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PostPosted: Fri Apr 21, 2017 3:25 pm 
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I have been on suboxone successfully without a relapse since October 2013 with the same doctor, who also kept me on my klonopin, which i've been on for years.

in november 2016, i went to see my doctor for my monthly visit and he told me the FDA had issued a black box warning on taking benzodiazipines and opiates/opioids simultaneously and told me i had to choose one drug or the other to start tapering off of, and said if he got audited, they'd look at his files. he also said he only had three patients who took both subs and benzos, and i was one of them.

i told him i wanted to detox from the suboxone since my insurance doesn't cover it and i pay $200 a month to see him for the prescription that costs me $7/strip with the discount card, and also because i always thought the end goal of being on sub treatment was to detox. i asked him what he thought and he said, "i think with your history of addiction, you'll always need to be on some sort of opiate," but he said the choice was mine. I'll point out here that of course, he makes his money from prescribing me subs; any psychiatrist can write me for anxiety meds (i also take paxil and remeron).

so since november, i have been slowly tapering my suboxone dose, and i'm down to one strip a day. yesterday, i go in to see my doctor and he admits, first off, that he had some kind of allergic reaction, had taken a benadryl and was very sleepy and he was talking funny and acting sort of odd. then at the end of my appointment, he said, "how about we take your klonopin down from 2mgs twice a day to 1mg three times a day?" and i said i already had started and was prepared to continue my suboxone taper, but he just acted like he didn't hear me and said, "you won't even notice it" (referring to the change in my klonopin dose).

First off, I looked up the black box warning back in november when he first told me about it, and it was issued in August 2016, yet he didn't say anything until november, and emphasized it was important to show we were doing something in case he got audited. when i returned for my appointment in december, he conveniently claimed he'd been audited by the DEA since i last saw him.

Secondly, although i know doctors are cracking down on benzos and opiates, the black box warning doesn't say you have to be forced to choose which disease to treat. i have several other friends who are on both benzos and subs and NONE of them have said their doctor has forced them to detox or stop taking one or the other. One friend who just got out of rehab said her doctor "advised" her to not take both together or at least take small doses. but there is a BIG difference between "advise" and forcing a patient to choose which drug to stay on.

is anyone else experiencing this kind of trouble? i'd also point out, and my doctor did agree, that at one point earlier in my treatment he tried to change my klonopin dose and i tried to taper, but i ended up using xanax i got from a friend, tested positive for it at a visit and he returned me to the dose I was on.

i've had anxiety since i was a child and i've been on the same dose of klonopin for longer than i've been on suboxone. i was told i had to choose which one to keep taking, and i told him in november i wanted to try to taper off the subs, but yesterday he just changed up my klonopin dose and kept my sub scrip at 1 strip a day.

what is happening?? am i now detoxing off both or not? i'm totally unclear and also upset because none of my other friends who take both meds have been told they have to choose. i'm aware of the dangers, etc., but i don't drink, i haven't relapsed and i was on methadone for 7 years before ever getting onto subs and i was always able to stay on my klonopin even when going to the methadone clinic.

i was going to call the FDA general number and ask, but thought I'd check online first. also, i'm curious if my doctor was really audited less than a month after saying this to me, and finding out if those records are public...?

is anyone else experiencing the same issues??


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PostPosted: Fri Apr 21, 2017 6:23 pm 
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If you have a tolerance to benzos and to opiates you are not at increased risk of dropping over dead. Perhaps the FDA has been watching your doctor or he or she has done something questionable with another patient. I ran into this problem when I first went on suboxone years ago. The doctor said "no klonipin." I told him that we would have to agree to disagree on that one. To my surprise he never said a word about it again. You are stable so you need to advocate for yourself. If you cannot work with this doctor, you may need to switch doctors.
I assume that you are young. Benzos are more dangerous for seniors to take due to increased falls and also an increased risk for dementia. I hope that you are working with a therapist and learning how to manage your anxiety without pharmaceuticals. Best of luck, and please do not take my comment as critical.


