Benzodiazepines: Lethal for Suboxone and Methadone Clients

Suboxone and methadone are medication assisted treatment (MAT) options for opiate addicts. Opiate addicts often fear complete abstinence due to the physical and emotional pain from opiate withdrawal. Opiate withdrawal can cause sweating, nausea, vomiting, diarrhea, agitation, anxiety, restlessness, chills and more. It is extremely uncomfortable and addicts will go to great lengths to avoid it.

This is where Suboxone and methadone can be helpful. An opiate addict can take Suboxone or methadone while getting counseling for the psychological aspects of addiction. They can get their life in order and learn new coping skills. When they are confident that they can handle life without drugs, they can taper off their medication.

However, some addicts don’t engage in the counseling process. They look for other means to meet the same need that opiates filled. Some addicts on Suboxone or methadone turn to benzodiazepines to fill this need to get high or to forget their problems.

What Are Benzodiazepines?

Benzodiazepines are a class of drugs used as tranquilizers. They are known for their sedating effects. They work by increasing the effect of the neurotransmitter gamma-aminobutyric acid (GABA). GABA works by reducing the neurons responsible for stress and anxiety. Benzodiazepines are often prescribed to reduce anxiety but have other uses such as for seizures and insomnia. There are many types of benzodiazepines that vary in their strength and half-life. Half-life is how long it takes half of a medication to leave the body.  

Different types of Benzodiazepines

Benzodiazepines have many different brand and generic names. Some of the more popular benzodiazepines are listed below. The brand name is first and the generic name is in parenthesis.¹

• Xanax (Alprazolam)
• Librium (Chlordiazepoxide)
• Klonopin (Clonazepam)
• Valium (Diazepam)
• Ativan (Lorazepam)

Why are Benzodiazepines Dangerous?

• High risk of overdose
• Benzodiazepines slow breathing
• Benzodiazepines slow heart rate
• Addicts often take more than they intend to take
• Addicts cannot control their use of addictive drugs
• Addicts forget how many they have taken and take more
• Addicts don’t realize how intoxicated they are and take more
• Benzodiazepines are highly addictive

Benzodiazepines are dangerous to take with Suboxone or methadone for a number of reasons. The most serious reason is the increased risk of overdose when benzodiazepines are taken with Suboxone or methadone. Suboxone and methadone are opioids which are depressants. As depressants, they slow the central nervous system which includes heart rate and breathing. Benzodiazepines are also depressants which mean they also slow the central nervous system including heart rate and breathing. When you combine two depressants which both slow heart rate and breathing, it is possible to slow down your heart rate and breathing until they stop.

• So, when you combine Suboxone or methadone with benzodiazepines, you risk your heart stopping (cardiac arrest) and stopping breathing.

Generally when someone overdoses from a combination of Suboxone or methadone and benzodiazepines, they fall asleep, stop breathing, and pass away in their sleep.

Some people who are on Suboxone or methadone take benzodiazepines illegally, buying them on the street. They are usually called “benzos”, “zannies” (Xanax) or “bars” on the street.  Other people are prescribed benzodiazepines for anxiety or insomnia. They are effective for treating anxiety and insomnia but there are other medications that are just as effective and not as dangerous. There are also ways to treat anxiety without medication. Cognitive Behavioral Therapy (CBT) has been found to be extremely effective for anxiety.

Why People Overdose on Benzodiazepines

Even if benzodiazepines are prescribed, they still pose a danger to someone on Suboxone or methadone. I worked in a methadone clinic for several years and see Suboxone clients in my private practice. Some of these clients have also been addicted to benzodiazepines. They have told me that they would often take more benzodiazepines than they intended. They might start out taking only one or two pills but as the day progressed, they would take many more often losing count.

There are several reasons people often take more benzodiazepines than they intend.

• First, addicts cannot control their use of addictive drugs. This lack of control is part of what makes an addict an addict. An addict may tell themselves they will only take one pill but may not be able to stop themselves from taking more than they are supposed to. They will begin to rationalize why they need to take more than prescribed. If they are prescribed for anxiety, they will tell themselves they have so much anxiety that they need to take more.
  
