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PRACTICE GUIDELINES
OFFICE-BASED OUTPATIENT WITHDRAWAL TECHNIQUES:
A GUIDE - ANXIOLYTIC/SEDATIVE/HYPNOTIC DRUGS
The TSPP Executive Council approved the Guidelines during
its meeting on November 16, 2002. The Guidelines were tentatively approved on
April 21, 2002 by the Executive Council. The Guidelines were published in the
April/May 2002 TSPP Newsletter for review and comment by TSPP members.
Nearly 2% of adults develop a dependence on anxiolytic, sedative, or hypnotic
drugs.
Benzodiazepine (Bzd) dependence is the most common, but barbiturates and
musculoskeletal relaxants need to be considered as well.
The same guidelines, as with alcohol, apply in determining whether office-based
outpatient
detoxification is appropriate. Also, obtain a physical exam and laboratory
studies; and educate the patient and significant others as to the symptoms and
course of withdrawal.
Physiological dependence on Bzds can be expected if Bzds are used for more than
six months. Short-acting Bzds will have an earlier onset of withdrawal symptoms,
longer-acting Bzds will have a later onset. Table 1 lists discontinuance or
withdrawal symptoms.
Table 1 Bzd
Discontinuance Symptoms:
Timing:
Appear within 24 hours for short-acting BZDS; Within 2-3 days for
intermediate-acting BZDS and up to one week for long-acting BZDS.
Maximum intensity is from three days to two weeks.
Usually subside by four weeks: occasionally lasts up to three months.
Very Frequent:
Anxiety
Irritability
Agitation
Restlessness
Insomnia
Muscle Tension
Common But Less Frequent:
Nausea
Depression
Lethargy
Ataxia
Blurred vision
Diaphoresis
Hyperreflexia
Aches and pain
Coryza
Nightmares
Hyperacusis
Uncommon:
Psychosis
Paranoid Delusions
Confusion
Persistent Tinnitus
Seizures
Hallucinations
Withdrawal Techniques
These techniques are best suited for the chronic BZD user; that is the patient
who has been on a relatively stable dose continuously for six months or more.
The patient who has been on a continuous but very variable dose (e.g.;, 15-20 mg
of alprazolam on Sunday but 2-4 mg on Monday and perhaps 6 mg on Tuesday, then 2
mg on Thursday, etc.) may be withdrawn using lower doses (preferably at least
one-half) of those doses described below.
Sporadic or intermittent use of anxiolytic/sedative/hypnotics may not require a
withdrawal regimen.
Withdrawal from the muscle relaxant Soma is necessary because meprobamate is a
metabolite of Soma.
Diazepam (Valium) Substitution
• Determine the equivalent dosage of diazepam from Table 2.
• The longer-acting Clonazepam (Klonopin) can be used rather than diazepam. (5
mg of diazepam = 1 mg of Clonazepam).
Table 2
Drug Being Discontinued/ Dose Equivalency of 10 mg of Diazepam (mgs):
Barbiturates:
Amobarbital - 100
Butobarbital - 50
Butalbital - 50
Pentobarbital - 100
Phenobarbital - 30
Secobarbital - 100
Other sedative-hypnotics:
Chloral hydrate - 500
Ethychlorvynol - 350
Glutethimide - 30
Meprobamate - 400
Methyprylon - 300
Benzodiazepines
Short-acting (half-life less than three hours)
Triazolam (Halcion) - 1
Intermediate-Acting (half-life 12-20 hours)
Alprazolam (Xanax) - 1
Lorazepam (Ativan) - 1
Oxazepam (Serax) - 30
Temazepam (Restoril) - 30
Long-Acting (half-life greater than 100 hours)
Chlorazepate (Tranxene) - 15
Chlordiazepoxide (Librium) - 25
Clonazepam (Klonopin) - 2
Diazepam (Valium) - 10
Flurazepam (Dalmane) - 30
• Divide the daily dose by 5. For example, the diazepam equivalent for a
patient taking 10 Fioracet ( 10 x 50 mg) per day is 100 mg of Valium (10 mg
diazepam is equivalent for withdrawal purposes to 50 mg of butalbital). Divide
daily dose by five: 100 mg of Valium divided by five is 20 mg (the dose which is
decreased each week). To further illustrate- the diazepam equivalent for a
patient taking 6 mg Ativan (lorazepam) per day is 60 mg. 60 mg divided by 5 is
12 mg (the dose which is decreased each week).
• The daily dose of diazepam is divided into three doses per day (last dose at
hs) For example, when 60 mg of diazepam is the determined equivalent; the weekly
dose will be decreased by 60 5 = 12 mg. Week one of withdrawal can start with a
daily dose of 48 mgs. This is 12 mgs/day less than the 60 mg/day calculated to
be the pre-detox level. Therefore, the first week of detox incorporates the
first weekly decrease (12 mg in this example).
7:00 AM/ 1:00 PM/ HS/ Daily Doses
Week 1 16 mg/ 16 mg/ 16 mg/ 48 mg
Week 2 12 mg/ 12 mg/ 12 mg/ 36 mg
Week 3 8 mg/ 8 mg/ 8 mg/ 24 mg
Week 4 4 mg/ 4 mg/ 4 mg/ 12 mg
Week 5 2 or 3 mg/ 2 or 3 mg/ 2 or 3 mg/ 6 to 9 mg
Weeks 6, 7, and 8 may require very gradual ½ to 1 mg taper per week. There is no
need to hurry the tapering schedule. A small (2 to 5 mg ) dose may be necessary
daily, on a pm basis, for some patients as they taper. (Tapering can be slowed
as necessary.)
• Trazodone 50- 150 mg hs, is a useful adjunct.
As the drug taper ends rebound symptoms may appear. Rebound is a mixture of
prior anxiety symptoms and withdrawal symptoms. These will typically abate after
two weeks of being drug free. Relapse symptoms, which are the re-emergence of an
anxiety disorder, may also appear.
Two months of being drug free is sufficient time to determine if re-emergence of
an anxiety disorder has occurred.
Table 3
Predictors of Increased Severity of Bzd Withdrawal
Drug Variables
High Dose
Longer Duration of Treatment
Shorter Half-life
More Rapid Taper
Clinical Variables
Higher pre-taper anxiety and depression
Personality Disorders
Panic Disorders
History of Alcohol and Drug Abuse
References:
1. Ashton H. Toxicity and adverse consequences of benzodiazepine use.
Psychiatric Annals 25(3) pp 158-165, 1995.
2. Benzer DO, Smith DE and Miller NS. Detoxification from benzodiazepine use:
Strategies and schedules for clinical practice Psychiatric Annals. 25(3) pp
180-185, 1995.
3. Dupont RL. A practical approach to benzodiazepine discontinuation. J.
Psychiatric. Res. Vol 24 Suppl. 2 pp 81-90, 1990.
4. Schweizer E and Rickels K. Benzodiazepine dependence and withdrawal: A review
of the syndrome and its clinical management. Acta. Psychiatr. Scand. 98
(suppl.393) pp 95-101, 1998.
5. Alexander B. and Perry P. Detoxification from benzodiazepines: Schedules and
strategies. Journal of Substance Abuse Treatment, Vol 8, pp.9-17, 1991
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