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PostPosted: Fri Apr 21, 2017 6:30 pm 
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hey madrina81,

Welcome here. The Dr that owns and runs this site, Dr J, has often written there is NO issue w benzos and bup as long as the patient is not benzo naïve AND bup naïve, meaning not new to both, which you are not. Some Drs, tho seems very few anymore, still allow benzos and bup together but most don't bc of the lumping in of bup, a partial agonist w ALL full agonist opiates meaning the black box warning and full on press releases not to allow opiates and benzos together. Full agonist opiates DO have respiratory depression/arrest w taking a benzo. Seems like your Dr is set on reducing your Klonopin, especially given his audit comments. Maybe he is trying to force you to see if you can handle low to none on it thinking its better for you to stay on bup, IDK
Hopefully others will stop by, clarify and help out!
Spend some time digging around here on this. i can't search well from my current device to post links but lots has been written here on it. Best to you today, P
yes, agree w jeandianne! Nice post.

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PostPosted: Sat Apr 22, 2017 11:41 am 
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So far we have not heard of a FDA Black Box Warning regarding Suboxone mixed with benzodiazepines. Like Pelican said, it really isn't a problem if you're adjusted to both and doing well. Do some research about what he is talking about. Normally, we hear about that kind of rule change here first.

Some deeper discussion is in order and maybe you should look for another Suboxone doctor if you feel it's not the time to taper off either drug.

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PostPosted: Sat Apr 22, 2017 11:50 am 
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Hi, I have scripts for Suboxone and Ativan ( a benzo). Black box warning is on the benzo and not the opiate. Actually, my last script of hydrocodone in December- same thing- no warning on hydro, but on benzo. Weird, but that may be why it hasn't come up on the forum.


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PostPosted: Sat Apr 22, 2017 12:55 pm 
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Hey all.

Epocrates shows drug monographs and is a part of a larger co that offers electronic health servcies.
If you check on epocrates, there is no black box warning for Suboxone, Bunavail, Zubsolv, which are brand Bup/nal products approved for opioid dependence. It says 'This information is currently unavailable or not applicable for this drug.'
But it you check Butrans and Belbuca, brand bup only products approved for pain management, there is a warning. These are much smaller doses than the opioid dependency meds. Also is a warning for buprenorphine. It says 'Risks from Concomitant Use w/ Benzodiazepines, CNS Depressants. Concomitant opioid use w/ benzodiazepines or other CNS depressants, incl. alcohol, may result in profound sedation, resp. depression, coma, and death; reserve concomitant use for pts w/ inadequate alternative tx options; limit to minimum required dosage and duration; monitor pts for s/sx of resp. depression and sedation'

IDK, can't explain... P

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PostPosted: Sat Apr 22, 2017 2:07 pm 
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Posted this in January

Quote:
MN Medicaid has taken the next step based on the black box warnings against opiates and benzo's. They denied the PA for Suboxone because the patient is on Ativan. In the midst of a long taper, she started from 8 mg a day and is now down to .5 twice a day, (the Ativan, not the Suboxone.) Of course they denied the Suboxone and not the Ativan. Two appeals and a detailed taper plan was finally approved. Bottom line, I think we will be seeing more of this in the future.


My other two patients that are on a benzo have since received notice that both will no longer be covered. One has commercial insurance so they purchase the Ativan. The other is on a state plan so in her final month of a Klonopin taper.

I think if you are on both you should be making contingency plans to get off one of them. In my view any anxiety disorder is better treated with CBT or an SSRI anyway. So I don't advocate very strongly to continue.
I am not set against Buprenorphine and Benzo's. I actively try to get all patients referred to me off the Benzodiazepine and into an effective therapy. Some stay with me, some move on.
For the past year any patient starting a buprenorphine product and is also on a benzo we set up a taper with the goal to be off in 3-6 months. If not agreed to then we don't initiate therapy and refer them to a comprehensive inpatient center.


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PostPosted: Sat Apr 22, 2017 3:20 pm 
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Afternoon
I have never heard of any of these new regulations. I was on suboxone 4 to 6mg for 6 months and quit 12 days ago ! At the time i was getting my subs i also had a small script for Valium ~ i get from my ENT surgeon for i have terrible Tinnitus in my ears. I do not take the Valium everyday ~ but believe me i have been using it on and off for RLS ~ when i quit the subs almost two weeks ago.