• Second, benzodiazepines cause memory loss (see section on side effects). A person may take several pills and later in the day forget how many they took and take more.
  
• Third, benzodiazepines tend to make the person feel like they aren’t intoxicated when they are. Much like someone who is drunk, they may not realize how intoxicated they are. They end up taking more benzodiazepines to get high when they are already highly intoxicated. Each of these situations put them at high risk for overdose.

Consider these statistics about overdose, benzodiazepines and opioids:

•  “Of the 22,134 deaths relating to prescription drug overdose in 2010, 16,652 (75%) involved opioid analgesics (also called opioid pain relievers or prescription painkillers), and 6,497 (30%) involved benzodiazepines.”²
• “In a Norwegian study, benzodiazepine users were more than seven times as likely to have at least 12 prescriptions for opioids than non-benzodiazepine users.”³
• “Benzodiazepines make frequent appearances as co-intoxicants in opioid-related deaths.”
• “In 2006, about half of all U.S. opioid related deaths involved more than one type of drug with benzodiazepines mentioned most frequently, being involved in 17% of the deaths.”
• “Benzodiazepine related unintentional deaths have also been increasing steadily since 1999, and are responsible for more unintentional drug overdose deaths in the United States then either cocaine or heroin.”⁴
• “Unintentional drug overdoses deaths are the second leading cause of all unintentional deaths in the U.S., after motor vehicle related deaths.”

From the official Suboxone website:

“SUBOXONE Sublingual Film can cause serious life-threatening breathing problems, overdose and death, particularly when taken by the intravenous (IV) route in combination with benzodiazepines or other medications that act on the nervous system (ie, sedatives, tranquilizers, or alcohol). It is extremely dangerous to take nonprescribed benzodiazepines or other medications that act on the nervous system while taking SUBOXONE Sublingual Film.”⁵

In addition to the risk of overdose, benzodiazepines are extremely addictive. When taken on a daily basis, even a non-opioid user will become physically dependent on benzodiazepines. Someone who is already an addict has an increased risk of addiction to other substances.

Why Are Benzodiazepines so Addictive?

• Releases dopamine
• Addicts are more likely to become addicted to other substances
• Tolerance
• Rebound effect
• Serious withdrawal symptoms which can be fatal

Benzodiazepines are highly addictive for a number of reasons.

• First, benzodiazepines cause the brain to release large amounts of dopamine. Dopamine is a chemical in the brain that makes a person feel good. It is part of the body’s natural reward system. They make a person feel relaxed, calm and euphoric. Addicts will seek the euphoric high that benzodiazepines can cause.
• Second, someone who is already an addict is more likely to become addicted to another substance. It is called substitution when an addict replaces one drug with another. Addicts who no longer have access to their drug of choice will sometimes substitute another drug. Addicts are addicts because they want to get high, whether it is to escape their feelings, self-medicate for mental health problems, to cope with problems or for other reasons. Addicts on Suboxone or methadone can no longer get the same effect from opiates due to the blocking effects of Suboxone and methadone. They tend to seek out other drugs to get the same effect that they once got from opiates. Benzodiazepines are one drug that Suboxone and methadone clients tend to substitute for opiates. Users claim the combination of Suboxone or methadone and benzodiazepines is similar to a heroin high.
• Third, a person taking benzodiazepines can develop tolerance to the drug rather quickly. Tolerance means you need to take more and more of the drug to get the same effects. Addicts who are taking the drug to get high will quickly find that a few pills that got them high in the beginning will no longer work. Soon, they need to take 5 pills and then 10 pills and so on. I have had clients who were taking as many as 50 to 60 pills a day. The more pills you take, the greater the risk of overdose.
• Fourth, benzodiazepines have a rebound effect. A rebound effect means that after a person stops taking benzodiazepines, they have an increase in the problem they took benzodiazepines for in the first place. If you take benzodiazepines for anxiety, stopping them creates more anxiety than you had before taking them. If you took them for insomnia, the insomnia will be worse once you stop taking them.6 This is a temporary problem but an addict will continue use to avoid the rebound effect.
• Fifth, benzodiazepines have severe withdrawal symptoms that can be life-threatening. Withdrawal from benzodiazepines includes symptoms like sweating, shaking, anxiety, restlessness, insomnia and seizures. Seizures are the most serious symptom of withdrawal and can be life-threatening. Someone who is taking benzodiazepines on a regular basis needs to be tapered off the drug. They should never stop taking it without medical attention. Benzodiazepines and alcohol are two drugs for which the withdrawal can kill you.

