Benzodiazepine Taper

[psychinkansas]

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Hello

I am a first time poster, but a long time lurker. As a psychiatry resident I have managed numerous cases of severe benzo withdrawal. Our hospital uses a symptom triggered protocol for detox. I was wondering if anyone has had success with a particular tapering schedule in the hospital. Most of my patients have done well on the symptom triggered protocol, but some I think would have benefited more from a scheduled taper. Any suggestions?

Congratulations to everyone entering psych residency and to my fellow first years finishing up their dreaded intern years. BTW I am pretty giddy since finishing the COMLEX step 3

psychinkansas

 

[OldPsychDoc]

Hello

I am a first time poster, but a long time lurker. As a psychiatry resident I have managed numerous cases of severe benzo withdrawal. Our hospital uses a symptom triggered protocol for detox. I was wondering if anyone has had success with a particular tapering schedule in the hospital. Most of my patients have done well on the symptom triggered protocol, but some I think would have benefited more from a scheduled taper. Any suggestions?

Congratulations to everyone entering psych residency and to my fellow first years finishing up their dreaded intern years. BTW I am pretty giddy since finishing the COMLEX step 3

psychinkansas

Either symptom-triggered or scheduled is acceptable. There's no one absolutely right way to do this.

 

[Anasazi23]

Research shows that symptom-based benzo taper can be less costly, and about as effective as scheduled taper. Depending on the patient's liver functions, and assuming an ativan taper for benzodiazepine dependence, we typically use:

Ativan 1mg PO BID
Ativan 1mg PO TID
Ativan 1mg PO BID
Ativan 1mg PO QD
Ativan 1mg PO q6h PRN
For severe symptoms, may give ativan 2mg PO PRN

The important thing to remember about symptom based detox is that the nurses must be properly trained to recognize benzodiazepine withdrawal symptoms, and be proficient enought to respond to prevent withdrawal seizures. These symptoms typically consist of
-tremors
-diaphoresis
-restlessness
-irritability
-fatigue
-fitful sleep
-change in apetite
-myalgias
-neuropathies
-weakness
-autonomic instability
-headache
-insomnia
-anxiety.

...these are just some of the reported symptoms.

 

[john182]

Hello

I am a first time poster, but a long time lurker. As a psychiatry resident I have managed numerous cases of severe benzo withdrawal. Our hospital uses a symptom triggered protocol for detox. I was wondering if anyone has had success with a particular tapering schedule in the hospital. Most of my patients have done well on the symptom triggered protocol, but some I think would have benefited more from a scheduled taper. Any suggestions?

Congratulations to everyone entering psych residency and to my fellow first years finishing up their dreaded intern years. BTW I am pretty giddy since finishing the COMLEX step 3

psychinkansas

I would suggest switching all prescribed benzos to an equivalent dose of diazepam and then reduce by 1/8th every 2 weeks. If someone is on lorazepam there is no point in reducing that as it has a short T1/2 so you are still getting the high and low to get dependency every day. Long half life benzo equivalent os solution. I suppose it similar to methadone treatment - longer T1/2 again.

As lorazepam is possibly the most dependency-forming benzo, it is madness to use it on a taper. Have a look at the pharmacology profile of it. It should be used only for short term symptom relief or rapid tranquilisation.

 

[OldPsychDoc]

I would suggest switching all prescribed benzos to an equivalent dose of diazepam and then reduce by 1/8th every 2 weeks. If someone is on lorazepam there is no point in reducing that as it has a short T1/2 so you are still getting the high and low to get dependency every day. Long half life benzo equivalent os solution. I suppose it similar to methadone treatment - longer T1/2 again.

As lorazepam is possibly the most dependency-forming benzo, it is madness to use it on a taper. Have a look at the pharmacology profile of it. It should be used only for short term symptom relief or rapid tranquilisation.

Anyone use phenobarb for this?

 

[Milo]

Anyone use phenobarb for this?

yup, GABA is GABA after all.

The nice thing about barbiturates is how infrequently they are used in the community these days. Most detoxers are completely naive to its effects and achieve response at a low dose.

Financial considerations, of course, are also a factor when using public sector monies and phenobarb is dirt cheap.

It is also nice to detox someone dependent on benzos using something other than their drug of choice. Tapering an etoh dependent person with etoh is a pharmacologically rational choice, but can be philosophically unsettling.

 

[Anasazi23]

As lorazepam is possibly the most dependency-forming benzo, it is madness to use it on a taper. Have a look at the pharmacology profile of it. It should be used only for short term symptom relief or rapid tranquilisation.

Benzodiazepines have about equal efficacy in the management of alcohol withdrawal on taper, including lorazepam (Diagnosis and Management of Acute Alcohol Withdrawal, Canadian Medical Association Journal, March, 1999.)

The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale can be used to quantify withdrawal symptoms and make predictive assessment of complication risk. The clinican gives a score for each response or observation using a Likert scale (0-7 in most cases), with a maximum possible total score of 67. Mild withdrawal is considered if the patient has a CIWA-Ar score of less than 15, moderate withdrawal between 16 and 20, and severe withdrawal if the score is above 20. Each rise in score group is associated with a higher relative risk of complications such as confusion, seizures, and hallucinations compared to those untreated.

The conducted meta-analysis reveals that all benzodiazepines showed equal efficacy, and that benzo use should be started early to prevent complications. “First, clinicians should start treatment with benzodiazepines early, as indicated by the CIWA-Ar score, rather than waiting for withdrawal to advance. Second, adequate doses of benzodiazepine should be used (20 mg of diazepam or 4 mg of lorazepam). These high doses are required to counteract the tolerance that most people with alcohol dependence have to benzodiazepines. Higher doses given early, along with close monitoring using the CIWA-Ar scale, are considered safe and may avoid the late sedation that occurs with ongoing administration of lower doses.”