As physicians, we are experts at prescribing medications. However, we often fail miserably when it comes to recognizing adverse reactions and tapering medications. It’s something that is simply lacking in our medical training. I have become a victim of this with benzodiazepines, as I detailed in a prior blog post. Benzodiazepines, in particular, are very difficult drugs to taper. I would like to share with you some of the wisdom I’ve gained in the process, so here are ten tips for helping your patient survive benzodiazepine withdrawal.
Disclaimer: I will be addressing patients physiologically dependent on benzodiazepines who are motivated to come off the drug and do not display signs of abuse or addiction.
1. Believe your patient. Often symptoms of tolerance and/or withdrawal can result in the patient being branded a drug-seeker when this is far from the truth. As physicians, we become jaded, but not everyone is an addict looking for a fix. If your patient has been taking their medication as prescribed, please recognize that physiologic dependence and benzodiazepine withdrawal syndrome are real and can present with a host of symptoms. A little validation of their condition goes a long way towards alleviating the patient’s suffering.
2. Taper, taper, taper. Please don’t “cold turkey” or send your benzodiazepine-dependent patient to detox. Just don’t do it. A certain percentage will be fine, but some will suffer a horrific and debilitating withdrawal syndrome that can last years. I have many friends that have suffered brutal symptoms for five years or more after an abrupt cessation. A sensible taper could have prevented this needless suffering. Please don’t play Russian roulette with your patients.
3. Consider switching to a long half-life benzodiazepine. Short half-life benzodiazepines such as Xanax and Ativan can be difficult to taper due to withdrawal symptoms between scheduled doses. A long-acting benzodiazepine such as Valium alleviates this issue. Valium is also lower potency, meaning it’s easier to make smaller dosage reductions. Of course, if your patient is able to taper directly from their current benzodiazepine, this is the simplest course of action.
4. Patient-controlled, symptom-based tapers are best. The process takes as long as it takes, and the key is for the symptoms to remain tolerable by giving patients control of their taper speed. There is no one “right way” to taper, but there are multiple options available. In the end, each patient will need to find their own way out with your excellent supervision, guidance, and support.
5. Adjunctive medications are not necessary but may be helpful in some cases.Unfortunately, the literature is sparse and often anecdotal at best. Very small studies and case reports have shown that drugs such as gabapentin, carbamazepine, and propranolol may help as aids in withdrawal. Trazodone, mirtazapine, and quetiapine may be helpful in some for insomnia. Some patients have reported relief of withdrawal symptoms with the use of CBD oil or medical marijuana. However, not everyone finds adjunctive medication helpful. Depending on the medication, it must often be tapered as well and carries the potential of its own discontinuation syndrome.
6. Encourage coping skills. These are much needed as the symptoms of withdrawal can be overwhelming. Distraction, meditation/relaxation techniques, taking a hot bath, leaving the house for a short outing and going for a walk can be helpful. Some days are so bad that coping skills provide minimal help. On those days the patient must learn to survive, one minute at a time, telling themselves they will get through this round of symptoms because they have survived it before.
7. Encourage acceptance. Tapering and withdrawal can be a long process. One of my friends who tapered before me shared his doctor’s words of wisdom, to “get comfortable being uncomfortable” and “learn not to fear the symptoms.” Acceptance isn’t easy. It takes a lot of effort and continued practice, but it is key to surviving this process and ultimately having a successful taper.
8. Adequate psychosocial support is extremely helpful during benzodiazepine withdrawal. I know many who are going through this process alone, and I have no idea how they do it. Having family and/or friends who can provide help with daily tasks, understanding of the symptoms and emotional support is very important in this process. Please take time to educate family members about benzodiazepine withdrawal and how they can help their loved one through this difficult season in their life.
