This post has generated a number of thoughtful responses from readers. In order to avoid misunderstanding I decided to change the title, which was originally “Is “Medication Tapering” The Best Term For Withdrawal?” and make a few clarifying changes to the text. I also am adding a link to my Coming Off Medications Guide:
The long-term dangers of abrupt withdrawal are not talked about enough, and I really agree with the commenters who are using this blog post as forum to push for greater awareness. I deeply appreciate everyone who is working as I am to bring coming off medications into public understanding. I do hope that the textbook chapter I co-wrote helps alert more practitioners to medication dangers: it’s the first time I’ve co-authored with psychiatrists and I did the best I could.
Unfortunately I don’t have the time availability to re-express my point of view in the comments dialogue, but I do encourage people to read the Guide I wrote, which was just revised in a second edition with the input of scores of contributors. I continue to need suggestions for any changes for upcoming editions, as the Guide is based on the input of many people. As I say in the Introduction, the Guide isn’t perfect but I do hope it’s helpful. I really appreciate all the people who have been involved with the making of the Guide happen and gave input that shaped the second edition — including some of the commenters below.
I also want to apologize to anyone who may have been distressed by this dialogue: my intention is to deepen our understanding of how to help each other around coming off medications. Going off too quickly is a huge danger and one of the reasons the Guide was written: at Freedom Center and through Icarus Project we all saw the problems with coming off abruptly. At the same time, one size does not fit all and gradually withdrawal is not alway best and other approaches are sometimes successful. I make this point in the Guide, and based on the feedback I’ve gotten over the years I do believe that honestly recognizing the diversity of medication withdrawal experiences has been more helpful for people to avoid some of the problems of coming off than creating a firm rule or protocol. And I also know the Guide can be improved. It’s an ongoing learning process for all of us — thanks to everyone who’s working on this issue. — Will
The phrase “medication tapering” is being used more and more as the preferred term for the psychiatric medication withdrawal or coming off process. Based on my years of work educating many people around coming off medications — clients, support groups, and in workshops and trainings — I think that term is misleading, and let me explain why.
Gradual withdrawal is a sound guideline supported by a growing body of research literature as well as personal accounts, but should not be elevated to a firm rule: tapering is one possible strategy, but not the only one or even always the best one. Abrupt withdrawal can create severe and even life threatening consequences, but at the same time there are people who do successfully withdraw abruptly, and abrupt withdrawal, even with its risks (including unknown risks), may be a more advisable course of action and better choice in some circumstances.
As I write with Dr. Neil Falk and Dr. Dan Fisher in the upcoming “Textbook of Modern Community Mental Health Work”
While this slow and tapering approach to reduction and discontinuation is generally advisable and has a growing body of research evidence in support of it, in practical settings this is only a guideline. For example, clinicians and clients sometimes face circumstances where abrupt withdrawal is indicated. Medication toxicity such as liver and kidney problems, signs of tardive dyskinesia, rash associated with lamotrigene, neuroleptic malignancy syndrome, serotonin syndrome, or acute reactions such as heart arrhythmia, suicidality, self-injury, or mania call for either immediate withdrawal or transfer to another medication with a different adverse effect profile. In such instances the risks associated with withdrawal are outweighed by the physical danger posed by medication continuation. Abrupt withdrawal should be cautiously considered, however, as some medications, such as benzodiazepines, can be life-threatening during abrupt discontinuation (Ashton, 2005). Clients may also choose abrupt withdrawal when adverse effects are subjectively experienced as intolerable. In these cases, clinicians should ensure that clients are informed about the possible consequences of abrupt withdrawal, while also acknowledging the motivation and concerns behind it, and any difficulties encountered met are treated as a learning process.
Medication withdrawal is not a medical procedure like surgery: it is driven by the subjective meaning of the medications and the human relationships surrounding them. Because of this, there is a lot of diversity in coming off. Though I would never recommend it, I have met people who did just throw their meds away (often just after coming out of the hospital) and reported no withdrawal effects at all. Many people who begin with “I want to come completely off my meds” may, in the process of reduction, discover new usefulness to their medications or face withdrawal obstacles that lead them to rethink their initial goals. Others do better breaking with their prescriber and leading the process on their own (the UK charity MIND did a study of coming off medications and, because it found physicians were so often unhelpful in the process, changed its policy, and now no longer recommends physicians always guide withdrawal). A surprising number of people “just forget” to take a medication, and find this is the starting point for successful withdrawal. And we should remember that “psychiatric drugs” encompasses a vast range of possible medication situations, from the occasional Ambien on trans-atlantic flights to long term life-threatening polypharmacy. We need to understand this diversity and recognize that people have unique life stories just as they have unique relations to medications.
“Medication tapering” implies that like any medical procedure, there is a standard practice for physicians to follow. It’s certainly true that there should be guidelines and protocols around medication withdrawal, as this information is greatly needed and sorely lacking. There needs to be research into the physical risks of medication withdrawal and how to avoid those risks, including understanding drug interaction, supportive therapies like supplements, and the chemistry of different medications in the body. And too often people who have problems with an abrupt withdrawal are told this shows they need to stay on the medications, not try more slowly next time. But assuming that gradual withdrawal is more than a general principle, or that physicians are the ones who should always be making the decisions, risks making the process more difficult and potentially more harmful.
To meet the complexity and unpredictability of medication withdrawal, we need a more flexible approach. Does calling the process “medication tapering” overlook the need for that flexibility?
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.