Tapering off Benzo's?

[ryerica22]

Do you guys have any general strategies you use? I'm getting patients who have been on Xanax their whole lives and I have made it clear to them that I will no longer be continuing the medication as they are also receiving Opioids. A few of the patients have already complained and left the clinic as their PCP's would be more than willing to refill their medications.

However, I have been trying to dose them on an equivalent version of Klonopin and taper 25-50% every 2 weeks. Am I being too aggressive?

I am only a resident but I just don't feel comfortable prescribing Benzo's to a population that is heavily involved with Alcohol and also receiving Opioids.

Thanks for any feedback.

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[birchswing]

However, I have been trying to dose them on an equivalent version of Klonopin and taper 25-50% every 2 weeks. Am I being too aggressive?

Yes. If you're saying someone has been on Xanax for life and you take them off in 1-2 months, that is too fast.

I would look to the Ashton or NICE guidelines.

One point in getting off benzodiazepines is that it improves mental and physical health. If you go too quickly, you run the risk of having opposite outcomes, with protracted withdrawal syndrome secondary to kindling. The patient may be off the benzo, but the disease caused by the benzo can last years or even indefinitely. The point is to get off and stay off in a way that minimizes long-term problems.

Klonopin is not an easy drug to taper either because of its high potency. The Ashton manual and NICE guidelines suggest Valium. However because of its soporific effects crossing over all at once is not a good idea.

The part about alcohol is just plain dangerous. I don't understand why they would continue taking alcohol and benzodiazepines at the same time, let alone mixing benzos and opioids.

It seems that your rush to get patients off quickly may be due to the patients not understanding or willing to not mix drugs that could very easily cause respiratory failure. My thinking comes from what is the best way to discontinue a benzodiazepine, which may be a different place than where your thinking comes from given that benzos/alcohol/opioids seems like a train on a collision course.

In terms of the safety of discontinuing a drug, it's physically safer and has less long-term ramifications to stop opioids more quickly than benzodiazepines or alcohol. So maybe start there? But I don't understand why alcohol is in the mix at all. If it's daily alcohol use they should be detoxed, no? Where presumably the level of benzodiazepine would be titrated to the withdrawal of alcohol and then the level of benzodiazepine titrated down more as allowed. Alcohol just seems like it should be eliminated and then a non-starter after it has been.

I am a patient. These are my thoughts.

The NICE guidelines are region blocked but you can see them here:

Benzodiazepine and z-drug withdrawal - NICE CKS

 

[NickNaylor]

A goal of a total dose reduction by 50% in 2 weeks is way too aggressive IMO. Most guidelines I’ve read recommend decreases by 10% over various periods of time - anywhere from 10% every week to 10% every month. Most guidelines also suggest holding at 50% for a period of time and that discontinuation of the second 50% of the dose may (will in my experience) take longer than the first 50%.

I have a patient that has been on alprazolam 1 mg QID for an unclear amount of time - at least several months. I have been tapering her total daily dose by 0.5 mg each month; I essentially cut one of the doses in half with each 30-day fill. This is probably overly slow and conservative, but it has gone reasonably well.

There are a lot of factors that go into this. For example, a patient on clonazepam 0.5 mg BID may be able to cut their dose by 50% with limited ill effects and discontinue shortly thereafter. Total daily dose, length of use, psychological factors, comorbid diagnoses, etc. etc. will all tie into your strategy. In general, I would try to focus less on as rigid schedule and more on the overall goal and be able to be somewhat flexible while always reiterating that the goal is to reduce and discontinue.

 

[splik]

well you have to figure out your own comfort level, but you are not going to get very far if you try and steal people's transitional object from them in their first session. patients need to know that you care first. discussing your concerns and providing education about risks and adverse effects is helpful. either patients will be "wow! I didn't know that, get me off these things!" or they will accuse you of being a liar (like their father) or withholding and uncaring (like their mother) etc.

