Klonopin taper

[Attending1985]

for those of you who have benzo contracts if someone violates the agreement how fast do you taper them?

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[Mass Effect]

I don't understand your question. Are you asking how fast the taper should go? How fast you taper them depends on safety, which depends on the dosage, frequency, and half life of the medication. It's not (or shouldn't be) a punitive thing. It's a safety thing.

Or are you asking how soon after the violation do you start a taper? My answer to that would be immediately. But I don't do benzo contracts. They're pointless. I just monitor with the state monitoring program and if I see they're seeing other prescribers for benzos or stimulants that I don't know about, I tell them that I no longer feel that I can prescribe for them.

 

[SpinDktr]

You should hopefully have supervision in residency to help with this issue. I know in my own residency program, every person had a different way of tapering off benzos different from another person, and there really is no consistent recommendation other than to do so slowly.

Basically the rule of thumb among the prescribers in my program was this (benzos in general):
1. If you want to be nice and it was a minor infraction and they had been on it for many years - 6 month taper
2. If it was a serious violation/diversion/selling/serious abuse/overdose - 4 week taper or inpatient detox if needed.

That being said, clonazepam has a long half life, so it is medically relatively safe to stop cold turkey at low doses. Higher doses is a grayer area, but I still don't do it.

Do you have supervision in your program? I would definitely make use of it if you do. I also don't do contracts, but if you do that should be spelled out in the contract.

 

[Attending1985]

I don't understand your question. Are you asking how fast the taper should go? How fast you taper them depends on safety, which depends on the dosage, frequency, and half life of the medication. It's not (or shouldn't be) a punitive thing. It's a safety thing.

Or are you asking how soon after the violation do you start a taper? My answer to that would be immediately. But I don't do benzo contracts. They're pointless. I just monitor with the state monitoring program and if I see they're seeing other prescribers for benzos or stimulants that I don't know about, I tell them that I no longer feel that I can prescribe for them.

Where I’m practicing we have a policy of random pill counts and uds just like opiate contracts.

You should hopefully have supervision in residency to help with this issue. I know in my own residency program, every person had a different way of tapering off benzos different from another person, and there really is no consistent recommendation other than to do so slowly.

Basically the rule of thumb among the prescribers in my program was this (benzos in general):
1. If you want to be nice and it was a minor infraction and they had been on it for many years - 6 month taper
2. If it was a serious violation/diversion/selling/serious abuse/overdose - 4 week taper or inpatient detox if needed.

That being said, clonazepam has a long half life, so it is medically relatively safe to stop cold turkey at low doses. Higher doses is a grayer area, but I still don't do it.

Do you have supervision in your program? I would definitely make use of it if you do. I also don't do contracts, but if you do that should be spelled out in the contract.

im an attending now and in residency there was much variation in recommendations like what you’ve mentioned. Typically I do a taper over several months but that was based on patient wanting to come off of them. At my current position there’s a high prevalence of opioid abuse so leaving them on benzos while abusing opioids is a safety issue and warrants a faster taper. I’ve seen others taper a dosage of 2 mg bid over two months which is way faster than I’ve ever done.

 

[SpinDktr]

Yes, with the opioid problem this is coming up a lot more; I am no addictionologist, but unfortunately I think most of us have had to become much more adept at dealing with addiction issues. If they are abusing narcotics AND using benzos, I would refer them for inpatient detox. I simply would not take them on as a patient, personally, until they had safely detoxed.

 

[SeniorWrangler]

This depends a lot on their other risk factors, age, heart condition, seizure history, etc.
If somebody is supplementing prescribed benzos with lots of street benzos, then I am going to taper fast and maybe start an anti-epileptic drug instead because they're not likely to actually stop using benzos no matter what you do.

 

[DisorderedDoc417]

This depends a lot on their other risk factors, age, heart condition, seizure history, etc.
If somebody is supplementing prescribed benzos with lots of street benzos, then I am going to taper fast and maybe start an anti-epileptic drug instead because they're not likely to actually stop using benzos no matter what you do.

Klonipin is longer acting, which is to your benefit. I like the protocol laid out by the VA. Take your benzo... convert it to equivalent diazepam, reduce by 12.5% a week until at half the original dose (1month), hold a month, then continue dropping 12.5% a week until at zero. Adjust rate as necessary. Consider adjuncts as needed.

 

[Ceke2002]

When I was under contract with one of my former GPs to do a Xanax taper (that was set up and monitored by a Psychiatrist) I was basically read the riot act before I'd even started. So I was left with absolutely no doubt what would happen if I messed up. If I messed up once, or twice then I would have to wait for the actual date my script was due and suffer through cold turkey until then; mess up a third time and I could find another Doctor's time to waste.

