Transcription
Each year, thousands of straightlaced people who have never had any problems with drugs or alcohol or any of that find themselves stuck on benzoazipene sedatives and other sleep aids like ambient. Not because they need to be on them, but because every time they try and stop, they get hit with severe withdrawal symptoms like rebound insomnia, intense anxiety, agitation, sometimes even physical symptoms like tremors or heart palpitations. These symptoms can be so frightening that many people even dread the thought of trying to come off again. I've heard this routinely described as the worst period in my life and an absolute bloody catastrophe.
But I'm here to tell you some good news, and that is that there is a safe and comfortable way off these medications if you just know how to do it properly. A way that most doctors aren't aware of because they were never trained to do this properly. And so today, I'm going to show you a simple, practical, and easy to follow tapering strategy that you can use to safely and comfortably come off sedatives.
And for those of you who don't know me, I'm Dr. Yseph Wuring. I'm a board-certified psychiatrist. I'm an expert in tapering and drug side effects. I used to work at the FDA and in several pharmaceuticals. And for the last 6 years, I've been running the largest drug tapering consultancy in the world. So, let's jump in. Okay.
To start with, what are the medications we're going to talk about helping people get off? They're the ones right here on the screen. So, if you're taking one of these drugs, this video is going to show you how to come off. I want to quickly talk about why most of these drug tapers fail with different doctors. And it really comes down to two things. They are tapering you too quickly and they are doing dose reductions that are far too large. And you're going to understand that more as we go through this video.
This is a super practical video. We're going to kind of walk through the whole tapering strategy start to finish. And so the first thing, the way to get oriented in this big mess is to decide what form of the drug that you need to come off. Now psychiatric medications, they come in several different forms. There are immediate release tablets. There are immediate release capsules. There are liquid formulations that get made at a compounding pharmacy. And you can have extended release capsules as well. It may sound complicated, but I'm going to simplify it for you.
There are two main forms of the drug that you can actually taper with. You can taper with instant release tablets and they are instant release capsules. The other form of the drug that you can taper with, and if you want to keep things really simple, just focus on this. Taper with a compounded liquid sent to a pharmacy cuz that's the one that we really recommend.
So, now that you know about the form of the drug that you want to taper with, whether it's the tablets, capsules, or liquid, let's talk about how to get to the right form of the drug. So, if you're on an instant release tablet or a capsule and you want to taper with that form, I wouldn't recommend it. I'd recommend a liquid. But, if you're happy doing that, you're good to go. If you are on an extended release form of the drug like ambient or laorazzipam come in extended release versions, you need to switch to the instant release version of the tablets or liquid.
Now, if you are going to use a compounded liquid, which is the method that we strongly recommend, what you're going to need is to find a local compounding pharmacy and have your doctor send a script to that compounding pharmacy to make a liquid version of your drug. Many doctors actually don't know how to do this. And so, for your convenience, I have put up a script that we routinely send to pharmacies to get these drugs made into liquids, which I'm going to explain why this is so important soon. And you could actually bring this to your doctor and they would be very happy to actually have something that they could follow.
And so if you are on a sedative and you're just taking it once a day at night, um here's essentially what you do. You want your doctor to ask the pharmacy to create a compounded liquid prescription of the drug and X milligrams is the dose that you take at night equals 1 ml. And it's going to say patient to take 1 ml daily dispense 35 mls for 30 days with 5 milliliters added to account for residual medication loss in the syringe tip during dosing. Here's what it's about. When you draw up a medication in a syringe to orally dose into your mouth. You know, we're not shooting this into our veins or anything. There's this little dead space here in the syringe tip which always accumulates a little bit of liquid. And so you use that liquid. So, whenever I write these scripts, I always ask for 5 mls more. And that way, it makes sure that the liquid lasts the whole time for the 30 days because you're getting a 30-day supply. The last thing is you want to ask them to include a 1 ml oral syringe and a bottle adapter cap. Now, this is just essentially so you don't have to pay for this stuff.
Now, an adapter cap is this thing here. You see this little white thing on the top of the bottle? It allows you to invert the bottle and stick a syringe into the small hole and draw it out without making a big mess. It's way easier than sticking a syringe down into the bottle where the outside of the syringe gets coated with the liquid and you lose all that liquid and it's just a big mess. So, that's what an adapter cap is. If for whatever reason they can't do that, you can buy an adapter cap here on Amazon. I like this brand. And if they don't give you syringes, I recommend you buy the 1 ml back syringes because they have a 100 spaces on the side and it makes it really easy for dosing.
Okay, so let's talk about a real world example for getting your drug in a liquid form. And so let's say you're taking tamasipam 15 milligrams once at night. You would say create a custom liquid prescription for tamasipam. 15 milligrams equals 1 ml. Patient to take 1 ml daily, dispense 35 mls for 30 days. yada yada yada.