9. Do not fear the internet. Yes, we all hate “Dr. Google,” but in the case of benzodiazepines, he saved my life. Just spending a little time on the internet, I was able to figure out why I was so ill when many doctors could not. Benzodiazepine withdrawal syndrome is often under-recognized and poorly understood, so when a patient comes to you with information about it they have obtained online, please don’t be arrogant. Take the time to read and listen. It could potentially save a life. In addition, online support groups such as BenzoBuddies and Facebook groups such as Benzodiazepine Recovery were invaluable resources for me in the beginning of my taper. Through these groups, I made many friends all over the world who understand what I’m going through when nobody else can. With that being said, the forums can be depressing and overwhelming, so patients should use caution in the amount of time they spend on them. Now that I’m further along in my taper, I have developed a core group of friends that I can call or text, and I have less need for the forums.
10. Most importantly, provide reassurance. Let your patient know you will support them through this process, no matter how long it takes, and that they will improve with time.
Originally published on KevinMD.com on March 20, 2018.
Christy Huff, MD, FACC is a board-certified cardiologist who resides in Fort Worth, Texas. She attended medical school at the University of Texas Southwestern Medical School in Dallas where she graduated Alpha Omega Alpha in 2001. She completed an internal medicine residency at Washington University in St. Louis in 2004. Her cardiology training was completed at U.T. Southwestern in 2008, with a focus in advanced cardiovascular imaging and noninvasive cardiology. She was in private practice as a cardiologist in Fort Worth from 2008-2011. Following the birth of her child, she made the decision to become a stay at home mom.
Dr. Huff is currently experiencing benzodiazepine withdrawal firsthand after she was prescribed Xanax for insomnia related to a major health crisis in 2015. After developing concerning symptoms and receiving no answers from her primary care doctor and a prominent neurologist, she began to research benzodiazepines and discovered her symptoms were consistent with benzodiazepine withdrawal syndrome. With the help of a local psychiatrist, she is slowly tapering off benzodiazepines using Valium. Christy’s personal experience has led her to realize the dangers of these drugs and the severity of the benzodiazepine withdrawal syndrome, neither of which were emphasized during her medical training. She is an advocate of better education of physicans regarding the dangers of benzodiazepines and how to safely taper patients off these drugs, and stronger regulation of the prescribing of benzodiazopines.
I am on lorazapam, was prescribed not knowing the hell you have trying to get off of it.One doctor tried tapering me to quickly, and it was the most horrible thing I have ever hone thru. I am scared to death. I’m not rich.,so I guess I’ll have this problem till I die.
I am so scared. My doctor pout me on 2mg of Klonopin at bedtime for GAD and chronic insomnia. It has been 12 years. In 2018, my orthopaedic surgeon performed 4 failed total knee replacements due to his malpractice. Adding insult to injury, HE prescribed oxycodone every week for almost exactly 365 days.
In January of this year, I realized I needed to get off everything and well to detox for a 5 day clonidine taper. I got out February 6th. It is now March and I feel horrible. I still have all the physical symptoms (anxiety, chest burning, dizziness, rebound chronic insomnia, etc). I am scared to death because I don’t know f this is normal. No doctor will tell me. In fact I think that all doctors are scared of me at this point since I am demanding answers. I am a lawyer with my own practice. Between the constant knee surgeries, continued withdrawal symptoms, detox, and a residential program, I am facing financial ruin. I can’t work and the insurance company is denying all treatment that I participated in.
Am I normal? Will I ever be normal again??
Jackie- sounds like you have really been through it. I applaud your decision to get clean but a 5 day detox—wow that is really fast. It takes a long time for the brain to heal from long term benzo use. With continued use the brain basically “shuts down” the number of sites that benzos and GABA (your brains chemical that normally stimulates this site) stimulate. A lack of GABA is NOT the problem. I suggest you look to facebook for support groups- there are several. What is generally recommended is converting to a low potency long acting benzo like valium and then tapering only 10% every 2-3 weeks. I think you came off way to soon- My belief that’s youf problem
What is normal again. I’ve been tortured with these benzos for over 20 years.
