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Helping patients come off
The Pulse, July 22, 1989
Professor C Heather Ashton DM, FRCP
School of Neurosciences
Division of Psychiatry
The Royal Victoria Infirmary
Queen Victoria Road
Newcastle upon Tyne NE1 4LP
The Ashton Manual · Professor Ashton's Main Page
There are probably one or two million long-term benzodiazepine users in the UK. Many are now seeking advice about withdrawal. The GP is the best person to supervise withdrawal, but confident management requires a knowledge of withdrawal effects and an understanding of the patient's anxiety. Essential ingredients of successful withdrawal are information, motivation, gradual dosage reduction, sometimes other medication, relaxation and, above all, time and effort by both GP and patient. The outcome often depends on the quality of the GP's support.
Many patients are anxious and frightened of withdrawal. Some have tried unsuccessfully before and have 'withdrawal' symptoms though still taking benzodiazepines. Sympathetic listening, explaining anxiety symptoms and benzodiazepine effects, and slow withdrawal are essential. Patients may feel relieved after an informative first interview and experience reduced anxiety. It is helpful to keep handy a list of local self-help or tranquilliser support groups. Both patient and GP require motivation, though patients already motivated should be encouraged. Aim initially for dosage reduction or limitation in those doubtful or reluctant.
Devise an individually-tailored withdrawal schedule of gradual dosage reduction with the patient's agreement. The plan should not make more demands than the patient can tolerate and may also require occasional revision depending on progress.
Withdrawal from diazepam is easiest because it is long-acting and available in 2mg tablets which can be halved or quartered. The optimal rate of dosage reduction is variable. Patients taking more than 20mg diazepam daily can usually tolerate a reduction of 2mg every one to two weeks; from 10mg diazepam decrements of 0.5mg every one to four weeks may be more acceptable.
Most patients taking other benzodiazepines can easily transfer to diazepam, provided the substitution is adequate in terms of dosage equivalents. Conversion can be made in stages, replacing one dose at a time over several days. Withdrawal can then proceed as for diazepam.
About 10 to 20 per cent of patients have difficulty in transferring from their usual benzodiazepine. This problem arises with lorazepam which is relatively short acting, 10 times more potent than diazepam, but available only in 2.5mg and 1mg tablets. In these cases, suspensions of lorazepam can be easily prepared by the pharmacist. Using a suspension containing 1mg lorazepam in 5ml, stepwise reduction by 0.5ml every one to four weeks is easily achieved.
Such slow reductions allow time for pharmacological and psychological readjustment and are compatible with a normal life. Patients should not be hurried into changing the habit of many years. Too rapid a reduction can precipitate acute anxiety or psychotic reactions; abrupt withdrawal may cause convulsions.
Temporary use of other drugs is sometimes helpful for particular symptoms. Promethazine 50-100mg, two hours before going to bed, may help insomnia. Propranolol 20-40mg bd or tds controls tremor, palpitations and muscle spasms and may alleviate panic attacks.
Sedative tricyclic antidepressants are indicated for depression, a definite risk in benzodiazepine withdrawal. Patients already taking antidepressants should continue until after benzodiazepine withdrawal is complete. The new anxiolytic buspirone is contraindicated during withdrawal. After withdrawal, adjuvant drugs can be withdrawn gradually, but may cause withdrawal symptoms in anxious patients.
Most patients withdrawing from benzodiazepines need frequent encouragement; provision of regular follow-up appointments is as important as supervision of dosage reduction. Benzodiazepine withdrawal is successful in the majority of chronic users. Many symptoms, usually increased anxiety, may be experienced but are sometimes mild and cause few difficulties. Symptoms may last weeks, or even months, but few relapse after withdrawal. Psychological health is often improved, and outcome is independent of age, sex, psychiatric history, benzodiazepine dosage or duration of use.
Other drugsPromethazine - 75-100mg nocte* - for insomnia
Propranolol - 10-20mg tds or qid - for tremor, palpitations,
Sedative tricyclic antidepressants: amitriptyline - 50-75mg nocte
(for insomnia) - 75-150mg daily (for depression) - in divided doses
Avoid buspirone (BuSpar)
Decrease caffeine intake
* Take at least two hours before retiring
† Withdraw slowly after benzodiazepine withdrawal
Equivalent doses of benzodiazepines
Xanax (alprazolam) 0.5 Librium (chlordiazepoxide) 25 Valium (diazepam) 10 Ativan (lorazepam) 1 Mogadon (nitrazepam) 10 Serenid (oxazepam) 20 Normison (temazepam) 20 Halcion (triazolam) 0.5
Note: these equivalents are approximate and adjustment
to individual requirements may be necessary.
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