Benzo Help and How to Manage in Outpatient
I wasn’t going to do this topic but a while ago someone contacted me about benzodiazepine (BZD) tapering and wanted to give some pearls. Caution: it’s not easy but this was my response (without disclosing the source) with a few notes and clinical considerations:
DOSAGE REDUCTION
It is generally agreed that dosage should be tapered gradually in long-term benzodiazepine users. Abrupt withdrawal, especially from high doses, can precipitate convulsions, acute psychotic or confusional states, and panic reactions. Even with slow withdrawal from smaller doses, psychiatric symptoms sometimes appear and anxiety can be severe. The rate of withdrawal should be tailored to the patient’s individual needs and should take into account such factors as lifestyle, personality, environmental stresses, reasons for taking benzodiazepines, and the amount of support available. Various authors suggest optimal times of between 6-8 weeks to a few months for the duration of withdrawal, but some patients may take a year or more. It has been suggested that very slow rates of withdrawal merely prolong the agony and that although symptoms may be more severe with more rapid withdrawal, they do not last so long. However, this is an individual matter and in general, the best results are achieved if the patient is in control of the rate of withdrawal and proceeds at whatever rate he/she finds tolerable. Occasionally, however, a therapist-controlled withdrawal rate with patient consent is more appropriate.
The size of each dosage reduction depends on the starting dose. Patients on higher doses can usually tolerate larger dosage decrements than those on lower doses. The majority of patients on therapeutic doses are taking less than 20mg diazepam (or equivalent) daily. In these cases, dosage reductions of 1mg diazepam (or equivalent) every 1-2 weeks are generally tolerated, although some patients prefer to reduce by only 1mg per month. Initial dosage reductions of 2mg every 1-2 weeks may be more appropriate for patients taking up to 40mg diazepam daily. When daily dosage has declined to 4-5mg diazepam, decrements of 0.5mg at a time may be preferred. Stopping the last few milligrams is often seen by patients as particularly difficult, mainly because of fears about how they will cope without any drug at all. However, the final parting is often surprisingly easy, and patients are encouraged by their new sense of freedom.
It is helpful to provide a written withdrawal schedule rather than only verbal instructions. Patients usually like to record their progress by ticking off dosages or weeks, and a chart also provides an incentive to continue to the final goal. Such schedules may require readjustments from time to time: if symptoms are minimal patients may prefer to increase the rate of withdrawal; if problems arise, either in the form of severe symptoms or major environmental stresses, it may be necessary to stabilize the dosage for a few weeks or to reduce the rate of withdrawal…..
About Ativan: For patients taking lorazepam as anxiolytic several times daily, conversion to diazepam is sometimes more difficult. Substitution is best carried out in stages, one dose at a time over the course of 1-3 weeks, beginning with the evening dose. Occasionally, changing from lorazepam to an equivalent dose of diazepam can cause excessive sedation while not fully controlling anxiety. Direct withdrawal from lorazepam by progressive dosage reductions is feasible, although it may be more problematic than withdrawing from other benzodiazepines (Murphy & Tyrer, 1991). It is regrettable that the minimum tablet strength available in the UK is 1mg (approximately equivalent to 10mg diazepam) although 0.5mg lorazepam tablets are available in the US and Canada. Some patients become experts at shaving small fragments off lorazepam tablets. Alternatively, oral suspensions of lorazepam can be prepared and slow reductions in dosage can be accomplished either by decreasing the volume to each dose, using a graduated syringe or by diluting the mixture, which most high street chemists will undertake.
-The Treatment of Benzodiazepine Dependence
The particular website had other great information, I just put in the Ativan portion because the person had a question about it but here are some other key points:
BENZODIAZEPINE WITHDRAWAL STRATEGIES
The two essential pillars of a successful benzodiazepine withdrawal strategy are: (1) gradual dosage reduction and (2) anxiety management. Of these, dosage reduction is by far the easier but psychological support is equally important for a successful outcome. The management of withdrawal has been reviewed by Lader & Higgitt (1986), the Lancet (1987), Edwards et al., (1990), Livingston (1991), Lader (1991), and many others. Pretty straightforward and stress/anxiety management is imperative. This is where the provider and patient come up with a written agreed plan so they won’t feel overwhelmed, know what to expect, and can stay focused. If the person continues to feel anxious or it’s not controlled, I don’t recommend tapering at this point.