Dr. Matthew Brink my family Dr. recently cut me off cold turkey. I was prescribed klonopin 2mg. 2× daily for 13 years. Switched from valium 10 mg. 4× daily for 12 years. Went through horrible withdrawal for about 7-10 days. Couldn’t take it anymore saw a psychiatrist he wouldn’t prescribe klonopin. Saw family Dr. last week had panic attack in front of Dr. He just sat there. Pulse doubles, face turns peaked, heart is beating irregular. Again I ask him for a script for my klonopin he says no I don’t write for control substance. The whole time he asks me what’s wrong? I said”I’m having a panic attack.
So until I can find a Dr. That has a “pair” and puts his patients before worrying if he gonna be able to buy that new Ferrari I will continue to buy mine off the streets. I do have a sister whose a pharmacist I don’t dare ask her for anything. That’s how she makes a living. Not to mention 5 years of the number 3 rated pharmacological school in the country.
Scott, please try and find a Doctor or a psychiatrist who will help you taper slowly. Cutting you off cold turkey is out of the question, as I have feared for my life twice in the last year under that circumstance. If all else fails, check into a detox program and throw all financial concerns to the side and deal with them later. Make sure you get a good program though, and stay clear of any that have reviews saying they are an insurance scam! MOST IMPORTANTLY, don’t go to the street because you don’t know what is in that stuff. Their could be Fentanol which is DEADLY. Please look for other sources of help, your Doctor doesn’t get it.
I am a retired nurse who suffered a back injury several years ago and was prescribed Valium 10 mg at bedtime for insomnia and muscle spasms. “This is the BEST muscle relaxer available” … said the neurosurgeon to me.
Taking the Valium was/is the biggest mistake of my life. I feel as if my very soul is missing from my body. I feel weak and very ill.
I have never taken more than the prescribed amount and I didn’t recognize the withdrawal symptoms of ‘tolerance’. I began my own taper two years ago and it is hellish. The tinnitus and short term memory loss are frightening.
I truly fear I will never be the same… I am a 60 yr. old wife, mother, and grandmother. I feel I have robbed my family of ‘really being there’ for them as I am no longer myself.
Thank you, Dr. Huff for your courage in coming forward to share your experience of the horrors of these drugs. I hope and pray other physicians will sit up and take notice.
Kaye, I too am a Mother of 2, wife and hard working career woman who is now 50, recovering from many years of being prescribed xanax for generalized anxiety. I too feel like it took part of my soul and stood in the way of my being present for everything I should have been with my family. I was transitioned 3 months ago from 3mg per day of xanax to a quick taper of 3/2/1 mg of ativan. When I was cut off over a year ago cold turkey from xanax by my Doctor, I went into a hellish withdrawal complete with muscle spasms, vomiting, chest pains, heart palpitations, and extreme fatigue and believed I was going to die. I am still weaning off the ativan now and experiencing some lesser version of the symptoms I experienced cold turkey. I have had to stick with the doctor that cut me off over a year ago because he is the only one willing to continue to prescribe ativan to me while I continue to wean, because I can’t currently afford a psychiatrist who may or may not even do the same thing for me. My recovery is slow but consistent, however it is still a struggle, given the amount of time I was on xanax and how much I was being prescribed. I wish you all the best and I know this can be conquered. We can’t feel any more guilt for following the advice of our doctors because we are now fully responsible for the rest of our lives, and our families will benefit greatly from what we are able to do now, vs us wasting time worrying about the past. My best to you!
Thank you for sharing, Shari. I am currently searching for a doctor who is willing to help me with this taper. Somehow we will get through this. Best wishes to you as well.