Obviously if someone has an alcohol use disorder as well i would be more concerned. ideally you would want to do an inpatient detox for these patients but that is often not possible. we can be more aggressive in that setting.

while the above is correct in general, in patients who are actively abusing alcohol and benzos to the point of concern about risk of overdose, then yes you can be aggressive about tapering off. you can't just take away the drugs though, you will need to use something like gabapentin to help them taper off (and may also be helpful for alcohol detoxing too). the goal may not necessarily be to taper off completely. sometimes patients get stuck on a small dose because its really hard to wean off the very last bit. also clonazepam is much more risky than Xanax in opioid using patients!

the other problem is that patients who've been on benzos for life often do not benefit much from SSRIs/SNRIs or buspirone.

the ashton manual and NICE guidelines above are excellent for patients who have become iatrogenically dependent on benzos. they are not helpful for patients with polysubstance use disorders and addictive behavior or antisocial patients however, which is where more aggressive tapering may well be necessary.

 

[thoffen]

There is a difference between detox and planned discontinuation. For the latter, physiologically the first jump down 50% can be quick, however it may not be a good idea. Splik's use of the words transitional object are appropriate here. Sometimes if you make a very clear conservative plan with the patient for the next step but give them the freedom to choose to go a little more aggressively if they feel comfortable, it can really speed things up. Don't let them go fast enough to put them into withdrawal, mind you, but it serves the purpose of communicating you won't take that teddy bear away. If it is their choice, it's a lot easier.

 

[MaximusMDPhD]

N Engl J Med. 2017 Jun 15;376(24):2399-2400. doi: 10.1056/NEJMc1705239

 

[BGDino]

I work in an inpatient detox unit in Australia and we rarely start any higher than 40mg diazepam daily on day 1. Then we cut by 5-10mg every 2-3 days depending on how they tolerate it. A big part of it is preparing them for the reality that they’re not going to feel comfortable.

When doing it as an outpatient on the other hand I’ve cut by the same amount per week-month, though if their use was high would have admitted them to an inpatient unit to stabilise on <=40mg daily first.

You’re right that EtOH + BZD + opioid = ☠️. I’d be saying detox from EtOH/stabilise BZD and look at substitution treatment for the opioids to get a bit more regulation and predictability.

Just how we do it in our neck of the woods...

 

[birchswing]

I work in an inpatient detox unit in Australia and we rarely start any higher than 40mg diazepam daily on day 1. Then we cut by 5-10mg every 2-3 days depending on how they tolerate it. A big part of it is preparing them for the reality that they’re not going to feel comfortable.

When doing it as an outpatient on the other hand I’ve cut by the same amount per week-month, though if their use was high would have admitted them to an inpatient unit to stabilise on <=40mg daily first.

You’re right that EtOH + BZD + opioid = ☠️. I’d be saying detox from EtOH/stabilise BZD and look at substitution treatment for the opioids to get a bit more regulation and predictability.

Just how we do it in our neck of the woods...

I'm not saying this doesn't work, but as someone who is halfway through a taper, I don't feel a cut in dosage of diazepam for 1-1.5 weeks. I have a polymorphism where I pass diazepam a bit more slowly than most, but even for most people I'm not sure I understand cutting ever 2-3 days if you wouldn't even know the effect of cuts prior to that.

 

[Mass Effect]

Alcohol just seems like it should be eliminated and then a non-starter after it has been.

If only it was that easy. Believe me, most practitioners would love to eliminate alcohol from the lives of many of their patients. It doesn't work that way. That said, I like that you label all your posts as a patient as opposed to pretending to be someone in the profession. Perhaps put that label at the beginning of your post? I didn't realize you were a patient until I read through your post and I think for threads such as this, which are asking medical questions, that's a very important distinction.

 

[WingedOx]

I'll go against the grain and say I've had better success in the outpatient setting by NOT switching to longer-acting benzos when tapering down off xanax initially. Later on, I can consider it if they're receptive, but for the most part I start by gradually cutting down the alprazolam dose, usually 25% and see how well they tolerate it. I've had a lot of 2 mg TID patients come in and in general they don't notice much discomfort if I have them try 1.5 TID initially.

Multiple dose xanax patients tend to notice the fluctuations in their anxiety as the med comes in and out of their system more than they notice the sheer amount going in/out. Adding an additional step of changing to klonpin just seems to make patients more resistant since it isn't what their body has been used to.

 

[Liquid8]

I'll go against the grain and say I've had better success in the outpatient setting by NOT switching to longer-acting benzos when tapering down off xanax initially. Later on, I can consider it if they're receptive, but for the most part I start by gradually cutting down the alprazolam dose, usually 25% and see how well they tolerate it. I've had a lot of 2 mg TID patients come in and in general they don't notice much discomfort if I have them try 1.5 TID initially.

