Methadone Maintenance Therapy and Benzodiazepines

Methadone Maintenance Therapy is the the harm reduction treatment for opiate dependence. It can be used for IV Heroin users or opiate pill takers or those who smoke opiates.  These are commonly purchased on the street.  Oxycontin, so called hillbilly heroin, was a commonly diverted opioid prescription that was withdrawn and replaced by oxy-neo, a form of the the same medication which comes in a delivery system which resists crushing for illegal injection.
Benzodiazepines are a large class of pharmaceutical preparations with many benefits and even life saving potentials.  They are used for the treatment of seizures, sedation, panic attacks and insomnia, just to name a few of their more common uses.  The most known of these is Diazepam, known by it's most common trade name, Valium.  Other common benzodiazepines go by the following names, ativan, lorazepam, clonazepam, rivotril, temazepam, etc.  These were all meant for short term usage, in the range of weeks to at most a few months.  Because of their high effectiveness and benefits they tend to be continued increasingly for psychological rather than the physiological benefits.  They have abuse potential and its common over months to a year of use for people to become dependent on them and chemical dependence can lead to addiction.
Further, it's been recently found that benzodiazepines interfere in the healing of the brain from acute trauma.  They are used most carefully in patients with head injuries and studies suggest that those who had strokes who were on benzodiazepines of any kind were least likely to recover completely from strokes. So here is a potential scenario where a person has a cerebral vascular accident loses the capacity to talk and walk, only to completely heal so that a year later they are back to normal. In contrast a person using benzodiazepines might experience the same brain condition only never get out of bed again, needing life long nursing care, bedridden for life.
The College of Physicians and Surgeons of BC has been carefully following the research on benzodiazepines and noted that those who died on methadone maintenance therapy were commonly taking benzodiazepines. One of the most significantly negative side effects of benzodiazepines, like valium, lorazepam and rivotril is that they depress the respiratory rate, making breathing shallower and slower.  When patients take Methadone they can also lose their alertness if the dosage is not yet correctly established.  Combined a person stops breathing and doesn't know it and doesn't wake up.
The College has been warning about the dangerous combination of Methadone Maintenance Therapy with the use of Benzodiazepines but this last week issued a position paper suggesting they were indeed contraindicated.
This is extremely helpful for clinicians in the front lines and shows that those at the College of Physicians and Surgeons are understanding of the basic plight of the practitioner.  I've had my life threatened many times for refusing benzodiazepines.  mOne of my patients who was on a benzodiazepine 'taper', slowly coming off an extremely high dose of benzos told dozens of people he was going to 'shoot Dr. Hay'.  He occasionally brought a gun to the office and showed me what I was facing.  He was actually a fine fellow just having a little difficulty coming off benzos.  More commonly a woman would threaten the doctor with sexual harassment as is common in our community where people marginalized almost dehumanized  will use whatever tools or weapons they have to get what they deem they need to reduce their obvious suffering.  This is unfortunate because these poor souls then get utilized by the downright evil machinations of others who will seek to profit from championing any cause.
So it's really appreciated when the College of Physicians and Surgeons of BC is indeed proactive rather than a 'monday morning quarterback', as commonly seen in beaurocracies which so easily move towards Mandarism unless checked early.
I have patients who are on 6 mg of clonazepam, the normal dose being only 2 mg a day and 4 mg being excessive. They argue threaten, throw tantrums, shout, scream, disrupt the clinic when I reduce them by .125.  It's like asking an alcoholic drinking 60 beer a day to go down to 59 or asking a 4 pack a day smoker to forego 3 cigarettes.  These people are already struggling with addiction, including, heroin, crack, nicotine or cigarettes, alcohol and we in the methadone maintenance services are not the ones who have made a fortune off the patients selling them all this stuff and being the 'good bartender', 'good drug pusher' or  'good doctor' who gives them candy.  Addiction Medicine doctors are the most maligned doctors on 'rate your doctor' services the world over.
So thankfully this week I can now point to a piece of paper and say 'this is the law', see, 'don't kill the messenger', we have to get you off this stuff slowly or I'll have to not prescribe it for you at all.  I've had a dozen complaints to the college directly and indirectly by patients who I've refused.  Thankfully the College has people who have worked in the front lines and know beyond a certainty that there is no 'nice' way to say 'no' because 'no' is 'no' and to severely disturbed addicted psychotic patients 'no' means 'yes'.
What they do understand is, "I will lose my job if I prescribe you more ativan" or "It's against the law for me to prescribe you rivotril".  "You told me you can buy a 10 mg valium on the street for $10, well if you want me to supply you valium at that rate, I can't. Somebody is doing bulk and I'd have to charge you $100 or $1000 a pill to justify the personal risk I'd be taking and I don't think you can afford that.  I think what you want is a dirty pharmacist or a doctor who has already lost his license. "  We can have reasonable discussions like that but saying that 'benzodiazepines are unhealthy' to a person who is walking dead already, having overdosed many times on drugs and willing to do anything to stop the pain, simply doesn't 'cut it'.  Frankly there are  too many 'silly' people out there who don't know anything about addiction or addicts or the real world outside their ivory towers and well protected neighbourhoods.  Their smug judgementalness is only comparable in stupidity to their indifference to the human condition.  We're all in this together.  It's time we really did make a difference rather than just spouting platitudes and pointing fingers.
Several of us addiction medicine doctors got the College report and almost danced together.  Only last week we'd weaned a methadone patient off clonazepam and they'd gone to a leading local psychiatrist who'd given them 6 mg clonazepam on the first visit.  Thanks to the College our colleagues who avoid working with addiction , and certainly don't have methadone patients, will be aware of the potential life threatening combination and think twice before cavalierly prescribing addictive and dangerous medications to patients with alcoholism and addiction. Hopefully too people will do more thorough histories. In BC there's the pharmanet too which allows doctors to learn what patients are on, because in fairness to doctors, psychiatrists especially,  addicts and alcoholics are 'cunning, baffling and powerful'. When they want drugs from a doctor they're not likely to be upfront with him about their history of abuse and addiction.
I don't want patients to die on my watch. I work with methadone patients because it's an area of greatest need  Addicts are society's 'bitch', to coin a jail term. I like to see patients crawl back from the grave and walk into the light. It's an exhilarating area of work.  I talked to an oncologist and we shared our joy in the thrill of winning against all odds and curing the incurable.  It's a whole lot more fulfilling than treating the common cold or saying 'there, there' to a person having exam anxiety.  All of this is important and in my earlier years I did all of that but today my greatest joy is seeing patients get on in recovery.  I've seen patients get on methadone and eventually have carries, so they can be trusted with their methadone like any patient with a chronic illness.  Some stay on methadone but get their lives back, go to recovery meetings, attend doctors appointment, take care of their health, return to work, and reestablish relationships with their families.  Some get stable on methadone and after a year or so taper off and go on to be wholly abstinent from mood altering drugs in NA and AA 12 step programs, some joining churches or temples or synagoges, and reconnecting with community.  Many do volunteer work.

