The Drug Taper Paradox

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My wife J.A. was on the couch in the living room crying and writhing in agony. It was the late summer or early fall of 2014 and I had no idea what to do. I called her then-psychiatrist and explained that I was worried for her safety.

“How many clonazepam do you have?” he asked me. J.A. had been taking a 1 mg tablet of the benzodiazepine every night at bedtime for sleep. I checked and told the doctor that the prescription had recently been filled so the bottle was almost full.

“Give her 8 mg,” he said.

“Is that safe?” I asked.

“Yes, it will calm her down and then we need to get her an appointment soon, so we can adjust medications.”

I gave J.A. eight pills as per her doctor’s directive and told her they would help. And in that moment, the pills did help. She calmed down and eventually fell asleep.

The eventual adjustment in medication was to prescribe J.A. dissolvable clonazepam tablets that she was to take PRN (pro re nata, Latin for “as needed”) whenever the anxiety or emotional turmoil became too great. Soon the little silver foil packets of clonazepam were stashed around the house, in the car, and in J.A.’s purse. For a while, I even carried a couple with me in case she needed them. At that point, we still did not know that the daily emotional upheaval was drug-induced akathisia.

Clonazepam continued to be used as a calming agent throughout her withdrawal from the “atypical antipsychotic” Latuda in 2016. As J.A. and I have mentioned in earlier articles, the impact of that withdrawal was devastating. Clonazepam was used extensively; at its height, J.A. was taking up to 4-5 mg per day.

Now, more than nine years after I first gave her that 8 mg dose, we are still tapering from clonazepam. We recently dropped the current daily dosage from 0.34 mg per day to 0.31 mg per day. Every time J.A. drops, we can’t help but brace for the numerous withdrawal effects that range from mild, to moderate, to severe. The taper process is incredibly slow and incredibly counterintuitivejust as she begins to feel better from the last dose drop, we know it’s time to do it all over again.

This paradox is at the heart of psychiatric medications. Intense emotional distress is counteracted by a pill, so an immediate crisis is averted, but all of the underlying factors that initiated the crisis remain. So another pill soon needs to be taken. And then another pill is taken. The entire process becomes a slow-moving downward spiral until the medications have you so far down in a hole it can feel impossible to climb out. The process of withdrawing from these drugs is a slow climb out of that steep hole.

A concerned family member or friend can only observe the process from the outside. When J.A. was in crisis in 2014, I reached out for help and the help I was offered came in the form of eight pills. The pills averted the crisis but did nothing to address the underlying cause of J.A.’s distress. In hindsight, I know her distress was caused by drug-induced akathisia from Latuda (among other psychotropic drugs she’d been prescribed).

She was on Latuda because after years of taking Abilify, she had developed metabolic syndrome. After the eight-pill clonazepam crisis, the medication adjustment her psychiatrist made was to switch her to the (then) latest and greatest “atypical antipsychotic” (though the more accurate term is ‘neuroleptic’), despite the fact that this class of drugs all work in roughly the same way and cause the same metabolic dysfunction (among other side effects, including akathisia). For a year or so things appeared to improve; the lateral shift to a new neuroleptic seemed to be the right, albeit more expensive, move. Yet, the reprieve from the shift was very temporary as the metabolic syndrome continued and her daily neuroleptic-induced akathisia worsened.

In 2015 and into 2016, I was still a believer in the pills and what the doctors said, but I was beginning to have my doubts. The pills seemed to help some things, but then, like clockwork, things would inevitably get worse. The search for the right “balance” of medications was like shining a bright flashlight in a completely empty basement. No matter how hard you searched, it remained empty.

At this juncture, although I had doubts about the medications, the medical system and J.A.’s suffering left no room to raise concerns until her neuropsychologist saw that she was suffering from drug-induced akathisia.

Prescribed psychotropic drugs are inherently paradoxical. A pill that’s supposed to calm or tranquilize comes with a warning that it can cause increased agitation. A pill prescribed to improve depressive symptoms comes with a warning that ‘worsening depression’ is a side effect. A pill prescribed to prevent suicide comes with a warning that it can cause suicidality.