The Symptoms of Benzodiazepine Withdrawal

Benzodiazepine withdrawal is a serious condition which can be life-threatening. Withdrawal symptoms can last for a few weeks to several months. The severity and length of the withdrawal depends on the strength of the benzodiazepines and length of time they have taken benzodiazepines. Withdrawal symptoms can vary from person to person as well. Some people seem to tolerate withdrawal better and report less symptoms. The following list is a few of the possible symptoms. For a complete list, follow this link.

• Muscle aches and pains
• Agitation
• Anxiety
• Nausea
• Vomiting
• High blood pressure
• Increased heart rate and palpitations
• Sweating and chills
• Headache
• Insomnia
• Impaired cognition
• Memory loss
• Shaking
• Restlessness and restless leg syndrome
• Confusion
• Delusions
• Hallucinations
• Seizures
• Suicidal and homicidal ideation
• Coma
• Death⁷

Signs of Overdose

Suboxone, methadone and benzodiazepines are all depressants. The signs of overdose would be similar for any one of these drugs or if Suboxone or methadone is combined with benzodiazepines. Some are the signs are:

• Shallow breathing or not breathing at all
• Snoring or gurgling sounds (this can mean that a person’s airway is partly blocked)
• Blue lips or fingertips
• Floppy arms and legs
• No response to stimulus
• Disorientation
• Unconsciousness and cannot be woken up

What Are the Side Effects of Benzodiazepine?

Even without the risk of physical dependence and overdose, benzodiazepines have many side effects which can be serious. There is some controversy whether long term use of benzodiazepines cause abnormalities to the brain. A study which conducted a meta-analysis (analyzing the results of other studies) on the effects benzodiazepines have on cognition found that benzodiazepines do cause changes in cognition which decreased after the person stopped taking benzodiazepines. However, cognition levels did not return to the level of functioning of someone who never took benzodiazepines.

Other benzodiazepine side effects include:

• Drowsiness
• Confusion
• Dizziness
• Trembling
• Impaired coordination
• Vision problems
• Grogginess
• Feelings of depression
• Headache

Take-Home Message

1. The evidence seems quite clear that benzodiazepines on their own cause many side effects which can be dangerous. They cause the user to develop a tolerance to them and to have withdrawal symptoms when they try to stop taking them. They raise the level of dopamine which results in a euphoric high for the user. It can be concluded that they are physically and psychologically addictive.
2. When combined with opioids like Suboxone or methadone, the risk of physical and psychological dependence to benzodiazepines increases. The risk of overdose also increases. The statistics show that an increasing number of opioid users are dying from combining opioids like Suboxone and methadone with benzodiazepines.
3. Addicts who are taking Suboxone or methadone for opiate addiction need to be aware of the dangers of mixing their medication with benzodiazepines. They need to recognize the risk of substituting benzodiazepines for the high they got from opiates. Being addicted to benzodiazepines while on Suboxone or methadone is more dangerous than being addicted to opiates alone.
4. Most new clients to Suboxone or methadone treatment will find that benzodiazepines are readily available and cheap to purchase. However, as with any addiction, the cost (both financial and psychological) goes up significantly once you become addicted. It is important for Suboxone and methadone clients to work with their counselor to develop the coping skills and relapse prevention skills they need to avoid substituting one drug for another.