Benzodiazepines, Methadone and Buprenorphine: Interactions and Clinical Management

Lintzeris, Nicholas; Nielsen, Suzanne

doi:10.1111/j.1521-0391.2009.00007.x

Cited by 97 publications

(83 citation statements)

References 109 publications

(155 reference statements)

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“…47,58,77,99 For persons not known to be at a higher risk of QTc interval prolongation, the panel found insufficient evidence to routinely recommend ECG screening. 72 Lintzeris et al, 65 and Gourevitch et al 40 However, given that QTc interval prolongation without arrhythmia is asymptomatic and may not be associated with recognized risk factors, the panel suggests that clinicians consider obtaining an ECG prior to initiation of methadone in all patients. Although there is no evidence to guide recommendations on how recent an ECG should be to guide risk assessments accurately prior to initiation of methadone, the panel suggests that in patients with risk factors for QTc interval prolongation that are unchanged, an ECG within the last 3 months showing no QTc interval prolongation can be used as the baseline study and a repeat ECG is unnecessary prior to initiating methadone.…”

Section: Baseline Electrocardiogramsmentioning

confidence: 99%

Methadone Safety: A Clinical Practice Guideline From the American Pain Society and College on Problems of Drug Dependence, in Collaboration With the Heart Rhythm Society

Chou

Cruciani

Fiellin

et al. 2014

The Journal of Pain

204

188

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Methadone is used for the treatment of opioid addiction and for treatment of chronic pain. The safety of methadone has been called into question by data indicating a large increase in the number of methadone-associated overdose deaths in recent years that has occurred in parallel with a dramatic rise in the use of methadone for chronic pain. The American Pain Society and the College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society, commissioned an interdisciplinary expert panel to develop a clinical practice guideline on safer prescribing of methadone for treatment of opioid addiction and chronic pain. As part of the guideline development process, the American Pain Society commissioned a systematic review of various aspects related Clinical practice guidelines are ''guides'' only and may not apply to all patients and all clinical situations. As part of a shared decision-making approach, it may be appropriate for the clinician to inform a patient that a particular recommendation may not be applicable, after considering all circumstances pertinent to that individual. This article is based on research conducted at the Oregon Evidence-based Practice Center (now the Pacific Northwest Evidence-based Practice Center) with funding from the American Pain Society (APS to safety of methadone. After a review of the available evidence, the expert panel concluded that measures can be taken to promote safer use of methadone. Specific recommendations include the need to educate and counsel patients on methadone safety, use of electrocardiography to identify persons at greater risk for methadone-associated arrhythmia, use of alternative opioids in patients at high risk of complications related to corrected electrocardiographic QTc interval prolongation, careful dose initiation and titration of methadone, and diligent monitoring and follow-up. Although these guidelines are based on a systematic review, the panel identified numerous research gaps, most recommendations were based on low-quality evidence, and no recommendations were based on high-quality evidence.Perspective: This guideline, based on a systematic review of the evidence on methadone safety, provides recommendations developed by a multidisciplinary expert panel. Safe use of methadone requires clinical skills and knowledge in use of methadone to mitigate potential risks, including serious risks related to risk of overdose and cardiac arrhythmias. M ethadone is a synthetic opioid used for the treatment of opioid addiction and for treatment of chronic pain. 15,61 The safety of methadone has been called into question by data indicating a large increase in the number of methadone-associated overdose deaths.38 This increase appears largely related to the dramatic rise in the use of methadone for chronic pain, though a small proportion of deaths occur in patients treated for opioid addiction. 21,37,68,76,91,103 Methadone poisoning deaths in the United States increased steadily from about 800 in 1999 to a high of about 5,500 in 2007; th...

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Section: Baseline Electrocardiogramsmentioning

confidence: 99%

Methadone Safety: A Clinical Practice Guideline From the American Pain Society and College on Problems of Drug Dependence, in Collaboration With the Heart Rhythm Society

Chou

Cruciani

Fiellin

et al. 2014

The Journal of Pain

204

188

View full text Add to dashboard Cite

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“…It is known that CYP3A4 inducers and inhibitors may reduce or improve buprenorphine N-alkylation. However, it appears that the interaction between buprenorphine and benzodiazepines or alcohol is more likely to be of a pharmacodynamic rather than of a pharmacokinetic nature 26,27 . The ceiling effect on the respiratory function of buprenorphine may not be present when it is co-administered with other psychoactive drugs 27 .…”

Section: Discussionmentioning

confidence: 99%

“…However, it appears that the interaction between buprenorphine and benzodiazepines or alcohol is more likely to be of a pharmacodynamic rather than of a pharmacokinetic nature 26,27 . The ceiling effect on the respiratory function of buprenorphine may not be present when it is co-administered with other psychoactive drugs 27 . In fact, CNS depressants, particularly benzodiazepines, act synergistically with opioids to reduce the respiratory function, which increases the toxicity of opioids 4,26 .…”

Section: Discussionmentioning

confidence: 99%

Opiate withdrawal syndrome in buprenorphine abusers admitted to a rehabilitation center in Tunisia

Derbel¹,

Ghorbel²,

Akrout³

et al. 2017

Afr H. Sci.

