So here’s another great CPCP, this time on protracted benzodiazepine withdrawal from resident psychiatrist, Dr. Matt Klein, DO, a repeat performer whom you’ll recall from his excellent previous presentation on Psychiatric Emergency Medications for Agitated Patients in December 2014.
This is a very intriguing subject and I can never find anything published and available in PubMed later than 1997 on it. I encounter literature which says that addiction specialists recognize the syndrome, but it’s probably rare and the latest paper I could find was not about benzodiazepine withdrawal but protracted alcohol withdrawal (Bonnet, U., et al. (2009). “Severe protracted alcohol withdrawal syndrome: prevalence and pharmacological treatment at an inpatient detoxification unit–a naturalistic study.” Pharmacopsychiatry 42(2): 76-78.), which is related because of the action of alcohol and benzodiazepines on GABA receptors in the brain.
Dr. Klein believes he’s seen a couple of patients with this syndrome. He and the other resident currently rotating on the consult service cannot recall hearing any lectures about protracted benzodiazepine withdrawal from two of our addictions specialists on faculty, although that doesn’t mean they’re unaware of it. I also couldn’t find it in the Psychotropic Drug Handbook 7th Ed. by Perry, Alexander, and Liskow, which was published in 1997. Awareness of the syndrome seems limited.
It’s a little disappointing to me sometimes to find that the only doctor who has something to say about difficult clinical situations like protracted withdrawal syndromes is Dr. Google–except for Dr. George Dawson, who I hope might comment.
On the other hand, if Google Glass ever catches on (not likely at $1,500 a pair), then maybe I could morph into Dr. Google myself.
When I think about protracted withdrawal from benzodiazepines and the suffering it causes, it makes me cringe that I see so many medically hospitalized patients whose doctors, either psychiatrists or primary care physicians, are prescribing them–and which not uncommonly lead to my colleagues consulting me about how to peel them away. They can lead to confusion, falls, and addiction. That’s not to say there are no safe indications for them, including temporary time-limited use getting panic attacks under control while initiating other treatments. And benzodiazepines are the medication of choice for treating alcohol withdrawal.
I just want to mention that, because of the panoply of somatic symptoms people can complain of during protracted withdrawal syndromes, it can overlap with other important disorders and behaviors psychiatrists see and need to be alert for including somatic symptom disorder, factitious disorder, substance use disorders, and malingering (not a diagnosis but an accusation) to name a few. Giving long-term benzodiazepines to these people can make them feel better in the short term but often lead to much greater suffering over the long run.
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