FatPat asked
What anxiety medication can be given while on Methadone safely? I have been on methadone for the last few years due to pain from Lupus. I have had open heat surgery about 3 months ago. Since then, I have been cursed with them. Please help me.
Answer
There are many options to treat anxiety available to you. Every situation is different of course, and we recommend you speak with your doctor regarding the best therapy options for you specifically. There are different forms of anxiety (e.g. generalized anxiety, panic disorders, social anxiety etc...) that have different treatment recommendations. Having said that, we can certain go over a few options that may be available to you.
You mention that you take Methadone, which is an opioid pain reliever. Due to this, you ideally want to avoid the class of medications known as benzodiazepines. This class includes drugs such as Valium (diazepam), Klonopin (clonazepam) and Ativan (lorazepam). Benzodiazepines are the most popularly used class of medications for anxiety but probably shouldn't be. They have all sorts of problems with them including:
- Possibility of dependence
- Increase the likelihood of falls in the elderly
- Can cause respiratory depression, especially when co-administered with an opioid drug
- Can cause heavy sedation
The reason why benzodiazepines are so commonly prescribed is because they work well and are a quick fix. In fact, despite the risks of prescribing them, the number of patients prescribed both an opioid (like methadone) and benzodiazepine has gone up by about 40% in the last 15 years. During this time period, overdoses have almost tripled. The situation has become has dire that the FDA released a new warning, strongly recommending against the combination of opioid drugs and benzodiazpeines. That recommendation can be found here: FDA Benzodiazepine & Opioid Warning.
If your doctor thinks a benzodiazepine drug is appropriate in your situation, I urge you to read to the FDA warning and educate yourself on the risks. There are certainly situations where the combination is warranted, you just need to be careful. There are many different options of drugs within the benzodiazepine class itself that are available to you... some long acting, some short acting etc...
Outside benzodiazepines, the most common options to treat anxiety are the following three classes of drugs, SSRI's, SNRI's and Buspirone.
SSRI (Selective Serotonin Reuptake Inhibitors)
SSRI's work by increasing the amount of the neurotransmitter serotonin in the brain and are typically considered a first line therapy for MOST anxiety disorders. This class includes drugs such as:
- Zoloft (sertraline)
- Paxil (Paroxetine)
- Lexapro (Escitalopram)
- Celexa (Citalopram)
SSRI drugs do NOT cause respiratory depression like methadone does and they don't carry the risk of dependence like benzodiazepines do. The only issue with SSRI drugs is the possibility of an interaction with methadone. SSRI's, combined with methadone carries a risk, although extremely small, of a rare side effect known as serotonin syndrome, in which the body gets overloaded with serotonin. Methadone has a small effect on serotonin and SSRI's obviously do as well. If you are taking any other drugs that affect serotonin, your doctor may not want to prescribe an SSRI drug in combination with your methadone.
SNRI (Selective Serotonin-Norepinephrine Reuptake Inhibitors)
These drugs work like SSRI's but also affect the neurotransmitter norepinephrine. Most studies show that SSRI's and SNRI's have similar efficacy in treating anxiety disorders. Drugs in this class include:
- Effexor (venlafaxine)
- Cymbalta (duloxetine)
These drugs carry the same risk as the SSRI's mentioned above and can also be slightly more risky if you have heart problems as they can affect blood pressure negatively. Since you have had heart surgery, your doctor may not want to prescribe this class of drugs.
Buspirone
Buspirone is typically used as a second-line drug for generalized and social anxiety disorders. It unfortunately does not seem to work as well as a benzodiazepine, especially if you have taken a benzodiazepine in the past. It also has a slow onset of action and needs to be taken regularly, not just as needed. The good thing about buspirone is it likely is one of the safer options for you. It doesn't carry most of the issues that benzodiazepines have and is less likely to interact with methadone than the SSRI drugs or the SNRI drugs.
Other Options
Believe it or not, there are still more options at you and you doctor's disposal. Other options include:
- Hydroxyzine
- Imipramine
- Wellbutrin (buproprion)
- Lyrica (pregabalin)
- Seroquel (quetiapine)
- Mirtazapine
- Brintellix (vortioxetine)
There are just too many options to go in detail about all of them. We recommend you speak with your doctor and try to come up with a few options that may work best for you. If you have narrowed down a few possibilities, feel free to come back and ask us some more specific information about them!
