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The following is a transcription from the above video on how to quit benzos
Hi everybody. My name is dr. B. And today’s topic is how to quit benzos recommended benzo taper schedule. So let’s get 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.
First 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 ask 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 subjective. Since 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 around Xanax. You need to get off with 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 believe these drugs have over prescribed. Why are they over prescribed?
I 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 the 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 ask 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 Ting Xanax 0.25 milligrams once a day for the last 25 years and he’s stable on us those and there’s never been any evidence of abuse or increasing the dose or seeking the drug elsewhere.
That’s where the clinician should weigh out the 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 at to higher dose is those things aren’t evaluated appropriately and constantly for every patient because once you get on this medication Ian you can have some serious short-term and long-term withdrawal effects if you try to come off of it. So, you know, the first question is why do wider is the patient on the benzodiazepines 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. Ridden 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 to get off benzos or who needs to lower their? The 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 2 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 its going to have severe consequences. And what are you going to do 5 10 15 20 25 years from now that dose really needs to be extended. Simply 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 dos but it will have profound long-term effects.
I would call that physiological dependence. Dependence that maybe doesn’t need to be there. Then there is the real addict who is taking benzos at large doses any benzo 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 are certain needs to be on a lower dose and they need to taper that dose down. So the folks that need to be on 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 Dos 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 the risk are quite a bit benzos Fallen under the class of sedative hypnotic 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 includes alcohol, which is the same class of 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 would drawls whether you just cut them off or your tapering the wrong way are absolutely a monster for again. There’s variations with different. Current people. Please. Keep that 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’ll call it post-acute withdrawal syndrome.
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 benzyl taper schedule. And this is really really important to me. And this is where I think it’s critical. I’m going to say this before I get into the schedule that I use I think this system whether stay Insurance system or the medical community. Bushman doesn’t really support both the tech payment structure and the clinical attention needed to benzodiazepine withdrawals. What do I mean by this? If you go into a detox or rehab or even if you go to your doctor these withdrawals and tapers are done relatively rapidly 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 to rapidly. I mean you might go on to attend a 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 lower their dose. 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 our 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 her 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 when you 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 will 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 We feel the pain and I won’t let you get sick and I won’t 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 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 built this report 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 your continuing where they’ve been that which you can go on a little bit longer than if someone spying 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. Way and give him a very close prescription and those other ones that have been on it 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 I’m being honest with themselves about the doses that they’re taking so I will see him 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 Taking a dose that I think is too high that needs to be brought down.
I will now attempt to make a cross tolerance. 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 It switches Annex the Klonopin if there are highly resistant to this change I won’t do it but 90% 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 tolerance, which I’ve also by this time made a pretty good rapport with the patient and I’ve built the trust now, I will start the really really neat part of the way. I approach this. What I do is I write them a prescription whatever it is. Let’s say in this case. It’s 1 milligram of 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 just this 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. And seeing them for four weeks. I know that were stable at one milligram of Klonopin twice a day. I see them every week for the dose. There are 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 bed say point five milligrams a day or we can cut this off completely.
I have them bring the medication bottle into the office and I say, okay and I draw it out for them. So you just got 60 of these for the month, correct? they say correct and they’re very very very very still timid about pulling out the medication showing it to me. There’s this really interesting fear about me taking away to 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 Patience. I’m giving you one example. So he says I take one in the morning one in afternoon. Then. I’ll say to the patient. Please tell me which those 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 bills but my afternoon those 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 those. Here’s a whole pill one in the Morning, one milligram one in the afternoon one milligram. That’s a total of two 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. Instead of taking one milligram in 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 0 days or 30 days. If you do it for 30 days, you’re going to be at one point five milligrams a day for 30 days and you’re going to have 15 full tablets left. Raising if you do it 4-0 days, you’re going to 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 to patient and giving them control of this very very high abuse potential drug that really becomes a fundamentals crutch and our 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 the 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 one 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 going to pull them off the drug because there’s a method to this madness. I tell him slow down. So I say bring all your pills next time when the first time they show up now, they’re worried. I’m going throw away those half pills, because again, I’m taking something away from Um 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 bottle and I’m like, here’s your new prescription that you also brought. There is only one and a half milligrams from last time and you can almost see they’re trying to protect it because But they’re afraid I’m going to take it away and throw it away because they don’t know what’s going to happen. And I tell them 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 the 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 doctor be dr. B. I just threw my old Xanax Klonopin away. I did it and I can tell you this is again another extremely empowering effect on their addiction.
You’re giving the control to the patient and allowing them to see what’s possible. And sometimes you have to actually 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 taper if I have to up to two years because I want the long-term outcome to be successful and by month three four 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 where they have issues.
I will go from seeing Once a month to once every two weeks to once a week and continued close monitoring 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 the beginning you got to keep a very close eye on them. We want to make sure they’re not having All symptoms were hat 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 video, please go ahead and click on the link above for more videos. Also, don’t forget to subscribe and ring the bell to the channel. Have a wonderful day.
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