What do I do if I’m iatrogenically dependent on benzodiazepines and the prescriber has expressed they will no longer prescribe?
Due to pending and active legislation and regulations on opiates in many states and on benzodiazepines (BZ) in a few states, many benzodiazepine prescribers are suddenly declaring to their long-term iatrogenically dependent patients that they are “no longer prescribing benzodiazepines”. This is actually a very negligent response to the problem. What is essentially being done, even if the prescribers take their patients off over the course of a few weeks, is a cold-turkey.
If you would prefer to listen to this information, as opposed to read, this video (9:11) by Gloria (prescribed BZ activist) summarizes the information:
Click on CC for captions in English.
Anecdotally, in the BZ withdrawal support communities, there are also reports of prescribers demonizing one BZ, such as Xanax (Valium has long since had a “bad rap”, despite being the drug recommended for use in tapering by benzodiazepine expert Dr. Heather Ashton and agencies like the British National Formulary), while still being willing to prescribe, say, Klonopin. There is no real scientific logic behind this demonizing of Xanax while still prescribing Klonopin. In fact, of all the benzodiazepines, Ativan carries the strongest language in the FDA’s Prescribing Guidelines, warning against the following: prescribing past 2-4 weeks, about withdrawal symptoms, and against abrupt cessation. And Klonopin (clonazepam), one of the nitro-benzodiazepines, has actually the highest incidence of adverse effects of the benzodiazepines. Withdrawal symptoms from Klonopin also increase markedly with accumulation of the drug, much of which is due to action of the inactive metabolites as well as the parent drug (Note: this is not to imply that all people have adverse effects or markedly increased withdrawal from Klonopin; many prefer to and are able to taper directly from it when it is the original benzodiazepine to which they developed iatrogenic dependence. Tapering from benzodiazepines is a black art, not a science, and experiences may vary from person to person).
This illogical demonizing and refusing to prescribed certain BZs presents a problem for some prescribed BZ-dependent patients for a few reasons: While the benzodiazepines are all pharmacologically similar, some of them bind to different benzodiazepine receptors (e.g., Klonopin binds tightly to central-type benzodiazepine receptors) than others. This variation in binding can, in some patients, cause them to go into withdrawal from their primary BZ when they are switched from it to another. Other patients can switch without a problem, but a stepwise crossover is recommended when crossing from a short-acting drug like Xanax to a longer-acting drug like Klonopin. Many prescribers are unaware of the need for a crossover or simply lack the understanding or education as to why it’s required. Some also do not understand or are unaware of benzodiazepine equivalents and will try to switch a patient from a much higher dose of, say, Xanax to a much lower dose of, say, Klonopin; when in fact the two are 1:1 equivalent (1mg Xanax = 1mg Klonopin = 20mg of Valium).
While the above scenarios—being forced to switch BZs by a prescriber, being offered less than the equivalent, and not being allowed to do a stepwise crossover—can cause devastating withdrawal-inducing and sensitization of the nervous system (as described in kindling) problems for some patients, an even worse scenario is when the prescriber refuses to prescribe anymore at all to a patient that is already physiologically dependent due to their long-term prescribed use. While it is commendable that a medical prescriber wishes to no longer prescribe these potentially dangerous drugs to their patients because they feel the risks outweigh the benefits, it is medically negligent to refuse to prescribe for someone already iatrogenically dependent because of the risks of severe withdrawal with over-rapid or cold-turkey cessation. The time refuse to prescribe benzodiazepines long-term or at all was before the patients were made iatrogenically physically dependent on them, not after. When a prescriber does this to a compliant patient, to the patient it feels like the medical community got them caught in this cobweb (often without informed consent) and now is refusing to assist them in untangling their way out. It is appreciated that some medical professionals inherit patients that were made iatrogenically dependent on BZ by another prescriber and who are not responsible for causing the problem to begin with.
According to the world’s leading expert in benzodiazepines, clinical research scientist and neuropsychopharmacologist Dr. Heather Ashton, D.M., F.R.C.P out of the UK:
There is absolutely no doubt that anyone withdrawing from long-term benzodiazepines must reduce the dosage slowly. Abrupt or over-rapid withdrawal, especially from high dosage, can give rise to severe symptoms (convulsions, psychotic reactions, acute anxiety states) and may increase the risk of protracted withdrawal symptoms. [emphasis added] Slow withdrawal means tapering dosage gradually, usually over a period of some months [for some more-sensitive patients whose body requires them to go slower, it can take some years].
