was reading a post written by a fairly new member a few days back, where she was insisting that life with bupe could only move forward if Clonazepam was part of the equation. Her reliance on Zanax(a truly evil benzo to get off of) for preventing panic attacks led her to believe that Clonopin(a longer lasting benzo) was the ticket to happiness and productivity. For me personally, 22 years of Clonopin resulted in a nervous system unable to cope with the smallest social challenges, a hypersensitivity to outide stimulus resulting in what's called "pseudopheochromocytoma" or an excess flow of neurotransmitters like adrenalin and cortisol, and an anxiety level 100 times worse than the original condition I was treated for. I think Clonopin was actually marketed as a first line drug for panic/anxiety back then, and was supposed to not have some of the addictive qualities of the shorter acting benzos like Zanax and Ativan. My experience with Clonopin was identical to that with Oxycodone, where my tolerance quickly grew to levels beyond what would be reasonable for any sane doctor to prescribe long term. Then started the monthly experience of running out early and suffering through w/d's until the next refill. After about 4 years on Clonopin I even started having in between dose withdrawals, and that was dosing 3-4times daily. Over the next ten or so years I had many failed attempts at tapering, including a two month hellish inpatient stint resulting in relapse. Part of the huge difficulty around benzo w/d's was with having the wrong expectations because of all the addiction specialists who really didn't "get" how benzo w/d's work- or rather how LONG they work. I credit a site based on the research of Dr Heather Ashton (The Ashton Manual) with saving my life AND helping me get tapered off of Clonopin once and for all. The "ah ha moment" for me was hearing Dr Ashton explain that long term use of benzos can cause "protracted withdrawals" of months to years- YES, YEARS. Reading the stories of other folks who when cold turkey'd didn't see any blue sky until the sixteenth month made me truly understand the true nastiness of this medication and the need to embark on a slow taper. I was cross addicted to opiates, I of course found opiates helped with the rebound anxiety from the Clonopin for a very short time, it took me two years to slow taper, using Diazepm as a taper med. Roughly a year and a half after completing the benzo taper I transitioned from ten yrs on/off Methadone to Suboxone. I've been benzo free since Aug of '13, and on Suboxone 4mg since Jan '15. Just in the last six months with the help of alpha blockers like Tizanidine and Clonidine, and until recently, propranolol, I have had a huge improvement in my residual benzo w/d's. Still have some really tough days but finally feel like it's worth getting up in the morning. The part that is the hardest for me to take is just how much this very common, albiet complicated co-addiction seemed to be beyond the ken of professonals supposedly specializing in addiction medicine. I remember speaking to a methadone clinic Dr about the problems I had with his expectation of benzo addicted methadone patients "just stopping" their benzo of choice because he said so, OR because he would cut them from the program otherwise. I asked him how well he thought it would work if he made the same demands of his patients with their opiate of choice- well we already know that answer-so thus the methadone. My big question was, if the standard of care for long term benzo dependency is to do a slow taper- over months NOT weeks, then why not implement such treatment, at least in the clinic setting where one can directly observe the taking of the taper med. The answer he gave was that Opiod Treatment Clinics can only dispense Methadone and Buprenorphine, nothing else. I was perplexed because this particular private sector clinic advertises that they treat ALL chemical dependency. I also undertand the enormous liability associated with prescribing benzos and opiates together, and have seen firsthand how benzos are quite often implicated in being the substance which pushes the opiate tolerant individual relapsing on opiates into respiratory depression or failure, causing injury or death. I also know the last thing anyone needs is more benzos on the street. So how do we approach humane and safe treatment of people suffering from long term dependency on opiates AND benzos? Given the protracted nature of benzo w/d's, 28 day inpatient treatment just doesn't really solve the problem either. If one could minimize the risk of diversion of the taper meds(Valium or Librium), it seems like the Buprenorhine's ceiling effect offers a good amount of safety for the benzo tolerant persons out there who want help eliminating the long term "benzo of choice" from their lives? Sorry if this is a little unorganized but I just feel like I was very, very lucky to be able to make it out the other end of benzo dep., I just think it should be easier to get from point A to point B, given how truly difficult and long the w/d's were. At the time I was finishing my benzo taper, restrictions on testng positive for them, even legally precribed ones, while in ORT have became more inflexible and absolute. Wheras I had recieved a fair amount of lattitude to complete my particular taper, this seems to be prohibited in most current treatment scenarios. There has got to be a way to get treatment for both, concurrently.
Also... really quickly I'd like to say thanks to Dr Junig and all the amazing people who take the time to share on this site, you have given me the oportunity to better understand my illness, and how to make Buprenorphine work best to support my recovery! Mike


