1. Inappropriate Model
It is important to note that physical dependence and addiction are not synonymous, nor are they always mutually exclusive. Having developed a physical or physiological dependence to benzodiazepines means that persistent change in GABA receptor conformation has occurred due to repeated prescribed dosing of benzodiazepines. More simply, the body now relies on a benzodiazepine to prevent withdrawal symptoms. Physical dependence is a normal and predictable outcome and one that should be expected after chronic exposure to many commonly prescribed tolerance-forming medications, not just benzodiazepines.
Unlike physical dependence, addiction is defined as a set of destructive behaviors, often driven by uncontrollable cravings, including compulsive drug use, drug-seeking, and the inability to control drug use in spite of resulting harms to self and/or others. A person can be both physically dependent and addicted to a drug or drug(s) simultaneously, but someone can also be physically dependent and not addicted. Thus, physical dependence in and of itself does not constitute addiction, although it can often accompany addiction. Patients who took their benzodiazepines as directed by their prescriber are physically dependent, not addicted.
Nearly all residential rehab/detox centers in the United States utilize a 12-step model. This model focuses on the compulsive use and behavioral problems of addiction and maintaining abstinence through fellowship and completing “the steps”——admitting that one cannot control one’s compulsion; recognizing a higher power; examining past errors; making amends for these errors; learning to live a new life with a new code of behavior; helping others with addiction——and is therefore inappropriate for those made iatrogenically physically dependent on benzodiazepines through prescribed, compliant use. None of those steps safely reverses the physiological changes in GABA receptor conformation (where the receptor won’t react to host GABA and only to the benzodiazepines) that occur in benzodiazepine physical dependence; only a slow taper addresses this problem and may restore function.
Patients are, often unknowingly and without informed consent, being made iatrogenically physically dependent on benzodiazepines. Once tolerance sets in, or some other reason or motivation for an attempt at stopping the drug, the patient tries to discontinue the benzodiazepine and cannot without intolerable withdrawal. Prescribers may try to solve this problem by parking them permanently on the drug, increasing the dose, or the proverbial “buck” is passed, perhaps due to equating evidence of tolerance and withdrawal symptoms with an incorrect assumption that the patient is addicted, and these patients may be unloaded on rehab/detox facilities.
This is not a problem unique to the United States. Dr. Malcolm Lader, one of medicine’s few benzodiazepine experts and Professor of Clinical Psychopharmacology at the Institute of Psychiatry, University of London, stated on BBC Radio 4 Face the Facts,
It’s very difficult to come off these drugs and the facilities are just not available and the great scandal is that the NHS [National Health Service] claims to be dealing with these people by referring them to addiction centres, where essentially they’ll sit next to a street user who’s injecting heroine and of course a housewife who’s been put on tranquillisers by her doctor is very upset by this….
If a medical need develops for specialized services that do not exist, the solution is not shove patients unknowingly into an inappropriate system, like a round peg into a square hole, potentially causing harm or to the detriment of their health, but rather to provide the medical education to prescribers that is lacking and develop and make available the appropriate facilities and resources that are required.
Lastly, we rarely hear reports of people taking prescribed antidepressants being sent to detox or rehab centers to discontinue their use——in fact, the mere suggestion of that might be viewed as quite unnecessary or silly by most——in spite of the fact that that class of medications can also cause physical dependence and withdrawal syndromes not that dissimilar to the benzodiazepines. Instead, antidepressants are typically discontinued outpatient and via taper. Because the withdrawal syndromes from benzodiazepines are notably more dangerous than from antidepressants, sometimes causing psychosis, seizures, or death, one might argue this is a reason to medically supervise the withdrawal in a rehab/detox facility, but those severe outcomes typically occur with overly-rapid or cold-turkey withdrawal, which is often the only type of withdrawal offered at those inpatient facilities.
Benzodiazepines are also a schedule IV controlled substance, which may explain why these patients are referred to rehab/detox when antidepressant patients are not. However, just because a drug is controlled, this does not indicate that it has been abused. Besides, other controlled substances are often appropriately utilized in a medical setting. For example, a motorcycle crash victim on a morphine drip in the hospital may develop physical dependence. In this instance, the patient is not deemed an addict and sent to rehab or detox, but instead tapered off once the pain management is no longer required.
The prescribers of benzodiazepines should hold the burden of being knowledgeable about the differences between prescribed physical dependence and addiction—— in other words, not automatically equating evidence of tolerance and withdrawal symptoms with assumptions that the patient is addicted. Sadly, when they get it wrong, patients are inappropriately sent to detox/rehab centers, often resulting in dangerous and sometimes protracted suffering.
