Benzodiazepine withdrawal

[cbrons]

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Is it really worse for some patients than many physicians realize? There are a number of "support" forums out there for people who have been severely "harmed" by taking (and subsequently following a "short" taper plan devised by psychiatrists) to get off certain benzodiazepines. Professor Heather Ashton from the U.K. wrote extensively about this. (and supposedly ran a benzodiazepine withdrawal clinic for 12 years in the 1980s and 1990s). I was wondering what the take of some psychiatrists and psychiatric residents might be on this issue. There are sure a lot of people out there on the net claiming they have been suffering for many years post-Xanax withdrawal (although the symptoms they present are usually inconsistent and confusing to follow). Also, anybody have any current research on this subject?

Also, what do you currently recommend for patients tapering off long-term benzo usage? Do you have any notable stories/problems/successes? I've recently become very interested in this subject. Thanks for your time.

 

[whopper]

I see this all the time, and I see hardly any action by state medical boards to curb this problem.

Just as an example, I know of a doctor that gives out benzos in high dosages to everyone. Several of his patients became addicted/dependence to the benzos. That doctor is still in operation. Everyone in the local area knows what's going on yet I know of no action taken against him and I see see him practicing. It's to the point where local drug counselors actively tell their patients to avoid this guy.

I've told some of my patients who used to see this doctor to report him to the state medical board. I still see nothing being done.

The rest of your questions, the answers can easily be found in a textbook on managing this problem.

 

[nitemagi]

Ashton has a bit of a cult following. Benzo's in general are bad news, and perpetuate a kind of hiding approach to anxiety, rather than exposure. The problem with the Ashton people is that many of the individuals don't recognize common anxiety phenomenon of somatosensory amplification (paying attention and being upset by every little physical sensation as though it's an indication of disease), and misattribution of that to the benzo's themselves.

The only exception is a small sub-group who're especially sensitive to doses of medications, often d/t being a poor metabolizer. I've also seen an interesting sub-population who've had chemotherapy who develop sensitivity to meds or conditions they've otherwise never had before.

 

[cbrons]

Ashton has a bit of a cult following. Benzo's in general are bad news, and perpetuate a kind of hiding approach to anxiety, rather than exposure. The problem with the Ashton people is that many of the individuals don't recognize common anxiety phenomenon of somatosensory amplification (paying attention and being upset by every little physical sensation as though it's an indication of disease), and misattribution of that to the benzo's themselves.

The only exception is a small sub-group who're especially sensitive to doses of medications, often d/t being a poor metabolizer. I've also seen an interesting sub-population who've had chemotherapy who develop sensitivity to meds or conditions they've otherwise never had before.

It seems to me that many on these forums/online communities suffer from anxiety (their original DX for which a benzo was prescribed) as well as several comorbidies. There seems to be some themes running through these sites - very "iatrophobic", anti-medicine, anti-pharmacy, "my doctor is out to get me", etc.

these people are trying to cut their benzo dose in equivalents of 0.5mg of Valium monthly, blaming visual hallucinations, painful parathesias, and even partial seizures on benzodiazepine withdrawal... even 18+ months after having stopped.

I am interested if anyone has had patients who swear that their three years on Alprazolam PRN has rendered them totally invalid for the remainder of their lives?

Additionally, what about those patients who need help coming off benzodiazepines? Is a detox stint really appropriate?

 

[nitemagi]

It seems to me that many on these forums/online communities suffer from anxiety (their original DX for which a benzo was prescribed) as well as several comorbidies. There seems to be some themes running through these sites - very "iatrophobic", anti-medicine, anti-pharmacy, "my doctor is out to get me", etc.

Yes. Agreed. It's much of the same attitude that medicine is malevolent and "natural"=benign, which is simplistic and misses much of the science behind it.

these people are trying to cut their benzo dose in equivalents of 0.5mg of Valium monthly, blaming visual hallucinations, painful parathesias, and even partial seizures on benzodiazepine withdrawal... even 18+ months after having stopped.

I am interested if anyone has had patients who swear that their three years on Alprazolam PRN has rendered them totally invalid for the remainder of their lives?

Additionally, what about those patients who need help coming off benzodiazepines? Is a detox stint really appropriate?

I had a pt. who was a high functioning individual, no history of anxiety, was a survivor of cancer, got sx's he thought indicated recurrence. Put on ativan by his PCP (only 1.5mg!), and had a great deal of trouble getting off of it. He got into the Ashton site, and has spent over a year trying to wean himself from 20mg valium, down to 10mg now. Very professional and together individual, but struggles tolerating physical symptoms. I've engaged him and allowed the slow taper because it isn't that much valium, and continued to try other interventions, but his hypochondriasis prevents him from trying any other medications such as an SSRI just out of the fear of any worsening side-effects. Cyber-chondriasis is a real thing and the biggest intervention I could make for him was getting him to stop reading online forums. Like a checking behavior in other anxiety disorders, reading these online forums gives a surface impression for the individual that they're lessening their anxiety by educating themselves, but really it's fueling an obsession and excessive attention to physical sensations, fueled by miseducation from others on these forums.