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PostPosted: Sat Apr 30, 2016 8:33 pm 
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Mike, I'm not sure what you're asking exactly... my thoughts about benzos are best summed up here: http://patienttimes.com/twelve-problems-with-benzodiazepines/

If a person is tolerant to an opioid, then taking a benzo does not dramatically increase the risks. The problem comes when a person NOT tolerant to opioids, and NOT tolerant to benzos, combines the two meds.

Buprenorphine is almost impossible to overdose on, but overdose is possible if 1. the person has little or no opioid tolerance, AND 2. has little or no benzo tolerance, AND 3. takes both buprenorphine and a benzo. But people tolerant to a full dose of buprenorphine have about the same risk of overdose from benzos as does a person who is not taking opioids at all.

Hope that makes sense....


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PostPosted: Sun May 01, 2016 2:20 pm 
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Hi Mike, First, congratulations on all the hard work you have done to get yourself clean and while dealing with depression! AMAZING! I started to experience depression as a result of menopause and it was horrible! That and knee pain is what led me to abusing the tramadol (another drug, like klonopin that they thought to be non addictive!) and ultimately on subs. Unfortunately, the days of long term inpatient treatment are over and I really believe bringing them back would make a huge impact on the number of overdoses that happen each day in this Country! You spoke about it yourself, the length of time to resume normal brain functioning! How does any professional think a 28 day stay is enough?! Thank you so much for sharing your story! It gives people hope that cross addiction can be conquered!


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PostPosted: Sun May 01, 2016 3:10 pm 
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Wheras I had recieved a fair amount of lattitude to complete my particular taper, this seems to be prohibited in most current treatment scenarios. There has got to be a way to get treatment for both, concurrently.
Hi Mike, I do concurrent treatment if; a person realizes they have a problem with both, and agree to start tapering off the benzo's after stable on Suboxone. They must agree to taper over the next 6-8 months and that I would take over all prescribing of controlled substances. During the taper I encourage a course of CBT and usually start an SSRI. During the end of the taper may use propranolol, clonidine or gabapentin, and may add it long term if helpful. During this process they remain on a stable dose of Suboxone, I don't even discuss a taper of the Suboxone until off the benzo for several months, unless they bring it up of course.
Coming off of a benzodiazepine can be a long and difficult journey. Like opiate withdrawal, treatment programs complete the taper and discharge you when most vulnerable, and then say well, they just didn't work the program right. Fade to Pontius Pilate washing his hands.


