Dr. Raymond Armstrong and I are currently working together to push Texas lawmakers to adopt restrictions on the prescription of benzodiazepines and sleep drugs. We feel fortunate to be able to draw from the experience of the benzo movement in Massachusetts, and we are grateful for the information that long time advocates like Geraldine Burns have provided us.
Dr. Armstrong and I connected on this issues in January of this year, after I came to him for assistance in tapering off the benzodiazepine, Klonopin. Currently, I am 18 weeks into a 40-week taper plan. Dr. Armstrong’s interest in this work stems from his own experience some years ago when he went through a protracted withdrawal after he abruptly cold turkeyed himself off of Valium.
For people struggling to discontinue psychiatric medications, Dr. Armstrong routinely uses a compounded, oil-based suspension of the drug. This can be gradually and precisely measured in a syringe with the dose reduced over time. He prefers the suspension because it allows for precision in dose delivery that cannot be achieved through pill cutting. He has successfully assisted hundreds of people to taper off psychotropic drugs.
A few months ago, Dr. Armstrong told me about a recent legislative initiative in Massachusetts to further regulate benzodiazepines and other hypnotic drugs (Bill 4062). Knowing this bill might be persuasive to Texas lawmakers, I decided to contact every legislator in Texas by e-mail. I also followed up with handwritten letters to all members of the Public Health Safety Committee in the Texas House of Representatives and all members of the Health and Human Services Committee in the Texas Senate.
Responses have trickled in from a few concerned lawmakers, and I continue to receive favorable responses from lawmakers from correspondence I sent them in May of this year.
The next legislative session in Texas will not begin until January of 2017. From this time forward, we intend to connect with physicians, particularly young psychiatrists who are wary of benzos, primary care doctors, and OBGYN’s, who often serve as primary care physicians for women.
Why This Legislation Is Needed
I am a lawyer, and in law school, the most important thing you learn regarding medical interventions is the notion and legal concept of informed consent. Informed consent is often defined as the permission a patient gives a doctor for a particular treatment with the patient’s knowledge of all the possible consequences of that intervention.
When I first saw a psychiatrist for trouble sleeping and resulting anxiety, I explicitly asked him whether Klonopin could cause dependency issues. He shook his head no and emphatically said, “I have tons of patients that have been on benzos for years, and they don’t develop tolerance, it’s fine…My eyebrows don’t start to raise until a patient is taking at least 4 mg of Klonopin a day.”
I was completely denied informed consent for the risks of long term use of Klonopin even after I explicitly stated my concern to this doctor. So we are focusing on a regulation that would require doctors to warn patients by having the patient sign a form stating all the possible risks of long-term use of these drugs, including new or worsening anxiety and depression, as well as, the potential for physical drug dependency. We also want to make sure that physicians cannot abruptly discontinue prescribing these drugs to people already physically dependent on them.
What Patients Need to Know For Informed Consent
Many doctors that frequently prescribe these drugs long-term focus only on addiction as the sole potential problem. They know that taking benzodiazepines alone rarely results in addiction. The doctor may conclude that the patient has no history of substance abuse and, therefore, feels completely comfortable prescribing a benzodiazepine for long term use. In fact, my psychiatrist prescribed enough pills and refills for Klonopin to last half a year. Alternatively, the patient may feel a false sense of security because he knows he doesn’t have an addictive personality. Unfortunately, far more widespread than addiction to these drugs is physical dependency leading to the inability to discontinue these drugs due to severe withdrawal symptoms that can be agonizing and thoroughly disruptive to a person’s life and that of his or her loved ones.
Dr. Armstrong refers to the bell-shaped curve of biostatistical variation of responses to a drug in any sizable cohort of patients. In the case of habit forming medications, such as benzodiazepines, this variation not only applies to direct side effects but also to sensitivity to the withdrawal process. There are individuals on the left side of the curve that show a large tolerance for benzodiazepine reduction. Sensitive people, however, who fall on the other end of the bell curve (right side) have poor tolerance for reduction of the drug.
It is important to note that there is not yet a reliable assessment tool for determining where an individual fits on the bell-shaped curve of tolerance. For discontinuation of a benzodiazepine, no one and no physician can reliably predict how sensitive an individual will be to a benzodiazepine reduction.
Unfortunately, many doctors prescribing psychiatric drugs dismiss a person’s side effects or symptoms of emerging dependency because they want to believe that the tools of their trade only help and do not cause harm to people. Moreover, it is tough for an individual to prove that the drug harmed him. Often physicians, particularly those unwilling to believe there is a downside to the pills they prescribe, prefer to diagnose that the patient as having a new somatoform or psychosomatic disorder.
Early on, Dr. Armstrong himself did not understand the connection between all his symptoms and protracted withdrawal. In those days, he simply thought he was developing “phobias.” I can relate to Dr. Armstrong’s withdrawal. It’s only natural for your anxiety to go up when you realize you’re trapped on a drug that’s making you feel awful but even worse when to try to discontinue it. There is no end in sight without the right assistance. Fortunately, taper plans for these drugs may be as long as 40 weeks in duration. This can provide a way out of the trap and lead to a hope of freedom and recovery.
A chronic user of benzodiazepines may experience withdrawal symptoms even while regularly taking the medication. This experience is due to tolerance to the drug or from failing to dose frequently enough in accordance to the half-life characteristics of the drug.
