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How to Quit Benzos | Effective Benzo Taper Schedule | Dr. B



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hi everybody my name is dr. B and

today's topic is how to quit benzos

recommended benzo taper schedule so

let's get right into it and today the

question I want to answer that I have

sent to me here is how to quit benzos

and then there's some follow-up

questions with them

with this question and this is a

wonderful question it's actually a topic

that's very near and dear to me but I

want to reframe the question how to quit

benzos that sort of assumes that anytime

someone's on benzos and benzodiazepines

like xanax klonopin valium temazepam you

need to quit them so the first question

to us is why do you need to quit benzos

and that needs a full assessment by a

competent clinician for example you know

nowadays because xanax is such a

substance of extensive abuse and someone

may be on it or someone here is that

they're on it it's like oh my god

they're on benzodiazepines or on xanax

you need to get off of that that's not

always necessarily true this gives an

opportunity to really explain the way

these drugs are prescribed I do believe

let's take xanax for example I do these

I believe these drugs are over

prescribed why are they over prescribed

I think sometimes it's a frustration of

the clinician on his side and then a lot

of it also has to do with cultural and

individual attitudes towards these

medications what they can do for them

and a propensity to use a quick fix for

a problem that needs a long-term

solution for example therapy and other

behavioral and cognitive modifications

so the first question to us is why are

we quitting benzos and again here I'm

going to try to answer very generally

and there's nuances and differences and

some things that might be out of the box

for example if I have an adult male

let's say in his 50s and he has a

particular kind of tremor or he really

has a particular kind of generalized

anxiety and he has been taking xanax

0.25 milligrams once a day

for the last 25 years and he's stable

under those and there's never been any

evidence of abuse or increasing the dose

or seeking a drug elsewhere that's where

the clinician should weigh out that risk

versus the benefit of short-term and

long-term effects on that of that drug

so this is key and I would say the

reason we have such an abuse potential

or rather we have such a disseminated

let me put it this way why we have

really such an epidemic in my view of

too many people on it a too high dose is

those things aren't evaluated

appropriately and constantly for every

patient because once you get on this

medication you can have some serious

short-term a long term withdrawal

effects if you try to come off of it so

you know the first question is why do

you why do is the patient on the bends

of the recipients and should they get

off of it once that's been settled and

again there's nuances and there's some

people that may need to be on this

medication long term including a lot of

neurological chronic diseases where

these patients may be bedridden or have

mobility issues or tremors or needed as

a muscle relaxant there's another video

or I cover a lot of these issues so you

really have to ask why that patient is

on the benzos and is the dose

appropriate and do they actually need to

taper down to a lower dose once that

question is answered you can say okay

this guy needs to get off benzos so who

needs

- get off pencils or who needs to lower

their dose again that's a question that

you really need to evaluate closely is

this a young person that is on a to

higher dose let's say two milligrams of

xanax twice a day and he's 24 years old

and he's on it for anxiety

well I think that dose is a little high

and over the long run it's gonna have

severe consequences and what are you

gonna do 5 10 15 20 25 years from now

that dose really needs to be extensively

reduced and/or cut off and other means

it's behavioral interventions behavioral

therapies need to be instituted so that

this patient doesn't stay on that dose

long enough so that might be one type of

patient another patient and again it's

very hard to I wouldn't necessarily call

that an addiction if they're staying

under dose but it will have profound

long-term effects I would call that

physiological dependence that maybe

doesn't need to be there then there is

the real addict who is taking benzos at

large doses any benzyl they can get and

it's been escalating over a short or

long period of time well that person

definitely needs to be put on a table or

somebody else that you're certain needs

to be on a lower dose and they need to

taper that dose down so there were folks

that need to be on a benzo taper to

either lower the dose or get them

completely off also differs and you need

a very close clinical evaluation to make

that decision that question within that

is what are the dose what are the risk

involved with tapering off of benzos and

I'm also asked what is your recommended

benzo taper schedule and finally how

long does it take to get off benzos I'm

going to combine all of those questions

the first one I will answer a little bit

more directly and succinctly and a risk

are quite a bit benzos fallen under the

class of sedative hypno

medications and it is the only class

that you can have what's called severe

morbidity and mortality you can get very

sick including seizures and you can

actually potentially die from coming off

of benzos this includes alcohol which is

the same class of doctor drugs

barbiturates which is the same class of

drugs sedative hypnotics benzodiazepines

fall under them it's the only class of

drugs that coming off of the wrong way

can potentially get you very sick

including seizures and it could lead to

death to the wood drawers whether you

just cut them off or your tapering the

wrong way are absolutely a monster for

again there's variations with different

people please keep that in mind but you

will get someone reporting that hey I've

