Can a patient taking Brixadi (buprenorphine) take Gabapentin to protect against seizures after an Ativan (lorazepam) taper?

Gabapentin After Lorazepam Taper in Patients on Buprenorphine

Gabapentin 300mg TID can be used as adjunctive therapy to help mitigate withdrawal symptoms during and after a lorazepam taper in patients taking Brixadi (buprenorphine), but it is NOT a reliable seizure prophylaxis agent and should not be relied upon as the primary strategy to prevent benzodiazepine withdrawal seizures. 1

Critical Safety Framework

Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must always be conducted gradually—abrupt discontinuation can cause seizures and death. 1 When a patient is taking both opioids (buprenorphine) and benzodiazepines, it is safer to reduce the benzodiazepines first due to the higher risks associated with their withdrawal. 1

The Core Problem with Your Question

The fundamental issue here is that gabapentin is not FDA-approved or guideline-recommended for seizure prophylaxis in benzodiazepine withdrawal. 1 While gabapentin can help mitigate general withdrawal symptoms like anxiety, insomnia, and muscle aches during a benzodiazepine taper, there is no high-quality evidence supporting its use to prevent withdrawal seizures specifically. 1

Seizure Risk in Benzodiazepine Withdrawal

• Withdrawal seizures have been reported even with therapeutic doses of benzodiazepines used for as little as 15 days, though they are more common with long-term use at high doses. 2
• Almost all benzodiazepine withdrawal seizures are grand mal (generalized tonic-clonic) seizures, with severity ranging from single episodes to status epilepticus, coma, and death. 2
• Seizures typically occur when benzodiazepines are discontinued abruptly rather than tapered gradually. 2, 3

The Correct Approach: Proper Tapering Protocol

The primary strategy to prevent seizures is a gradual benzodiazepine taper, NOT adding gabapentin after the taper is complete. 1

Recommended Tapering Schedule

• Reduce the benzodiazepine dose by 25% of the current dose (not the original dose) every 1-2 weeks. 1
• For patients on benzodiazepines for more than 1 year, consider extending the taper to 10% per month. 1
• The taper rate must be determined by the patient's tolerance to withdrawal symptoms, not by a rigid schedule—pauses in the taper are acceptable and often necessary. 1
• The taper will likely take 6-12 months minimum, possibly longer. 1

Monitoring During Taper

• Follow up at least monthly during the taper, with more frequent contact during difficult phases. 1
• Monitor for withdrawal symptoms including anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion, and seizures. 1
• Maintain the patient's buprenorphine (Brixadi) dose stable during the benzodiazepine taper. 1

Role of Gabapentin as Adjunctive Support

If gabapentin is to be used, it should be started DURING the taper as an adjunct to help with withdrawal symptoms, not after the taper is complete as seizure prophylaxis. 1

Gabapentin Dosing Protocol

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

What Gabapentin Can and Cannot Do

• Can help with: General withdrawal symptoms like anxiety, insomnia, and muscle aches during the taper. 1
• Cannot reliably prevent: Benzodiazepine withdrawal seizures—there is no high-quality evidence supporting this use. 1

Alternative Adjunctive Medications

• Carbamazepine may have adjunctive properties for assisting benzodiazepine discontinuation, though data are limited and it may affect alprazolam metabolism. 1, 4
• Pregabalin has shown potential benefit in facilitating benzodiazepine tapering. 1
• SSRIs (particularly paroxetine) may help manage underlying anxiety during tapering. 1

When to Refer to a Specialist

Immediate specialist referral is indicated for: 1

• Patients with a history of withdrawal seizures
• Unstable psychiatric comorbidities
• Co-occurring substance use disorders
• Previous unsuccessful office-based tapering attempts

Critical Pitfalls to Avoid

1. Never rely on gabapentin as primary seizure prophylaxis after completing a benzodiazepine taper—the only reliable way to prevent withdrawal seizures is a proper gradual taper. 1, 2

2. Never taper too quickly—research shows that even a 10% reduction every 3 days resulted in only 24% of patients completing withdrawal successfully. 1

3. Never abandon the patient—maintain the therapeutic relationship even if tapering is unsuccessful, and consider maintenance therapy if needed. 1

4. Avoid prescribing additional CNS depressants during the tapering period, as the patient is already on buprenorphine. 1

The Bottom Line for Your Specific Scenario

If the lorazepam taper has already been completed, starting gabapentin 300mg TID now will NOT provide reliable seizure protection. 1 The window for seizure prevention was during the taper itself through proper gradual dose reduction. If the patient has already completed an abrupt or too-rapid taper and you are concerned about seizure risk, this requires urgent medical evaluation and possible specialist consultation, not simply starting gabapentin. 1, 2

If the taper is still ongoing or about to begin, gabapentin can be added as adjunctive support for withdrawal symptoms, but the primary seizure prevention strategy must be a slow, gradual taper of the lorazepam itself. 1