My question to you guys is ~ is this black box or blockade you are talking about just restricted to Dr's that are prescribing both meds to you ? In my case i have two Dr's ~ one sub and another a ENT surgeon for my Tinnitus and Cancer. I only get like 8 valiums a month for bad tinnitus night ~ they are 5 mg so i brake them in half and stretch them out. I do not want a benzo habit ~ they say those are brutal to kick and not a thing to do at home. (impatient) Are the feds coming down on individual Dr's that are prescribing both ? only. I know that the last 7 months my sub dr urine tested me every 2 weeks and the V would show up ~ i guess Benzos stay in system long time ~ Sub dr would give me a hard time about it ~ but i would tell him "it is not your area to interfere ~ "Im getting them from my ENT Surgeon ~ who actually just operated on my esophagus and throat for cancer ~ so it is none of your business." Believe me my Surgeon and Oncologist have a little more weight in my care presently. And now that i have stopped Subs ~ no more urine test when i go see my sub Dr this Monday !! For i am not in his subox program anymore. I just want to go back and talk to him about some other issues ~ for he is a psych dr ~ it just wont be about Suboxne ~ that stuff i will never take again !

My assumption or hypothetical guess would be that benzodiazapines are not a real safe mixture with any type of opiates. Maybe "Doc Suboxone" can shed some light on this. Benzo's in the wrong hands can be lethal. Are they not both respiratory depressants ? Maybe that is why ? I do not know ~ i am not a Dr ~ that is why i am asking these questions.

With all the opiate deaths occurring ~ absolutely staggering amount of deaths ~ maybe the feds are just trying to alleviate cocktails of medications handed out by dr's to save lives. I do not know ~ can anyone shed any lite on this for me ?

Hawthorne


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PostPosted: Sat Apr 22, 2017 6:31 pm 
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I really appreciate all y'all's input on this. I am not surprised so few people have heard of this! Like I say, I have multiple friends on both benzos and subs and their docs are not forcing a detox of EITHER, yet my dr started a sub detox in November and then this week started a Klonopin detox after asking me which I wanted to taper off of, and I said the subs. He is directly contradicting what I said. And I have been his patient since October 2013 and he's just now saying something about it.

I have been on benzos (not every day, just PRN) for years for anxiety and the subs for 3.5 years and no problems until he started forcing me to choose a detox, then changed what drug I was going to dt from himself despite my very vocal choice I would taper off suboxone.

What is this about the black box warning NOT applying to suboxone but only benzos? Anyone know more? Are there any links you can share that I can take to my doc?


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PostPosted: Sat Apr 22, 2017 8:44 pm 
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Hi Madrina,
Just to clarify, I was making a guess based on my experience in the past few months. There is a black box warning on the Ativan i last got in January. There was no warning for either hydrocodone, which I last got in December, or Suboxone which I last filled at the start of April. I have no official information. I do think it is weird that it's on my benzo and not opiate. No idea why that has happened.


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PostPosted: Sat Apr 22, 2017 10:25 pm 
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Madrina, lots of info here that you can follow up w. I encourage you to reread and reread posts here on your thread. And then search for yourself. That's where the real learning is for some some. No, its NOT new to learn on no bup w benzos, it's common. Been going on for a long awhile. Seems many Drs don't like benzos -- for many reasons -- including benzos aren't a good long term med.

Apologies -- I meant to come back and clarify my comments, its my understanding that Dr J says bup and benzos are not a problem bc bup has a safe respiratory ceiling and bup should not be lumped in w the respiratory depression and arrest on full agonists. BUT, from my reading, I know he thinks benzos aren't a good long term med which is totally separate. Just bc Bup is safe w benzos does not mean a benzo can and should be prescribed. Search his posts here. He doesn't like benzos. And on Talkzone on the top menu. docm2 is a practicing addiction physician and his posts are highly valued here. If he is not comfortable prescribing both, and separately, his state now has rules prohibiting benzos and bup for medicaid -- think about it -- your Dr says no, another Dr here says no, his state says no, I think Dr J says no, some Insurers are saying no, the The FDA is sorta saying no... Folks come here and tell us their Dr's won't accept benzos and bup and UA test for both. A few come here and as rule and jennjenn will say, some Dr's allow it - for now or for how long? I'm thinking the tide has turned and benzos and bup is going to be seen far less... You can try to show no current black box for suboxone, as I found today, but my point was other bup products w far lower doses than suboxone DO have the black box warning so its maybe just a matter of a short time... Plus, imo, any Dr that mentions the DEA coming in, ya, that's powerful and motivating... Imo, if you are set on both, then switch to the Dr's your friends are certain have no issues w both.