Unfortunately, after observing the paradox of these pills for almost eight years firsthand, the contradictions forced me to see the drugs’ ultimate inefficacy. When you first discover the pills don’t really work as advertised, the urge is to shout how damaging and ineffective the medications are, but that declaration is lost on the very people who need to hear it most. The warning is silenced by the occasional (and temporary) efficacy of the pills, along with the system that prescribes them. The pills do something, and for at least a moment, the pills may help.

For those taking these pills, understand that family who may be unsupportive of you getting off of them may only see the positive side of what the medications do. The pills stopped your agony, if only for a momentsomething your support person was incapable of doing on their own. If you are the support person, you may be missing the alternate agony the pills are causing your loved one.

To successfully navigate these medications, we have to resolve the paradox of why the pills can make those who take them simultaneously better and worse.

The Opponent-Process Theory

With multiple systems and functions, nothing in the body happens in a vacuum. Everything that happens within our bodies was honed over centuries of evolution to keep the body alive and functioning. Introducing something from the outside, specifically psychotropic drugs, creates unintended and unforeseeable consequences.

Optical illusions offer a glimpse into the complexity of these systems through our sense of vision. In 1878, a German physiologist, Ewald Hering, proposed something called “opponent-process theory” to explain color vision. The simple version of his theory is that humans see color because of three competing color systems. The competition between these systems is what creates our ability to see color.

The vertically red striped circle shows how the process works. Stare intently at the red striped circle for at least fifteen seconds and then if you shift quickly to the similarly striped circle with only white stripes, you will get an image of a light green striped circle. It is a clear illusion of a green striped circle created by the sudden withdrawal of the red.

The opponent process kicks in and your brain sees a color that isn’t there.

In 1980, Richard Solomon co-opted opponent-process theory to explore addictive behavior. His theory, in a simplified form, is that when we are presented repeatedly with an outer stimulus, three things happen:

  1. The outer stimulus creates a contrast in the person’s experience.
  2. Repeated presentation of the outer stimulus creates tolerance.
  3. After tolerance forms, whenever the stimulus is removed, a withdrawal or abstinence syndrome develops.

The theory has been used to explain a diverse range of human experiences from skydiving to drug addiction.

Another way of looking at the theory is as an exploration of the interaction between allostasis and homeostasis. Homeostasis is the body’s stable baseline for all its bodily processes. When an outer stimulus disrupts homeostasis, the entire body reacts to bring the body back to baseline in a process known as allostasis. After the outer stimulus is removed, a counter processan alternate version of allostasiskicks in to bring the body back to its normal baseline. Solomon, in expounding the theory, compares an a- process, which is initiated with a stimulus, followed by a bprocess to counter the stimulus, then observes how the countering processes express themselves in human subjects, both objectively and subjectively, over time.

While my house is nowhere nearly as complicated as the human body, it goes through an opponent process in regards to the HVAC system. There are three stories, which we jokingly refer to as the “tropical, temperate, and arctic zones.” Heat rises, leaving the upstairs hot and the basement frigid. The thermostat is planted in the center of the main floor, right above the stairs that go down into the basement. There is often a ten-degree difference between the basement and the main floor in the summer, with a nice 73 degrees on the main level, and a frigid 63 degrees downstairs. To counteract this disparity, the basement has a gas fireplace that also runs on a thermostat. The fireplace is in the family room right at the base of the stairs.

The heat from the fireplace will warm the family room up to the desired temperature, but the majority of the heat goes right up the stairwell in a direct attack on the main floor thermostat, which then kicks on the air conditioning, causing the basement to get even colder. Until one of the thermostats is turned off or until the weather changes, the heating and the cooling are in a constant opponent process. If the weather is warm enough, just leaving both systems running would eventually cause a breakdown of the entire HVAC system.

The opponent process of illicit drugs is well worn into our collective psyches. The user takes the drug, gets the desired effect, the effects wear off, the user wants more, takes the drug, gets the desired effect, and as tolerance builds, it takes more and more of the drug to achieve the same effectand to stave off withdrawal between doses. When someone tries to discontinue the drug, horrific withdrawals make returning to the drug the easiest option. The opponent processes of tobacco or caffeine use are also easily and quickly understood by almost everyone.