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PostPosted: Sun May 01, 2016 5:12 pm 
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I hate having to admit this but to get treated for both addictions I decided to compartmentalize the care. Benzo taper with the psychiatrist, and continuing methadone maint. with the opiod treatment clinic. Didn't tell the psychiatrist about the Methadone, and falsified my u/a's at the clinic to hide the taper med (Diazepam). I suppose I should make sure to say that I don't recomend doing this, ever. After about 5 mos I did get tripped up by a u/a at the clinic and told them what I was doing, signed a release of info between them and the psychiatrist, and begged them to allow me to continue. They instituted a 21 day detox from my dose of 80mg. When I told my psychiatrist he was justifiably furious with me for lying to him, but then a strange thing happened... He told me that he was a methadone clinic doctor coming out of medical school and understood the catch-22 I was in. It also turned out that he was the on call doc for the very Methadone clinic I was at when the clinic dr was sick or on vacation. Of all the psychiatrists in the Seattle area, I picked the one with an existing relationhship with the clinic I was going to, what luck! So once everything settled down, agreements signed, this amazing psychiatrist called the clinic and arranged for me to stabilize at 70mgs Methadone, while continuing the supervised benzo taper. Unfortunately, they weren't doing ORT with Buprenorphine YET. It took me almost two years to complete the benzo taper using liguid titration at the end, but the outcome was success.
I asked the psychiatrist if at the outset when I was seeking help getting off the 22 years of Clonopin, I had told him about the methadone, would he have treated me? He very honestly said "no." Knowing me better and seeing me lower my benzo dose according to our schedule and doing well with the SSRI, I think, made it easier for him to keep treating me while maintained on Methadone. I was very lucky. It does frustrate me that the methadone clinic (CRC Health Group) would have no part in helping me get off benzos by means of taper, and I knew several people who were detoxed off methadone in 21 days because they had tried and failed to cold turkey off their prescribed benzos. My case was an exception to their rules, which apply now to Buprenorphine patients as well.
I am glad that there are a few docs out there familiar with and willing to help patients taper off Benzodiaepines during treatment with Suboxone, wish there were more! Given that an opiate dependent patient wants help getting through the nightmare that long term benzos are, there should be a place for them in treatment with Suboxone.


Last edited by downreg'd4now on Wed May 04, 2016 1:37 am, edited 1 time in total.

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PostPosted: Sun May 01, 2016 5:52 pm 
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I forgot to say thanks to the two doctors and Michelle F. And, docm2, your biblical reference is just so on the mark! When I left my SECOND month of residential care some aspects of my benzo w/d's were better but others were much worse, probably because they had tapered down the Subutex to zero after eight weeks on it. In 2003 this facility had just started trying it out thankfully, but there just weren't any options to continue it on the outside so they were only doing titrations with it. So when I reported having continued ACUTE withdrawals from the benzos at that time they simply told me that I wasn't fully engaged and that I was still in denial about my addictions. Completely my fault they said. That was pretty humiliating and had me worried that I had permanently damaged my brain in such a way that I would never function in society again. All those lectures and small groups are a blur of people telling me I'm just a drug seeker lying about my symptoms. The counselor for my group called me "walking detox" because I was taking Suboxone for the opiate part of my w/d's during my time there. What a hellish experience that was. cue relapses 2,3 and 4.


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PostPosted: Sun May 01, 2016 10:18 pm 
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docm2 said, "Coming off of a benzodiazepine can be a long and difficult journey. Like opiate withdrawal, treatment programs complete the taper and discharge you when most vulnerable, and then say well, they just didn't work the program right. Fade to Pontius Pilate washing his hands."

I can't tell you how much I have been railing against this practice in the discussions I have with classmates in my addiction studies graduate program!! I ask things like, "How can we just throw away the segment of addicts who aren't in compliance with their treatment program?" "Why are we OK at stopping treatment of addicts at the point of relapse when they most need our help??" "Why don't we have a safety net of harm reduction for addicts who relapse and get kicked out of their treatment program?"

I can pretty much guarantee that no one will graduate from our program with the delusion that throwing away our relapsing addicts is acceptable. They also all get an ear-full about how MAT and buprenorphine in particular is evidence-based practice. I'm definitely outspoken!

Amy

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PostPosted: Mon May 02, 2016 4:56 am 
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That's awesome Amy!! Keep up the fight!


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PostPosted: Mon May 02, 2016 2:52 pm 
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"Why don't we have a safety net of harm reduction for addicts who relapse and get kicked out of their treatment program?"

