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 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, as suggested by general clinical guidelines 1. The benzodiazepine should be tapered gradually as well, potentially switching to a longer-acting option like diazepam first.

During detox, supportive medications like clonidine for autonomic symptoms, hydroxyzine for anxiety, and trazodone for sleep may be helpful. The patient's alcohol use complicates the situation and increases seizure risk during withdrawal, making medical supervision essential, as highlighted in the management of alcohol withdrawal syndrome 1. After successful detox, the patient should transition directly to his planned IOP program with no gap in treatment.

This approach is necessary because gabapentin withdrawal can cause severe symptoms including anxiety, insomnia, pain, and seizures, especially after long-term high-dose use. Combined withdrawal from multiple substances increases risks substantially, and the patient's history suggests he may self-medicate with alcohol when withdrawal symptoms become intolerable. A primary care approach to substance misuse emphasizes the importance of medically supervised withdrawal and referral to appropriate treatment modalities 1.

Given the patient's history of relapse and the complexity of his substance use, a comprehensive treatment plan that addresses both the physical and psychological aspects of his addiction is crucial. The plan should include close monitoring, supportive medications, and a gradual tapering of both gabapentin and benzodiazepine, with the goal of minimizing withdrawal symptoms and preventing complications.

Key considerations in the treatment plan include:

• Medically supervised detoxification to manage withdrawal symptoms and prevent complications
• Gradual tapering of gabapentin and benzodiazepine to minimize withdrawal symptoms
• Use of supportive medications like clonidine, hydroxyzine, and trazodone to manage autonomic symptoms, anxiety, and sleep disturbances
• Close monitoring of the patient's condition and adjustment of the treatment plan as needed
• Transition to an IOP program after successful detox to provide ongoing support and treatment for addiction.

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 Withdrawal and Dependence

• 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 of gabapentin, described as "worse than heroin", is consistent with the findings of studies that highlight the potential for gabapentin dependence and withdrawal 4, 5.
• The use of benzodiazepines to manage gabapentin withdrawal symptoms, as in the patient's case, is not uncommon, but it may not always be effective in alleviating symptoms 6.

Tapering Gabapentin

• A slow and patient-centered tapering approach, such as the BRAVO Protocol, may be necessary to minimize withdrawal symptoms and ensure a successful taper 4.
• The BRAVO Protocol, originally developed for opioids and adapted for benzodiazepines, provides a framework for tapering gabapentin in patients with severe dependence and withdrawal 4.
• The patient's experience of relapsing on alcohol 5-6 times since being given 1mg of benzodiazepine suggests that a more gradual tapering approach may be necessary to prevent relapse and minimize withdrawal symptoms.

Detoxification and Treatment

• The patient's request to detox from 1mg of benzodiazepine and gabapentin before continuing with intensive outpatient treatment (IOP) elsewhere may be a reasonable approach, given the potential risks associated with benzodiazepine and gabapentin withdrawal 7, 3.
• However, the decision to detox the patient from benzodiazepine and gabapentin should be made on a case-by-case basis, taking into account the patient's medical history, substance abuse history, and current symptoms 3, 6.
• The patient's history of alcohol use disorder and recent drinking episodes may require careful consideration and monitoring during the detoxification process 7, 3.