Is it negligent to prescribe benzodiazepines (Benzodiazepines) along with cannabis?

Prescribing Benzodiazepines with Cannabis: Clinical Risk Assessment

Prescribing benzodiazepines along with cannabis is potentially negligent due to the significant risk of respiratory depression, increased mortality, and central nervous system depression when these substances are used concurrently. 1

Risks of Co-Prescribing Benzodiazepines and Cannabis

Central Nervous System Depression

• Both benzodiazepines and cannabis cause central nervous system depression, which can lead to:
  • Respiratory depression
  • Excessive sedation
  • Impaired cognition and motor function
  • Increased risk of falls, especially in elderly patients

Mortality Risk

• While benzodiazepines are relatively safe when prescribed alone, there is increased mortality when combined with other central nervous system depressants 1
• Similar to the documented dangers of benzodiazepine-opioid combinations, cannabis can potentiate the sedative effects of benzodiazepines

Clinical Guidelines

• The CDC Clinical Practice Guideline (2022) explicitly recommends avoiding concurrent use of benzodiazepines with other central nervous system depressants whenever possible 1
• The 2016 CDC Guideline states: "Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible" - this principle extends to other CNS depressants like cannabis 1

Decision-Making Algorithm

1. Assess necessity of benzodiazepines:

   • Determine if evidence-based alternatives to benzodiazepines have been tried first
   • Consider if the patient has a legitimate indication for benzodiazepines that cannot be managed with safer alternatives

2. Evaluate cannabis use:

   • Is the cannabis medically prescribed or recreational?
   • What is the frequency, dose, and THC/CBD content?
   • What is the patient's purpose for using cannabis?

3. Risk stratification:

   • High risk: Elderly patients, history of substance use disorders, respiratory conditions
   • Moderate risk: Concurrent use of other sedating medications
   • Lower risk: Occasional cannabis use with low-dose benzodiazepines

4. Decision point:

   • If patient requires both medications, consider:
     • Reducing benzodiazepine dose
     • Recommending CBD-dominant cannabis with minimal THC
     • More frequent monitoring
     • Providing naloxone for overdose risk

Alternative Management Strategies

For Anxiety Management

• First-line: Evidence-based psychotherapies (CBT), SSRIs/SNRIs
• Second-line: Buspirone, certain antidepressants, pregabalin
• Non-pharmacological: Mindfulness, exercise, relaxation techniques

For Sleep Management

• First-line: Sleep hygiene education, CBT for insomnia
• Second-line: Low-dose trazodone, certain antidepressants
• Non-pharmacological: Melatonin, relaxation techniques

Tapering Considerations

If a patient is already on both benzodiazepines and cannabis:

• Consider tapering benzodiazepines gradually (10% reduction per month, slowing to 5% at lower doses) 2
• Weekly monitoring for withdrawal symptoms during tapering
• Adjunctive medications to manage withdrawal symptoms may include:
  • α2-Agonists (clonidine)
  • Gabapentin for anxiety and insomnia
  • Trazodone for sleep disturbances 2

Research on Cannabis and Benzodiazepines

There are conflicting findings regarding cannabis as an alternative to benzodiazepines:

• One retrospective study found 45.2% of patients discontinued benzodiazepines after starting medical cannabis therapy 3
• However, a more recent propensity score matched cohort study from 2024 found that "medical cannabis authorization had minimal effects on benzodiazepine use" 4

Clinical Pitfalls to Avoid

• Underestimating risk: The combination may seem benign but carries significant risk of respiratory depression
• Assuming patient disclosure: Patients may not disclose cannabis use; direct questioning is necessary
• Inadequate monitoring: Patients on both substances require more frequent follow-up
• Abrupt discontinuation: Never abruptly stop benzodiazepines as this can lead to severe withdrawal including seizures and delirium tremens 1
• Ignoring drug interactions: Cannabis may affect metabolism of benzodiazepines through cytochrome P450 pathways

Documentation Requirements

When prescribing benzodiazepines to patients using cannabis, documentation should include:

• Rationale for concurrent use despite risks
• Evidence that safer alternatives were considered
• Risk-benefit discussion with patient
• Monitoring plan with specific follow-up intervals
• Exit strategy (tapering plan)

In conclusion, while there may be individual cases where benefits outweigh risks, the standard of care generally discourages concurrent use of benzodiazepines and cannabis due to the significant risks of respiratory depression and increased mortality.