To Diazepam or Not to Diazepam: Methadone Patient.

A DOCS Education member asks:
I am seeing a 58 year old female with hypertension for sedation. She is allergic to sulfa and taking the following medications:

  • Atenolol 100mg 1/2 tab daily,
  • Topiramate 200mg 1 pill 2x a day 1 in am 1 pm,
  • Trazadone 100mg 2 tablets at bedtime,
  • Methadone 10mg 2 tablets am 1 tablet pm.

She smokes around 3-5 cigarettes per day and does not consume grape fruit juice or any other herbal supplements. This patient has undergone multiple back surgeries.

Her weight is 190lbs with the following vital signs:
SYS/DIA:127/95
MAP: 117
BPM: 72
SPO2: 96

I am planning to do whole mouth scaling and root planing and would like to know what the appropriate sedation protocol would be in this case.

Thank you!


Dr. Anthony S. Feck, DOCS Education Dean of Faculty, responds:

If you can incrementally dose, I would use incremental protocol #1 (aka "Golden Protocol"), described in detail in your sedation course workbook. The only modification I would use is to not prescribe diazepam the night before at bedtime. Otherwise, have the patient take all her meds as usual. This protocol incrementally doses triazolam in amounts based on assessment criteria once the patient is in the office and at appropriate intervals.

Another DOCS Education member seeks to clarify:
I’m curious why you suggest using triazolam? I thought all benzodiazepines could be deadly when combined with methadone. What makes this a better choice than diazepam?

Dr. Feck responds:

Benzos are not necessarily "deadly" when combined with methadone; methadone is an opiate that depresses the CNS and benzodiazepines also depress the CNS. If used appropriately in combination with one another on an appropriately selected patient, the patient's safety is not in jeopardy.

Triazolam has the least amount of respiratory depression, which is the main concern during sedation.

Diazepam is administered outside the office when the patient is not being monitored by qualified personnel, therefore we do not recommend using diazepam in this patient.

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