2. Not Enough Resources or Time
In 2013, annual industry revenues were about $35 billion for addiction treatment centers——attending these places proves unaffordable for most, the cost usually ranging anywhere from $15,000 to the low six-figures for a 30-day stay at a private facility. That aside, as some government agencies or psychiatric wards offer free or more affordable detox programs, the facilities usually do not offer programs or stays lasting any longer than 7-90 days. These time frames are too short and unsafe for a large percentage of people who struggle to discontinue benzodiazepines. Some physically dependent benzodiazepine patients report requiring upwards of 12 to 18 months or even years to complete a tolerable withdrawal program.
These detox/rehab facilities, which are grossly ill-suited for iatrogenic benzodiazepine physical dependence, are sometimes being utilized solely due to a lack of resources specifically dedicated to deprescribing. Since most reputable guidelines for benzodiazepine discontinuation call for a slow, patient-controlled taper, the common sense solution, in addition to prescriber education and training, is that withdrawal-specific resources and facilities need to be developed and offered to patients——much like what is available through the UK withdrawal charities and in Australia, set up specifically with withdrawal advisers educated and experienced in aiding benzodiazepine- and Z-drug- (and sometimes antidepressant- and opioid-) dependent patients with withdrawal via slow taper.
3. Poor & Dangerous Outcomes
Many rehab/detox facilities, if called and queried about benzodiazepine detox, will refuse service or indicate that it is not even offered——this may be due to fears of liability for poor outcomes, prior experience with poor outcomes or difficulties rapidly withdrawing benzodiazepine patients, or due to awareness that overly-rapid or cold-turkey benzodiazepine withdrawal can increase the risk for developing protracted withdrawal, psychosis, seizures, and/or death and that most guidelines recommend a slow, gradual taper for cessation.
The rehab/detox facilities that do accept benzodiazepine-dependent patients will often abruptly stop the patient’s benzodiazepine(s) and/or Z-drug, replacing them with a short (one week or so) phenobarbital or Librium “taper,” sometimes followed by the prescription of adjunctive medications like gabapentin, Lyrica, beta blockers, antidepressants, antipsychotics, etc. to “manage” the withdrawal. In these cases, patients can be admitted to the facility on one drug——the benzodiazepine—— and are then discharged home on prescribed polypharmacy, including drugs which carry their own similar risk of physical dependence and withdrawal and requirements for taper. This in spite of the fact that the British National Formulary specifically states of the benzodiazepine withdrawal process, “The addition of beta-blockers, antidepressants and antipsychotics should be avoided where possible.”
Also, after a rapid “taper” or cold-turkey withdrawal, some patients anecdotally report a “delayed (or tardive) withdrawal syndrome”——one where the severe symptoms of withdrawal do not fully manifest until a few months post abrupt cessation——so, those patients are discharged from their rehab centers with little to no support or aftercare in place, only to go on to develop psychosis, seizures, suicidality at home a few weeks or months later. At this point, due directly to the detox from benzodiazepines, patients may also find themselves in an even more precarious position as is explained by Dr. Heather Ashton in her manual: “Many benzodiazepine users who find themselves in this position have withdrawn too quickly; some have undergone ‘cold turkey’. They think that if they go back on benzodiazepines and start over again on a slower schedule they will be more successful. Unfortunately, things are not so simple. For reasons that are not clear, (but perhaps because the original experience of withdrawal has already sensitised the nervous system and heightened the level of anxiety) the original benzodiazepine dose often does not work the second time round. Some may find that only a higher dose partially alleviates their symptoms, and then they still have to go through a long withdrawal process again, which again may not be symptom-free.”
Lastly, according to Dr. Heather Ashton, benzodiazepine expert who ran her own withdrawal clinic for 12 years and Emeritus Professor of Clinical Psychopharmacology at the University of Newcastle upon Tyne, England, “Nobody should be forced or persuaded to withdraw against his or her will. In fact, people who are unwillingly pushed into withdrawal often do badly”. Anecdotally, this proves true in the over-rapidly tapered or cold-turkeyed patients BIC has encountered, via they or their families contacting us directly or online in the withdrawal support communities, many reinstating to attempt a slow taper, others emailing us or posting desperately in the support groups looking for help or advice on what to do, and even some sadly taking their own lives via suicide, the severity of the withdrawal syndrome too severe or protracted to continue to endure.
