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PostPosted: Sat Sep 15, 2012 1:21 am 
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I found an older post thread on a similar issue when I was Googling, but thought I should post a new one with my specific questions and background.

About 3 weeks ago, I found out my 16 year old daughter had become a heroin addict. Fortunately she had gone to a school counselor herself and actually wanted help. After intensive research and exploring all options, we found a suboxone doctor and she has successfully been on that treatment for just over 2 weeks now. Everyone has been impressed with her progress and ability to get on with life overall.

However, here's the big question/issue at this point: About a year ago, our family doctor prescribed ativan for her, specifying it should be "for occasional use" as a remedy for insomnia and anxiety. She went to stay with her dad over the summer and while there took 2-3 mg on average of the ativan a day and basically got hooked.

I have now been told and read a lot of differing info on the combination of suboxone and ativan, including from doctors(!). We switched suboxone doctors because I found one that took my insurance (and had been paying the first out of pocket to get it going).
The first psychiatrist that started her on it said that low doses of ativan would be OK while starting the suboxone treatment.
The second one said he just moved here from a place where he worked in a clinic where they will not give suboxone to anyone taking ANY kind of benzos. He insisted she stop cold turkey on the ativan. He gave her trazadone for sleeping.

It had been 5 days without the ativan and even though she was fine getting through her day, it seems that, like clock work, at the time in the evening that she normally took her ativan, she had an increasingly bad episode of screaming, depression, and anxiety. After the worst episode, I made the executive decision to give her 1mg of ativan at that usual time. We are on day 3 of this regime and I am nervous about it, especially since her current doctor doesn't approve and people talk about the dangers of mixing the two, but it seems to be the best plan I can think of.
Our plan is to try tapering the ativan, probably with 1mg for a week and then half each week, etc. which is what I've seen as a plan used by a lot of folks.

Everyone says "talk to your doctor" but what to do when doctors have different opinions?
Beside the obvious goal of becoming addiction free (including to the ativan), I know the two drugs are CNS depressants and the danger is in stopped breathing. Of course I want to minimize any risk to my daughter, but I also need to help her get through this and the cold turkey on the ativan just didn't seem to be a good thing and potentially just as dangerous in other ways. I wonder if at this point of seeing her do fine with both (she takes 16mg (two film strips) of subox in the morning and the 1mg of ativan at night) is an indication that we don't need to worry at this point, or if the danger is in doing both over time. She has been doing well in school and doing chores and all in all in a fine space in the day time, and with the 1mg ativan she seems to be OK at night too which feels like a relief.

Any other info, warnings, experiences, or opinions are welcomed.


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PostPosted: Sat Sep 15, 2012 4:26 am 
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Hello,

Here is a quote from dr junig about benzos + suboxone.

suboxdoc wrote:
It makes me feel so useful when I come across a question I can answer! There are two considerations as I see it—the bupe/benzo interaction issue, and the ‘benzo/addiction’ issue. On the first issue, there is nothing special about buprenorphine that makes it lethal with benzos. You are always safer mixing a partial agonist like buprenorphine with a benzo than you are mixing a full agonist like oxycodone with a benzo. Realize, though, that Suboxone has a HUGE dose of buprenorphine in it- I encourage thinking in ‘micrograms’, as the potency is in micrograms. Buprenorphine is potent at 5-10 micrograms, and one tab of Suboxone contains 8000 micrograms! Even so, I don’t think a person could die from buprenorphine alone, even if the person has no tolerance to it at all—he/she would need to mix in another respiratory depressant to have fatal effects. If an opiate-naïve person takes 8 mg of Suboxone, he will puke all night but won’t die—unless he takes a bunch of Xanax. If that some opiate-naïve person takes 30 mg of methadone, he MIGHT die even without the Xanax, and almost certainly would WITH the Xanax. You need two things to die from buprenorphine--- first, you cannot be completely tolerant to the effects, and second, you need a second respiratory depressant. With an agonist you don’t need the second one.

A couple points related to this issue--- benzos and alcohol are interchangeable. They bind to different subunits of the same (gaba) receptor, so taking Xanax is like drinking a shot. BOTH are respiratory depressants.

The other thing is that once a patient is ‘stable’ on buprenorphine/Suboxone, and is not getting a ‘buzz’ from it, the risk from benzos essentially goes away. Once tolerant to a ceiling dose, I doubt a person could die from buprenorphine even with a second respiratory depressant—at least not any easier than from the other substance alone.