 

[birchswing]

This is the basis for the NICE guidelines and was sort of the epicenter for all advice that followed: benzo.org.uk : Benzodiazepines: How They Work & How to Withdraw, Prof C H Ashton DM, FRCP, 2002

Came across this the other day:
10 tips to help patients through benzodiazepine withdrawal (Written by a physician who herself went through benzo withdrawal)

 

[WingedOx]

Klonipin is longer acting, which is to your benefit. I like the protocol laid out by the VA. Take your benzo... convert it to equivalent diazepam, reduce by 12.5% a week until at half the original dose (1month), hold a month, then continue dropping 12.5% a week until at zero. Adjust rate as necessary. Consider adjuncts as needed.

I've found that patients don't handle the switch to the long-acting well if coming from xanax/ativan. I just gradually lower the dose of whatever they're on. I've had better results doing it this way. Patients on xanax at least tend to be in it for the quick rush of relief that alprazolam gives more than anything else (it works as way to prevent them from every developing anything resembling a coping skill for their anxiety). Klonopin/valium doesn't give them that, so they tend to struggle.

 

[DisorderedDoc417]

I've found that patients don't handle the switch to the long-acting well if coming from xanax/ativan. I just gradually lower the dose of whatever they're on. I've had better results doing it this way. Patients on xanax at least tend to be in it for the quick rush of relief that alprazolam gives more than anything else (it works as way to prevent them from every developing anything resembling a coping skill for their anxiety). Klonopin/valium doesn't give them that, so they tend to struggle.

Wasn’t this thread about a patient on klonipin?

 

[WingedOx]

Wasn’t this thread about a patient on klonipin?

Just responding to a related point about the VA's guidelines. I don't think "longer-acting switches" work all that well in practice.

 

[DisorderedDoc417]

Agree with your reasoning otherwise.

 

[birchswing]

Just responding to a related point about the VA's guidelines. I don't think "longer-acting switches" work all that well in practice.

I don't know what the VA guidelines are, but you definitely can't switch over all at once. There's no real way of determining equivalency without some trial and error (and genetic testing can aid if you're switching to a drug like Valium). The equivalency guidelines between Ativan and Valium vary by a factor of 2x (1:5 vs 1:10). Plus Valium is soporific so switching to an estimation of an equivalent dose could snowball somebody. And if someone responds more to certain metabolites more than others, it can take days for a response to Valium vs. Xanax, etc., even though Valium itself is very fast-acting. Personally, I don't respond to Valium for about several days, and I don't feel a cut for about a week. And the 1:10 ratio is too high for me personally, but it's anticipated with me being an intermediate CYP2C19 metabolizer.

Also if anyone is interested, it is legal for doctors to order from Taperingstrip.org | Savely and succesfully coming off medication if you want to stay on a shorter-acting drug and make small cuts over time. It probably takes a bit of legwork I imagine, but it is legal to import when the equivalent isn't available in the US.

 

[Armadillos]

If we find out someone is doing something egregious like alcohol+heroin+benzo and are on a high standing dose of benzo do we have any obligation to offer a outpatient taper? Or could you just stop prescribing and tell them they need inpatient detox and if they refuse they may die?

 

[st2205]

If we find out someone is doing something egregious like alcohol+heroin+benzo and are on a high standing dose of benzo do we have any obligation to offer a outpatient taper? Or could you just stop prescribing and tell them they need inpatient detox and if they refuse they may die?

You could do whatever you want but the trick is convincing some non-clinical people that you made the right decision in the event that there’s a bad outcome, and I don’t think there’s much of a science on predicting what people may or may not think about that reasoning in those circumstances.

Anyway, I think the idea of giving someone a taper who’s proven to be irresponsible with the medication someone silly. Obviously it’s what I’ve done before, but if I’m taking them off for misuse, I’m presuming they’re misusing the taper, too.

 

[WingedOx]

You could do whatever you want but the trick is convincing some non-clinical people that you made the right decision in the event that there’s a bad outcome, and I don’t think there’s much of a science on predicting what people may or may not think about that reasoning in those circumstances.

Anyway, I think the idea of giving someone a taper who’s proven to be irresponsible with the medication someone silly. Obviously it’s what I’ve done before, but if I’m taking them off for misuse, I’m presuming they’re misusing the taper, too.