Multiple dose xanax patients tend to notice the fluctuations in their anxiety as the med comes in and out of their system more than they notice the sheer amount going in/out. Adding an additional step of changing to klonpin just seems to make patients more resistant since it isn't what their body has been used to.

I use a similar approach, aiming for an initial reduction in total benzo use rather than being too rigid and insistent on patients not being on any alprazolam at all. Have found that it's a bit easier to get patients to buy in, too.

The following isn’t something I’d recommend or do now, but I had one case as a junior where I took an inpatient off Xanax 6mg/day in about 2 weeks, converting to valium around when he got to the halfway mark. It was quite an unusual situation: my supervisor at the time was very laid back/hands off allowing me to run with it, the patient was willing to come off the medication, and had stopped cold turkey in the past without any withdrawal symptoms. Would check on him each day for signs of withdrawal, and aside from some mild symptoms after the first drop to 5mg it went well.

Nowadays, I wouldn’t use such an aggressive regime.

As others have pointed out, you can go a bit harder earlier on, especially if you are dealing with larger quantities, but you’ll usually have to slow down about half way. A lot of guidelines talk about converting to a long acting benzo and a 10% per month reduction which is fairly safe for outpatients, but it is possible to go quicker depending on other patient factors and readjust later if required.

On a slightly different note some patients are eager to come off and may do so on their own accord too quickly which has its own set of problems. Had an interesting case last year who was initially on Clonazepam 4mg/day, but he found it helpful so he decided to increase it to 6, 8 and 10mg, I remember not being particularly pleased when I reviewed him, but had already planned an admission to change his antidepressants in the next few days. He was fine with reducing the clonazepam dose, and I’d suggested a drop to 8mg with the rest to follow while under observation in hospital. Two days later he comes for the admission, and he’s decided to cut it down straight to 2mg leaving me freaking out that he might have a seizure.

 

[Armadillos]

From a medico-legal standpoint are you under any obligation to offer an outpatient benzo taper if you discover a pt has been misleading you and are doing dangerous stuff like a ton of drinking/opiates ontop of the benzos?

My natural tendency would to stop prescribing completely and tell them they need inpatient admission for detox, and may die if they decline. I wouldn’t feel safe writing even a taper for some hypothetical patients, but not sure what a jury would think.

 

[WingedOx]

Not sure about medico-legal, but if they're lying to me, that's an instant taper off from a keeping your own sanity perspective. There's no benefit to me as a clinician to continue prescribing to them and certainly no shortage of problems for them. More than likely these patients are going to simply find another provider the instant you tell them it's taper time, but if you document the hell out of the encounter and agree to continue working with them and provide the appropriate taper/alternative therapy you'll have covered your ass appropriately. You really don't want to be the one caught with the hot potato of an active benzo script when an adverse event happens. I use a "I'm sorry, but I can no longer consider it safe to continue to prescribe this for you given your repeated dishonesty. I'm unable to trust that what you are reporting to me is honest and true which makes your risk of death or other morbidity inappropriately high due to the fact that I need to be aware of all substances you put in your body if I'm continuing to prescribe you controlled substances and I cannot in good conscience put you at that level of risk," type of line.

 

[Mass Effect]

Had an interesting case last year who was initially on Clonazepam 4mg/day, but he found it helpful so he decided to increase it to 6, 8 and 10mg, I remember not being particularly pleased when I reviewed him, but had already planned an admission to change his antidepressants in the next few days. He was fine with reducing the clonazepam dose, and I’d suggested a drop to 8mg with the rest to follow while under observation in hospital. Two days later he comes for the admission, and he’s decided to cut it down straight to 2mg leaving me freaking out that he might have a seizure.

You guys can plan admissions to change antidepressants? That's pretty cool. Patients at my hospital have to be acutely ill to get an admission. Things like med adjustments/switches are done outpatient.

From a medico-legal standpoint are you under any obligation to offer an outpatient benzo taper if you discover a pt has been misleading you and are doing dangerous stuff like a ton of drinking/opiates ontop of the benzos?

My natural tendency would to stop prescribing completely and tell them they need inpatient admission for detox, and may die if they decline. I wouldn’t feel safe writing even a taper for some hypothetical patients, but not sure what a jury would think.

