Do you continue to prescribe Suboxone (buprenorphine/naloxone) if a patient tests positive for benzodiazepines?

Management of Suboxone Therapy When Patients Test Positive for Benzodiazepines

Do not automatically discontinue Suboxone (buprenorphine/naloxone) when a patient tests positive for benzodiazepines, but implement enhanced monitoring and safety measures due to the significantly increased risk of respiratory depression and fatal overdose.

Risk Assessment and Initial Response

When a patient on Suboxone tests positive for benzodiazepines, follow this approach:

1. Assess overdose risk immediately:

   • The combination of benzodiazepines and opioids (including buprenorphine) increases overdose risk nearly four-fold 1
   • Check for signs of sedation, which typically precede respiratory depression 1
   • Evaluate vital signs, particularly respiratory rate and oxygen saturation

2. Determine source and pattern of benzodiazepine use:

   • Check prescription drug monitoring program (PDMP) to identify if benzodiazepines are prescribed by another provider 1
   • Discuss the positive test with the patient to understand:
     • Whether use is prescribed or non-prescribed
     • Frequency and amount of use
     • Reason for use (anxiety, insomnia, recreational)

Treatment Decision Algorithm

Scenario 1: Prescribed benzodiazepines from another provider

• Contact the prescribing physician to coordinate care
• Consider whether one medication can be tapered or discontinued
• If both medications must be continued:
  • Prescribe naloxone and educate patient and family on its use 1, 2
  • Increase monitoring frequency (weekly visits initially) 3
  • Consider dose reduction of Suboxone if appropriate 2

Scenario 2: Non-prescribed/illicit benzodiazepine use

• Do not immediately discontinue Suboxone as this could lead to withdrawal, relapse to illicit opioid use, and increased mortality risk 3
• Implement a structured safety plan:
  1. Increase visit frequency and urine drug testing
  2. Prescribe naloxone and ensure patient/family know how to use it 1
  3. Consider shorter prescription intervals (weekly or biweekly)
  4. Refer for additional substance use counseling or higher level of care if needed
  5. Consider a formal treatment agreement addressing the benzodiazepine use

Enhanced Monitoring Requirements

For all patients on Suboxone who use benzodiazepines:

• Increase monitoring frequency: More frequent office visits and urine drug tests 3
• Prescribe naloxone: Ensure patient and family members are trained in its use 1, 2
• Document risk-benefit assessment: Clearly document why continuing Suboxone outweighs risks of discontinuation 1
• Consider dose adjustment: Lower Suboxone doses may be safer when combined with benzodiazepines 2

Important Clinical Considerations

• Withdrawal risks: Benzodiazepine withdrawal can be more dangerous than opioid withdrawal and can cause seizures or death if stopped abruptly 1
• Treatment retention priority: Maintaining patients on Suboxone reduces mortality compared to no medication treatment, even with benzodiazepine use 4
• Tapering approach: If tapering is necessary, taper opioids first rather than benzodiazepines due to greater risks of benzodiazepine withdrawal 3

Common Pitfalls to Avoid

1. Automatic discontinuation: Abruptly stopping Suboxone can lead to withdrawal, relapse to full agonist opioids, and increased overdose risk 3
2. Ignoring the benzodiazepine use: Failing to address the concurrent use increases overdose risk 1, 2
3. Inadequate monitoring: Not increasing monitoring frequency when benzodiazepines are detected 3
4. Failure to prescribe naloxone: All patients using both benzodiazepines and opioids should have naloxone available 1, 2
5. Dismissing patients from care: This constitutes patient abandonment and increases risk of adverse outcomes 1

By following this approach, you can maintain the mortality benefit of Suboxone treatment while implementing appropriate safety measures to address the increased risks associated with concurrent benzodiazepine use.