What is the best approach for a patient experiencing severe withdrawal symptoms from gabapentin (Neurontin) and requiring benzodiazepines (1mg) to manage symptoms, who has relapsed into alcohol use multiple times and is seeking detoxification from both medications?

From the Guidelines

I strongly recommend a medically supervised detoxification program for this patient due to the complexity of his situation involving gabapentin withdrawal, benzodiazepine dependence, and alcohol relapse. The patient's history of severe withdrawal symptoms, described as "worse than heroin," and his recent relapses on alcohol, indicate a high risk of complications during withdrawal, including severe anxiety, insomnia, and potentially life-threatening seizures 1.

Key Considerations

• The patient should be admitted to a detox facility where both the gabapentin and benzodiazepine can be tapered under close monitoring.
• For gabapentin, a slower taper than previously attempted would be appropriate, perhaps reducing by 300mg every 7-10 days.
• The benzodiazepine should be tapered gradually as well, potentially switching to a longer-acting option like diazepam first, then reducing by 10-15% every 1-2 weeks, as suggested by studies on benzodiazepine tapering 1.
• During this process, adjunctive medications like clonidine for autonomic symptoms, hydroxyzine for anxiety, and trazodone for sleep may be helpful.

Importance of Medical Supervision

The patient's alcohol use complicates the situation and increases seizure risk during withdrawal, making medical supervision essential. After successful detoxification, the patient should transition directly to his planned IOP program with no gap in treatment. This approach is necessary because simultaneous withdrawal from gabapentin, benzodiazepines, and alcohol carries significant risks, including severe anxiety, insomnia, and potentially life-threatening seizures 1.

Additional Recommendations

• The patient's mental health should be screened, and primary comorbid mental health disorders can be treated with standard psychological and pharmacologic therapies 1.
• Referral resources for patients with substance use disorders, such as mutual help meetings, medically supervised withdrawal, outpatient treatment, and residential treatment, should be considered based on the patient's needs and characteristics 1.

From the FDA Drug Label

Drug Abuse and Dependence 9.1 Controlled Substance Gabapentin is not a scheduled drug. 9. 2 Abuse Gabapentin does not exhibit affinity for benzodiazepine, opiate (mu, delta or kappa), or cannabinoid 1 receptor sites. A small number of postmarketing cases report gabapentin misuse and abuse. These individuals were taking higher than recommended doses of gabapentin for unapproved uses Most of the individuals described in these reports had a history of poly-substance abuse or used gabapentin to relieve symptoms of withdrawal from other substances. When prescribing gabapentin carefully evaluate patients for a history of drug abuse and observe them for signs and symptoms of gabapentin misuse or abuse (e. g. development of tolerance, self-dose escalation, and drug-seeking behavior). 9. 3 Dependence There are rare postmarketing reports of individuals experiencing withdrawal symptoms shortly after discontinuing higher than recommended doses of gabapentin used to treat illnesses for which the drug is not approved. Such symptoms included agitation, disorientation and confusion after suddenly discontinuing gabapentin that resolved after restarting gabapentin Most of these individuals had a history of poly-substance abuse or used gabapentin to relieve symptoms of withdrawal from other substances. The dependence and abuse potential of gabapentin has not been evaluated in human studies.

The patient is experiencing withdrawal symptoms from gabapentin, which is consistent with the rare postmarketing reports described in the drug label 2.

• The symptoms include agitation, disorientation, and confusion, which are similar to those reported in the label.
• The patient's history of poly-substance abuse and use of gabapentin to relieve symptoms of withdrawal from other substances may contribute to the development of dependence and withdrawal symptoms.
• The label recommends careful evaluation of patients for a history of drug abuse and observation for signs and symptoms of gabapentin misuse or abuse.
• Given the patient's experience with withdrawal symptoms and history of substance abuse, it is essential to approach the situation with caution and consider a gradual tapering of the medication under close medical supervision.
• The patient's request to detox from gabapentin and benzodiazepines should be evaluated on a case-by-case basis, taking into account their medical history, current symptoms, and potential risks associated with withdrawal.

From the Research

Gabapentin Dependence and Withdrawal

• Gabapentin has been reported to cause severe physiologic dependence and withdrawal, especially in patients with a history of substance abuse 3.
• The patient's experience of withdrawal symptoms when tapering down from 3600mg to 2400mg, described as "worse than heroin", is consistent with the reported cases of gabapentin withdrawal syndrome 4.
• A slow taper plan, such as the BRAVO Protocol, may be necessary to manage gabapentin dependence and withdrawal 5.

Benzodiazepine Use and Detox

• The patient's use of 1mg benzo to manage withdrawal symptoms, and subsequent relapses on alcohol, highlights the complexity of managing gabapentin withdrawal and co-occurring substance use disorders 6, 7.
• There is limited evidence to support the use of gabapentin as a replacement for benzodiazepines in the treatment of acute alcohol withdrawal syndrome, and more research is needed to determine the effectiveness of gabapentin in this context 6, 7.

Treatment and Detox Options

• Given the patient's history of substance abuse and current use of benzos, it is likely that detox authorization would not be given without a comprehensive treatment plan in place.
• Residential treatment (RTC) may be a suitable option for the patient, considering their recent drinking and struggles with benzo use.
• A patient-centered approach, incorporating a slow taper plan and addressing co-occurring substance use disorders, may be necessary to support the patient's recovery 5, 3.