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Please review the information listed here and put your initials next to each item when you have reviewed it with your provider and feel you understand each statement.
______I understand that I am being prescribed ________________ which is in the class of drugs known as benzodiazepines.
______My provider is prescribing a benzodiazepine for the following condition(s):
_____________________________________________________________________
______My provider has discussed with me all available alternatives to benzodiazepines. (Provider please list below, including nonpharmacologic options)
______________________________________________________________________
______Benzodiazepines are meant for short-term (<2-4 weeks) or intermittent use according to most guidelines. Clinical trials showing their benefit studied patients over a time period of a few months. There are no studies showing convincing evidence of long term benefits.
______The risks of benzodiazepines include (but are not limited to) slowed thinking and reaction times, poor focus, confusion, memory loss, less control of emotions and actions, dementia, depression, weakness, falls and broken bones, car accidents, breathing problems (especially in those with an underlying lung condition such as COPD or sleep apnea), sleepiness/sedation, osteoporosis, suicidal and violent thoughts, tolerance, withdrawal symptoms, physical dependence, addiction, worsening of the original symptoms that were being treated, and increased healthcare costs. For a comprehensive list of adverse effects, please see the pharmacy and/or FDA drug sheet.
______Tolerance to the medication can develop over time, necessitating an increase in dose to achieve the same effect. Patients may also develop symptoms of tolerance withdrawal (withdrawal symptoms that occur even though the dose has not been reduced). Symptoms of tolerance and tolerance withdrawal are often difficult to diagnose, and may be attributed to worsening of the patient’s underlying disease or a new medical condition.
______Physical dependence can develop in a matter of days. This means your body becomes reliant on the drug to function. Withdrawal symptoms will develop if the drug is stopped or the dosage is reduced.
______Interdose withdrawal (withdrawal symptoms between doses) may occur, especially with shorter acting benzodiazepines such as Xanax and Ativan. This issue may be corrected by switching to a benzodiazepine with a longer half life.
______A benzodiazepine should never be stopped abruptly after daily use, as this can result in severe withdrawal symptoms including psychosis, seizures, and death. It can also increase the risk of post-acute withdrawal syndrome (PAWS) and protracted withdrawal.
______A benzodiazepine taper can last anywhere from months to years, depending on the needs of the individual. Benzodiazepines are not available in doses that are convenient to taper and may need to be compounded or divided in order to make small reductions. Benzodiazepine withdrawal syndrome (BWS) can be extremely severe and disabling, with symptoms lasting years in some cases, even with a slow taper plan (5-10% reductions every 2-4 weeks).
______Symptoms of BWS include (but are not limited to) extreme fear/anxiety, tremor, fast heart rate, high blood pressure, agitation, perceptual disturbances, blurry vision and floaters, severe muscle spasm and pain, involuntary twitching/movements, nerve pain, memory problems, loss of thinking ability, loss of ability to do everyday tasks, extreme fatigue, muscle atrophy and weakness, weight gain or loss, hypersensitivity to light and sound, suicidal thoughts, gastrointestinal problems (delayed emptying of the stomach, malabsorption, food sensitivities, diarrhea, constipation, and abdominal pain), tinnitus (ringing in the ears), head pressure/pain, blood sugar disturbances, disrupted menstrual cycle and other hormone problems. For a comprehensive list of symptoms please see: https://www.benzoinfo.com/2017/10/09/common-benzodiazepine-withdrawal-post-withdrawal-symptoms/
______BWS can result in protracted withdrawal and neurologic injury lasting years, and in some cases the damage may be permanent.
______I understand the above listed benzodiazepine adverse effects–including tolerance, withdrawal, and dependence–can occur at any dose of the medication (even “low doses”), and even when taken exactly as prescribed by my provider.
______I understand physical dependence and withdrawal syndrome can develop in the absence of addiction or an “addictive personality.”
______Taking benzodiazepines while pregnant carries a risk of fetal abnormalities and can cause risk to the newborn–including breathing problems, flaccid muscles, and withdrawal syndrome.
______Patients over age 65 have an especially high risk of side effects like falls, fractures, and dementia due to slower metabolism of the drug from aging.