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PostPosted: Sun Apr 23, 2017 2:43 am 
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Hi. Also, a black box warning is the strongest warning the FDA gives regarding serious, often life threatening risks. It is called "black box" because the information is literally inside of a black box. These warnings require drug manufacturers to put the warning on the medication. It is a recommendation, and doctors can use their discretion to decide if the benefits outweigh the risks. So, some doctors will probably continue prescribing both medications for certain individuals. Some doctors will probably have policies like your Doctor- no prescribing of both, no exceptions.

My point is that it is a strong recommendation, but not a regulation, or a law (at least no now). Like Pelican said, you can probably find a doctor that will prescribe both (at least now). But, it may be worth considering that gradually fewer and fewer doctors will prescribe both and at some point you wouldn't be able to take both. And benzos are falling out of favor because of how quickly people become dependent or addicted, and the danger in combining them with opiates or alcohol. It may be worth considering the benefits of tapering your benzo. Just a suggestion. Good luck!


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PostPosted: Sun Apr 23, 2017 2:16 pm 
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Many good answers. Tragicom sums it up nicely.

As noted already, there is no black box warning on buprenorphine drugs used for opioid use disorder. But there is on plain buprenorphine and low-dose buprenorphine, as well as on benzodiazepines:

Risks from Concomitant Opioid Use

concomitant benzodiazepine use w/ opioids may result in profound sedation, resp. depression, coma, and death; reserve concomitant use for pts w/ inadequate alternative tx options; limit to minimum required dosage and duration; monitor pts for s/sx of resp. depression and sedation


But as pointed out, this is not a 'ban'; it is a recommendation. But insurers will surely use it, as they always do, to deny covering whatever they can get out of covering.

I am no fan of benzos; I think that in most cases people only get worse on them, as I've written here:http://patienttimes.com/twelve-problems-with-benzodiazepines/

But once tolerant to buprenorphine, there is little or no risk from taking a benzo that one is also tolerant to. But unfortunately, that fact is too complex for most lawmakers to understand-- so there will be more and more regulations that impact benzodiazepines. One thing to realize-- benzos have no friends in medicine. There is nobody out there interested in supporting their use. Many patients believe that they need them, but those experiences are not shared by doctors-- not even by the doctors of the patients who think they need them!

AATOD, the American Association for the Treatment of Opioid Dependence, just issue official guidelines about the use of benzos in patients receiving treatment with methadone or buprenorphine. Those guidelines will likely impact practice patterns. You can find the guidelines here: http://www.aatod.org/guidelines-for-addressing-benzodiazepine-use-in-opioid-treatment-programs-otps/


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PostPosted: Mon May 01, 2017 6:26 pm 
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I really appreciate all the comments.

So to be clear: the "black box warning" is on benzos, not suboxone? I have a really slow computer at home and can't easily look things up.

Medicaid does not cover my doctor visits, my subs or my klonopin, so I don't see how Medicaid is playing a role here. This is coming from my doc.

I have been on benzos for years counting AS NEEDED and subs now 1 strip daily but as stated, my dr appears to be the only one in my area actually making his patients choose. I chose subs, since I always thought I'd be detoxed off those.

Now he's decided to take down my klonopin dose "to make the feds happy" (and I literally quote).

Is there a way to find out if my dr was actually audited within 30 days of telling me about the "black box warning" to see if he was detoxing his 3-4 patients who were on boths subs and benzos?

Also: He pointed out he thought I made a good choice in that when he tried to take me off my klonopin before, I tested positive for illicit xanax and he put me back on. So why the decision to take me off the anxiety meds I've been on for probably 10 years when I just started suboxone three and a half years ago?

thoughts?


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