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Forced Switching or Stopping

Often due to new information on the state and federal level about benzodiazepine risks, often frequently when mixed with opiates, along with increasing concerns about benzodiazepine’s impact on the elderly, many prescribers decide to suddenly stop prescribing benzodiazepines, even to their compliant, physically dependent patients.  A secondary issue is prescribers forcing their physically dependent patients to switch their benzodiazepine to a different one they deem “safer”.

This response by prescribers is very dangerous as benzodiazepine cessation is unpredictable, with potential damage lasting for years, sometimes even leading patients to their deaths. Most prescribers are not adequately trained in safe benzodiazepine practices. Because of this they may force overrapid switching, tapers or sudden cessation. Even with safe, patient led methods, some patients will still become disabled long term, harmed or even die from switching or stopping their prescribed benzodiazepine.

The issue of forced benzodiazepine switching is common. Prescribers frequently demonize one benzodiazepine like Xanax (alprazolam) or Valium (diazepam), while still heralding the safety profile of another benzodiazepine like Klonopin (clonazepam) and Ativan (lorazepam). These alleged safety profiles are, to put it simply, the result of deceptive pharmaceutical marketing strategies in the 1970s and 1980s. The reason for Valium’s poor reputation today is due to its early success in the market. Serious concerns about physical dependence and withdrawal were emerging. As explained in A Brief History of Benzodiazepines

In 1975, La-Roche began marketing clonazepam (brand name, Klonopin); two years later, Wyeth Pharmaceuticals released lorazepam (brand name, Ativan).

Both drugs were marketed to doctors and the public as “different” from Valium — safer, faster-acting, requiring much lower dosages, and carrying less risk. But the new drugs’ similarities with Valium were more important than the differences accentuated by the drug makers, who now eschewed the old label “tranquilizer” altogether, in favor of the new umbrella-term “anxiolytic.” This new rubric falsely suggested an entirely new class of drugs, with a fundamentally different neurochemistry. Their lower dosages, meanwhile, masked the new drugs’ dramatically increased potency: 1 milligram of clonazepam (Klonopin) and alprazolam (Xanax) equals roughly 20 milligrams of Valium.

In 1979, Massachusetts Senator Ted Kennedy led a Senate hearing into the dangers of benzodiazepines, of which Valium was still the best known. Ironically, Valium’s growing notoriety helped ensure the hearings failed. Rather than produce legislation to head off the growing crisis, the hearings were dominated by an industry narrative in which Valium played the fall guy — the “scary tranquilizer” — while the new and rebranded benzodiazepines coming onto market (Xanax, Klonopin, Ativan) were heralded as “good anxiolytics.”

Many patients seek Valium to taper, as it is required to follow the Ashton Manual, which is one method of safer benzodiazepine cessation. Xanax concerns tend to be centered around its short half life, which could also be said about Ativan, as well as Xanax’s popularity in both the mainstream media and with illicit drug users. 

No real scientifically sound rationale exists behind demonizing one benzodiazepine while still prescribing the other. In fact, of all the benzodiazepines, Ativan carries the strongest language in the FDA’s Prescribing Guidelines, warning against the following: prescribing past 2-4 weeks, about withdrawal symptoms, and against abrupt cessation. And Klonopin (clonazepam), one of the nitro-benzodiazepines, has actually the highest incidence of adverse effects in the benzodiazepine-harmed community. Withdrawal symptoms from Klonopin also increase markedly with accumulation of the drug, much of which is due to action of the inactive metabolites as well as the parent drug.

While all benzodiazepines are pharmacologically similar, some of them bind to different benzodiazepine receptors (e.g., Klonopin binds tightly to central-type benzodiazepine receptors) than others. This variation in binding can, in some patients, cause them to go into withdrawal should their benzodiazepine be switched to a different type. To switch safely a stepwise crossover is recommended. Many prescribers are unaware of the need for a slow crossover. Some also do not understand or are unaware of benzodiazepine equivalents and will try to switch a patient from a much higher dose of, say, Xanax to a much lower dose of, say, Klonopin; when in fact the two are 1:1 equivalent (1mg Xanax = 1mg Klonopin = 20mg of Valium).

While the above scenarios—being forced to switch benzodiazepines, being offered less than the equivalent, and not being allowed to do a stepwise crossover—can cause devastating withdrawal-inducing and sensitization of the nervous system (as described in kindling) problems for some patients, an even worse scenario is when the prescriber refuses to prescribe anymore at all to a patient that is already physiologically dependent due to their long-term prescribed use. 