I do outpatient tapers. You can't stop prescribing completely. That would be dangerous, unless they go straight from your office to detox, which most are not going to do. Unless they come in intoxicated or I have a strong case to send them to involuntary detox, I start the taper with the understanding I will no longer prescribe controlled substances to them while they're doing this. Also, FYI, A LOT of patients are on opiates in addition to benzos. I get patients like this all the time. They get their opiates at the pain clinic and benzos from the PCP.

 

[thoffen]

From a medico-legal standpoint are you under any obligation to offer an outpatient benzo taper if you discover a pt has been misleading you and are doing dangerous stuff like a ton of drinking/opiates ontop of the benzos?

My natural tendency would to stop prescribing completely and tell them they need inpatient admission for detox, and may die if they decline. I wouldn’t feel safe writing even a taper for some hypothetical patients, but not sure what a jury would think.

You have a duty, but not to offer that specific intervention or to offer an alternative if your intervention is refused. Certainly you need to justify your refusal to offer the benzo taper if requested instead of inpatient detox, which can be done due to ongoing hazard of perpetuating abuse, risk of med/EtOH combination, facilitating further avoidance of the needed treatment. However, you can't simply let them walk out your door either. If they are imminently unsafe, hospitalize them, and otherwise they need to be well-informed of the risks of refusing the recommended treatment and your recommendations when they need to get emergency care if they start to withdrawal. And you can't abandon them as patients. You can say you need them to get other treatment, but you have to assist them in finding an alternative and be available until that alternative is established. Of course you must ensure they have capacity to refuse the treatment offered. If you are concerned enough, you might contact outside supports and do so against their will if they don't have capacity. If there is no one, and there is not capacity, and there is not imminent risk to justify involuntary commitment, you have to do your best to pick the safest course of action that they accept and implement that. Getting supervision from a colleague is always a great way to minimize potential liability when you are stuck without any options you are comfortable with. Of course none of this counts without documenting it.

For abandonment concerns specifically, a patient can avoid connecting to alternate outpatient care indefinitely. I'd like to hear other's chime in on this. I think it's reasonable to establish a limit on continuing treatment duration which is sufficient for them to make a connection if they choose and to be available to assist in getting them to emergency treatment if needed beyond that limit. I recently had a patient whose past doctor was prescribing 3 controlled substances across state lines for 9 months before saying no.

 

[WingedOx]

However, you can't simply let them walk out your door either. If they are imminently unsafe, hospitalize them, and otherwise they need to be well-informed of the risks of refusing the recommended treatment and your recommendations when they need to get emergency care if they start to withdrawal.

FWIW, The ability to do involuntary commitment due to danger from substance use can vary by state, as far as I'm aware. I'm pretty sure it's a no-go where I'm at, though it's been quite a few years since I've had to manage a case that fell into that category.

 

[hamstergang]

For abandonment concerns specifically, a patient can avoid connecting to alternate outpatient care indefinitely. I'd like to hear other's chime in on this. I think it's reasonable to establish a limit on continuing treatment duration which is sufficient for them to make a connection if they choose and to be available to assist in getting them to emergency treatment if needed beyond that limit. I recently had a patient whose past doctor was prescribing 3 controlled substances across state lines for 9 months before saying no.

I don't know about elsewhere, but in NJ you can fire a patient with 30 days notice according to the state medical licensing board.

 

[thoffen]

I don't know about elsewhere, but in NJ you can fire a patient with 30 days notice according to the state medical licensing board.

A quick search shows that it varies by state, with some giving a specific time and others saying "reasonable" and that 30 days is generally considered reasonable. Even with a specific number given by law, I wonder how reasonable that is for certain patients with limited access.

 

[thoffen]

FWIW, The ability to do involuntary commitment due to danger from substance use can vary by state, as far as I'm aware. I'm pretty sure it's a no-go where I'm at, though it's been quite a few years since I've had to manage a case that fell into that category.

This is definitely worth noting, as are any laws in your state RE: provision of emergency or urgent medical care for a patient who lacks capacity.

 

[clausewitz2]

FWIW, The ability to do involuntary commitment due to danger from substance use can vary by state, as far as I'm aware. I'm pretty sure it's a no-go where I'm at, though it's been quite a few years since I've had to manage a case that fell into that category.

We routinely get involuntary commitment petitions overturned because petitioners often feel the need to emphasize substance use in their testimony. We now coach people a bit when petitioning to keep things factual and maybe not talk so much about how their husband/daughter/elderly father was drinking or snorting.