This is part four of a series responding to a particularly inaccurate article published in the Aiken Standard by Dr. Greg Smith of Aiken, South Carolina.  Subsequent parts to follow until the entire article is addressed in full. The original article can be read here. Dr. Smith’s statements from the article are bolded and italicized for reader convenience.

Part one of the response can be read here.
Part two of the response can be read here.
Part three of the response can be read
here.

Some patients who have chronic physical or emotional illnesses may take very stable doses of benzodiazepines under a doctor’s care for months or even years and do fine.

While sometimes true, the above is short-sighted. If this is the sole message doctors are relaying to their patients before prescribing a benzodiazepine, they are failing to provide them with the complete picture and the fully informed consent they deserve. A patient’s body doesn’t physiologically know or care if it’s “under a doctor’s care,” so this is irrelevant as to whether that body will develop physical dependence. Likewise, monthly, or even more frequent, fifteen-minute follow-up visits with oversight will not prevent the development of physical dependence if a patient takes the drug past the recommended four-week time period.

While some lucky patients may take benzodiazepines long-term without experiencing physical dependence, tolerance, or withdrawal symptoms, many cannot. According to the benzodiazepine dependency advocacy group Reconnexion, between 50 percent and 80 percent of people who use benzodiazepines for six months or longer will experience at least some withdrawal symptoms after stopping them. And those symptoms may continue long after the drug is out of a person’s system, as Dr. Heather Ashton points out: “Withdrawal symptoms can last months or years in 15 percent of long-term users. In some people, chronic use has resulted in long-term, possibly permanent disability.”

To date, there is no available test or amount of “doctor’s care” that can predict who will fall into the category of “do fine” and who will not. Because of this lack of foresight, all patients should be given fully informed consent prior to the initiation of benzodiazepines or Z-drugs, information that should accurately represent how difficult, time-consuming, and severe the withdrawal syndrome can sometimes be.

It is important to remember that when your body is in this physically dependent state, it is always unwise to just stop taking the medication cold turkey. This must be done by tapering the drug over time, and once again should be done under medical supervision for safety.

“Over time” in this context can translate to many years in order for discontinuation to be tolerable and for the patient to remain functional. Patients should be told this before they are first prescribed a benzodiazepine, and medical providers need to become aware ofthis reality as well—that in order for a taper to be successful, the rate and speed must be determined by the iatrogenically dependent patient, not the doctor.

Oftentimes the medical community’s expectations of tapering and withdrawal do not line up with what is actually required, or what is experienced by their patients. As for patients, when they encounter a withdrawal syndrome they didn’t expect, from a drug prescribed by their doctor, often without informed consent about its risks, it only adds insult to injury when their prescriber tells them that their taper or their withdrawal symptoms are “taking too long.”

From the patient’s perspective, the overwhelming trend seems to be that doctors and other medical providers are good at prescribing benzodiazepines but (save for a small percentage) uninformed on how to get people off of them. In reference to this, this, Dr. Allen Frances, Chairperson of DSM-IV Task Force, professor emeritus and former chair of Department of Psychiatry at Duke University, states (and I quote): “It is important to understand that any idiot can prescribe a medication. De-prescribing a medication,getting a patient off medication, is a high art.”

Because patients who are iatrogenically dependent on benzodiazepines often encounter backlash from the medical community, they’re forced to become “citizen scientists” or “subject matter experts” on benzodiazepine withdrawal as a matter ofsurvival. Online support groups (BenzoBuddies, Facebook groups,Surviving Antidepressants and so on) are filled with tens of thousands of everyday people helping one another with taper plans and patient-developed methods that, through trial and error, have proven over time to be extremely successful, albeit often painful.

If there are medical providers out there who would like to, with an open mind, educate themselves about what benzodiazepine withdrawal syndrome means for many of their patients, or who want to learn about effective patient-controlled tapering methods, they would be welcomed with open arms into these corners of the internet where people go to survive benzodiazepine withdrawal syndrome for lack of anywhere else to turn.

Medical professionals are also invited to contact one of the few benzodiazepine withdrawal charities in the UK and Australia for guidance, as some of these groups have existed for many years, and their members can offer a wealth of information based on their experience supporting and assisting prescribed-benzodiazepine- dependent patients one-on-one.

Addiction is different from physical dependence. When one is taking a stable dose of Xanax one mg three times a day for a severe panic disorder and doing fine, there is no problem. When one takes more pills than the doctor prescribes, shops around for more than one doctor to provide more pills to take, forges prescriptions to get more drug, or buys pills off the street to supplement the prescriptions that the doctor has already written, that is almost always evidence of addiction and is a problem.

First, a thank you to Dr. Smith for being knowledgeable about the fundamental differences between prescribed physical dependence and addiction, as many medical providers are not when it comes to benzodiazepines, a reality that sometimes causes grave harm or added insult. While benzodiazepines abuse exists, most cases of physical dependence are iatrogenic—resulting from as-prescribed and compliant use. As stated above, when dose-escalation by the patient does occur, it may be a sign of pseudoaddiction, spurred by a need to obtain relief from symptoms of prescribed dose dependence, tolerance, and/or interdose withdrawal.

So, the bottom line is, used correctly benzodiazepines are very helpful to a lot of people for a lot of different physical and mental conditions. The problem is that many doctors, primary care, internal medicine, psychiatry and surgical specialists among them, are spooked by all the potential problems with benzos and may not want to prescribe them at all, even when they are most likely the drugs of choice and would do very well for the patient.

In light of all evidence presented here, there seems to be good reason to be “spooked.” If Dr. Smith or other medical professionals still aren’t convinced, I invite them to spend some time in the benzodiazepine withdrawal support groups mentioned above (e.g., Benzo Buddies or Facebook groups), to watch some of the thousands of benzodiazepine withdrawal testimonials on YouTube, to read testimonials by cancer patients and physicians who were made ill by prescribed benzodiazepines, to call or write some of the aforementioned withdrawal support charities in the UK, or to watch the Council for Evidence-Based Psychiatry’s “Withdrawal Advisers” videos featuring professionals who would adamantly disagree with them.

Further examples that may contribute to a legitimate “spook factor” include the many cases of successful litigation for long-term misprescribing and/or negligent withdrawal management, or incidents of persons being left to die in jail from cold-turkey withdrawal when their benzodiazepine prescriptions were denied to them in prison.

Read Part Five Here