Benzodiazepines in Canada: Is a Withdrawal Crisis Looming?

Editor’s Note: This article was written by Marnie Wedlake, PhD, RP, Mad in Canada’s founding publisher. This piece first appeared on our affiliate site, Mad in Canada.

On February 16^th, CBC News published an online article: ‘Quebec doctors to face increased scrutiny for overprescription of anti-anxiety medication’. Clearly a commentary on the subject of Cauchemar sur ordonnance, this piece names “misuse of benzodiazepines [as a] concern in Quebec”. In response to this issue, the college of physicians in Quebec, The Collège des médecins du Québec, will be increasing its monitoring of those physicians thought to be overprescribing benzos.

Benzo overprescription is getting a fair bit of bad press …. again. But why are these drugs, that are supposed to be for short-term use only, being doled out, in some cases, for years? Fingers are being pointed at prescribers. But why would prescribers knowingly push users into harm’s way by overprescribing drugs known to have dangerous side effects, including dependence? The most likely answer: prescribers don’t know what they don’t know.

It seems pretty clear that prescribers are not as informed as they should be. Being adequately educated about psychiatric drugs means knowing enough about what they’re prescribing to give patients the opportunity to provide informed consent to treatment. Where benzos and other psychiatric drugs are concerned, required knowledge should include: what the drugs do, what they do not do, potential short- and long-term side effects, and how to enable and support safe tapering and withdrawal.

If benzos are being overprescribed—to the point of repeatedly drawing widespread attention in the popular media—it seems pretty clear that too many prescribers are poorly informed about the potentially serious risks attached to these drugs. So poorly informed, they’re putting patients in danger. If prescribers are this much in the dark on what could happen to those who take these drugs, then its also likely they don’t know how to enable and support safe tapering and withdrawal with those who have been taking these drugs for any length of time.

CBC News quoted Camille Gagnon, pharmacist and associate director of the Canadian Medication Appropriateness and Deprescribing Network (CADeN). CADeN is a collective of individuals, from varying backgrounds, all of whom share an interest in promoting “the safe and appropriate use of medications”. According to Gagnon, the rate of prescription of benzos in Canada is about one in 10 people. CADeNs interests include deprescribing and their website features what they refer to as ‘deprescribing algorithms’ for several drug classes, including benzodiazepines. CADeN states, “few evidence-based guidelines exist to support safe deprescribing for specific classes of medication”.

In my work as a health educator and board member with the International Institute for Psychiatric Drug Withdrawal, I’ve voiced concerns about the withdrawal protocols recommended by CADeNs psych drug algorithms. To weigh in, I reached out to two experts in psychiatric drug safe tapering and withdrawal. Nicole Lamberson, PA is a physician assistant and medical advisory board member with the Benzodiazepine Information Coalition based in the US and co-founder of The Withdrawal Project. Nicole also appeared in Cauchemar sur ordonnance. Dr. Mark Horowitz, MBBS, PhD is an academic psychiatrist in training, a clinical research fellow in psychiatry, and he runs a psychotropic drug deprescribing clinic in the UK, where he’s based.

From Nicole Lamberson:

The long-overdue exposure of benzodiazepine problems resulting from long-term prescription—including physical dependence, withdrawal and protracted injury—in Canada should be championed by all who desire better outcomes for patients. That said, regulators who put forth guidelines, with all good intentions to solve this issue, could wind up unintentionally harming benzodiazepine patients yet again.  

Radio-Canada’s show, Enquête, filmed me in my living room, in November 2023, from 10:00 am until about 5:00 pm. During the interview, I made it a priority to discuss the importance of ‘grandfathering in’ patients who are already physically dependent on benzodiazepines. As often happens with editing and time constraints when making a documentary, that testimony wound up on the cutting room floor. What I hoped to convey is that regulators and guidelines must respect that patients who are already physically dependent on benzodiazepines should never be forced against their will to withdraw. Patients who choose to withdraw should have complete control over the rate and speed of their taper. This same guidance was prominent throughout Dr. Ashton’s pioneering Manual and should be echoed in any regulations and guidelines put forth in Canada, and elsewhere, going forward. Ripping patients off using too-rapid withdrawal schedules, followed like a recipe out of a cookbook and not tailored to an individual’s symptoms, could prove disastrous, resulting in severe withdrawal symptoms and setting those patients up for protracted withdrawal injury which can be detrimental to people’s lives and health, persisting for years in some cases. 