4. Russian Roulette
Each person’s experience of benzodiazepine withdrawal will be unique, varying in severity and duration. Some people, even those who took high doses of prescribed benzodiazepines long-term, will experience only minor or, in some cases, no withdrawal. According to Dr. Heather Ashton, “Some people can stop their benzodiazepines with no symptoms at all: according to some authorities, this figure may be as high as 50% even after a year of chronic usage. Even if this figure is correct (which is arguable) it is unwise to stop benzodiazepines suddenly”. Dr. Malcolm Lader states, “I estimate about 20-30% of people who are on a benzodiazepine like diazepam have trouble coming off and of those about a third have very distressing symptoms.” His figures are conservative, as Reconnexion, a nonprofit organization in Australia offering counseling and support for benzodiazepine dependent patients, states: “It is estimated that between 50-80% of people who have taken benzodiazepines continually for six months or longer will experience withdrawal symptoms when reducing the dose.”
Regardless of the exact figure of those affected, it is unwise to stop a benzodiazepine prescription suddenly or rapidly in a detox or rehab facility simply because there is no medical testing or crystal ball available when it comes to benzodiazepines——in other words, there is absolutely no way for anyone to know in advance which patients, specifically, will experience a withdrawal syndrome upon attempts at cessation, which patients will go on to develop severe or protracted withdrawal, or which patients could cold-turkey or rapidly taper with minimal to no symptoms. For this reason, medical providers and patients should not play “Russian roulette” when it comes to benzodiazepine cessation, as it puts patients at unnecessary risk for the sometimes-devastating outcomes detailed just prior in the ‘Poor & Dangerous Outcomes’ section of this article.
*Note: There may be some instances where a patient is exhibiting symptoms of a paradoxical reaction to the prescribed benzodiazepine, or some other severe adverse event or complication, in which case the prescriber will have to use their own discretion or consult an expert as to the best course of action in regards to tapering versus a rapid or cold-turkey withdrawal. This circumstance would be rare, however, and not the norm.
5. Tapering Is Most Successful
Dr. Heather Ashton, reports a 90% success rate for her stepwise, gradual, patient-controlled taper plan found in The Ashton Manual, developed by her after working one-on-one for twelve years in a clinic with physically dependent benzodiazepine patients wishing to withdraw.
This study, done to establish the efficacy of an intervention program which included tapering to reduce the chronic use of benzodiazepines, resulted in 45.2% of patients in the intervention group discontinuing their benzodiazepine compared to 9.2% in the control group. For every three interventions, one patient achieved withdrawal. 21.9% of subjects from the intervention group and 16.7% of the controls reduced their initial dose by more than 50%. The study concludes that “standardised advice given by the family physician, together with a tapering off schedule, is effective for withdrawing patients from long-term benzodiazepine use and is feasible in primary care.”
This study assessed the effect of a direct-to-consumer educational intervention——the EMPOWER brochure, which contains a 4.5 month taper plan——on benzodiazepine discontinuation in people aged 65-95 taking chronic benzodiazepine prescription. A total of 261 participants (86%) completed the 6-month follow-up. Of the recipients in the intervention group, 62% initiated conversation about benzodiazepine therapy cessation with a physician and/or pharmacist. At 6 months, 27% of the intervention group had discontinued benzodiazepine use compared with 5% of the control group. Dose reduction occurred in an additional 11%.
This study compared “the effect on withdrawal severity and acute outcome of a 25% per week taper of short half-life vs long half-life benzodiazepines in 63 benzodiazepine-dependent patients. Patients unable to tolerate taper were permitted to slow the taper rate. Ninety percent of patients experienced a withdrawal reaction, but it was rarely more than mild to moderate. Nonetheless, 32% of long half-life and 42% of short half-life benzodiazepine treated patients were unable to achieve a drug-free state. The most difficulty was experienced in the last half of taper.” So, utilizing a taper where the rate was controlled by the patient, 68% of long half-life benzodiazepine treated patients did successfully withdrawal, as did 58% of short half-life benzodiazepine treated patients.
More studies which more closely examine variables such as taper methods (dry cutting, liquid titration, microtapering, gram scale, compounded liquid, tapering strips, cut-and-hold, etc), duration of taper, rate/speed of taper, longer half-life versus shorter half-life drugs utilized, etc. are needed to determine the absolute best discontinuation practices with most favorable outcomes. However, it is clear that slow patient-controlled tapers are safer, more successful, have better outcomes, and are recommended overwhelmingly in respected published guidelines and medical literature for appropriate benzodiazepine cessation. For these compelling reasons, detox/rehab facilities are inappropriate and substandard for physically dependent benzodiazepine patients.