Individual benzodiazepines: Because of the available dosage forms (scored 10mg, 5mg, and 2mg tablets), it is usually most convenient to withdraw from diazepam. Many patients on benzodiazepines with less flexible dosage strengths can be changed over to diazepam, provided equivalent potencies are kept in mind (Table 1). It is worth noting that diazepam has a rapid onset of action and is as efficacious as temazepam or nitrazepam as a hypnotic, while also providing daytime anxiolytic cover by virtue of its slow elimination. Diazepam, temazepam, and nitrazepam are also available as oral solutions. These are sometimes helpful for slow reduction, especially in the final stages of withdrawal. Switching to long-acting BZD’s (e.g. diazepam) lessens the effects of the withdrawals so they’re better tolerated.
For patients taking lorazepam as anxiolytic several times daily, conversion to diazepam is sometimes more difficult. Substitution is best carried out in stages, one dose at a time over the course of 1-3 weeks, beginning with the evening dose. Occasionally, changing from lorazepam to an equivalent dose of diazepam can cause excessive sedation while not fully controlling anxiety. Direct withdrawal from lorazepam by progressive dosage reductions is feasible, although it may be more problematic than withdrawing from other benzodiazepines (Murphy & Tyrer, 1991). It is regrettable that the minimum tablet strength available in the UK is 1mg (approximately equivalent to 10mg diazepam) although 0.5mg lorazepam tablets are available in the US and Canada. Some patients become experts at shaving small fragments off lorazepam tablets. Alternatively, oral suspensions of lorazepam can be prepared and slow reductions in dosage can be accomplished either by decreasing the volume to each dose, using a graduated syringe or by dilution of the mixture, which most high street chemists will undertake. Formularies and insurance coverage may be an issue but I don’t recommend a patient attempting to bite for smaller dosages (because they usually don’t do that), just utilize the smallest dose.
Adjuvant drugs: Several drugs have been tested for their ability to alleviate benzodiazepine withdrawal symptoms; none have been shown to be generally effective. Clinical experience suggests that antidepressants are the most important since depressive symptoms, sometimes amounting to major depression, are common after withdrawal (Olajide & Lader, 1984; Ashton, 1987). Suicides have occurred in several studies. Antidepressants are clearly indicated when depression occurs, but there is as yet no clear evidence from placebo-controlled trials for their routine use in withdrawal (Tyrer, 1985; Rickels et al.,1989). Most authors recommend sedative tricyclic antidepressants, many of which are also effective in relatively low doses for anxiety and insomnia. To date, there is little experience with specific serotonin reuptake inhibitors (SSRIs) in withdrawal, but in personal observations, these drugs have precipitated acute anxiety in some cases. Because of the limited dose preparations of most SSRIs, it is difficult to initiate treatment with small doses, a measure that might obviate such reactions. Before tapering, make sure the person has a stable regimen for depression and sleep. You don’t want to figure this out while tapering because you will risk relapse or worsening the depression. If the PHQ is high, the patient has poor sleep, or mood instability I don’t recommend tapering.
Beta-blockers such as propranolol attenuate palpitations, tremor, and muscle twitches but have little effect on subjective states and do not reduce the overall incidence of withdrawal symptoms or dropout rate in controlled trials of withdrawal (Tyrer, Rutherford & Huggett, 1981; Abernethy, Greenblatt & Shader, 1981; Lader & Higgitt, 1986; Ashton, 1984, 1987; Cantopher et al., 1990). Some patients experience exacerbations of anxiety, insomnia, or physical symptoms on withdrawing from antidepressants or beta-blockers, and these drugs should be tapered slowly after benzodiazepine withdrawal is complete. Beta-blockers are great options for PRN, they don’t have to have it on a regular basis or be tapered unless the anxiety is worsening but you can also use clonidine, hydroxyzine, and other options to target anxiety and/or withdrawal symptoms. The post mentioned using carbamazepine but I’ve never used it for BZD tapering. In general, r/o what helped and didn’t work in the past and try to use medications that can be PRN to have minimal side-effect risks.
Antipsychotics are not recommended. The majority of patients withdraw successfully from benzodiazepines whether taking a placebo in clinical trials or without additional drugs in clinical practice. Simply not true, sometimes you have to use antipsychotics to target sleep/anxiety and some can be PRN like aripiprazole, olanzapine, haloperidol.