The other issue is more difficult. I do prescribe benzos for my patients on Suboxone in some cases, but it always makes me cringe a bit. The treatment of choice for all forms of anxiety is an SSRI or SNRI, not a benzo… benzos are good for the short-term, but long-term their effectiveness goes away and the person gets stuck in a cycle where there is anxiety from the ‘mini-withdrawal’ from the benzo that the patients thinks is HIS anxiety. He then needs to take another benzo for THAT anxiety—that he wouldn’t even have if he wasn’t taking anything. It isn’t the patient’s ‘fault’—it is just how addiction works. People want them SO badly sometimes that I feel bad if I don’t give in… but if I know that it would be a disservice, I can’t go along with it. My recommendation is for people with any addictions to avoid benzos if at all possible; first use an SSRI or SNRI; consider a beta blocker, consider Seroquel, consider remeron… if you DO need a benzo, try to avoid daily use (as that causes tolerance). And use it only for the worst episodes—that way it will keep working for you.


This is the whole thread: http://suboxforum.com/viewtopic.php?t=79

-gb


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PostPosted: Sat Sep 15, 2012 5:58 am 
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Hi and welcome to the forum. You got an excellent, comprehensive answer to this by glen bee (and Dr. Junig). In summary, benzos are safe with suboxone IF and only IF they are taken as directed and IF the person is tolerant to both medications. That's the long and short of it, as I understand it.

As for you taking it upon yourself to try and wean her off the ativan, well, I sure don't blame you for that. From the sounds of it, she's suffering withdrawals from the ativan and her doctor isn't being very responsible taking her off it cold turkey. (Although Trazodone is generally fine for sleep.) She should be tapered off that medication, in my opinion.

I wish you and she the very best. Let us know how she's doing.

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PostPosted: Sat Sep 15, 2012 11:28 am 
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Thanks for the response.
So is is switching to an SSRI abruptly another option, or one still should wean off the ativan?


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PostPosted: Sat Sep 15, 2012 4:31 pm 
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I would say wean off the Ativan. Switching to an ssri will not stop the Ativan withdrawal.


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PostPosted: Sun Sep 16, 2012 7:40 am 
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In my nonmedical opinion, keep weaning her off the Ativan, but you can also add an SSRI, if another doctor is willing to do that. They are completely separate types of meds. Again, good luck. I really hope you both get through this successfully. Keep posting if you need to.

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PostPosted: Sun Sep 16, 2012 8:13 am 
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I wouldn't be too worried about the Suboxone / Ativan thing. Even some people on high doses of methadone have been prescribed benzos, and it's ..okay.. as long as they're tolerant to both. When a patient comes into a doctor hooked on both high doses of heroin and benzos, what's a doc gunna do? Sometimes it's more dangerous to take away the benzos cold turkey than to keep prescribing them while on a drug like Sub, or even methadone.

It's possible your daughter's getting really worked up at the same time in the evening because that's the time most of the Ativan has left her body, and her benzo withdrawal is starting to kick-in. I've had a couple of periods hooked on benzos which I've been lucky to escape from. And the anxiety that kicks-in when the withdrawals start is really hard to deal with. I was living with family at the time, and my anger and intensity when I was craving Xanax or Valium was so much they'd often give me a Valium to keep me calm.


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PostPosted: Mon Oct 01, 2012 3:44 pm 
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ive been on bupe and benzos for over 3 years and i didnt have any problems.


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PostPosted: Sun Jan 13, 2013 11:44 am 
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I take 6 mg of Clonazepam a day with 24 mg of bupe and it doesn't effect me at all 1 mg of ativan will not hurt you're daughter.


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PostPosted: Mon Jan 21, 2013 5:44 pm 
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Ativan or Lorazepam from what I have heard is the most addictive benzo out of all of them. I believe in the UK they just enacted prescribing restrictions for physicians allowing them to prescribe ativan for no longer then 4 weeks. This is not to say there are no benefits to taking ativan, only that it should be prescribed for very short treatments/terms.

weening is the best way. I have heard of doctors switching a patient over to diazepam or valium then ween off of the valium which I hear is a lot easier then ativan. going Cold turkey though is not a good idea and not recommended.

I hope things work out and good luck.

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

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