 

[Ceke2002]

I hope you don't mind me wandering into the conversation, I'm not a healthcare provider, but I am, or at least was, a patient who went through the Ashton Protocol to withdraw from Xanax (I enjoy reading some of the discussions on here, particularly the research based ones). Quick background, I was on Xanax on and off for a little over 8 years for treatment of panic and anxiety disorder, the last four of those I was on a daily average dose of between 8 and 10 milligrams. Initially I made the mistake of trying to jump off cold turkey, I'd been warned not to, but I didn't listen, and I thought I could handle it - one grand mal seizure, and a trip to the ER later, I realised I was wrong. . When I eventually did the Ashton Protocol, under a Psychiatrist's supervision, it was a lot better, but I still had to go through a withdrawal. I don't know if its the same with other patients, or if there's been any research on it, but just personally I found that once the physical withdrawal was over, it still took me several months to feel completely normal. I felt like I was having difficulty processing sensations, I had trouble differentiating between what was a normal state of stress, and what was the start of a panic attack, I couldn't always tell the difference between normal daily aches and pains, and stuff I should be worried about. I went through something similar when I did a methadone withdrawal program after being addicted to heroin, it's kind of like your brain/body needs an adjustment period of rediscovering what baseline 'normal' is actually like (I'm sure you know this stuff already). It did eventually settle down, and I have absolutely no residual or ongoing issues related to either my use of Xanax, or my withdrawal from it. I think though, had I found one of these types of support groups at the time, it would have been very easy for me to believe the 'blame everything on the benzos' rhetoric, because it probably would have made that post withdrawal adjustment period seem a lot less confusing. I can also see how it would then be possible for a person to become mentally trapped in that state if they're constantly surrounded by, and interacting with people that are reiterating that every little twinge is somehow related back to benzodiazepines use and/or withdrawal.

Just a layperson's 2 cents worth from a personal point of view. Not sure if it's helpful to your interests, so feel free to disregard, or take from it what you will. 😎

edited to add - sorry, just one more thing I thought of. I did find after trying to come off Xanax cold turkey that I was very fearful of withdrawal for a while after that, simply because that experience had been so frightening. I needed a lot of reassurance from my primary caregivers when I was doing a tapered withdrawal, because even the mildest of possible withdrawal symptoms had the potential to send me into a total panic of 'Eek, this is going to be bad, really bad, I'm going to have another seizure, I'll end up in hospital again'. It did make me very hyper vigilant, and hyper aware of what I was experiencing, even during a slow withdrawal, that I knew was safe. I wouldn't be surprised if other patients, or former patients felt the same way, or had experienced the same types of feelings. I also wouldn't be surprised if that fear/hyper vigilance/hyper awareness manifested itself post withdrawal as well. I'd personally love to read some research on this myself.

 

[Ibid]

many of the individuals don't recognize common anxiety phenomenon of somatosensory amplification (paying attention and being upset by every little physical sensation as though it's an indication of disease), and misattribution of that to the benzo's themselves.

The amusing and ironic thing about this is that it is highly likely that these same people are likely to accuse the psychiatric establishment of pathologizing everything in sight.

What a gulf.

 

[whopper]

The only exception is a small sub-group who're especially sensitive to doses of medications, often d/t being a poor metabolizer. I've also seen an interesting sub-population who've had chemotherapy who develop sensitivity to meds or conditions they've otherwise never had before.

I've noticed the above, but also a subpopulation that appeared to have some type of immunological exacerbation. E.g. Guillian Barre, Epstein Barr, etc, and these people develop hypersensitivity to meds.

While I've seen plenty of patient message forums addressing this problem, I've never seen any good evidenced-based articles on it.

Some examples, I had a patient that couldn't tolerate any SSRIs except for Lexapro at 5 mg Q daily with a prior Epstein Barr virus infection and she developed chronic fatigue syndrome afterwards, another patient where we've gone through over 20 meds (all the SSRIs, SNRIs, Buspirone, Gabapentin, Lyrica, Vistaril, TCAs, etc), and another guy with bad PTSD, and Guillian Barre, and can't tolerate most meds except at low dosages.

Unfortunately in all the above patients, they were able to tolerance benzos fine. Why they could do that and not tolerate other meds, I don't know. I do not think they are malingering because they don't want benzos and fully understand that using them will make the problem worse in the long-run.

 

[BobA]

For tapering someone off chronic benzo's I've been instructed to first decrease the dose by 25%, and then 10% a month. However, I would probably go faster if they had co-morbid substance use disorders.

 

[nitemagi]

For tapering someone off chronic benzo's I've been instructed to first decrease the dose by 25%, and then 10% a month. However, I would probably go faster if they had co-morbid substance use disorders.

I've seen 25% q2-4 weeks as a recommendation. I would vary based on which benzo and how long they were on it.