Approaches for Managing Benzodiazepine Dependence Arising From Use of the Adulterated Opioid Supply: A Delphi...

Benzodiazepine adulteration of the unregulated opioid supply presents significant clinical challenges, whereby patients can develop physical dependence to benzodiazepines inadvertently. Currently, clinicians lack evidence to guide care of patients potentially experiencing benzodiazepine withdrawal when ceasing use of unregulated opioids. We used a Delphi technique to build consensus around assessment and management of people at risk for benzodiazepine dependence due to the use of unregulated opioids.

We administered a Delphi Technique with 12 clinicians (physicians, nurses, nurse practitioners, pharmacists) with expertise in substance use disorders, from a Canadian province with a high prevalence of benzodiazepine-adulterated unregulated opioids. The technique involved 4 rounds of consensus building and resulted in 122 consensus statements related to direct clinical care.

Final consensus statements include approaches to risk stratification, diagnosis, and management of benzodiazepine withdrawal secondary to use of benzodiazepine-adulterated opioids. At-risk groups include daily/high-volume opioid users, those who intentionally seek benzodiazepine-contaminated opioids, and those who abruptly cease using unregulated opioids. Common co-opioid and benzodiazepine withdrawal symptoms include anxiety, agitation, gastrointestinal upset, insomnia, and confusion, usually peaking around 72 hours from the time of last use. Experts formed consensus on tracking benzodiazepine withdrawal using vitals, CIWA-B, and treatment response to benzodiazepines administered in inpatient settings.

As benzodiazepines become more prevalent in the unregulated drug supply, there is an urgent need for evidence-based care. Key future priorities should focus on developing evidence-based clinical guidance, creating decision-support tools, and advancing research efforts.