I am a nurse which can be very stressful and demanding.my pcp started me on Xanax 1mg three time a day for anxiety 9 years ago.im currently having tolerance withdrawals which are pretty bad.my doctor doesn’t seem to understand or care to learn. I’m attempting to taper any advice
Karen, I was on the same dosage, and had been prescribed xanax many years back for my anxiety. I hope you are on a gradual taper. Back in November I went to a treatment facility where I was switched from the 3+mg xanax to ativan, starting with 3mg for 5 days, then 2, then 1mg. over a 10 day period. Three months later I was down to 1mg ativan and have recently dropped to .5 per day, which is still causing me symptoms but not as bad. If there is any advice I can give you, it would be to keep looking for a doctor who does get it. You need someone who will continue to prescribe a less potent dosage of another benzo until you are in the clear. Personally I had no success trying to wean off the xanax itself because of my extreme dependence toward it, rather, I have been able to wean off the ativan gradually because I do not get any “euphoria” from it, thus it is easier for me to stay on a regimented dosage and decrease it over time. I was a defenseless prisoner to “popping” the xanax “as needed” which was around the clock, until I was switched to another benzo with NO access to xanax whatsoever. It has been a difficult battle but I now see what xanax was doing to my life, and I will never turn back. Please be patient with yourself, and above all do not try and go off too quickly and find the right doctor or psychiatrist who will support your recovery by believing that you want to taper and continuing to prescribe until you are safely ashore.
Thank you Dr Huff for your poignant article on
Benzodiazepine dependence and addiction. My wife currently has all the symptoms of benzo withdrawal. She has been on Xanax for the past 20 + years initially prescribed by me in my ignorance. Of course she developed tolerance. I am trying to help her. She is not at the point that she wants to attempt gradual reduction. She is 81 years old and has many symptoms of withdrawal with all negative workups. I will continue to encourage her and support her. At the present time I do as much as I can for her. Thanks for your helpful article.
I am having withdrawal after being g floxed by cipro..I am taking clonazepam.
I am going to the doctor today to have her switch me to valium.. this I fo is very helpful.. thanks..
It’s great that your sharing your experience if only other doctors would be open to learning more about this. it seems like only if the doctors experience withdrawal from benzos they understand what we are going through. I don’t know why they don’t want to listen and learn from the doctors that are or were going through the suffering of withdrawal first hand because they don’t want to listen to the patients they prescribe benzos to. hope that other doctors are reading this. God bless all benzo sufferers
Paul, in some cases I have found that doctors who originally prescribed benzos have been recently informed they must cease and desist in prescribing them, and some who were all so readily dispensing these drugs in the last 3 decades are now treating those who are dependent like street addicts. Some of us who have been looking for help have been treated poorly by the medical profession, and have been left to our own to figure this out and search for resources to get us through withdrawal. I am hoping there will be more education for the medical profession going forward as to the struggle and potentially deadly withdrawal patients are facing that have fallen into the benzo and/or opiod trap.
I used and abused benzos for insomnia for 30 years. The last 12 years they were legally prescribed….reputable psychiatrist. Over the years I had many odd, painfull, scary symptoms. I soungt medical advice. I was told I might have MS, CFS, Fibromyalgia, Parkinsons and many other things. I knew I felt awful most of the time. My health gradually slipped downward. I began falling a lot. My weight dropped from 125 to 89 lbs. I broke several major bones in those falls and spent too much time in Rehabs. My Primary Care doctor finally thought he had figured it ouy and called my psychiatrist. Between the two of them they decided to force me into a Detox Program to go cold turkey.
We all know this isnt the right or best thing to do. But with a very few people, it just might be their only hope of a normal healthy life without benzos. This is true about me. My acute withdrawal was so horrendous I still cannot quite describe it. Then it very slowly morphed into just outright misery that lasted about 4 years. The only thing that helped me was finding information and support on BenzoBuddies. Once I began to slowly understand that I had NOT gone insane, I started learning how to cope with my hundreds of symptoms. The support I got there was just tremendous.
I applaud all of you who are trying to make physicians more responsible when it comes to benzos.