Another issue with this recent coverage in Canada (specifically in this article/the video embedded within) is one far too frequently encountered in benzodiazepine advocacy: the inappropriate use of terminology**. Conflating the terms ‘addiction’/’addictive’ with ‘dependence’/’physical dependence’ will also result in more harm. All of the subjects in Radio Canada’s piece suffered a form of iatrogenesis—prescribed physical dependence—after benzodiazepines were prescribed to them long-term and without informed consent. This is not addiction, by definition. When journalists and the media use addiction terminology to describe what is really prescribed physical dependence, they cause harm in three ways: (1) patients taking benzodiazepines as prescribed get a false sense of security and are not properly warned by the media exposure because they do not identify as addicts; (2) regulators may develop guidelines with irrelevant and ineffective treatments (rapid withdrawal/”detox”, AA/NA, 12-step programs, etc) aimed at problems of abuse and addiction which are not present; (3) doctors and other prescribers may refuse the ongoing prescriptions needed for patients to do the slow, gradual taper that is required to mitigate harm, misinterpreting the requests for repeat prescription of benzodiazepines as “drug seeking” or “doctor shopping.

**Feb 21/24 Update: After Enquête’s producer reached out to Matthew Lapierre regarding his improper use of terminology (conflation of addiction/addictive with dependence/physical dependence) Lapierre amended his article to correct this issue.

From Dr. Mark Horowitz:

It was very encouraging to see Radio Canada’s documentary on benzodiazepine dependence and withdrawal blow the lid off a calamitous situation that has been allowed to continue for years, where patients suffer severe and prolonged withdrawal effects and brain injuries from coming off benzodiazepines too fast without adequate help from the medical system. This issue has been opaque to clinicians because of the poor training of doctors and other prescribers in recognising withdrawal effects and other harms from benzodiazepines. Instead, doctors often perceive ‘relapse’ of patients’ conditions (such as anxiety) or onset of new conditions rather than withdrawal effects. This leads to mis-diagnosis, incorrect treatment and much unnecessary suffering for many patients, as portrayed so heartbreakingly in the documentary. 

In the wake of increased public awareness of the dangers of benzodiazepines there can sometimes be unintended negative consequence of further harm. When doctors are made aware of the harms of benzodiazepines, the pendulum can swing to the other side, and prescribers can react in knee-jerk fashion by compelling their patients to stop benzodiazepines too quickly. It is often difficult to hold these two competing ideas in mind: that it can be both bad to be on a medication, and even worse to stop it too quickly. I often use the (visceral) analogy of an arrow: it is bad to have an arrow in your chest (equivalent to being on a drug that causes multiple harms) but it can be even worse to rip that arrow out of your chest (the harm that comes from severe withdrawal effects after quickly stopping). 

The only way to steer between these two poles is to stop these drugs carefully – if people are willing to do so. Given how difficult the process can be for some people it may be the lesser of two harms is to stay on the drugs, especially for older people who have been on the drugs for decades. If people do decide that they wish to come off benzodiazepines then they should do so gradually.

The Canadian Medication Appropriateness and Deprescribing Network should be commended for all the efforts to reduce polypharmacy and unnecessary prescribing and I admire their work, however, their benzodiazepine deprescribing algorithms recommend a rate of taper that is much too quick, is not adjusted flexibly for an individual and does not take into account the pharmacological action of benzodiazepines and z-drugs. 

Firstly, tapering has to be gradual – which can mean months or years, not weeks, for long-term users. The Ashton Manual and the NICE guidelines in the UK have been the gold standard guides for how to stop benzodiazepines for many years with recommendations that tapering off benzodiazepines should take 6 to 18 months for long-term users – much longer than the few weeks suggested by the Deprescribing Network’s algorithm. Even that rate of taper is too fast for some long-term users. Secondly, the rate of taper has to be adjusted to an individual because everyone is different and it is very hard to predict ahead of time how fast someone can tolerate. And thirdly, because of the way that benzodiazepines affect the brain, very small doses have out-sized effects and so the drugs need to be tapered very carefully for the last few milligrams which are the hardest to stop. This is not taken into account in the Deprescribing Network’s algorithms. 