It's really rewarding too to know that the Minister of Health and the College of Physicians and Surgeons of BC are there understanding and helping front line clinicians do their job.

Marijuana and Mental Health Controversy

The controversy surrounding marijuana as medicine has changed dramatically in the last 20 years.  20 years ago it was clearly 'illegal' and as such using it was evidence of 'addiction' as the risk/benefit ratio was so negatively weighted with potential incarceration and long  term negative consequences of criminal record.
These days the 'value' of marijauana continues to be supported especially with newer pharmaceutical cannabinoids seeking approval every month.  Further the federal Canadian political legislation has essentially 'decriminalized' marijuana by making it a 'medicine'.  Even in California someone wanting to smoke marijuana just needs to create a disease category, present with symptons and go to the drive through marijuana clinics making millions with the new laxity of the laws there.
There is still no support for 'smoke' of any kind.
But there's really good evidence for it's benefit in spasms and chronic pain especially 'neuropathic' pain (nerve pain) and also with nausea.  The benefits of the pharmaceutical components of standard marijuana are clearly outweighed by 'smoking', marijauna's dangers being essentially the same as tobacco smokers with chronic respiratory disease, cancer, asthma and heart disease associated with smoking. Smoking isn't good for you.
So marijuana cookies and tea are probably okay especially for Multiple Sclerosis and Nerve root pain in Diabetics. It was once the drug of choice for nausea in cancer treatment but better drugs have been developed.  The trouble is marijuana 'users' want to 'smoke' it suggesting that the majority of such are using it not for intrinsic slow release 'medical value' but it's ability to cause a 'high'.  Smoked marijuana is decidedly the route of choice for addicts.
Cesamet, Nabilone and Sativex are pharmaceutical cannabinoids.  Cesamet is on the provincial formulary for chronic pain.
The difficulty though is that 'smoking' is an 'addictive' 'process'.  This was seen with people given nicotine patches who smoked on top of that.  It's the 'ritual'.  Heroin addicts will 'shoot up' rather than 'smoke' heroin once they become addicted to the paraphernalia. There is a link between addiction and rapid access to brain of the compound.
But here's the controversy in mental health.  The Diagnostic and Statistical Manual of the American Psychiatric Association describe clearly Cannibis (Marijuana) Induced Anxiety Disorder and Cannibis (Marijuana) Induced Psychosis.  Bipolar II , the bipolar disorder associated with angry mood swings as opposed to Bipolar I where the mood swings are euphoria and depression, is the most common mood disorder in combination with addiction, clinically.  It's no stretch to say that Cannibis Induced Mood Disorder is readily apparent too.
So how do you decided if the Anxiety Disorder is a product of marijuana use or helped by marijuana use. The subjective experience of alcoholics is that alcohol makes them calmer and less violent yet the overwhelming community experience and 'objective' experience is that this is simply not the case. There is indeed a benefit from one drink and even an alcoholic will be calmed initially by one drink as a marijuana smoker will describe a joint benefiting their anxiety for a half an hour. The anxiety that follows is worse though and with addiction there is increasing need for more substance with decreasing benefit.
Initially a marijuana joint might cause hours of 'calm' but in the addict a half hour is a good success.  The alcoholic will get maybe 10 minutes of benefit from a shot when they're in withdrawal. Indeed the 'anxiety' and 'irritability 'seen in addiction is 'withdrawal.'
If you are using a substance that has caused the addiction to treat the anxiey which is the way the 'withdrawal' is experienced, then it's like pour gasoline on a fire.  There's that briefest moment when the fire is 'doused' but after that the fire is clearly a whole lot worse.
As early as the 30's alcohol withdrawal was called 'restless, irritable, and discontent", "the RID's".  Marijuana has been called 'marijuana maintenance' for those who mixed alcohol and marijuana or switched from alcohol to marijuana. Regardless the marijuana 'withdrawal' is experienced as the 'RID's" as well and lasts weeks if not months.