These bodily reactions are nature’s way of returning us to homeostasisthe fixed temperature in our bodily ’thermostats’. Both the drug effects and resulting withdrawal symptoms are examples of allostasisthe entire body’s attempt to return to homeostasis.

Opponent-Process Theory and Psychiatric Medications

It takes very little effort to transpose opponent-process theory onto psychiatric medications to explain why they can simultaneously make someone feel better and worse. These medications are designed to impact neurobiological processes to change a psychological state, i.e. psychotropic, –tropic meaning ‘to affect the activity of’. The patient takes the pill. The psychological state changes. The daily use of the pill creates tolerance. After tolerance is reached, a withdrawal syndrome develops as the competing processes flip-flop with each other. Too much of a flip-flop and the whole system can crash.

The competing processes show themselves through their impact on behavior and physiology. When we look to pills to solve one problem, we forget the opponent processes the body will naturally employ to return to homeostasis.

I only recently read about opponent-process theory in a book entitled Strangers to Ourselves: Discovering the Adaptive Unconscious, by Timothy D. Wilson. As I read about opponent-process theory, my entire history of being J.A.’s spouse and support system as she has battled iatrogenic and prescription drug harm came into clear focus.

For illustrative purposes, I will focus on just one aspect of drug harm we have dealt with, specifically benzodiazepine withdrawal, to illustrate how opponent-process theory can be applied to psychiatric drug withdrawal. For us, clonazepam was introduced as a tool to combat other drug harm, and initially it worked. This would have been the a- process. The pill calmed down J.A.’s wildly out-of-control system, caused by Latuda, and later, because of Latuda withdrawal. The initial 8 mg dose calmed the system and eventually the daily dose rose from 1 mg to 4 mg per day. As J.A. described it to me, the 4 mg eventually didn’t bring relief; it just took the edge off the bodily agitation she experienced.

The b- process of clonazepam begins when the levels of clonazepam drop within the body. The withdrawal process for clonazepam for J.A. manifests with severe headaches/migraines, nausea, dizziness, anxiety, fatigue, cognitive issues, sensitivity to light and sound, brain “zaps,” insomnia, and even a recurrence of akathisia. At some point in the withdrawal, J.A. developed tinnitus, which is also a common withdrawal effect and with its particular auditory horror, reason alone to get off the drug. When I asked her to describe clonazepam withdrawal to me for this article, she quipped, “It’s like getting hit by an airplane in midair.”

Figuring out when the opponent process for clonazepam kicks in is complicated by the drug’s long half-life. The half-life of a drug is the length of time it takes for half of the initial dose to get out of the system. Clonazepam has a half-life that can vary between twenty and fifty hours, depending on the person’s individual metabolism of the drug. Unless you know someone’s metabolism rate, calculating hourly blood levels is impossible. Instead, you are left with subjective evidence and symptomsbasically, when does it feel like the plane just hit you?

The 4 mgs J.A. took were spaced out through the day, since the pills were often taken PRN. The ability to take clonazepam PRN actually fueled the opponent process, because she would fall into interdose withdrawal symptoms. To avoid that, we now have times and amounts set for the doses throughout the day to keep the overall blood levels as steady as possible.

Thinking about the impact of clonazepam on J.A.’s system and the opponent process of withdrawal, the goal in tapering has morphed into an objective of lowering the blood levels as slowly and steadily as possible to keep the opponent process from overreacting. Solomon actually described why it would be wise to employ a taper process in his 1980 article:

Therefore, one would expect the pathology to develop much more rapidly following the termination of the reinforcer [a- process], when the b state is “pure,” than during the presence of the reinforcer, when the quantity |a — b| may be very small.

To say that another way, when the body becomes used to the daily outer stimulus (ingestion of a drug, in this case clonazepam), things get really bad when you stop taking the medication because the withdrawal symptoms (b- process) will not have an a- process to check them. A long, tapered withdrawal is lowering the amount of the drug taken slowly enough that the withdrawal process doesn’t overwhelm the person who is withdrawing. The trick is to keep the a- process and the b- process closely aligned, so the withdrawal effects are as minimal as possible.