I think much of the problem is that providers perceive that we do not have a safety net, if something happens then somehow we are responsible. That has been part of the problem getting Narcan on the streets and in the hands of first responders.
It is incredibly anxiety promoting to hear of a patient's death and know that you were probably the last to have contact with them.


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PostPosted: Mon May 02, 2016 8:36 pm 
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None of what I just said was directed at sub doctors, docm2. I am complaining about the treatment industry in this country and my fellow addiction counselors. I'm talking about the abstinence only programs that will abandon an addict if they relapse. The "come back when you're ready for recovery" people. I wasn't talking about doctors who prescribe bupe.

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PostPosted: Mon May 02, 2016 9:35 pm 
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I know you didn't mean any offense nor did I take any. But as a collective group we are not willing to even come to the table to be part of the solution.
And just as there are treatment programs that drop patients 'that weren't ready' so do bup docs. When I first came here I was appalled at the section 'damn doctors/pharmacists and the stories I read there. We have a couple of folks recently come back into MAT and they don't trust me, after the way they were treated I would be wary as well. Hopefully with time we will have a good, strong relationship.
If we are going to have a safety net for people we are going to need buy in from a lot of players, and an atmosphere of trust/collaboration rather than blame.
The overdose epidemic is getting a lot of press right now, but our little slice barely rates a mention, unless it is to slam Sub.
Right now, I work with a couple of LADCs that could be Amy clones and it is great to be on their team.
keep up the good fight...


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PostPosted: Tue May 03, 2016 12:30 pm 
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From what I've read and experienced personally, the most likely time for an overdose to result in hypoxic brain injury or death is those first days or weeks of abstinence when the physical and psychological w/d's are at their worst and tolerance is low.
When the alchoholic, meth addict, benzo addict gets bumped out of treatment for whatever reason, the likleyhood of them dying from their next relapse seems much much lower than the patient addicted to opiates. I know from my inpatient experience that mastering step 1 (of AA 12 STEPS) seemed like it was a requirement for continuing participation, and those who either didn't bother faking it or suffered from complicatons of w/d's so bad that they couldn't were treated as though they were being non compliant and sometimes asked to come back when they're "serious about recovery." We all know what that could mean to the optiate dependent patient. The family of the patient recovering from opiates had breathed a collective sigh of relief when their loved one got into treatment, as if the worst of the chaos was behind them. If they only knew more about the risks of lowering tolerance and the benefits of MAT with Buprenorphine, they could make a more informed decision. The theme of abstinence only based treatment programs in particular indirectly causing harm by taking away an opiate addict's tolerance and then for whatever reason, applying principles of tough love, booting the person curbside really concerns me. No-one should be booted curbside, but of the various patients I would think the ones with the highest statistical probability of dying from their next relapse would warrant a good second look.
The first Suboxone doc I had when I moved to MN, was in the habit of firing patients after their second positive screen for opiates, saying "I'm not going to support their habits with Suboxone." She seemed to be taking cues from the DEA agent who came to the office a week earlier about wrapper counts and only prescribing Buprenorphine w/ Naloxone. She also asked her sex therpist daughter with no addiction medicine backround to come and fill the roll of drug counselor. And so suddenly one day without notice, we were forced to meet with her monthly(and pay extra) for B.S. sessions using a pamplet provided by the Reckit Benkiser rep. Her main concerns were: my $350./month, keeping the DEA happy, and committing to prescribing only Suboxone brand Buprenorphine. The "counseling" was just a wink and a nod to say she was legit, and not a pill mill. I shutter to think of sharing anything remotely personal with that insane woman, not a fun 20-30 mins. People actually got kicked off for refusing to engage with her, like they were noncompliant or something ugh. One very serious problem though, I believe her fear of the DEA was legit. That's another topic altogether I supppose- harm reduction instead of incarceration!


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Fond Du Lac Psychiatry
Dr. Jeffrey Junig, M.D., Ph.D.

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