I asked Dr. Armstrong how I would be able to distinguish between anxiety unrelated to the medication from stress caused by tolerance withdrawal or inter-dose withdrawal symptoms. He explained that it’s hard to make a distinction between the two. However, one telling sign of inter-dose withdrawal is experiencing increasing symptoms in the immediate time before taking the next dose of the drug or in the mid-to-late dosing interval.
It appears that physicians generally lack a clear understanding of the pharmacokinetic half-lives of the various benzodiazepines. This knowledge is fundamental in choosing the appropriate dosing intervals for the different benzodiazepines in order to minimize inter-dose withdrawal symptoms. Klonopin, for example, has a 12-hour half-life, thus allowing every 12-hour dosing intervals. In contrast, Ativan has a clinical half-life of 5 hours, Xanax a 4 hour clinical half-life, and Valium a mixture of long half-lives. The half-life factor is important in choosing a proper dosing interval in order to avoid inter-dose withdrawal symptoms.
If one were to prescribe Klonopin once a day, at bedtime only to treat insomnia, theoretically this could lead to a 75% decrease in function by the end of the 24-hour dosing interval. However, dividing the 24-hour load by two and giving half the daily dose every 12 hours will optimize dosing with the avoidance of inter-dose withdrawal symptoms, save for the possible need for minor dosing changes applied equally to the two 12 hour dosing points.
Addiction Medicine, I am told, does not use a taper method but rather favors the rapid reduction or cold-turkey approach. Historically, when drug rehab or detox centers were established as early as the 1940’s, the technique for alcohol discontinuance with its short half-life was abrupt cessation with seizure prophylaxis. When alcoholics showed up at detox centers hooked on Valium when it was first marketed in 1963, the method of abrupt cessation was applied for both the alcohol and Valium. The sudden termination approach to benzodiazepine “detox” is generally used 53 years later. However, it is associated with significant benzodiazepine withdrawal symptoms. Unlike physical withdrawal from alcohol, that has a definite three-day acute period with residual symptoms lasting up to a few weeks, physical withdrawal from abrupt cessation of benzodiazepines can last months or years, during which the person endures much needless suffering.
Recently, most of the attention in the news regarding drugs has been focused on the opiate epidemic. Little mass media attention has centered on the more subtle but equally devastating benzodiazepine epidemic.
To place this into context, some individuals find that detoxing from benzos is harder than detoxing from opiates, including singer-songwriter, Stevie Nicks. Additionally, a close friend of mine had to detox from both an opiate, and a benzodiazepine, Xanax, both prescribed to treat frequent migraines. My friend has said more than once to me, “Hands down detoxing from the benzo [Xanax] was harder than detoxing from the opiate [Vicodin]” The combination of the drugs he was taking is particularly dangerous and prompted his physician, an addiction specialist, to tell him, “You know cocaine really isn’t that bad compared to the combination of drugs you were taking.” The danger of such a drug combination is baffling when we consider that doctors are prescribing them. What happened to the Hippocratic Oath and the rule of medicine, First do no harm?
I’ve heard the majority of people, including myself, felt that they had no choice but to take benzos or other hypnotic drugs, like Ambien because they were desperate to get more sleep. Moreover, psychiatrists often tell us that we have a family history of anxiety so that we might be genetically dependent on their drugs.
But the efficacy of psychiatric drugs is being questioned more and more. For instance, mass media reports and publications, including Consumer Reports (February 2016 edition), state that all sleep medications leave much to be desired not only regarding potential side effects, like excessive daytime sedation but also in their lack of efficacy. It appears that even the upside to these drugs as a long term solution is quite limited.
Research has indicated that benzos tend to increase overall sleep time, but significantly reduce the amount of deep phase sleep a person receives at night. I remember thinking myself how much more refreshing, hour for hour, natural sleep was than medicated sleep. I miss not having a hangover in the morning. In my personal experience, I feel that the benzos are deceiving because when used on isolated and rare occasions, the drug tends to produce few unwanted side effects like the morning after hangover feeling. So the user is lulled into a false sense of security that the drug will continue to be as kind in the long term.
There are, however, non-pharmacological options for sleep and anxiety. I have read articles and heard reports from licensed therapists that cognitive behavioral therapy for insomnia, or CBT-I, is more effective than sleeping pills. And there appear to be additional non-drug treatment options for sleep and anxiety on the horizon. Sedatives may become a thing of the past as safer and more effective options emerge.
Call to Action
Readers, especially those in Texas, can contact me to try to coordinate our efforts to raise awareness of the dangers of these drugs, and push lawmakers to pass laws to safeguard the public. We can likely get a bill introduced in the Texas House or Senate because members of the health committees are concerned about this. But to get a majority of the full body in the house or senate to vote for an informed consent law, we’ll likely need major medical organizations such as the Texas Medical Association on board with this. I am encouraged to know that more and more physicians, particularly physicians in their 30’s and 40’s are wary of these drugs.
Additionally, we’ll need to share with Texas lawmakers video testimonials from as many Texas residents who have been harmed by benzos or other hypnotic drugs as possible. The more testimonials we have captured on video, the better.
Persons seeking to help the cause in Texas in any way possible can contact me by e-mail: [email protected]
Authors Note: This blog was prepared with the editorial assistance of Dr. Raymond Armstrong.