While it is commendable that a medical prescriber wishes to no longer prescribe these potentially dangerous drugs to their patients because they feel the risks outweigh the benefits, it is medically negligent to refuse to prescribe for someone already physically dependent because of the risks of a severe withdrawal reaction. The time to refuse to prescribe benzodiazepines long-term or at all was before the patients were made iatrogenically physically dependent on them, not after. When a prescriber does this to a compliant patient, to the patient it feels like their doctors trapped them in a cobweb (often without informed consent) and now is refusing to assist them in untangling their way out. It is appreciated that some medical professionals inherit patients that were made physically dependent on benzodiazepines by another prescriber and who are not responsible for causing the problem to begin with, but the patient’s plight remains the same.

According to the world’s leading expert in benzodiazepines, clinical research scientist and neuropsychopharmacologist Dr. Heather Ashton, D.M., F.R.C.P out of the UK:

There is absolutely no doubt that anyone withdrawing from long-term benzodiazepines must reduce the dosage slowly. Abrupt or over-rapid withdrawal, especially from high dosage, can give rise to severe symptoms (convulsions, psychotic reactions, acute anxiety states) and may increase the risk of protracted withdrawal symptoms. [emphasis added] Slow withdrawal means tapering dosage gradually, usually over a period of some months [for some more-sensitive patients whose body requires them to go slower, it can take some years].

Dr. Ashton, speaking to physically dependent patients prior to attempting withdrawal:

The advantages of discontinuing benzodiazepines do not necessarily mean that every long-term user should withdraw. Nobody should be forced or persuaded to withdraw against his or her will. In fact, people who are unwillingly pushed into withdrawal often do badly [emphasis added]…The option is up to you…Your doctor’s agreement and co-operation is necessary since he/she will be prescribing the medication. Many doctors are uncertain how to manage benzodiazepine withdrawal and hesitate to undertake it. But you can reassure your doctor that you intend to be in charge of your own program and will proceed at whatever pace you find comfortable, although you may value his advice from time to time. It is important for you to be in control of your own schedule. Do not let your doctor impose a deadline. Leave yourself free to ‘proceed as the way openeth’, as the Quakers say.

Sometimes prescribers will suggest that their patients check into a detoxification (or “rehab”) center to get off of the benzodiazepines. , in lieu of continuing to prescribe them for a slow taper. Unfortunately, this is not a responsible solution as most detox centers are not equipped to manage the long-term functional brain changes benzodiazepine cessation can invoke.  Instead of a slow taper, the “rehab” or “detox” center will rapidly taper (over days or a week) or cold-turkey patients and send them home, sometimes in severe withdrawal states; this sets the patients up for a greater risk of protracted withdrawal, which may last years and lead to patient death.,

What Can The Physically Dependent Benzodiazepine Patient Do?

  • Print The Ashton Manual and highlight paragraphs 8 and 10 in Chapter 2 (which indicate that no one should be forced to withdraw against their will and that the patient, not the prescriber, should be in charge of the rate/speed of the taper) and present it to the prescriber.
  • If the patient wishes to taper off, reassure the prescribing physician doctor that they would prefer to stop using a slow, symptom led taper, not arbitrary cessation rates decided in advance.
  • Supply the prescriber with some more information on safe benzodiazepine cessation, including the printable Withdrawing Prescribed Benzodiazepine Patients pamphlet.
  • Agree to regular follow-up appointments (and keep those follow-ups), or drug testing, if asked, as that will make the prescriber more comfortable
  • In the US, ask that your prescriber consults the prescription drug monitoring program (PDMP) to prove that you have been compliantly taking the benzodiazepine and not “doctor shopping”. If you are located outside of the US, ask that they check whatever database keeps track of that information —if any.
  • If residing in the UK, offer for them to speak with one of the experts at the withdrawal charities (many can be found on our Resources Page).
  • Ask for their refusal and the reason for their refusal in writing. Document everything, including that they were provided  with information and warnings about the risks of abrupt withdrawal from benzodiazepines. Obtain a copy of all medical record(s).
  • If fired as a patient, ask for a referral to another prescriber as physicians have an ethical duty to promote the continuity of their patients’ care.
  • After finding a safer prescriber, consider filing a complaint with your State’s Board of Medicine (or another prescriber regulatory board).
  • Similarly, if the prescriber works for a practice, write a complaint to or schedule a meeting to discuss the situation with the acting Medical Director of the practice.
  • If needed, seek malpractice advice/representation from an attorney (especially if you or your loved one was cold-turkeyed, resulting in death or other serious adverse events). There have been some accounts of successful lawsuits for benzodiazepine injury and death from cold-turkey withdrawal.
  • For more suggestions, read How To Find Benzodiazepine Tapering Help.

Further Reading:

How To Find Benzodiazepine Tapering Help

“Help! My doctor stopped prescribing my benzo!” What to do.