Suboxone and Xanax: Can You Take Benzodiazepines While on Suboxone?

A lot of people who call me are already taking a benzodiazepine. Xanax for panic attacks. Klonopin for anxiety. Valium for muscle spasms. Ativan to sleep. Some have a prescription. Some buy them.

They usually ask one of two questions. Will you still treat me? And do I have to stop my Xanax?

The answer to the first is yes. The answer to the second is not suddenly. Here is why.

What counts as a benzodiazepine

Benzodiazepines, often called benzos, are sedatives. NIDA explains that they calm or sedate a person by raising the level of GABA, a chemical that slows activity in the brain. They are commonly prescribed for anxiety and insomnia.

The FDA's list includes:

• Alprazolam (Xanax)
• Clonazepam (Klonopin)
• Diazepam (Valium)
• Lorazepam (Ativan)
• Temazepam (Restoril)
• Chlordiazepoxide (Librium)
• Triazolam (Halcion)

If your pill bottle has one of those names on it, this article is for you.

Why the combination is risky

Buprenorphine, the main medicine in Suboxone, is an opioid. Benzodiazepines are sedatives. Both slow down the central nervous system, and the FDA notes that the central nervous system controls most of the body's functions, including breathing.

NIDA says combining opioids and benzodiazepines can increase overdose risk because both can cause sedation and suppress breathing, which is what kills people in an overdose. They also impair thinking.

The numbers back that up.

• In 2021, nearly 14% of overdose deaths involving opioids also involved benzodiazepines, according to NIDA.
• A North Carolina study cited by NIDA found the overdose death rate in patients prescribed both was 10 times higher than in patients prescribed only opioids.
• A study of U.S. veterans published in the BMJ in 2015 found that about half of the overdose deaths among veterans on opioid pain medicine happened while they were also prescribed a benzodiazepine. The risk rose as the benzo dose went up.

Those studies were mostly about opioid pain pills. What about Suboxone specifically?

A large Massachusetts study looked at 63,389 adults on buprenorphine from 2012 to 2015. About 24% filled at least one benzodiazepine prescription during treatment. Periods when people were getting both were linked to about three times the risk of fatal opioid overdose, compared with buprenorphine alone. Of the 183 opioid overdose deaths in that group, 31% happened while the person was getting benzodiazepines during buprenorphine treatment.

So the risk is real. I am not going to tell you otherwise.

Why the FDA still says do not turn these patients away

Here is the part most people do not know.

In September 2017, the FDA issued a safety communication telling doctors that buprenorphine and methadone should not be withheld from patients taking benzodiazepines or other sedating drugs. The FDA's reasoning was direct: the combination increases the risk of serious side effects, but the harm caused by untreated opioid addiction can outweigh those risks.

The FDA also said that kicking people out of treatment for using benzos is not likely to stop them from using the two together. It may just move that use outside of treatment, where the outcome can be worse.

The research supports that. The same Massachusetts study found that people receiving benzodiazepines were less likely to drop out of buprenorphine treatment. A study in the American Journal of Psychiatry, using insurance claims from more than 23,000 people on buprenorphine who had a drug poisoning, found that days on buprenorphine were linked to a nearly 40% lower risk of poisoning. Days on benzodiazepines were linked to a higher risk. The authors concluded that buprenorphine partly offsets the benzo risk, and that lowering the benzo dose while staying on buprenorphine may reduce poisoning risk.

In plain terms: Suboxone protects you. Benzos add risk. Stopping Suboxone because of benzos usually makes things worse, not better.

Do not stop your benzo suddenly

This is the most important thing in this article.

If you have been taking a benzodiazepine every day for weeks or months, do not quit it on your own. The FDA warns that physical dependence can develop when benzos are taken steadily for several days to weeks, even as prescribed. Stopping abruptly or cutting the dose too fast can cause withdrawal reactions, including seizures, which can be life-threatening.

The FDA lists other severe withdrawal effects too, including delirium, hallucinations, psychosis and thoughts of suicide. It also notes some people have withdrawal symptoms that last many months.

I see people who decide to get clean from everything at once. They stop the opioids and the Xanax on the same weekend. That is how people end up in the emergency room with a seizure. Opioid withdrawal feels awful. Benzo withdrawal can be life-threatening.

The FDA's guidance is a slow, individual taper with your prescriber, with monitoring and support. There is no one schedule that fits everyone.

What the FDA tells doctors to do

The 2017 FDA communication lays out a plan for doctors treating patients who take both. It includes:

1. Teaching patients about the risks of combining them, including overdose and death.
2. Making a plan to manage prescribed or street benzos when starting treatment.
3. Tapering the benzodiazepine to stop, if possible.
4. Confirming the diagnosis behind a benzo prescription for anxiety or insomnia and considering other treatments for those conditions.
5. Recognizing that patients may need buprenorphine indefinitely, for as long as it is helping.
6. Coordinating with the other prescribers so everyone knows about the buprenorphine.
7. Monitoring with urine or blood testing.

That is how I approach it. It is not a punishment. It is the safest route through a dangerous combination.

Street benzos are a different problem

A Xanax bought on the street may not be Xanax. NIDA notes that researchers have found benzodiazepines in the illicit opioid supply in some areas, which means people may be taking benzos with street opioids without knowing it. Street pills are not tested or regulated, so you cannot know what is in them. I wrote this week about what is in street fentanyl now.

The FDA's advice to patients on buprenorphine is clear: do not take non-prescribed benzodiazepines or other sedatives, and do not use alcohol. Alcohol carries the same breathing risk. I cover that in Suboxone and alcohol.

If you are buying benzos, tell me. You will not be kicked out. We need a plan, and you may need a medically supervised taper.

What you can do today

1. Make a list of everything you take, prescribed or not, and bring it to your visit. The FDA suggests keeping a medicine list in your wallet.
2. Tell every doctor, dentist and pharmacist that you are on Suboxone.
3. Do not stop a daily benzo on your own.
4. Do not take an extra benzo to sleep or calm down on a bad night.
5. Keep naloxone in the house, and make sure someone you live with knows where it is.
6. If someone is very hard to wake or is breathing slowly, call 911 and give naloxone.

If you want to know what treatment looks like from the first day, read what to expect at your first appointment.

How I can help

I was an orthopedic surgeon. I lost that career to addiction, and I recovered. I treat adults with opioid use disorder at 102 E Sunbridge Dr, Suite 3, in Fayetteville.

I answer my own phone 24 hours a day, every day of the year, at 479-856-1505. I will come in at any hour if you need to be seen.

A scheduled visit is $200. An unscheduled after-hours visit is $300. Follow-ups are about every 28 days. I do not bill insurance, but insurance can still be used at the pharmacy for the medication and for lab work.

Your records are protected under HIPAA and 42 CFR Part 2, the federal rule that gives addiction treatment records extra privacy.

Being on a benzo is not a reason to stay away. It is a reason to call.

More reading: What the first visit looks like · Frequently asked questions