Drug seeking addicts will always tell me that they felt anxious off marijuana, alcohol or heroin in fact.  The truth is that those who develop addiction had an underlying 'anxiety disorder' and were 'self medicating'.  Normal people don't 'self medicate' and control the use of substances reasonably because they don't have the same underlying anxiety disorder.
Once an addiction is established it takes at least a year, some say 5 years, to be over the addiction. Seasons, 4 of them, seem to be associated with differing 'trigger's' for relapse.  So 'recovery' is not considered to be 'weeks' or 'months' but rather 'years'.
So what to do when a marijuana smoker is 'bullying' and even 'threatening' you and definitely angry if their agenda is thwarted in any way, when they see the doctor and ask for his support in getting them the 'license' to smoke marijuana.  It's said on the 'street' that 'good' doctors 'sign' and 'bad' doctors don't.
The government and it's regulatory bodies are all giving mixed messages but mostly their song is 'opinion poll' and 'cover your ass'.  As usual, clinicians, like soldiers are on their own, damned if they do and damned if they don't but certain to be judged by "monday morning' quarter backs with sometimes years to mull over a decision the clinician must make in the 'real world 'of 'here and now."
I'm in the middle. I've definitely supported 'medical marijuana' for some patients and am wholly behind 'decriminalization' of drugs, drug court and yet I draw the line at full 'legalization' because it will increase the risk to those who are vulnerable and society at large will definitely have more traffic accidents and work accidents and psychiatric problems.
I'd like to be 'black or white' in this grey area.  It's the same with benzodiazepine (valium type drug) prescriptions where patients who are addicted to marijauna, or alcohol or heroin say that the 'benzos' take the edge off.
My oath is 'do no harm' .  In the short run there are 'benefits but in the long run I'm probably at risk of compounding the patients problems.
Each case I think is unique but the politics treat the world as a mass and certainly the marijuana promoters are 'recruiter's and have a 'conflict of interest'. I've none but it's a challenge and I thought it worth mentioning.
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Psychiatric Medication in Recovery

Psychiatric Medications are an acceptable part of a good Recovery Program. That said, there are clear guidelines which while not written in stone should be well known to those in recovery or those prescribing to those in recovery should the need for medications arise.
Abstinence from all substances is clearly the aim in the first year of recovery. A study out of Hazelton showed that there was greater relapse in those who used antidepressants than those who did not. There were factors of what was controlled for in this study but it did give an indication of the potential hazard 'treating a drug' problem with a drug might be.
Any drug that has a "price" on the street has potential for abuse and should be seriously considered before use in early recovery. This specifically refers to all the benzodiazepine class and the the amphetamines and pain killers.
The benzodiazepine class includes valium, diazepam, alprazolam, ativan, clonazepam, and temazepams as examples. The amphetamine class includes the dexedrine and ritalins. The pain killers are the narcotic class of drugs codeine, tylenol#1,2and 3, oxycontins, demerols etc.
This doesn't however refer to antidepressants or antipsychotics which necessarily have a positive place in recovery. Medications such as the SSRI's, paxil, prozac, zoloft, celexa, cipralex and the more broad spectrum antidepressants, effexor, duloxetine, remeron, wellbutrin are often beneficial in recovery. Antipsychotics or tranquillizers such as seroquel, zyprexia, rispiridone, zeldox, loxapine, flupethixol are very beneficial and commonly used instead of the benzodiazepine class for anxiety.
At an addiction medicine conference this summer the presenter asked how many of the hundreds of addictionists present had prescribed benzodiazepines or amphetamines or pain killers and 90% admitted to this practice. The majority of those doctors there were in 12 step recovery programs themselves.
The presenter said that the key factor was the 'recovery' program and the duration of recovery before the introduction of medication.
Each case required individualization within the context of strong guidelines putting recovery in the forefront.