We have recently published the Maudsley Deprescribing Guidelines in Canada, the US, and round the world which outlines for clinicians and patients step-by-step guidance for how to reduce all widely available benzodiazepine and z-drug available in Canada according to the above principles. It outlines fast, moderate and slow tapers for Xanax (alprazolam), Ativan (lorazepam), Valium (diazepam), Klonopin or Rivotril (clonazepam) and the sleeping tablets Lunesta (eszopiclone), Ambien (zolpidem) and Imovane (zopiclone), and how to adjust these for the individual by tracking withdrawal symptoms and taking feedback from patients. A central aspect of all these dose schedules is that the experience of the patient is paramount, something often not taken into account in schedules that are dictated to a patient. Sometimes patients will need to reduce by as little as 5% of their most recent dose every month (so that the reductions become smaller and smaller), as recommended by NICE in the UK, because the withdrawal effects can be so aversive.

These guidelines are consistent with guidance put out by the NICE guidelines (authoritative medical guidelines in the UK) and are being used in clinics in the UK and around the world to allow people who have had great difficulty in coming off their benzodiazepines and z-drugs to do so without severe withdrawal effects. Sometimes, patients will need liquid versions of their medication or compounded capsules or tablets to be able to facilitate the very gradual reductions that some people require.

CBC News tells readers ‘help is on the way’, but is it really? Or, is it possible a much bigger, potentially catastrophic, problem might be looming? There’s no doubt greater oversight of the prescribing of benzos is needed. However, this cannot happen without addressing the obvious gaps in knowledge and understanding about benzodiazepines, on the part of prescribers. I fear this glaring gap, coupled with the potential for prescribers’ knee-jerk reactions prompted by the stepped up monitoring coming from the Quebec college of physicians, could set off a benzodiazepine withdrawal crisis in Quebec, and the rest of Canada.

Editor’s Note: The following information and clarification was added on March 30, 2024.

The deprescribing algorithms referred to above were not created by CADeN but are referred to by CADeN using a link to the source.

From Mark Horowitz: The Canadian Medication Appropriateness and Deprescribing Network should be commended for all the efforts to reduce polypharmacy and unnecessary prescribing and I admire their work, however, the benzodiazepine deprescribing algorithms developed by deprescribing.org housed on their website give example rates of taper that are much too quick for many patients. They do recommend that the rate should be adjusted to the individual but without any specific guidance on how to do this (e.g. appropriate example rates, which formulations of medication must be used, how measurements can be made) it is difficult to see how this could be implemented in clinical practice. Although they do recommend tapering slower at lower doses, this guidance does still not adequately take into account the pharmacological action of benzodiazepines and z-drugs which dictate that very small doses of drug have outsized effects and require much slower tapering (such that, for example, reducing from 1mg of diazepam to 0mg causes a greater change in effect on the brain than reducing by 20mg from 100mg). These issues are more closely reflected in NICE guidance which recommends going down by a ‘proportion’ of the most recent dose, and not the original dose, which traces out a pattern of reduction that closely resembles the pharmacological effect of these drugs. https://cks.nice.org.uk/topics/benzodiazepine-z-drug-withdrawal/management/benzodiazepine-z-drug-withdrawal/ 

The Ashton Manual and the NICE guidelines in the UK have been the gold standard guides for how to stop benzodiazepines for many years with recommendations that tapering off benzodiazepines should take 6 to 18 months for long-term users – much longer than the few weeks or small number of months suggested by the specific examples given in the deprescribing.org algorithm.

This is not taken into account in the deprescribing.org algorithms.

For information on safe tapering and withdrawal of benzodiazepines see: The Benzodiazepine Information Coalition, the International Institute for Psychiatric Drug Withdrawal, Inner Compass’s The Withdrawal Project.