Q) Okay, you have convinced me to try to stop taking my sleeping pill. I’m willing to try this, but I don’t want to go through a month of feeling like crap in order to accomplish this. How is the best way to get off of these drugs?
A) Here is a quick recap of the last two weeks regarding benzodiazepams.
We discussed why these drugs can be dangerous, especially in the elderly who are ironically and regrettably the demographic who are most likely to be prescribed them. We also pointed out when they are appropriate to use as they can literally be lifesavers with their ability to stop prolonged seizures and can help people deal with extremely stressful situations for a short period of time.
Lastly we described what a withdrawal might feel like for many people. Withdrawing from a drug is an incredibly unpleasant experience, and in the case of the benzodiazepines (remember, this is the group of drugs whose generic names end with “am” such as lorazepam and alprazolam) there is no need for it. The problems benzo’s pose such as memory loss, addiction, fall risk, confusion among others are not the sort of ones that are likely to put you in a hospital bed in the next few weeks.
For most of the patients we are talking about, they have been taking the drug for at least months and in many cases decades, so slowly coming off of the drug over weeks to months makes a lot more sense than tackling it more quickly and likely less successfully.
To start with, there is no single guideline that is considered to be the medical standard that works for everyone. However, there is a significant amount of documentation supporting the effectiveness of the following two strategies and both choices embrace most of the same tenets when it comes to getting off of these drugs. The only real difference between the two strategies is to decide whether it is in the patient’s best interest to switch them from the drug they are taking to an equivalent dose of a longer acting member of the family or to just leave them on the same drug they have been taking all along.
The rationale behind going to a longer acting drug is that, because they stay in your system for hours longer than their shorter-acting brethren, they are less likely to induce withdrawal type side-effects and are therefore perhaps easier to get off of. The other advantage of changing to a longer-acting version is that the drug that is most often chosen, diazepam, comes in a wider variety of strengths and is a larger tablet than the other members, allowing it to be halved or quartered if necessary, thus making it easier to gradually taper the dose over time.
The disadvantages of converting the existing benzodiazepine to diazepam is that, especially in those who are only taking a dose at bedtime to sleep (as opposed to those who take them multiple times a day to counteract anxiety), the prolonged sedative effects of diazepam can increase the risk of daytime drowsiness and subsequent falls, especially in the elderly or those with liver impairment.
If you decide the best approach is to covert to diazepam, in general, 5mg of diazepam is equivalent to:
-Clonazepam 0.5 to 1 mg
-Lorazepam 0.5 to 1 mg
However, regardless of which drug a patient is slowly taken off of, the process is pretty much the same.
The first step always is to sell the benefits of why getting off of the drug is a good thing. Some people who take them for sleeping only (and this applies to the “z” type drugs as well such as zopicloneIm (Imovane) or zolpidem (Sublinox)) don’t really care if they are “hooked” on the drug or not as long as they can sleep.
Although, as we age, most are concerned about the links to dementia, brain fog, memory retention and might consider help to stop taking these pills. Studies have consistently shown that as a patient lowers their dose and eventually (hopefully) gets off of these pills, their energy and “alertness” levels tend to improve. Both of those are major problem issues for many seniors and so it tends to be a strong selling point to at least convince them to try.
Many react skeptically to this claim, not seeming to believe that taking away a drug that helps them sleep, could actually help make them feel more awake. This is because these drugs actually do not make that big a difference when it comes to sleep, but do nonetheless “deaden” the brain and our cognitive faculties. An analysis of multiple studies involving adults aged 60 and above found that collectively benzo’s and the “z” drugs are associated only with a modest increase in total sleep time of about 25 minutes. The average reduction in night time awakenings was 0.63 and patients self-reported only a modest improvement in sleep quality.
Once the patient buys in at least partially, most experts suggest reducing the total daily dose by 10% every one to two weeks until the patient is taking 20% (or 1 fifth) of their original dose. At this point, the tapering schedule is slowed down to reducing the dose by 5% every two to four weeks as often the hardest part of the process are the last few reductions.
A pill cutter is a necessity as often, in order to decrease this gradually, you may be splitting a single tablet into literally 8 small pieces. If withdrawal type effects start to emerge or severe anxiety or depression occurs, halt the taper and increase the dose to the level before for a couple of weeks. If the patient was taking the benzo multiple times a day, schedule his/her doses on a strict time schedule rather than just giving the next dose when withdrawal symptoms start to emerge.
And, of course, the last part of this program is to take the time to give the patient alternative strategies to better deal with their health issues. Not many people take benzo’s just to put their head in a “different” place. The vast majority were prescribed them for real health/quality of life problems such as insomnia or anxiety. Patients need to be taught real and practical solutions to these challenges such as cognitive behavioural therapy in the case of anxiety or sleep hygiene rules in the case of insomnia.
In some cases, other, less dangerous drugs may need to be prescribed such as the SSRI’s in anxiety or melatonin or trazodone for those who can’t sleep.
Benzo’s are a problem. They are a significant source of morbidity and mortality in our society but fail to generate the headlines that the opioids do. Most people can thrive without these drugs in their lives on a daily basis. With willpower and discipline from the patient and patience and empathy from their loved ones and their health professionals, the vast majority of us can eventually rid our lives of these drugs. For more information about this or any other health related questions, contact your pharmacist.