Dr. Ashton, speaking to iatrogenically BZ dependent patients prior to attempting withdrawal:
The advantages of discontinuing benzodiazepines do not necessarily mean that every long-term user should withdraw. 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 [emphasis added]…The option is up to you…Your doctor’s agreement and co-operation is necessary since he/she will be prescribing the medication. Many doctors are uncertain how to manage benzodiazepine withdrawal and hesitate to undertake it. But you can reassure your doctor that you intend to be in charge of your own program and will proceed at whatever pace you find comfortable, although you may value his advice from time to time. It is important for you to be in control of your own schedule. Do not let your doctor impose a deadline. Leave yourself free to ‘proceed as the way openeth’, as the Quakers say.
Sometimes prescribers will suggest that their patients check into a detoxification (or “rehab”) center to get off of the BZ, in lieu of continuing to prescribe them for a slow taper. Unfortunately, this is not a responsible solution to the iatrogenic BZ dependence problem—as most detox centers are not equipped to keep patients for the time it takes to responsibly discontinue the benzodiazepine; nor can most patients afford to be kept for the time it would require. Instead of a slow taper, the “rehab” or “detox” center will rapidly taper (over days or a week) or cold-turkey BZ-dependent patients and send them home, sometimes in severe withdrawal states; this sets the patients up for a greater risk of protracted withdrawal (which can persist and be severe for years in some patients).
What can the BZ dependent patient do in these scenarios?
If your prescriber is open to more information/education:
In a calm and rational tone (or with an advocate for you—like a parent or spouse—if you require one)…
- Print The Ashton Manual and highlight paragraphs 8 and 10 in this chapter (which indicate that no one should be forced to withdraw against their will and that the patient, not the prescriber, should be in charge of the rate/speed of the taper before presenting it to your prescriber) and present it to your prescriber.
- If you wish to taper off, reassure your doctor that you intend to be in charge of your own program and will proceed at whatever pace you find comfortable—although you may value his/her advice from time to time.
- If you are trying to taper off, make out a dosage reduction schedule for the initial stages and to give your doctor a copy, indicating that you have a plan. You may need to mention the importance of flexibility so that the rate of dosage tapering can be amended at any time. There may even be circumstances when you need to stop the taper, or “hold,” for a while at a certain stage.
- Supply your prescriber with some more literature on benzodiazepine withdrawal
- Show your provider links to articles about patients being cold-turkeyed (e.g., in jail) and the poor outcomes which often result (sometimes death and lawsuits).
- Agree to regular follow-up appointments (and keep those follow-ups), as that will make the prescriber more comfortable with managing your continued use of BZs or your slow taper off.
- Agree to or suggest random or regularly scheduled drug testing (if you can afford it), if the prescriber requires that to continue repeat prescriptions to allow for your continued use of BZs or taper, to prove that it is compliant and as prescribed use occurring as opposed to addiction.
- In the US, ask that your prescriber consults the prescription drug monitoring program (PDMP) to prove that you have been compliantly taking the BZ and not “doctor shopping”. If you are located outside of the US, ask that they check whatever database keeps track of that information —if any.
If residing in the UK, offer for them to speak with one of the experts at the withdrawal charities (manycan be found on our Resources Page)
Some avenues to explore, should your prescriber not be open to learning more and are refusing to prescribe the BZ altogether:
- Ask for their refusal (or firing) and the reason for their refusal (or firing) to be given to you in writing (document everything, including that you provided them with information and warnings about the risks of abrupt withdrawal from BZs) as well as for a copy of your medical record(s).
- If they fire you as a patient, ask for them to provide you a reference for another prescriber who will treat you for iatrogenic BZ dependence and withdrawal, as they have an ethical duty to promote the continuity of their patients’ care.
- Consider filing a complaint with your State’s Board of Medicine (or another prescriber regulatory board, depending on where you reside).
- Similarly, if the prescriber works for a practice, write a complaint to or schedule a meeting to discuss your situation with the acting Medical Director of the practice.
- Interview new prescribers and try to find one that is ethical and educated on (or at least cooperative with) iatrogenic BZ dependence and withdrawal; they do exist. Sometimes calling the local compounding pharmacy in your area is a good place to inquire about BZ taper-cooperative prescribers, since prescribers who write for compounded BZ are usually doing so to allow for tapers.
- If needed, seek malpractice advice/representation from an attorney (especially if you or your loved one was cold-turkeyed, resulting in death or other serious adverse events). There have been some accounts of successful lawsuits for benzodiazepine injury and death from cold-turkey withdrawal.
Another video addressing this topic:
This video (12:30) is from activist Jocelyn and is titled “Help! My doctor stopped prescribing my benzo. What to do”: