Benzodiazepine Dependence and Withdrawal - How To Avoid This

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Hi, I'm Dr.Tracey Marks, a psychiatrist,

and I make mental health education videos.

Today, I'm talking to you about

what you need to be aware of

if you're gonna take benzodiazepines

like Xanax, Klonopin, or Ativan.

I've gotten several requests for this topic

with most of them centering around the issue

of benzodiazepine withdrawal and what that looks like.

Benzodiazepines, or benzos for short,

is the class of drug that works at the GABA receptors

in your brain to produce a relaxing or sedative effect.

We use benzodiazepines to treat

short-term anxiety and sleep.

Some doctors will use them as a muscle relaxer

and Valium is pretty typical for this.

They can also be used to stop a seizure.

You may get Valium or Ativan prior to a procedure

such as a colonoscopy.

The most common benzodiazepines are

Ativan, Klonopin, Xanax and Valium.

Benzodiazepines are habit-forming

and it's easy to become addicted to them and here's why.

Benzos cause a tolerance effect

and this means that if you take them regularly

like daily or several times a week,

over time the effect can wear off

and you'll need to take more to get the same effect.

So now, instead of say taking a half of a pill

and having that work now you notice

that you need to take two pills to get the same effect.

And this is a medication tolerance effect

it can happen to anyone

and it's not the same as an addiction.

If this happens to you,

it doesn't mean that you've been misusing the medication

or have an addiction.

Addiction involves developing

a psychological dependence on it where you need to take it.

Now you may say how's that different

from taking it for anxiety

after all, anxiety is psychological?

Let me illustrate this.

Phil has anxiety and sees his primary care doctor

because he's not sleeping well.

He has a lot going on at work

and can't afford to go without sleep.

He tells his doctor that he can't

get his brain to shut down at night

and he's been having some panic attacks at work.

His doctor gives him Xanax and tells him

to take it as needed.

Phil takes it and he notices

that he falls asleep as soon as his head hits the pillow.

Then, he takes it at work

and he doesn't feel anxiety for several hours.

It doesn't make him sleepy

and he's able to get a lot more work done

because now he can calmly focus.

It's like magic.

The directions on the bottle say

to take up to four times a day as needed.

Now it says this because Xanax

is a very short acting benzodiazepine.

It works quickly and it doesn't hang around very long.

But a huge downside to it

is that when it wears off

you can get rebound anxiety.

And this is anxiety that can feel worse

than the anxiety that you started with.

So what happens?

You take more to make that feeling go away.

So this is eventually what happens to Phil.

He takes it at work but he and his wife

aren't getting along very well.

So when he gets home and she starts criticizing him,

he takes another Xanax to deal with her.

So he ends up taking the medicine four times a day

and a month later he tells his doctor

that things are much better for him

but he needs a refill on the Xanax.

His doctor says okay

but he tells him that now the Fluoxetine

that he also prescribes should be doing its job

so he shouldn't need to take the Xanax as often.

But Phil has a really tough month at work

and took a little more Xanax to help him through that.

When he asked for another refill

his doctor said that you need to see a psychiatrist.

He comes to me and I give him my

this is why I hate Xanax speech

and switch him from Xanax to Klonopin

with the intention to wean him off of the daily use.

Klonopin, like all of the benzos,

is habit-forming especially when you get to where

you're taking it everyday.

But Klonopin, and the generic name is Clonazepam,

is a longer acting medication

and longer acting medications have a smoother transition

off when it wears off and you get less rebound anxiety.

Now, Phil has two things going on here.

He's got the physical dependence

because he needs to take the Xanax around the clock

to control his anxiety.

But he also has a psychological dependence

and this is how it looks for him.

Since Klonopin is a longer acting medication,

it's prescribed a maximum of two to three times a day.

Less than the Xanax frequency of four times a day.

Many people can get by with it just once a day.

So, I instruct him to take it twice a day,

three only if he feels he has to.

Phil comes back early for his next appointment

because he ran out of Klonopin.

He admitted that it was his year end at work

and he had a lot more anxiety

so he would take the Klonopin every two to three hours.

Sometimes he'd only take half of the pill

because he noticed that it did seem to work

or to be a little stronger than the Xanax.

Now Klonopin lasts much longer than two hours.

He shouldn't need to take it that frequently.

But the problem was that Phil wasn't taking the pill

because he needed it for his unmanageable anxiety,

he was relying on the pill

to deal with any kind of emotional distress.

So when something bad would happen,

his reaction would be to take a pill

and that's where he shifted from taking the benzo

to treat anxiety to using it

to take away any negative experience.

So what happened to Phil?

He said he just wanted to get through

this busy period at work

and then he would stop taking the Klonopin.

And he promised though that he would

not take it multiple times a day.

After things slowed down at work,

he and his wife went on a long weekend trip

but Phil forgot to pack his Klonopin.

But he figured since he was planning to stop it anyway,

then this would be the time on his vacation.

On day two of the trip,

he woke up in a panic and spent the entire day

feeling as though his whole body was shaking.

He'd tried to tough it out

thinking that maybe he was just reacting to something

that he drank the night before.

On the third day, his wife found him

on the floor unconscious and jerking.

She called 911 and he was treated

at the hospital for benzodiazepine withdrawal.

Now this is an extreme example

just to illustrate what can happen.

Most medication withdrawals like what you can get

from the antidepressants are uncomfortable

but they're not dangerous.

I did a video of brain shocks and antidepressants

that you'll see in the corner

and I'll link to it in the description.

Benzodiazepine withdrawal can be dangerous

in that in extreme cases it can cause a seizure

and this tends to be in people

who have taken it longer than three months

and take high doses.

Which what's a high dose?

It'd be a step or two higher than the starting dose.

There's lots of withdrawal symptoms

that you can get but it usually looks like

increased anxiety, tremors,

poor sleep, irritability or sweating.

You can also get elevated blood pressure and heart rate.

So is it ever okay to take benzodiazepines daily?

The proper treatment for daily anxiety is an antidepressant.

We also use medications like Propranolol and Buspirone.

These medications are not habit-forming and,

except for Propranolol,

they don't work immediately.

The onboarding process can take a month

to six weeks before you can feel some relief.

So to help you feel better sooner than that,

it's a common practice to also prescribe

a benzodiazepine as needed for anxiety

on a short-term basis.

Short-term is generally considered three months or less.

So, this is what I'll tell someone in a similar situation.

I'll say this medication is to help your anxiety

until the antidepressant kicks in.

I would rather you not take it everyday

but if you need to, it's okay for now.

We'll keep our eye on it and I'll help you wean off of it

starting around three months.

Now things are a little different

if you don't take it everyday.

There are people who get a bottle of 30 pills

that last them six months or more

because they only take it when they fly

and they fly four or five times a year.

Or they take it on average of once every couple of weeks.

And that would be irregular use.

I consider regular but infrequent use as weekly.

I think twice a week is on the cusp of becoming frequent.

And in my experience,

once a person starts taking it three times a week,

three becomes four and four becomes daily.

Daily long-term use is associated with cognitive changes

like not being as mentally sharp.

It can also create balance problems in some people

where you just aren't quite solid on your feet.

And this can be a big problem with elderly people

by increasing their risk of falls.

If you've been taking the medication

for more than three months and you're taking it daily,

you definitely need to have your doctor

taper you off slowly when you

get to the point of discontinuing it.

You don't want to just stop taking it suddenly.

This is the kind of medication that you have to keep up with

and not let it run out because you're leaving town

and you notice that you only have two pills left.

If you travel a lot or you just have a very busy life,

these mediations can create a tether to your pharmacy

which can feel very confining.

The longer you've been taking it daily,

the slower your taper should be.

And there's not a set protocol for this,

your doctor would use his or her clinical judgment

on a case-by-case basis.

But how long it takes also depends

on how high your dose is.

I've had people where it's taken a couple of years

to slowly wean off.

We just keep chipping away at the pill size over months.

It's like tricking your body into realizing

that it's getting less and less medication.

One of the ways I help patients avoid this problem

is I tell them to think of the medication

as a break the glass pill

that you take to keep from going to the hospital

because you feel like you're having a heart attack.

It should not be a take the edge off of a crappy day pill.

When you start to think of it that way

and take it that way,

it very easily becomes something

that goes from infrequent to daily.

And once you enter daily use

you become tethered to the medicine

and need to take it daily just to feel well.

Now I have to emphasize that everyone is different

and there are people who are able to take

one benzodiazepine a day for years

and never need to increase their dose.

My thought about that person is that it may be

that they no longer have the problem

that they originally took it for

whether that be sleep or anxiety.

But they think they still need it because

if they stop taking it,

they have terrible anxiety or don't sleep.

But probably what they're experiencing is withdrawal

and not a return of their original problem.

If you want to see more on medication withdrawal

from antidepressants, watch this video

that I have on antidepressant withdrawal and brain shocks.

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on mental health education.

See you next time.