No Quick Fixes

At the very beginning of 2019, after going through the Latuda withdrawal, J.A. and I realized we had at least three or four medications she still needed to withdraw from to regain her health. The strong impulse is to want to withdraw quickly. On the heels of a very rapid and very short withdrawal from Latuda, neither J.A. nor I felt emotionally or physically capable of undertaking the withdrawal from yet another medication.

We began looking for something that could help us get her off of clonazepam first. At the time we hadn’t discovered the Ashton Manual and really had no idea about how to even go about withdrawing. We stumbled on the Alternative to Meds Center (“ATMC”) in Sedona, Arizona, and J.A. contacted them on January 4, 2019. Amid the first week of love-bombing, flattery, and high pressure sales, we cobbled together the $30,000 they required after our “scholarship” was given.

The high-pressure emotional sales pitch focused on commiserating with J.A. about the difficulty of medication withdrawal and commiserating with me about the difficulty of being a caregiver. On one phone call, the sales rep told me, “We have 53 people to do what you’ve been trying to do alone.” It was an emotional gut-punch that convinced us both that this was the right move. The price seemed high but worth it if we could emerge with some semblance of our lives back. We paid the deposit on January 12th and left for Sedona on January 15 to check her in on January 16only twelve days from when we initially contacted them.

I dropped J.A. off at the ATMC and headed back to Utah from Sedona. J.A. had her first appointment with the medical staff at the ATMC on Thursday, January 17. The plan was to immediately cut her clonazepam dosage by 50%, and because such a drastic drop could cause seizures, they wanted to put her on Gabapentin or Tegretol. She rejected both of those medications, having had them in the past with severe negative side effects. They opted for a dose of Trileptal, another drug from the same class, one J.A. wasn’t familiar with. After an exhaustive high-pressure consultation with several staff and medical personnel, she felt too overwhelmed to argue. She was alone, outnumbered, and faced with a rapid change in medicationsshe felt like she had no choice.

A dangerous drop in dosage and a new drug wasn’t what we had been told or promised in the slick sales pitch when we signed on. Early the next morning, Friday, January 18, J.A. contacted me. She had been placed in a room far from the staff, with no way to message them. The new drug had rendered her unable to speak and walk for a time. Instead of 53 people to replace me, no one was there and she was incapacitated. I booked a flight that same morning, rented a car, and picked J.A. up from the ATMC that same day. After some wrangling over a couple of weeks, most of our $30,000 was refunded after deducting for the two days she was there.

As the opponent-process theory suggests, the human body is not going to react well to a rapid withdrawal from a medication that has been taken regularly for years. J.A.’s system was already in disarray from the Latuda withdrawal and the ATMC experience only highlighted the fact that we would be in the withdrawal process for the long haul and there would be no quick fixes or fast tracks. Instead, we settled in for what has now been an almost 5-year process of slowly tapering medications.

The taper process has improved over time because it has become predictable. When the drop in medications happens, we both know that in two or three days, the flu symptoms will appear, moods will shift, fatigue will become overwhelming, and sleep will be disrupted. Simply knowing what is coming and knowing it won’t last as the body adapts to the new medication levels makes it possible to continue tapering. The dosage continues its slow decline.

What is Suffering?

Psychiatric medications do things. If there is a severe emotional crisis, the pills may indeed be a magic elixir that erases emotional pain, but these pills are like the magic of fairy tales, where the magic carries with it a dark side, an opponent process, as if without an opposing force, the magic could not, and would not, work. Simply understanding the paradox of these pills is critical for any family member who truly wants to help a loved one navigate the world of psychiatric medication and recovery.

The confusion is compounded by the drug labeling. The side effects of a prescription drug describe both the a- process of the drug’s effect and the bodily b- process in response to the drug. The medication insert literature doesn’t differentiate. Too often, working out the paradoxical effects of the medications feels like an intensely personal science experiment with few resources that offer practical guidance.

