How should we manage a patient on buprenorphine‑naloxone (Suboxone) who is also taking lorazepam (Ativan)?

Managing a Patient on Suboxone and Ativan

This combination carries an FDA black-box warning for fatal respiratory depression and should be avoided; you must initiate a gradual lorazepam taper while continuing buprenorphine-naloxone maintenance therapy. 1

Immediate Risk Assessment

The concurrent use of buprenorphine-naloxone (Suboxone) with lorazepam (Ativan) dramatically increases the risk of:

• Respiratory depression leading to coma and death 1
• Loss of consciousness from additive CNS depression 1
• Fatal overdose when two CNS depressants are combined 2, 1

The FDA has issued its highest-level drug safety alert (black-box warning) specifically addressing this combination, stating that opioids plus benzodiazepines markedly increase the risk of slowed or difficult breathing and death. 1

Core Management Principle

Never discontinue the buprenorphine-naloxone. Stopping Suboxone precipitates withdrawal, dramatically increases relapse risk to illicit opioids, and raises overdose mortality. 1 The CDC explicitly recommends maintaining medication-assisted treatment with buprenorphine as the cornerstone of opioid use disorder management. 2

Step-by-Step Management Algorithm

Step 1: Continue Buprenorphine-Naloxone Without Interruption

• Maintain the current Suboxone dose (typically 16 mg daily for most patients) 1
• Discontinuing buprenorphine therapy precipitates withdrawal and increases relapse to more dangerous illicit opioids 1
• There is no maximum recommended duration of buprenorphine maintenance—patients may require treatment indefinitely 1

Step 2: Initiate a Gradual Lorazepam Taper

The CDC recommends tapering benzodiazepines first when patients are on both medications, because benzodiazepine withdrawal carries greater risks (seizures, delirium tremens, death) than opioid withdrawal, and because tapering opioids can worsen anxiety. 2

Standard benzodiazepine taper schedule:

• Reduce the lorazepam dose by 25% every 1–2 weeks 2
• This is a commonly used schedule that has been used safely with moderate success 2
• Consider switching to a longer-acting benzodiazepine (clonazepam or diazepam) before tapering to reduce withdrawal symptoms 1

Step 3: Replace Lorazepam with Non-Benzodiazepine Alternatives

Evidence-based alternatives for anxiety management:

• SSRIs or SNRIs for generalized anxiety disorder 2
• Cognitive behavioral therapy (CBT) increases benzodiazepine tapering success rates and is particularly helpful for patients struggling with the taper 2
• Buspirone as a non-sedating anxiolytic 1
• Gabapentin for anxiety symptoms 1

The CDC emphasizes that if benzodiazepines prescribed for anxiety are tapered or discontinued, evidence-based psychotherapies (e.g., CBT) and/or specific antidepressants or other non-benzodiazepine medications approved for anxiety should be offered. 2

Step 4: Coordinate Care with Mental Health Providers

• Communicate with mental health professionals managing the patient to discuss needs, prioritize goals, weigh risks of concurrent exposure, and coordinate care 2
• Check the prescription drug monitoring program (PDMP) for concurrent controlled medications prescribed by other clinicians 2
• Consider involving pharmacists and pain specialists as part of the management team 2

Step 5: Intensive Monitoring During the Transition

If the combination cannot be immediately discontinued:

• Obtain informed consent explicitly documenting the discussion of respiratory depression and death risk 1
• Use the lowest effective doses of both medications 1
• Schedule frequent follow-up visits (initially weekly) to monitor for adverse effects 1
• Monitor respiratory rate, oxygen saturation, and level of consciousness at each visit 1
• Ensure naloxone is immediately available and train caregivers in its administration 1

Common Pitfalls to Avoid

Pitfall 1: Discontinuing Suboxone to "Make Room" for Lorazepam

This is dangerous and contraindicated. Buprenorphine maintenance is evidence-based treatment for opioid use disorder with demonstrated mortality benefit. 2, 1 Discontinuation precipitates withdrawal and dramatically increases relapse risk. 1

Pitfall 2: Abrupt Benzodiazepine Cessation

Abrupt benzodiazepine withdrawal can cause rebound anxiety, hallucinations, seizures, delirium tremens, and in rare cases, death. 2 Always taper gradually using the 25% every 1–2 weeks schedule. 2

Pitfall 3: Tapering Buprenorphine Instead of Lorazepam

The CDC explicitly states that when patients receiving both benzodiazepines and opioids require tapering to reduce risk for fatal respiratory depression, it might be safer and more practical to taper opioids first only in the context of chronic pain management—not opioid use disorder treatment. 2 For patients on Suboxone for opioid use disorder, taper the benzodiazepine, not the buprenorphine. 2, 1

Pitfall 4: Prescribing Without Checking the PDMP

Clinicians should check the PDMP for concurrent controlled medications prescribed by other clinicians before continuing this combination. 2 If multiple prescribers are involved, immediately coordinate care rather than dismissing the patient. 3

Monitoring for Benzodiazepine Withdrawal During Taper

Watch for and treat:

• Rebound anxiety (consider increasing CBT intensity or starting an SSRI/SNRI) 2
• Insomnia (trazodone 50–100 mg at bedtime or gabapentin 300–600 mg three times daily) 1
• Tremor, sweating, tachycardia (supportive care; slow the taper if severe) 2
• Seizures (medical emergency; resume benzodiazepine and taper more slowly) 2

Evidence Strength

Multiple high-quality guidelines uniformly recommend against this combination:

• CDC guidelines (2016) explicitly address the risks of combining opioids with benzodiazepines and recommend tapering benzodiazepines first 2
• FDA black-box warning (highest level of drug safety alert) for respiratory depression and death 1
• American College of Emergency Physicians recommends against co-prescribing opioids with benzodiazepines 1
• National Comprehensive Cancer Network guidelines warn of dramatically increased respiratory depression risk 1

Summary Algorithm

1. Continue Suboxone at current dose 1
2. Taper lorazepam by 25% every 1–2 weeks 2
3. Start non-benzodiazepine alternatives (SSRI/SNRI + CBT) 2
4. Monitor intensively (weekly visits initially) 1
5. Coordinate with mental health providers 2
6. Never discontinue buprenorphine to accommodate benzodiazepine use 1