Can a patient be on Gabapentin, Ativan (lorazepam) taper, and Suboxone (buprenorphine/naloxone) for opioid and benzodiazepine withdrawal?

Concurrent Use of Gabapentin, Lorazepam Taper, and Suboxone for Dual Opioid-Benzodiazepine Withdrawal

Yes, a patient can safely be on gabapentin, an Ativan (lorazepam) taper, and Suboxone (buprenorphine/naloxone) simultaneously for managing combined opioid and benzodiazepine withdrawal, but the benzodiazepine taper must take precedence and be managed with extreme caution due to the life-threatening risks of benzodiazepine withdrawal. 1, 2

Critical Safety Framework

When managing dual opioid and benzodiazepine dependence, prioritize the benzodiazepine taper first because benzodiazepine withdrawal carries greater risks than opioid withdrawal, including seizures, delirium, and death. 1, 2 In contrast, opioid withdrawal, while extremely uncomfortable, rarely causes seizures, delirium, or death except in seriously ill patients. 3

Key Safety Principle for Concurrent Medications

The FDA explicitly warns that concomitant use of buprenorphine and benzodiazepines increases the risk of respiratory depression, overdose, and death. 4 However, medication-assisted treatment of opioid use disorder should not be categorically denied to patients taking benzodiazepines, as prohibiting treatment poses an even greater risk of morbidity and mortality from the opioid use disorder alone. 4

Recommended Management Algorithm

Step 1: Initiate Buprenorphine While Stabilizing Benzodiazepine Dose

• Start Suboxone for opioid use disorder treatment at appropriate induction doses 4
• Do not reduce or discontinue buprenorphine in an attempt to comply with dosing guidelines - this partial mu agonist has unique respiratory-depressant plateau effects and most patients tapered from buprenorphine relapse to more dangerous opioids 3
• Maintain the current benzodiazepine dose initially to establish stability 1
• If the patient is sedated at the time of buprenorphine dosing, delay or omit that buprenorphine dose 4

Step 2: Begin Gradual Benzodiazepine Taper

Tapering protocol:

• Reduce by 25% of the current dose (not original dose) every 1-2 weeks initially 1
• For patients on benzodiazepines >1 year, consider slowing to 10% per month 1
• The taper rate must be determined by patient tolerance, not a rigid schedule - pauses are acceptable and often necessary when withdrawal symptoms emerge 1
• Expect a minimum duration of 6-12 months for the complete taper 1

Critical warning: Abrupt discontinuation of benzodiazepines can cause seizures and death - this is never appropriate. 3, 2, 5

Step 3: Add Gabapentin as Adjunctive Support

Gabapentin serves dual purposes in this scenario:

• Mitigates benzodiazepine withdrawal symptoms 1, 6
• May help with residual opioid withdrawal symptoms 7

Dosing strategy:

• Start with 100-300 mg at bedtime or three times daily 1
• Increase by 100-300 mg every 1-7 days as tolerated 1
• Adjust dosing in patients with renal insufficiency 1
• Titrate cautiously to avoid dose-dependent dizziness and sedation 1

Evidence supporting gabapentin: A retrospective study of 172 patients showed that those receiving gabapentin as an adjunct during benzodiazepine withdrawal required less total benzodiazepine dosing and had shorter hospital stays. 6

Monitoring Requirements During Concurrent Treatment

Monthly Minimum Follow-up

• Follow up at least monthly during the taper, with more frequent contact during difficult phases 1
• Monitor for benzodiazepine withdrawal symptoms: anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion, altered mental status, and seizures 1
• Screen for depression, anxiety, and substance use disorders that may emerge during tapering 1

Medication Coordination

• Ensure all prescribers are aware of the complete medication regimen 4
• Conduct toxicology screening for prescribed and illicit benzodiazepines 4
• Confirm patients are taking medications as prescribed and not diverting or supplementing with illicit drugs 4

Sedation Assessment

If the patient appears sedated, this requires immediate attention - delay or omit the buprenorphine dose if appropriate, and reassess the benzodiazepine taper speed. 4

Patient Education Priorities

Educate patients about:

• The extreme danger of combining benzodiazepines with opioids or alcohol 4, 5
• That their tolerance for alcohol and other CNS depressants will be diminished 5
• Not to operate dangerous machinery or motor vehicles 5
• The increased overdose risk if they return to previous opioid doses after tolerance is lost 1
• That withdrawal symptoms are temporary and manageable with proper support 1

Adjunctive Non-Pharmacological Support

Integrate cognitive-behavioral therapy (CBT) during the benzodiazepine taper - this significantly increases success rates. 1, 2 Additional supportive measures include mindfulness, relaxation techniques, sleep hygiene education, and exercise training. 1

When to Refer to Specialist

Immediate specialist referral is required for: 1

• History of withdrawal seizures
• Unstable psychiatric comorbidities
• Co-occurring substance use disorders beyond opioids and benzodiazepines
• Previous unsuccessful office-based tapering attempts

Common Pitfalls to Avoid

Never taper too quickly - even a 10% reduction every 3 days resulted in only 24% of patients successfully completing withdrawal. 1 The goal is durability of the taper, not speed. 1

Never abandon the patient - even if tapering is unsuccessful, maintain the therapeutic relationship and consider maintenance therapy rather than forced discontinuation. 1

Do not create arbitrary buprenorphine dose caps as a strategy to address benzodiazepine use - there is no evidence supporting this approach. 4

Avoid substituting one drug dependence for another - if using additional medications for symptom management (like antiseizure medications), remember these also require tapering. 1

Special Considerations for This Combination

The combination you describe is not only feasible but represents evidence-based best practice for managing dual opioid-benzodiazepine dependence. The key is recognizing that benzodiazepines are not the treatment of choice for anxiety or insomnia in patients on buprenorphine treatment - consider alternative medications and non-pharmacologic treatments instead. 4 Gabapentin can serve as a safer anxiolytic alternative during this transition period. 1, 6