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In this Grey Zone case, we follow a patient with opioid use disorder who is becoming more stable on buprenorphine but continues buying pressed “Xanax bars” to manage anxiety and prevent withdrawal.
The central question is whether replacing an unpredictable street supply with a known, structured benzodiazepine prescription can reduce overall harm. We work through how I approach that decision, set prescribing boundaries, and use changes in functioning and street exposure to judge whether the plan is helping.
In this case:
- Why knowing the patient’s baseline and treatment trajectory matters before taking over benzodiazepine prescribing
- Why a reported street-pill strength cannot be treated as a known dose or converted directly into a prescription
- Using clonazepam as a longer-acting option and starting conservatively when the actual exposure is uncertain
- How short dispensing intervals can reduce risk without becoming punitive or requiring a full visit with every refill
- Distinguishing withdrawal, anxiety, and the desire for a stronger subjective effect when a patient says the dose “isn’t enough”
- Setting limits on dose escalation and judging benefit through less street use, less dealer contact, and more predictable functioning
- Interpreting an unexpected negative urine screen and knowing when targeted confirmatory testing is needed
- Responding to lost or stolen medication while accounting for withdrawal risk, housing instability, and practical refill barriers
- Protecting effective buprenorphine or methadone treatment and allowing stabilization to consolidate before considering a taper
Continue online:
View Case 4 and its accompanying resources online
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