______I understand I should not combine this medication with alcohol, Z-drugs (such as Ambien or Lunesta), other benzodiazepines, opioids, or any other drug that causes sedation. Doing so can put me at risk of overdose and death due to combined effects on breathing. I agree to notify my provider of any new medications that are added to my regimen.
Patient Name: ________________________________ Patient DOB: ___/___/___
Patient Signature: _____________________________ Date: ___/___/___
Provider Signature: ____________________________ Date: ___/___/___
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 experienced 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 slowly tapered 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.
When I was 30 years old, I was having major panic and I can honestly say… Life was hell… I could not go anywhere or do anything . My quality of life was non existent. A psychiatrist put me on .75 a day of Xanax. Almost. Immediately my life started to get improve. 25 years later I still need the same dose. We sometimes forget where we were when we started the medication. The truth is the medication works. It’s a two edged sword like everything else is n life. There is good and bad. I’m thankful there was something available that allowed me to enjoy some of my life. My doctor told me it’s no different than being a diabetic who needs insulin. We are all made differently with different life history. So ask yourself why was that seeking help at the time. Believe me I tried everything before going on Xanax. I knew it could be addictive. So I take my meds and yes I have noticed some memory lapses but how do I know it’s Xanax? It could be the Prozac I’m on. My doctor also told me never to take more than 1 mg a day. I’m not going to! I have found that medical marijuana tinctures works as well and I haven’t done a taper yet using marijuana… but I am going to.
I am going thru hell and was on low dose lorazapam .5 mg 1x daily for 4 weeks and became dependent. Then went to detox and put on phenobarbital immediately and 6 weeks later still severe anxiety ,ear ringing ,fear, etc. Is this protracted withdrawal and how long will this go on? Some good days mostly not so good…going broke and in for treatment. Losing family and boyfriend….worried sick….can anyone help me?
Omg I’ve been on 1 mil a day of kalnopin for 14 yrs because everytime I’ve put myself into detox I’d be shipped out n the major peak of my withdrawal!!! Cold turkey will not work and it’s dangerous! I’ve quit sever times but never felt normal and started taking again around 2 yrs off them each time! No dr can help me taper slowly! I’m desperate for help!!! All I can say is I’ve kicked many habits but this is like no other!! The drs ruined my life and the feeling u hve now goes on and on! Shame on those drs
Karen,
Did anyone help you? I know what it’s like to lose everyone/thing. I hope you are ok and message me back.
Jeanette
I think this consent form is well done. Everything in it is accurate, and needs to be brought to the attention of the prescribed. If I only had a fraction of this info presented to me I most certainly would NOT have taken klonapin. I believed in my prescriber, and trusted she knew what she was prescribing. We all need educated on Benzodiazepines especially the prescribers. I know I will NEVER take another drug without doing my own research first. My life has been a living HELL I am 3 yrs post withdrawal. There isn’t one thing we can do to speed up the healing process. This not only trashed my life, but my whole family as well. Then add insult to injury I was never belived by any professionals. I had side effects while on the drug, and they were totally missed. Change has to happen. I am very greatful to the coalition for all their hard work. They WILL make a difference.
I’m so sorry!! I know what ur feeling all the way around! I’m right were u are!!! Drs ruined my life! My life as a mother!
This form saved me from behing cut cold turkey from my doc so thank u so much I just told her she couldn’t do that cuz she never had me sign this form. She was stunned and prescribed the med. So if ur doc tries to cut u off u tell them u never had me fill out this form saying if I’m cut cold turkey I could die. God bless us all going thru this. Hope this helps it did me thank u for doing this I believe this form will save alot of people from horrors of being n benzo withdrawal
This is wonderful!! How I wish that I would have a warning like this!! I do agree with the previous comment mentioning tinitus. I do wish that it stated something to the affect that many Medical Doctors are Not trained in weaning. Thanks!!
I agree. My medication was changed too quickly and i fell into a deep depression but the doctors at the clinic i go to dont care. For them its just a job. You are reprimanded if you do something wrong. I sometimes battle with bad anxiety but they dont want to help you!!!!
