Concurrent Use of Brixadi and Clonazepam Taper
Yes, a patient can be on Brixadi (buprenorphine) for opioid use disorder while undergoing a long clonazepam taper for benzodiazepine dependence, but this requires careful management with close monitoring due to significant respiratory depression risks. 1
Critical Safety Framework
The FDA explicitly warns that concomitant use of benzodiazepines and opioids (including buprenorphine) may result in profound sedation, respiratory depression, coma, and death 1. However, the guidelines acknowledge this combination occurs frequently in real-world practice—approximately 1 in 8 buprenorphine prescriptions overlaps with benzodiazepine use 2, and nearly half of patients on opioids are concurrently taking benzodiazepines 3.
The key is that concurrent use should be reserved for patients where alternative treatment options are inadequate, which applies to someone already dependent on both substances. 1
Recommended Management Approach
Initial Assessment and Prescribing Strategy
- Prescribe the lowest effective dosages of both medications and use minimum durations of concomitant use 1
- Follow patients closely for signs and symptoms of respiratory depression and sedation 1
- Check the Prescription Drug Monitoring Program (PDMP) to identify all controlled substances the patient is receiving 4
- Assess for concurrent substance use disorders, psychiatric comorbidities, and history of withdrawal seizures before initiating the benzodiazepine taper 5
Tapering Sequence: A Critical Decision Point
When both medications need adjustment, the CDC guidelines from 2016 recommend tapering opioids first because benzodiazepine withdrawal carries greater risks than opioid withdrawal, including seizures and death. 4 However, more recent guidance from 2025 suggests the opposite approach: taper benzodiazepines first due to higher withdrawal risks. 5, 6
Given this contradiction, the safer approach in your specific scenario is to maintain stable buprenorphine (Brixadi) while tapering clonazepam, since:
- The patient needs buprenorphine for opioid use disorder treatment (medication-assisted treatment is evidence-based) 4
- Buprenorphine has a ceiling effect for respiratory depression, making it safer than full opioid agonists 7
- Abrupt benzodiazepine discontinuation can cause seizures and death, requiring gradual taper 5, 6
Clonazepam Tapering Protocol
- Reduce clonazepam by 25% of the current dose (not the original dose) every 1-2 weeks 5
- For long-term use (>1 year), consider extending to 10% reductions per month 5
- The taper rate must be determined by patient tolerance, not a rigid schedule—pauses are acceptable when withdrawal symptoms emerge 5
- Expect a minimum duration of 6-12 months for the complete taper 5
Monitoring Requirements
- Follow up at least monthly during the taper, with more frequent contact during difficult phases 5
- Monitor for withdrawal symptoms: anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion, and seizures 5
- Screen for depression, anxiety, suicidal ideation, and emerging substance use disorders 5
- Assess for signs of respiratory depression and sedation at every visit 1
Adjunctive Support Strategies
- Integrate cognitive behavioral therapy (CBT) during the taper—this significantly increases success rates 5, 6
- Consider gabapentin (starting 100-300 mg at bedtime or three times daily) to mitigate withdrawal symptoms 5
- Offer sleep hygiene education, mindfulness, and relaxation techniques 5
- Provide patient education about risks and benefits of tapering 5
Critical Pitfalls to Avoid
- Never taper benzodiazepines abruptly—this can cause seizures and death 5, 6
- Never abandon the patient if tapering is unsuccessful; maintain the therapeutic relationship 5
- Avoid prescribing additional CNS depressants during the tapering period 4, 5
- Do not dismiss patients from care based on treatment challenges—this constitutes patient abandonment 4
When to Refer to Specialist
Immediate specialist referral is indicated for: 5
- History of withdrawal seizures
- Unstable psychiatric comorbidities
- Co-occurring substance use disorders beyond opioid and benzodiazepine dependence
- Previous unsuccessful office-based tapering attempts
Special Considerations for This Combination
Research shows that buprenorphine appears to have lower opioid toxicity risk compared to methadone, even with concurrent benzodiazepine use 7. However, two-thirds of buprenorphine users report concurrent benzodiazepine consumption 7, and the risk of drug-related mortality increases significantly with this combination 1.
Counsel both the patient and caregivers about respiratory depression and sedation risks. 1 Advise the patient about increased overdose risk if they return to previous benzodiazepine doses after tolerance is lost during tapering. 5