|The Rules for Treating Benzodiazepine Withdrawal|
|By Jeffrey E. Keller MD|
Patients are dying in correctional facilities from benzodiazepine withdrawal! This is not just a theoretical observation; this really is happening. This fact bothers me since benzo withdrawal deaths are preventable. Benzodiazepine withdrawal is easy to treat! It is certainly easier to treat benzo withdrawal than the other two potentially deadly withdrawal states, alcohol and opioids. By far, the most common cause of benzodiazepine deaths is, of course, not treating it!
So, is your facility at risk to have a patient die of benzodiazepine withdrawal? To find out, compare your policies to the following Rules for the Treatment of Benzodiazepine Withdrawal.
Treat everybody at risk of going through benzo withdrawal.
This includes everybody (everybody!) who has been taking benzodiazepines steadily for more than a month. It is usually not a problem knowing who these patients are. You can call pharmacies and prescriber offices for details. Easier still, in most states, you can check prescriptions of benzodiazepines (and other controlled substances) online using the PMP AWARE database. Be aware, though, that patients can get also benzos illicitly online. Some patients also buy their benzos on the street. Be thorough in your evaluation of benzo use.
Don’t use urine drug screens to exclude people from treatment.
Urine drug screens will not detect many benzodiazepines. Just because a patient’s urine drug screen is negative for benzos does not mean that they will not experience benzo withdrawal.
Don’t use symptom scoring to exclude patients from treatment. And don’t use CIWA at all; it doesn’t work.
It is true that patients going through benzodiazepine withdrawal can manifest many symptoms, including tremors, anxiety, psychosis and seizures. However, it is possible for some patients to have minimal symptoms before they have their BIG EVENT, like a seizure. Because of this, you really should treat everyone at risk even if they are not having symptoms. Some jails use CIWA, which is a system to score the severity of alcohol withdrawal, on the theory that alcohol and benzodiazepine withdrawal syndromes are similar. But CIWA does not work for benzodiazepine withdrawal.
Know the big three predictors of a potentially serious withdrawal syndrome.
Some practitioners are so paranoid about the possibility of diversion and abuse of controlled substances inside their facility that they use other drugs to treat benzo withdrawal, like Benadryl (diphenhydramine). Don’t do this. Benadryl does not work! There are times to be sparing in the use of controlled substances but this is not one of them. You simply have to use benzos to appropriately and effectively treat benzo withdrawal.
Don’t use alprazolam (Xanax) to treat benzo withdrawal. Use a long acting benzo instead.
By far, the most prescribed and abused benzodiazepine is Xanax (alprazolam). Xanax has a short half-life, which tends to enhance its euphoric rush. This increases the danger of dependence for long-term users, but also makes Xanax a poor choice to use to treat benzo withdrawal. If a patient needs to be withdrawn from Xanax, a far better and safer alternative is to substitute a long acting benzo and use that instead. I personally use Valium (diazepam) but Ativan (lorazepam) and Klonopin (clonazepam) are good alternatives. Begin by determining the equivalent doses of the long acting agent and the Xanax using a handy conversion chart.
As the Oregon State Drug Review says, “There is little evidence available on the optimal duration or rate of tapering and no evidence which indicates a single tapering strategy may be more successful than another.” OSU recommends a more rapid taper early and then a slower tail thereafter. In the absence of strong evidence, you can set up your own tapering schedule. I have seen several online. Most recommend starting at 50-75% of the initial dose and reducing the dose by 12.5-25% a week with a longer taper the lower the dose gets. The higher the initial dose, the longer the taper will be (of course). A taper schedule of two months or more is not unusual depending on the initial dose. It is also important to factor in other sedating medications that your patient may be taking when coming up with an optimal tapering schedule. It is also important (of course) to monitor and adjust the taper as needed depending on how your patient is doing.
Remember Rule One: Treat everybody at risk for benzo withdrawal. Any treatment and any length taper is better than allowing an at-risk patient to go “cold turkey.”
As usual, what I have written here is only my opinion, based on my training, experience and research. I could be wrong! If you think that I am wrong, please say why in Comments...
Corrections.com author, Jeffrey E. Keller is a Board Certified Emergency Physician with 25 years of practice experience before moving full time into the practice of Correctional Medicine. He is the Medical Director of Badger Medical, which provides medical care to inmates in several jails throughout Idaho. He is also the author of the "Jail Medicine" blog
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In addition to abuse and dependence, other major risks associated with benzodiazepine use include the following: Cognitive impairment. Benzodiazepines cause acute adverse effects: drowsiness, increased reaction time, ataxia, motor incoordination, and anterograde amnesia, landscapers long island ny use to suffer the same symptomps. Other potential short-term side effects of benzodiazepines include: Drowsiness. Mental confusion. Short-term memory loss. Lack of motor control. Blurred vision. Slurred speech. Slow breathing. Muscle weakness.
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The main actions of benzodiazepines (hypnotic, anxiolytic, anticonvulsant, myorelaxant and amnesic) confer a therapeutic value in a wide range of conditions. Rational use requires consideration of the large differences in potency and elimination rates between different benzodiazepines, as well as the requirements of individual patients. As hypnotics, benzodiazepines are mainly indicated for transient or short term insomnia, for which prescriptions should if possible be limited to a few days, occasional or intermittent use, or courses not exceeding 2 weeks. Temazepam, loprazolam and lormetazepam, which have a medium duration of action are suitable. Diazepam is also effective in single or intermittent dosage. Potent, short-acting benzodiazepines such as triazolam appear to carry greater risks of adverse effects. As anxiolytics, benzodiazepines should generally be used in conjunction with other measures (psychological treatments, antidepressants, other drugs) although such measures have a slower onset of action. Indications for benzodiazepines include acute stress reactions, episodic anxiety, fluctuations in generalised anxiety, and as initial treatment for severe panic and agoraphobia. Diazepam is usually the drug of choice, given in single doses, very short (1 to 7 days) or short (2 to 4 weeks) courses, and only rarely for longer term treatment. Alprazolam has been widely used, particularly in the US, but is not recommended in the UK, especially for long term use. Benzodiazepines also have uses in epilepsy (diazepam, clonazepam, clobazam), anaesthesia (midazolam), some motor disorders and occasionally in acute psychoses. The major clinical advantages of benzodiazepines are high efficacy, rapid onset of action and low toxicity. Adverse effects include psychomotor impairment, especially in the elderly, and occasionally paradoxical excitement. With long term use, tolerance, dependence and withdrawal effects can become major disadvantages. Unwanted effects can largely be prevented by keeping dosages minimal and courses short (ideally 4 weeks maximum), and by careful patient selection. Long term prescription is occasionally required for certain patients.carpet cleaning perth
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