I ran into the latter problem last week. Guy who of course got himself hooked on xanax when his (now retired) psychiatrist started him on it as a bridge for his SSRI for panic attacks walked in saying he's "messed up" from it and has been getting it twice a day from friends. I haven't written a script for him in months and when I did he'd burn right through it. I was conflicted if actually writing him a taper was going to be at all helpful or just another source for him to temporarily abuse. I gave him explicit instructions for how to gradually lower his dose, but risk assessment is tricky with these guys.

 

[hamstergang]

Anyway, I think the idea of giving someone a taper who’s proven to be irresponsible with the medication someone silly. Obviously it’s what I’ve done before, but if I’m taking them off for misuse, I’m presuming they’re misusing the taper, too.

I would do it more for the optics than for thinking it makes medical sense. You give the taper so you can show you were giving them a chance to do this correctly. Then, if they call you up saying that they used it all up in one week, you can refer them for inpatient detox with a clear conscience.

 

[Attending1985]

I would do it more for the optics than for thinking it makes medical sense. You give the taper so you can show you were giving them a chance to do this correctly. Then, if they call you up saying that they used it all up in one week, you can refer them for inpatient detox with a clear conscience.

What if the patient refuses inpatient detox or it’s not available. If you educate them on risks if withdrawal and they still overuse then the onus is on them correct?

 

[NickNaylor]

What if the patient refuses inpatient detox or it’s not available. If you educate them on risks if withdrawal and they still overuse then the onus is on them correct?

I would simply provide them adequate warnings that if XYZ symptoms of benzodiazepine withdrawal develop they should present to their local ED as there is a potential for the withdrawal to be fatal. Warning a family member or other close support, if present, may not be a bad idea as well.

Ultimately it is the patient’s choice as to what course of action they take. You cannot control that. All you can do is advise, provide alternative treatment options, and make recommendations that would be in their own best interest. Whether or not they follow those recommendations and subsequently experience harm as a result is not your responsibility if you properly warned them of the risks of failing to do so.

 

[Ceke2002]

There was meant to be a point in that anecdote above, I just forgot to continue it. Obviously coming from a layperson, but if you have a contract in place with a patient, and that patient knows exactly what is expected of them and what the consequences will be for failing to uphold their end of the contract; then if they do break that contract stick to your guns and follow through on whatever consequences were laid out - and especially if you're dealing with benzo use in terms of addiction. Of course I can't give any real advice on how fast to taper, or how to taper a patient off benzos, etc, but in terms of how to respond if a patient breaks a contract for a substance of abuse and/or addiction - again, stick to your guns. The ability of an addict to manipulate those around them in order to get what they want often knows no bounds, so don't play into their hands by caving on what has already been agreed to.

 

[AD04]

Anyway, I think the idea of giving someone a taper who’s proven to be irresponsible with the medication someone silly. Obviously it’s what I’ve done before, but if I’m taking them off for misuse, I’m presuming they’re misusing the taper, too.

For someone misusing taper, what do you think of tegretol or another AED? Sources are conflicting if it works for preventing seizures but it seems better than enabling misuse.

 

[st2205]

For someone misusing taper, what do you think of tegretol or another AED? Sources are conflicting if it works for preventing seizures but it seems better than enabling misuse.

I’d presume the most likely thing it would treat is psychiatrist anxiety. I would not anticipate them taking it.

 

[Blitz2006]

For someone misusing taper, what do you think of tegretol or another AED? Sources are conflicting if it works for preventing seizures but it seems better than enabling misuse.

I had an attending suggest gabapentin 100 mg TID...

 

[NickNaylor]

I had an attending suggest gabapentin 100 mg TID...

Gabapentin has clear efficacy in managing alcohol withdrawal, but I don't puss around with gabapentin doses when managing withdrawal. Most of the studies used doses of 300 mg TID, and for someone with heavy use and/or currently active symptoms of withdrawal, I just start 600 mg TID and warn them that they will likely be sedated. For most folks that I've used this on - either due to alcohol or BZD withdrawal - it seems to work pretty well with minimal additional doses of BZDs for breakthrough.

 

[birchswing]

Gabapentin recently became a "drug of concern" in my state and is now part of the PMP.

 

[Blitz2006]

Gabapentin has clear efficacy in managing alcohol withdrawal, but I don't puss around with gabapentin doses when managing withdrawal. Most of the studies used doses of 300 mg TID, and for someone with heavy use and/or currently active symptoms of withdrawal, I just start 600 mg TID and warn them that they will likely be sedated. For most folks that I've used this on - either due to alcohol or BZD withdrawal - it seems to work pretty well with minimal additional doses of BZDs for breakthrough.

What about for benzo withdrawal. As good response as EToH withdrawal?

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