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Background: Illicit use of high dosage buprenorphine has been well documented in several countries, including Tunisia. Objectives: The aim of this survey is to assess the buprenorphine withdrawal syndrome time course, and how it may be affected by the population characteristics among subjects admitted to a rehabilitation center in Tunisia. Methods: A prospective research has permitted study of the socio-demographic characteristics and assessment of buprenorphine withdrawal syndrome among 32 subjects admitted for buprenorphine dependence by using the clinical opiate withdrawal scale. An ANOVA was conducted to examine the effect of different factors on the withdrawal scores. Results: 32 subjects were included. Among them 30 were males, 27 had been injecting buprenorphine, 16 were poly-drug abusers and 2 had a history of mental disorders. Buprenorphine withdrawal syndrome was of a mild intensity and had a delayed onset. Withdrawal mean scores varied between 0 and 9, and maximum values were reached at day 21. These scores varied significantly over time (p<0,001). The sex v time interaction and the mode of consumption of buprenorphine had significant effects on the withdrawal scores (p<0,001). The poly-drug consumption and the history of mental disorders did not have any significant effect on the withdrawal scores. Conclusion: This study has permitted description of buprenorphine withdrawal syndrome among patients going through a detoxification treatment at a rehabilitation center. Understanding this syndrome would help elaborate effective and suitable buprenorphine dependence management plans.

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“…Lifetime use of benzodiazepines among opioid-dependent individuals is reported to be 66-100%, with estimates of problematic benzodiazepine misuse or dependence in people on MMT being 18-50%. 14 Research indicates that benzodiazepine misuse or dependence is associated with complex needs and negatively influences MMT outcomes. [15][16][17][18][19] There are many reasons why patients on MMT use benzodiazepines.…”

Section: Discussionmentioning

confidence: 99%

“…In addition, patients on MMT who use benzodiazepines often receive higher methadone doses than those who do not use benzodiazepines. [14][15][16][17][18][19] In addition to morbidity, benzodiazepine misuse and dependence is implicated in 20-80% of methadone-related deaths. 14 In this study, we examined MMT patients' perceptions of unmet needs for comprehensive treatment care and explored the relationship between benzodiazepine misuse and severity of need.…”

Section: Discussionmentioning

confidence: 99%

Perception of unmet needs and association with benzodiazepine misuse among patients on a methadone maintenance treatment programme

et al. 2012

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Aims and methodTo examine patients' perceptions of unmet needs during methadone maintenance treatment (MMT), and to explore the relationship between co-occurring benzodiazepine misuse and severity of needs. A cross-sectional survey was carried out at an MMT programme in Dublin, Ireland. All patients were invited to participate on a voluntary basis. Of the 191 eligible patients, 107 agreed to participate and completed the Camberwell Assessment of Need questionnaire.ResultsUnmet needs for substance misuse treatments, daytime activities, socialisation, money management and psychological distress were high. Fifty-two respondents (49%) reported using non-prescribed benzodiazepines during the past month. Compared with non-users of benzodiazepines, benzodiazepine users reported higher ratings of total and unmet needs (P < 0.05). The number of days using benzodiazepines predicted the severity of needs.Clinical implicationsThe findings highlight the importance of addressing coexisting psychological needs, and further support enhancing treatment interventions for benzodiazepine misuse or dependence among patients on MMT.

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Benzodiazepines, Methadone and Buprenorphine: Interactions and Clinical Management

Cited by 97 publications

References 109 publications

Methadone Safety: A Clinical Practice Guideline From the American Pain Society and College on Problems of Drug Dependence, in Collaboration With the Heart Rhythm Society

Methadone Safety: A Clinical Practice Guideline From the American Pain Society and College on Problems of Drug Dependence, in Collaboration With the Heart Rhythm Society

Opiate withdrawal syndrome in buprenorphine abusers admitted to a rehabilitation center in Tunisia

Perception of unmet needs and association with benzodiazepine misuse among patients on a methadone maintenance treatment programme

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