Our society is not geared for paradoxical thinking. Most of what bombards us in our lives encourages black-and-white thinking. For example, the word “suffer” used to mean “tolerate” or “allow,” as found in the King James Bible when Jesus said, “Suffer the children, and forbid them not to come unto me.” The word has kept the sense of something happening, but it’s now used almost exclusively to mean tolerating or experiencing something negative. We suffer psychological stress. We suffer through drug withdrawal. We suffer from side effects. I’ve found it helpful to think of ‘suffering’ in its original sense, something that needs to happen, even something that must be allowed to happen, especially when dealing with prescribed drug withdrawal. You have to suffer, meaning allow the body’s different processes to occur as it heals and works its way to a new, healthier homeostasis.

The dual, almost paradoxical thinking that is required by opponent-process theory also shows just how complex the withdrawal process can be when you realize that it isn’t just drugs that create opponent processes in our bodies. The high that comes after a strenuous workout has the opponent process of muscle soreness and fatigue. Food and supplements can add further complexity. Even emotional and psychological stress create physiological reactions when cortisol and adrenaline flood the body, but there is also an inevitable crash that follows.

Because so many different processes are ongoing, withdrawal requires cultivating an environment that is as stable as possible. Given my experience in helping and supporting J.A., I don’t know if withdrawal could be successful in a tumultuous environment. So, an important step in beginning the withdrawal process will be to create an environment that is flexible enough to tolerate the back-and-forth swings that come with tapering psychiatric medication.

One thing we have also learned is that the emotional effects of writing about drug harm, or interacting with others about harm they have suffered, brings its own opponent processes. J.A. must take occasional breaks from writing for MIA or doing advocacy work, so some of her energy is currently going toward completing school. However, her series on healing from drug harm will recommence soon.

I began this article with a focus on J.A.’s withdrawal from clonazepam, but as we’ve detailed in our previous articles, J.A., like too many others, was poly-drugged. Another drug she is tapering from is Vyvanse. The effect of a stimulant and its opponent process are very different from a benzodiazepine, but the concept remains the same. J.A. was given the Vyvanse to counteract the enormous sedative effects of the neuroleptics and benzodiazepines she had been prescribed.

In meeting with J.A.’s psychiatrist, we had him prescribe chewable Vyvanse (designed, horrifically, for young children) to create ease in cutting the pills for tapering. On one occasion, we made a horrible decision to drop both the clonazepam and Vyvanse at the same time, thinking lowering a sedating drug and stimulating drug simultaneously would limit the opponent processes of withdrawal. Predictably, yet only in hindsight, every process went into overdrive as bodily systems were overwhelmed and overtaxed.

Our current taper schedule seems to be working the best, which is alternating drugs as the doses drop. Cut the clonazepam and wait out the withdrawal symptoms. After about six weeks, when the more severe withdrawal effects have subsided, lower the Vyvanse dose and wait outsufferthe new withdrawal symptoms because they are a necessary part of recovery. We no longer approach these changes with overwhelming dread or fear, because in suffering, or allowing them, we know we are progressing towards a time when J.A.’s body can simply respond to her world and environment without chemical interference.

Understanding and accepting the paradoxical nature of these powerful drugs gives us the emotional strength and much-needed hope to continue the taper. Every effect comes with an equally powerful counter-effect, a stark reminder that ultimately, the remedy for human suffering will never reside in a pill.

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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.

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10 COMMENTS

  1. Thank you for this article. Opponent-Process Theory is one way to visualize psychotropic drug withdrawal. However, we really do not know the mechanism causing withdrawal symptoms. All we know is that withdrawal symptoms indicate the body has adapted to the drug.

    Because taking a drug regularly causes the body to adapt to a homeostasis based on regular drug intake, not getting that regular intake — sometimes even if the drug schedule is only off by an hour or two — disturbs the homeostasis, withdrawal symptoms representing that disturbance, which can be visualized as the difference between the drug-based homeostasis and the lowered drug level. But the symptoms are not as simple as A vs B, push vs pull, or rebound: Withdrawal symptoms can show up anywhere in the body, and travel around, indicating some drug adaptation occurs throughout.