been off this stuff two years three

years and I'm still having a lot of

problems with this I still have what

they call it post acute withdrawal some

them I still with opiates but they

applied to benzos I'm still having

withdrawal issues whether it's sleep

nervousness some people will even see

floaters all kinds of things so the

would drawl off of this stuff can not

only be dangerous or coming off of it

but it's very inhumane the way people

come off of this stuff and here's where

we really get into the question your

recommended benzo taper schedule and

this is really really important to me

and this is where I think it's critical

I'm gonna say this before I get into the

schedule that I use I think the system

whether it's the insurance system or the

medical community establishment doesn't

really support both the payment

structure and the clinical attention

needed to benzodiazepine withdrawals

what do I mean by this if he going

through a detox or rehab or even if you

go to your doctor these withdrawals and

tapers are done relatively rapid

a lot more rapidly than should be done

for most people that have a serious

issue whether it's an addiction issue or

long-term use issue they're done much

too rapidly I mean you might go into a

ten day 20 day detox program to get you

off of benzos and you've been abusing it

for four years and this can be very

dangerous and very painful in the short

and long term I do it a little bit

differently and I think there's plenty

of evidence scientific evidence to

approach it in this way when patients

come to me with this issue any of the

types of patients that I see whether

it's straight-up abuse and addiction or

someone who's been on it a long time but

needs to at least Lourdes or those first

thing you need to I do is I build a

really good trusting rapport with the

patient because their first concern is

withdrawals and their first concern is

getting their benzos and it's very

interesting when you watch these

patients and you really get to know them

there is a fear in your eyes of getting

their benzodiazepines taken away and you

really have to build that clinical trust

because they truly feel that they

desperately need this medication to make

it day to day at the doses they are

taking and to a great extent they are

absolutely right when you deal with them

at the clinical level word there's just

interaction it's almost as if their

anxiety receptors have been burned out

you'll see little tremors you'll see

this contorted face one day deal with

you and you see the fear and concern in

their eyes

and so you have to really build a

relationship first of all that I am NOT

going to hurt you

I do know what I'm doing and I'm you

won't really feel the pain and I won't

let you get sick and I

let anything happen to you I go over

this because this is a crucial part of

the benzodiazepine taper the next thing

I do and sometimes this takes a day but

usually it could take me a few weeks and

depending on the patient under

underneath if they're abusing it on the

street if they have been on it I will

continue to make an equivalency dose

prescription until we build this rapport

and I don't let it go too long you don't

want to do that because now you're

supporting their habit if it's abuse and

addiction and or you're continuing where

they've been at which you can go on a

little bit longer than if someone's

buying on the street but my main goal

first of all is to be able to measure

where they're at which means get them to

stop buying it on the street for those

that are abusing it in that way and give

them a very close prescription and those

other ones that I've been honored

legitimately with the prescription

continue the prescription until we build

that trust if the patient's buying it on

the street I need to make sure that they

are actually telling me and being honest

with themselves about the doses that

they're taking

so I will see them very regularly maybe

every few days and continue to refill

the prescription that way and again this

gives me a few opportunities one to

really get at the root of how much

they're using and adjust the dose that

I'm giving them to I make sure that they

are not abusing my medications and going

along with the plan and that's where I

need to be so I can get a handle of the

milligrams and how often they're taking

it once I get there with those patients

and once I get there with the patients

that are taking it those that I think is

too high that needs to be brought down I

will now attempt to make across

tolerance and what does that mean simply

if it's something like xanax which

theoretically has a higher abuse

potential I will switch it over to a

longer

acting drug and one that gets you gets

the rush much more slowly so I have a

better chance of a long term taper so I

might switch these annex the klonopin if

they're highly resistant to this change

I won't do it but 90% of the time I can

make this cross tolerance switch from

something like xanax which will give you

a quick rush versus something that is

longer acting and goes in your body

slower this helps me theoretically at

the pharmacological level to go ahead

and taper on the long run once those

things are done a I have a control over

the amount they're using be if I can I

make a cross tolerant switch I've also

by this time made a pretty good rapport

with the patient and I've built a trust

now I will start the really really neat

part of the way I approach this what I

do is I write him a prescription

whatever it is let's say in this case

it's one milligram of klonopin twice a

day and I have the patient come into the

office and again please remember there's

variations of this depending on where I

get to feel the patient is at so yeah

and I and I justice accordingly so I'm

just giving you one example of where I

might end up on the spectrum let's say

we have a 25 year old patient we've made

a good rapport I've been seeing him for

four weeks I know that we're stable at 1

milligram of klonopin twice a day I see

them every week for their dose they're

