Acute Benzodiazepine Withdrawal: A Public Health Crisis

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Late last week a desperate 46-year-old woman contacted me. She was experiencing symptoms of acute benzodiazepine withdrawal including palpitations, constant pacing, and exhaustion. When her prescribing PCP retired,  she could find no one willing to continue to prescribe the benzodiazepine she had been taking for most of her adult life.

She was someone who did not drink and had never used drugs recreationally. She described that she had a long history of obsessive-compulsive disorder and panic and had originally been reluctant to take medications, but that the doctors she had seen were insistent that she needed to do so. When her PCP retired and she tried to find a psychiatrist to continue to prescribe for her, she was told that they did not prescribe benzodiazepines and that she would just need to get off of them. She was treated like she was a drug-seeking addict. One psychiatrist prescribed seven tablets of 0.5 mg lorazepam, though her daily dose had been 2-3 mg a day. Repeated distressed calls to their office were not returned. She made several visits to the hospital emergency room but they had nothing to offer.

This is unfortunately not a rare story. I have lately been getting an increasing number of calls like this.

Benzodiazepines were freely prescribed in the past. The bar was very low for offering them. A patient would report anxiety or sleeplessness and they would be given a prescription. I remember a psychopharmacology seminar during my psychiatry residency in the late 1980s when the lecturer described a patient who had worn a hole in the pocket of his jeans because he kept rubbing the spot where he kept his alprazolam (Xanax) when he left the house. Xanax is extremely short-acting and therefore one of the most addictive. It both provides quicker relief from anxiety, which incentivizes taking it, and wears off quickly, setting the person up for craving the next dose. We were taught that clonazepam (Klonopin) was a safer choice because of its slower onset of action and longer half-life. Clonazepam is unfortunately also highly addictive.

These days, it is burdensome for psychiatrists to prescribe benzodiazepines. It is prohibited to prescribe more than a month’s supply at a time. If for any reason the pharmacy system does not function seamlessly (a common occurrence), if the patient runs out and needs a new prescription but cannot get it in a timely way, they can be vulnerable to very uncomfortable withdrawal symptoms. When I plan a vacation, I need to be certain that my patients have enough medication until my return.

We were offered no training about the safe and appropriate way to wean a patient from these medications, and still today, 35 years later, most psychiatrists are not aware of the need for a very slow and gradual taper while providing holistic support to the nervous system. Some patients are admitted to detox facilities that offer to wean patients from medications over a short period, but this is doomed to failure for most people. The withdrawal process must be done very slowly and cautiously. Benzodiazepine withdrawal is so traumatizing, that I have repeatedly heard from patients that they live in extreme fear of the disruption of the medical supply chain. They have nightmares about the anguish they would endure if they were unable to get their medications.

Chapter Six of my book Sacred Psychiatry entitled “Weaning from Medications” describes the multi-modal approach that I take to this process. Initially, the patient must be stabilized before making any attempt to wean them. This typically means returning to the dose of benzodiazepine that they were taking before experiencing withdrawal symptoms. After stabilization, I do not recommend decreasing the dose by more than 10% a month, which means that to get the exact dosage, the medication must sometimes be compounded by a compounding pharmacy. Sometimes only 5 % is tolerated and sometimes it is necessary to stay at the same dose for more than a month until a person’s nervous system recalibrates.

A holistic approach includes appropriate diet and nutrition, avoiding toxins, managing stress with limbic system and vagus nerve retraining, appropriate lifestyle including recommendations about sleep, fresh air and movement, homeopathic support, healthy relationships, finding belonging and community, and cultivating a spiritual practice. Weaning from psychiatric medications is a marathon not a sprint, but it is possible if done skillfully and carefully. There is no rushing it.

Here is a link to the wonderful website of the Benzodiazepine Support Coalition where multiple very useful resources related to tapering can be found. There is information about support groups that some of my patients have found very helpful as well as a list of practitioners who are literate about weaning from benzodiazepines.

This is a philosophical and soulful conversation with attorney, author, and podcaster Phillip Comella on his radio show, “Beyond Science and Religion” where we discuss what it means to take a holistic approach to psychiatry. I very much enjoyed talking with him.

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