CPCP: Protracted Benzodiazepine Withdrawal by Dr. Matt Klein

Matt Klein DO

Matt Klein DO

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.

Dr. Amos-Google

Dr. Amos-Google

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.

In order to see the picture galleries of photos or powerpoint slides, click on one of the slides, which will open up the presentation to fill the screen. Use the arrow buttons to scroll left and right through the slides or up and down to view any annotations.

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Comments

  1. We typically use Depakote for 21 days and add the gabapentin to that if necessary. All off label of course.

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  2. Thanks, George! I’m going to make sure that Dr. Klein sees your remarks.

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  3. Hi Jim,

    This is a tough clinical situations for a couple of reasons. The first is that primary care physicians like benzodiazepines. That is changing to some extent but given their utility is limited by tolerance they are overprescribed. Psychiatrists also fall into the same trap when they are seeing complicated patients who have overwhelming anxiety and insomnia. It seems like benzodiazepines offer a solution for that but instead, it leads to an anxious person or a person with insomnia on progressively higher doses of benzodiazepines. Like most addictive drugs, everyone has their success story, the question is how rare they are.

    The next clinical hurdle is safely getting patients off of benzodiazepines and the associated problem of few functional detox units unless you are in an ICU with DTs. Dr. Ashton’s approach is fine for the few people who are highly motivated enough to complete those protocols. What is needed is more detox units where patient can be started on anticonvulsants prophylactically, given some high dose benzodiazepines for a week or two and rapidly detoxed. The major residential centers can usually do this in a week or two and they typically stop the usual benzodiazepines acutely and switch to that protocol.

    The final hurdle is protracted withdrawal syndromes that I think were well documented in the British literature in the late 1980s. Very long duration symptoms like insomnia, anxiety, night sweats and the atypical symptoms listed in the presentation. We find gabapentin very useful and often add it to the anticonvulsant we are using for acute detox. This is also an area where we could use some clear markers to distinguish recurrent anxiety from protracted withdrawal. As an example, the problem of severe panic disorder that was clearly present before the use of high dose benzodiazepines will occasionally cause me to use the STAR*D approach of SSRI or SNRI + buspirone and it seems incredibly effective in some cases for the panic disorder with or without depression.

    This is another area that should not be rationed. Too many people are sent out from emergency departments with a bottle of alprazolam or lorazepam that they take in the parking lot instead of following the tapering instructions.

    George

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    • Hey George, Matt the psychiatry resident who wrote the CPCP wonders what anticonvulsant you would add the gabapentin to in your comment about treating acute detox.

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