showing up for their appointment I feel

confident there's no other drug use this

is where we're at and I'm pretty sure

that they need to go down to birthday

point five milligrams a day or if we can

cut this off completely

I haven't bring the medication bottle

into the office and I say okay and I

draw it out for them I

say you just got 60 of these for the

month correct and they say correct and

they're very very very very still timid

about pulling out the medication showing

it to me there is this really

interesting fear about me taking away

the medication and you have to

understand that you have to empathize

with that and I say tell me when you

take these medications and he's like

well I take one in the morning and one

in the afternoon and again please

understand I work with any kind of

variation of presentations I'm giving

you one example so he says they take one

in the morning one in the afternoon

then I'll say to the patient please tell

me which dose is the least important

dose for you and he's like well my

afternoon dose in the mornings I'm very

stressed out and usually in a rush so I

really need that dose but my afternoon

bills usually I'm home from work and I'm

calm and I don't necessarily need it

once they tell me that I say okay your

afternoon dose here's a whole pill one

in the morning one milligram one in the

afternoon one milligram that's a total

of 2 milligrams a day and you have two

of those per day for 30 days that's 60

of them put two of them out for me and

they put it out and I say until your

next visit which I'm not going to see

you for 30 days I want you to take as

many days as you can and cut that

afternoon dose in half just cut the pill

in half so instead of taking one

milligram in the afternoon I want you to

take point five milligrams and I say

please hold on because they start to get

paranoid I said please hold on and slow

down you're going to be able to do this

either zero days or 30 days if you do it

for 30 days you're gonna be at one point

five milligrams a day for 30 days and

you're going to have 15 full tablets

left amazing if you do it for zero days

you're gonna have zero tablets left

amazing I don't care which one happens

it's all under and here's the key your

control and they almost don't believe

you at first and when you pull this off

the first time the very fact that you've

empowered a patient and given them

control of this very very high abuse

potential drug that really becomes a

fundamentals crutch and or psyche for

some reason and they take control and

they take over their dosing and succeed

even one day I can tell you the effects

for the future of our taper are powerful

and amazing they might do it one day

they might do it three days you know

I've seen guys chase me in a parking lot

oh and so and then at the end of that

what I do when they show up the next

time they are so excited whether they

have won or whether to have five pieces

they feel so invigorated so empowered I

have to tell them slow down please slow

down don't start doing cutting down even

more slow down and now they see I'm not

gonna pull them off the drug cuz there's

a method to this madness I tell them

slow down so I say bring all your pills

next time when the first time they show

up now they're worried I'm gonna throw

away those half pills right because

again I'm taking something away from

them they're very excited they've

accomplished this but we got a long ways

to go so I take let's say they pulled it

off for three days and they have three

half pills left so that's one and a half

milligrams I take those and I put it

back in the pill a bottle and I'm like

here's your new prescription that you

also brought there's only one and a half

milligrams from last time and you can

almost see they're trying to protect it

because they're afraid I'm gonna take it

away and throw it away cuz they don't

know what's gonna happen and I thought

now you have a job to do I don't care if

you do it I want you to take that pill

bottle of what's

left over and you throw it away when you

leave here discard them in this way and

I've seen people chase me in a parking

lot and they shouldn't be doing this but

they'll throw it away in the garbage

outside in the dumpster they'll be

chasing me in a dr. B dr. B I just threw

my old xanax or klonopin away I did it

and I can tell you this is again another

extremely empowering effect on their

addiction

you're basically given to control to the

patient and allowing them to see what's

possible and sometimes you have to

actually be slow their tapering down

what do i do from here again depending

on the patient what their frequency of

use is what their other issues are how

long they've been using their age other

problems that they have and I will

continue this tapered if I have two up

to two years because I want the

long-term outcome to be successful and

by month three four or five they are

really into it they have built a very

deep trust with me we are cutting down

this medication which is really a harm

reduction approach and once we get

towards the tail-end maybe I will decide

that they need to be on a low dose of

this stuff long term which is very few

patients and during this time if I need

to when they increase their dose or

we're going to have issues

I will go from seeing it once a month to

once every two weeks to once a week and

continued close moderate monitoring and

that is the way my general approach to a

benzodiazepine taper is it's very

individualized for the patient it's

extremely safe it takes away any put and

I and you have to understand your doses

so they're not withdrawing and in the

beginning you got to keep a very close

eye on them we want to make sure they're

not having withdrawal symptoms or I want

to make sure they don't get sick and

have seizures we want to make sure that

they are

going to be successful so every aspect

of it is closely monitored by me

a lot more early on and I slightly back

off as time goes by if you enjoyed this

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