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 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.
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
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..
P.S. Folic acid/folate*, vitamins M*B-12, D and K, biotin (grossly depleted), calcium, magnesium, melatonin, CoQ10, glutathione and maybe more nutrients. (Armstrong, Cass, Code, Cohen, Crocker, Dean, Harper, Rain, LaValle, Pelton) I can’t remember all names, as some posted online, plus I spoke with brave souls while taking sloppy notes in addition to information from books. I was dealing with living in the hell’s narthex that was my benzo withdrawal, even though it was a titrated one. Being an hyperspaz didn’t help things, and neither did being a damaged, dumbed-down, disinhibited cariacature of myself. A nail-biter all around. Wow, I’m getting ticked off again just from writing this comment.
I have great appreciation for the lifesavers who have disseminated such valuable information, and my eyes rolled back in my head when I saw folic acid, nitric oxide uncoupling, tetrahydrobiopterin/BH4…, etc. OOHHHMMMM!!!
I suggest buying the very valuable books on the subject,using keywords “Benzodiazepines deplete” and such, and having a very serious discussion with your physicians.
Best wishes and prayers. Courage to you.
Thank you for this highly-empowering educational article, Doctor Huff, and I wish I’d had the knowledge back then…
Something came to mind again while awakening this morning (happening a lot now and a bit unsettling, but has helped to save my life over time)which is a question I would like to ask medicos.
Benzodiazepine: Oxygen thief????? Hence a lot of the symptomology?
What is the effect of benzodiazepine drugs on the production of oxygen in the body, since it depletes quite a list of vital nutrients? Hyla Cass, M.D. and Suzy Cohen, RPH give good lists of those nutrients in their books Supplement Your Prescription: What Your Doctor Doesn’t Know About Nutrition, and Drug Muggers, as do others such as Carolyn Dean, M.D. and N.D.
The lists are alarmingly long. These co-factors, enzyme facilitators, transporters and things which are beyond my scope of understanding do things, and I enjoyed reading the abstract of ‘How chronic administration of benzodiazepines leads to unexplained chronic illnesses: An hypothesis’ by Stephen LaCorte, J.D. re the NO/ONOO cycle, as my initials are NO and NO needs NO sans ONOO. 😉 Nancy Orban needs Nitric Oxide sans peroxynitrite. It has helped that my supportive hero of an husband Tom troubleshoots for a company which manufactures oxygen equipment, and we’ve had many a conversation about this question.
Mr. LaCorte’s article spoke to this severe Prinzmetal’s Variant Angina patient whose endogenous Arginine is inadequate for her needs. Citrulline and co-factors/antioxidants (line upon line; precept upon precept) are now dealing beautifully with my coronary needs, but re 17.5 years of Xanax and calcium channel blockers (25-75% interaction-credit Alesandra Rain-and CCB’s don’t work for up to 60% of PVA patients) when it comes to a med-damaged GIT/uro-renal, much more healing is needed.
So, what happens to the cells that make up the organs, that comprise the systems of the body when they are depleted of electrolytes, co-factors, transporters and other, plus have their mitochondria poisoned? What can anyone, let alone a PVA patient expect from that situation, especially when taken long term?
I would be very interested in the replies of the leadership and readership of BIC re this issue. I consider all of you to be a networking brain trust of the highest order.
I also believe in a beneficent Creator whose means of healing have been largely bastardized by greedy entities to the great detriment of medicos and their patients. I can only imagine what my brother Steve would be feeling re his patients if here now, and I miss talking with him. He taught me much. He personified doctor-as-teacher, would have been appalled by this situation, and would have loved the BIC.
While I understand that it’s not o.k. to give or receive medical advice on this website and am doing neither, what about my question? Anyone?
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
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.