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How do opiates and benzos interact when trying to withdraw from a benzo ?

K

Kdem

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Mar 14, 2015
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Note: this is not about me, I have never taken an opiate except for the humble codeine.

While I'm not sure it's allowed to ask a question this way, I'll do it anyway for brievity.
This is both a question about pharmacology/neuroscience and the problems of an individual.
The person in question has not yet been able to get adequate help and his doc doesn't really know what to do with the situation.

Case: person who went through multiple benzo withdrawals (both CT and detox), one major alcohol withdrawal, and has been using (abusing?) opiates. Currently taking 6 mg lorazepam a day/unstable, and on methadone 40 mg, gabapentin 900 mg a day. The individual has not yet been able to taper lorazepam/too unstable/interdose withdrawal/tolerance withdrawal.

How do the methadone and the lorazepam interact ? I know sedatives are sometimes used for opiate withdrawals.
He has received different suggestions: first taper the benzo while trying to stay stable on the methadone, and the other suggestion is to get off the methadone first and taper the benzo later. The methadone doesn't seem to bother him (much).

What happens to the body if you stay on the opiate while tapering the lorazepam, and what happens to the body if you taper the opiate first while keeping the lorazepam stable ?
 
I'm probably the wrong person to weigh in here, but I do know that methadone.has some nmdar antagonism properties, which would in theory help protect against glutamate excitotoxicity incurred from the lorazepam withdrawal.

Maintaining proper lorazepam while decreasing methadone could potentially help the over activation of the autonomic nervous system, but if one had a tolerance, it's unlikely to be very beneficial.
 
Afaik the supposed protocol is to leave the methadone / opioid firstly and taper off the lorazepam. Keep in mind that BZD/GABAergic withdrawals are much more physically dangerous than opioid ones. And the gabapentin (900mg is not that big dose although) should further prevent adverse reactions from the benzo taper. After the lorazepam is done, there are other ways to support the methadone detox.
 
My impression was that the opiate dependence was a more minor issue for the person in question, the 40 mg of methadone may actually be too high to replace the oxycodone. The person in question thinks so.
He has a seriously kindled CNS from multiple benzo CTs and detoxes, and one major alcohol withdrawal. He experiences some issues and wonders if it's not partly the methadone. He hasn't been on the methadone THAT long. (I don't know the details)

My idea was that it was better to get rid of the methadone first (perhaps easier) while trying to be semi stable on the lorazepam or replacement benzo.

Being on a few drugs as possible. Possibly getting rid of the gapapentin first, then starting a slow benzo taper.

Dopamimetic, isn't there some kind of pharmacological/neurobiological interaction between benzos and opiates that has some kind of impact on a benzo taper ? *I* couldn't find anything conclusive in the literature.
 
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I do know that gabapentin is often prescribed for both opiate detoxes and especially benzo detoxs, so I would make that the last medication to step off.
 
I was dependent on both methadone and clonazepam at the same time. I first quit methadone and then a year later I quit clonazepam. However, I didn't really recover from methadone withdrawal, I started taking Suboxone, so I was still on an opioid when I was tapering clonazepam and then in the last few weeks clorazepate. While Suboxone didn't really help me at all during benzodiazepine withdrawal, I can't imagine how I could ever quit benzodiazepines while suffering from the PAWS.
 
I hope this isn't nagging, but is there ANY reason in the realm of neurobiology or neuroscience that would suggest that staying on the opiate (which the person in question probably isn't very dependent on) while tapering the benzo is beneficial ?
Better to stay on the opiate, then taper the benzo ? Better to stabilize on the benzo, then taper the opiate ?

Drug interactions/withdrawal syndrome interactions ?
 
Thanks.

But the person in question has been on the methadone for only a month, and previous exposure to opiates is limited.

So that research says that methadone would help a benzo taper.
Would tapering the methadone first have negative consequences for the benzo taper ?

The person in question is experiencing some 'weird' symptoms, that could be attributed to the interaction or lorazepam, gabapentin and methadone.
 
When you want to quit methadone after quitting benzodiazepines, your GABA/NMDA imbalance will start again anyway, I'm sure much of methadone withdrawal may be attributed to over-active NMDA receptors. When we're talking about methadone and benzodiazepines taken together long-term, I doubt that methadone's NMDA antagonism can still offer much relief from benzodiazepine withdrawal symptoms, on the other hand it seems much easier to adjust benzodiazepine dose during opioid withdrawal.

I'm wondering if plain MOP agonists could actually make benzodiazepine withdrawal worse, after all MOP receptor activation inhibits GABA release which in turn results in more dopamine release. But does it have any other consequences? Could anyone elaborate on it?
 
dopamimetic said:
Afaik the supposed protocol is to leave the methadone / opioid firstly and taper off the lorazepam. Keep in mind that BZD/GABAergic withdrawals are much more physically dangerous than opioid ones. And the gabapentin (900mg is not that big dose although) should further prevent adverse reactions from the benzo taper. After the lorazepam is done, there are other ways to support the methadone detox.
Click to expand...
Agreed.
 
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