It is really difficult to sue with almost anything regarding the benzos. I spoke to no less than ten lawyers regarding the abrupt cessation of my brother from klonopin. He had been taking it as prescribed for 7 years. He did start to have problems on it though nobody understood it was from the klonopin. He began to drink to mask the physical pain. He went to a detox center where they stopped the klonopin cold turkey and he was never the same afterward. Multiple hospital stays, seizures, a psych ward all within 4 months lead up to his suicide. The saddest part was how bright and capable he was before. He flew helicopters in the Coast Guard, went to top universities and had a family. Klonopin changed him and the detox center absolutely caused a completely horrific mental state for the remaining few months of his life. I’ve never seen anything like it. I’ve gone through reporting the detox facility’s drs to the medical board and I found out at least one of the drs advertised as having an MD doesn’t actually have one. I also found out from a review of the partial med records that someone “witnessed” that my brother took phenobarbital to prevent seizures during the detox, but it never shows up in his lab work. It’s just atrocious what these detox facilities are doing to people on benzodiazepines. I learned that my brother is not the only one that they similarly medically mistreated at this center, but still, they’re in business taking in new unsuspecting people every day. We as a family have basically no recourse. All I can do to hopefully prevent others this suffering is to report them to the proper agencies.
I’ve put myself in detox at the risk of my children many times hopeless!!! They all hve made me stop cold turkey and shipped me on my way within 7 days right when the true withdrawal starts!!! I remain on it cause no dr will help me get off safely!!! I need true help!!!! I relate and hurt with this story
should be banned. I cannot see any justification for these demonic drugs to remain in our Society.
Hi Nancy Orban: Thanks for your info on possible help with Glutamate Magnesium and GABA balance. Will look
into this. Just had a hell of a sleepless night with high ringing…some days it’s at a lower pitch, more tolerable. Like cicadas’ high-pitched sound….
And, in addition to my comment, Lord Montague won a settlement of $1.25 Million dollars. A hit to a few Doctor’s pocket books could possibly help them wake up to the Iatrogenic Addiction and Injury they are causing!!!
Speaking of suing and Doctors settling for millions: Lord Luke Montague sued his London, Eton-educated Psychiatrist for his irresponsible neglect and abuse regarding his long-term prescribing of a benzodiazepine and anti-depressant. Here is a link to Lord Montague’s story and to the website he and James Davies created as a forum for the voices of injured patients. Presently, Cepuk.org is encouraging people to share their stories of injury from anti-depressants for documentation. Patients are now seen as the “Evidence Base.” not Pharma or the APA. http://cepuk.org/2017/01/31/cep-co-founder-luke-montagu-tells-story-daily-mail/
That is nice but lengthy and with all the lengthy shit we sign now days it will just be slipped right in.
The problem is that doctors don’t treat the withdrawals and are taking people off cold turkey.
I was on Clonazepam for over 16 years and did just fine — until one visit the doctor said she wasn’t going to prescribe it anymore, along with hydrocodone I had been on for a longer period with never needing more of both, I was doing fine.
This was March 1st, 2016 – I had NO clue that I was about to enter absolute hell for the next two years before any signs of improvement were seen and I believe my eyesight and brain has been permanently damaged. The entire medical field needs educated, this is a great effort but unfortunately won’t do shit – nothing will happen until one doctor gets his/her ass sued for $ Millions due to forcing a person to Cold Turkey and causing permanent damage – then they will pay attention – one thing that gets a doctors attention is MONEY.
I agree with this user. I have to attend a government hospital for treatment and i’m afraid they dont care about you. Something needs to be done
I wish my brother had been given a consent form like this prior to going on Klonopin. He might be alive today.
I was just informed that my comment was a duplicate. Well for god’s sake, at least print the latest one!! I’m hoping this site is a forum for the Patient’s Evidence Base…and that a patient’s account of their experiences is respected and validated as Knowledge…and not merely tossed off as anecdotal.
This Informed Consent write-up is pretty thorough. from personal experience, one of the most damaging conditions is severe, bilateral tinnitus. For some people, it gradually goes away…but for countless others it becomes a chronic condition, affecting the ability to have a decent sleep. Waking up to high ringing ears makes it extremely difficult to go back to sleep. This is a very disabling, creating a chronic sleep deprivation that affects the ability to function normally in daily life. It is seriously criminal that the crude, destructive, highly addictive chemicals are used so very frequently, for long periods (I’ve people on Klonopin for 10 years!) And withdrawals, even at low doses can be hell!! And Doctors do not have a clue how to properly help a patient withdraw from this Iatrogenic Addiction!!!