Tough one. Here's my 2 bits (2 options):
1. I'd do the office induction of giving them 2mg of bup every half hour until COWS score is 2 or less, or they show no signs of opioid withdrawal. I'd then dose the benzos the same, and tell them not to go to bed within 4 hours of taking the last dose of benzos.
2. Do it one thing at a time, I'd hate to tell a problem drinker to keep drinking, but it's not safe to do both at the same time.
(3. this one doesn't count) find their average number of drinks per day, if it's 18, then they are allowed to continue drinking alcohol, but they must drink only beer, and each day they are allowed one less than the day before. So the next day they would drink 17, then 16, etc. Alcohol is safer than benzos with buprenorphine, though neither is ideal.
Please let us know how this comes out.
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I have put several patients on (long, gentle) diazepam tapers to get off chronic, sometimes extremely high doses, of either benzos or barbs (along with licit or illicit use of opioids). I stabilize the dose of buprenorphine first, then approach the subject of tapering the sedatives with diazepam. There haven't been any adverse effects so far, but the process is really tedious - they all bump their own dose back up when anxiety hits. I would imagine that outpt benzo taper for alcohol withdrawal would be similarly safe, but would also be a shorter length of time on benzos (and maybe less temptation to adjust their own dose over time).
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