    While reference to addiction medicine may inform about certain universalities in psychotropic withdrawal, addiction medicine is often fuzzy about “dependence”, often attributing it to psychological dependence resulting in “craving” when the drug is reduced. But the homeostasis resulting from any regularly ingested psychotropic is a neurobiological fact, not psychological.

    Because dependence has been long held to be synonymous with addiction, this fuzziness has led to the coining of a new term, “physical dependence”, to distinguish this neurobiological dependence from addiction. (Psychological dependence is an essential requirement for addiction.)

    It’s essential to remember that regular ingestion of psychotropics causes this physical dependence and removal of the drug can cause havoc expressed as withdrawal symptoms, some of which can be physical and some mental.

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    • Altostrata,

      Thank you for your comments. I think we agree on most of the things you mention, but I want to clarify that my article was actually more about the paradoxical (unpredictable, subjective, and disruptive) results that happen when tapering from medication.

      Opponent-process theory is simply a handy and familiar framework that has not yet been applied to psychiatric drugs. Because of that gap, I see it as a highly effective way to illustrate the dangers of psychiatric medications to family, friends, medical professionals, and any one else who doesn’t frequent Mad in America.

      When someone takes illegal drugs, society has done a great job in informing them about the potential negative side-effects from incarceration to withdrawal. However, with psychiatric drugs, only the benefits are touted, which has given rise to the entire informed consent movement.

      Unlike illicit drugs, there has been almost no scientific inquiry or examination of how the opponent-process works with these medications. What I am suggesting is we need to take the next step which is educating society that the opponent-process is baked into psychiatric drugs. Paradoxical and conflicting results from the medication are what happens every time any drug is taken, that is how the human body works. Because of that, I see opponent-process theory as a potentially effective way to illustrate the biological harm psychiatric medications cause.

      Thanks,

      Kent

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      • You may be interested in the work of Giovanni Fava regarding psychiatric drug withdrawal. You may find his “oppositional model” resembles opponent-process. E.g. Fava, G. A. (2020). May antidepressant drugs worsen the conditions they are supposed to treat? The clinical foundations of the oppositional model of tolerance. Therapeutic Advances in Psychopharmacology, 10, 204512532097032. https://doi.org/10.1177/2045125320970325

        Personally, I don’t think the term “opposition”, however used, provides accurate visualization for whatever happens in withdrawal because, as you say, withdrawal effects are so various. My model is of a network that has broken down in patches with feedback gone awry, causing more dysfunction (as in falling dominoes), with very slow rebuilding of the web from the intact areas into the dysfunctional areas.

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  2. Very well written. I pray for your wife’s recovery. I too was polydrugged and suffered with akathasia. Everything the doctors told me was wrong and none believed me when I said it was caused by the drugs. Thank God I persisted and didn’t listen to them. I’ve been back to normal for 6 years now.

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  3. I was told long ago by a wise man long ago..”never go near psychiatrists. If you do you will leave with a prescription (that you may or may not need). Go he said to psycologists instead. You probably won’t be prescribed in 20 minutes.

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  4. 100% agree with this. I was given clonazepam for no reason and it made me so depressed and intrusive thoughts made my thinking difficult to focus. It was given on top of lamotrigine which itself triggered mania. So this endless cocktail of medications lead you nowhere but in the path of destruction. Psychiatrist want you to be dependent on meds and enhance their career, they don’t teach you how to cope with feelings and correct the behaviors. Spirituality and meditation and religious books helped me more than anything else.

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  5. I’m so sorry you and your wife have been going through hell for so many years. Something similar happened to my adult daughter. I describe it as going through hell because of always having to be on high alert since her behavior could always change at any moment and we never got helpful advice from Psychiatrists -quite the opposite. One of the lowest points was when our daughter started to develop uncontrollable laughter, which was absolutely hideous and which was caused by all the different changes in medication, but there was not a single Doctor Who attributed it to the psychotropic drugs. It took four years to taper off of everything and for the past two years she’s been completely drug-free as she had been for the first 32 years of her life. I do wish you all the best, and pray that your wife will be free of mind controlling drugs soon.

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