High dose abusers: Patients on very large doses of benzodiazepines, either on prescription or illicitly, may need to begin withdrawal in hospital. Such patients may be taking the equivalent of 0.5-1g diazepam daily. Fairly rapid partial reduction at the rate of approximately 10mg diazepam daily may be undertaken safely over 2-3 weeks, with appropriate surveillance and psychological support, followed by a period of stabilization. Several spaced admissions may be necessary to reduce dosage to manageable levels when withdrawal can continue as for therapeutic dose users. My high-dose users usually take 6-9 months to properly wean without going through major issues. The post doesn’t mention alprazolam (Xanax), but I inherited some on 10mg TID and rapid tapering simply doesn’t work in outpatient and you will risk relapsing back to the original/high dose. If the patient wants to do it rapidly/cold turkey they may have to be admitted to the hospital. In other words, it’s not recommended to taper rapidly.
Providing information: Many patients fear the process of withdrawal itself because of misconceptions derived from lurid accounts of others’ experiences. It is helpful to provide, at the first consultation, clear information about benzodiazepine withdrawal and to emphasize that slow and individually titrated dosage reduction rarely causes intolerable distress. Other patients become frightened by particular symptoms which are overinterpreted as signs of physical or mental illness. Information may need to be repeated in these cases; in practice, the realization that a symptom is a “withdrawal symptom” is temporary, and is not a sign of disease, is immensely reassuring to some patients. Books written for patients are available (Trickett, 1986; Tyrer, 1986), and often the provision of correct information combined with a sympathetic attitude is the only intervention necessary.
What About Outpatient?
Avoid Them (with certain groups): I feel like you only need one bad case and it’s a true wake-up call to avoid benzo’s or diligently screen, weigh the pros/cons because it’s really not in the best interest for the long-term and requires a higher acuity of care to discontinue. However, I get many who are already on a stable regimen with BZD because it’s still possible but I gave a list of reasons why I wouldn’t put a person on a BZD. Plus how I would consider starting…
Work with people who have experience in SUBSTANCE ABUSE: I had a patient via telehealth who was a truck driver on pain meds from being in an MVC and wanted a higher dose of BZD for panic attacks. I declined because I’m like I don’t want to risk another car accident but they complained to the physician and he increased the dose. Well, it sent a message that our clinic is on 2 different pages. I was upset because the patient was under the impression if he needs an increase just call but I was out of the loop of that plan so, of course, I’m the one looking crazy even though the doctor agreed the dose shouldn’t have been increased. I am STRICT with alprazolam and most providers are so working in a place where everyone is on the same page is extremely important.
Have PROTOCOLS: Like the previous point, I would never suggest a patient just call to get more (scheduled) medications especially BZD. It’s not good practice especially working in the mecca of drugs aka America. Sometimes you have to protect the patient from themselves, hence there should be protocols. It also limits “doctor shopping” and stops this notion that if you can’t get what you want, you’ll just go to a colleague. If I made a mistake then God bless be free, but if this person got into an accident again or OD, a provider could get blamed for that as well. I don’t get offended when people complained or leave because maybe I can get one less headache in my life. But people who get easily irate, demanding, or agitated also could mean we are dealing with a drug problem. Ironically, the doctor is now more strict than anyone else about benzos but like I said it just takes one bad incident.
In Conclusion (A Process) with Tapering off Benzos
- Make sure the patient is stable: if they’re going through a divorce, poor mood, depression…etc. Don’t taper. Use f/u meetings to stabilize the mental health with anticipation or a timeframe that the tapering can start. Don’t blindsight a patient about tapering (because that will cause a panic attack) but discuss a follow-up plan for tapering. For example, I’ll say in 2-3 months we can discuss a plan for tapering…
- Once STABLE. Have a written plan about the process of tapering. (It’s another upcoming post but I literally do write out how to taper meds for my patients but as you can tell I LIKE writing) and it helps because patients are sometimes forgetful and need that reminder to not go into stress mode. You don’t need to write an essay but on one page (I use their med list) I write out the taper (an example is above in my email response). Also, remind patients how this isn’t a plan to make them cold turkey but how this process may take months if not at least years. This is why we need the patient to be stable and cooperative.
- Consider a long-acting BZD to minimize withdrawals symptoms. This is usually necessary with chronic users of BZD, at very high doses, or who have a poor tolerance to withdrawing.
- PRN as much as you can. This is controversial but I’m trying to avoid additional side effects (hence PRN what you can), it also gives that security blanket and takes advantage of the placebo effect. Basically, we are trying to utilize everything but a benzo.
- Use supportive medications. Sometimes I would prescribe ondansetron, meclizine, hydroxyzine, or additional PRNs just to deal with the withdrawal/flu-like symptoms. This is common with my polysubstance patients as well.
