Tapering Off Benzodiazepines
Benzodiazepines (benzos) are powerfully addictive drugs that are routinely prescribed as anti-anxiety medications. Prescribing rates of benzos in the United States jumped by 50% between 2005 and 2015. Among the most commonly prescribed benzodiazepines are Valium (generic name diazepam), Ativan (lorazepam), Klonopin (clonazepam) and Xanax (alprazolam). Prescribing guidelines suggest that benzos be prescribed for short-term and intermittent use only (less than 30 days) to minimize the risk of dependence. Unfortunately, prescribers commonly provide prescriptions for several months or even years to patients.
Benzodiazepines are known to quickly cause a tolerance to develop, meaning that the dose must be increased to achieve the desired effect. This factor is a major driving force behind benzodiazepine misuse.
Tolerance and dependence often go hand-in-hand. Benzodiazepines are associated with a high risk of developing dependence, even when used as directed. Dependence is characterized by the presence of withdrawal symptoms if someone tries to cut back on their dose or stop taking the drug altogether. Addiction is an extension of dependence and is characterized by compulsive drug-seeking even in the face of negative consequences.
Benzodiazepine use disorders pose unique challenges to recovery that should be addressed by a multidisciplinary drug rehabilitation center that is equipped to manage a medically assisted detox if needed. It is never recommended that someone quit benzodiazepines “cold turkey.” A benzodiazepine taper is far safer and more effective.
How to Taper Off Benzos
Anyone who wishes to quit using benzodiazepines is urged to seek a consultation with a medical professional before trying to quit or taper benzo use. Although there are general benzodiazepine taper guidelines, the safest and most effective taper will be one that is customized to a person’s specific needs and lifestyle.
Benzodiazepine withdrawal can be uncomfortable. People who try to quit benzos “cold turkey” often find that they are unable to manage the symptoms of withdrawal. Symptoms of benzodiazepine withdrawal include:
- Muscle cramps or stiffness
- Gastrointestinal upset
In extreme cases of benzodiazepine dependence, severe symptoms that can be dangerous, even life-threatening may be present. Severe symptoms include:
- Convulsions or seizures
- Psychotic reactions
- Acute anxiety states
There are two tapering methods that are often used to help people quit taking benzos, the direct taper method and the substitution taper method. Some people may also be candidates for adjunctive medications, that is, non-benzodiazepine medications that can ease withdrawal symptoms or manage symptoms associated with the disorder that benzos were treating.
A direct benzodiazepine taper involves gradually reducing the dose of the drug that has been prescribed. In most cases, the dose can be reduced by 10% to 25% initially and further reduced another 10% to 25% every one to two weeks, depending on how well the reduced dose is tolerated.
“Supratherapeutic” doses (doses that are higher than the standard effective dose) can be initially reduced by up to 30%. However, people who have taken supratherapeutic doses for long periods may be at increased risk for dangerous withdrawal symptoms when their doses are significantly reduced.
Short-acting benzodiazepines (lorazepam, alprazolam) are metabolized so quickly that it is difficult to successfully achieve a direct taper schedule that minimizes withdrawal symptom severity. The goal of a substitution taper is to gradually replace short-acting benzos with longer-acting benzos (clonazepam, diazepam) that are eliminated over the course of days, rather than hours. The presence of a drug with similar pharmacological effects and longer effective time frames can reduce the severity of withdrawal symptoms that are particularly apparent when tapering short-acting benzos.
In some cases, adjunctive medications may be appropriate to help people manage withdrawal symptoms. Particularly high doses of benzodiazepines may be tapered in the presence of the anticonvulsant drug gabapentin to limit potential hyperactivity in the brain. Drugs that have been shown to mitigate the discomfort associated with withdrawal include mirtazapine, imipramine, divalproex and trazodone. For people who take benzodiazepines to manage chronic pain, antidepressants like duloxetine or amitriptyline may be beneficial. The use of adjunctive drugs during a benzodiazepine taper must be done with the guidance and supervision of medical professionals who are familiar with both the benzodiazepine and the adjunctive drug.
Benzo Tapering Schedule
People who are having trouble reducing or eliminating benzodiazepine use are urged to make an appointment with their doctor or an addiction specialist to discuss the best strategy for them. While withdrawal signs and symptoms overlap between people, each person’s experience of quitting benzos is unique. A professional who is familiar with designing benzo tapers can account for differences between clients and develop a tapering schedule that minimizes withdrawal symptoms and maximizes the odds of success for each client.
Most people who successfully overcome benzodiazepine dependence follow a tapering regimen that lasts for several months, even a year or more. There are several general guidelines that provide slow tapering schedule examples for particular types and doses of benzodiazepines, but the most effective way to develop a tapering strategy is by consulting with a professional who has experience with benzo tapering.
In particularly complex cases of benzo dependence or addiction, a stabilization period may be beneficial: Once the tapered dose reaches 50% of the original dose, maintaining this dose for several months allows some people to stabilize before continuing the taper. This can help achieve long-term recovery.
Several factors can influence how a taper is designed, including:
- The type of benzo
- The dose used
- The age of the client
- The client’s metabolic rate
- The client’s lifestyle
- Whether other drugs or alcohol are being used
- The presence of a healthy social support network
Rapid Benzodiazepine Taper
In some cases, rapid benzo tapers can be dangerous. Serious dependence issues are a consequence of chemical changes in the brain and, if benzos are abruptly discontinued, the brain can accelerate into a state of hyperexcitability. Seizures or convulsions may occur as a result. Acute anxiety, panic or psychosis are also potential symptoms. Rapid benzodiazepine tapers that are moderately safe are generally considered to last between 8 and 12 weeks.
Another experimental method of rapid benzodiazepine detox is constant intravenous infusion of a drug called flumazenil over the course of several days to a week or more. Flumazenil is a benzodiazepine “antagonist”, meaning that it directly opposes the effects of benzodiazepines. While flumazenil has been successfully used to treat benzodiazepine overdoses, the use of flumazenil as a treatment for benzo dependence has not been well-validated and is associated with risks. At this point in time, there is not enough evidence to support the use of flumazenil as a therapeutic approach for people who are attempting to overcome benzo dependence.
Medically Assisted Benzo Detox
Severe cases of benzodiazepine dependence may require medically assisted detox. Medical detox is done under the supervision of professionals who can intervene in the case of emergencies. When appropriate, pharmacotherapies can be provided to clients undergoing medical detox to mitigate symptom severity.
It is always recommended that anyone with a benzodiazepine use disorder seek an evaluation before adjusting their dose. By working with a medical professional or rehab center before beginning recovery, a customized plan and an appropriate tapering schedule will be in place before detox and subsequent stages of recovery begin.
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