Now, what if you're taking a medication twice a day? Well, now this can be pretty common if you're taking one of these drugs for anxiety. It's essentially the same thing, but you are going to double the amount of liquid that you get. So, let's check out this example of someone taking Xanax or Alprazolam. Half a milligram twice a day. You're going to ask for a custom compounded liquid script of 0.5 milligrams equals 1 ml. Now, this is the change. Patient to take 1 ml twice daily. Dispense 65 mls now for 30 days with 5 mls added for residual loss.
Okay, so now that we have figured out what form of the drug we want to use, we're like, okay, we're going to use instant release or capsules or we're going to use a compounded liquid. How do you make your first reduction? Well, the first step is to pick the initial tapering speed. Now, essentially for everyone, I want you to start with 5 to 10% reductions per month. That is a great speed to start with, but there are two exceptions here. One exception is if you're having severe side effects, you're obviously going to want to move a lot faster than that so you can feel better soon. And the second one is if you've been using the medication for less than 2 months. If you've been using it for less than 2 months, you're probably not that physiologically dependent on it. And you could likely do a 25% reduction every couple of weeks or sometimes even higher. But for most people who've been on it for several months or years, 5 to 10% is the way to go.
Now, how do we actually do the first reduction if you are using instant release tablets or capsules? This is what it looks like. And this is kind of annoying and kind of finicky. And this is why I do not recommend this. If you're using the tablet, you buy a syringe like this Gemini syringe here from Amazon. This is the one a lot of our patients have used in the past. You have to weigh the tablet and then you need to calculate what 95% of that weight would be if you're going to do a 5% reduction. And then you get a razor and you actually grind down that tablet to that weight and then you take it. And then you would do that for the next like 28 days or a month because you're going to be doing a 5% reduction, waiting a month, then doing another reduction again. And then you take it. If you're using a capsule like Tamasipam comes in an instant release capsule, you kind of open the capsule up, you pour out all the powder onto the scale, and then you remove 5% of that powder and then repeat. It's really messy and that's why we don't recommend it that much.
Now, if you are going to do the reduction with liquid or a syringe, this is how easy it is. Now, remember, we have converted the strength of your drug into 1 ml. And the cool thing about a 1 ml syringe is there's 100 spaces on the side of it. And so, let's say you want to do a 5% reduction. That's five lines on the space of this syringe. So, you stick your syringe into the puddle, you draw it out all the way up to 100, and then you drop down five lines. You've just done a 5% reduction. It was quick. It was easy. It took 2 seconds. It wasn't messy at all. It was super precise. And then you dose it. And then just every morning or every evening when you're taking this, when you brush your teeth, you just dose it in that way. And it is really, really fast.
So, now that you've done your first reduction, we're going to talk about how to optimize your tapering speed. Now, the guiding philosophy in drug tapering for me is I want to get people moving at the fastest rate that's safe for them. I don't want them going too fast so that they have bad withdrawal symptoms and I also don't want them going needlessly slow so they're stuck on a drug that's an inconvenience to take and is probably having some adverse effect on their body. And so, how do we do that? Well, we do that with something called the traffic light system. And what this is is essentially three metaphorical like kind of light signals. So I use light green, green, yellow, and red. And they come with rules on how to adjust your speed.
So let's start with light green. Okay. So if you do a reduction, maybe five lines on that syringe, and you notice no withdrawal symptoms for the one month, you will say, "Okay, that's light green. I'm going to increase my rate." And you could bump it up by five lines. And then you could do that again for another month. And if that was still easy for you, you could bump it up by another five lines. And so now you're removing 15 lines every month. Another thing that some people like to do instead of maybe waiting 30 days between reductions, they may decide that, hey, I actually want to do a reduction every 2 weeks. And so that's another way of actually speeding up your taper. If you don't want to change the amount of lines you're removing, you can change the frequency of it.
Now, moving on to the green traffic light. So what's this? This is when you do a reduction and you have mild but tolerable symptoms and there is no disruption to your daily functioning. When you hit this place, you are going to maintain the current tapering rate. This is the sweet spot because it is normal to have some withdrawal symptoms during when you're removing this drug. After all, those are the symptoms that are going to tell your brain to regrow all of those GABA pathways and essentially have you readapt to life off the medication. And so mild tolerable symptoms, that's a sweet spot. If you're removing maybe eight lines a month or eight lines every two weeks, just keep on that. Just just follow that down. Don't change anything.
The next traffic light is the yellow traffic light. This is where you are having clear symptom worsening. Not only that is these symptoms are now starting to interfere with your daily life, but it is still manageable. These are symptoms that are starting to interfere with your daily life, but it is still manageable. And so when this happens, what I want you to do is I want you to hold the dose and just wait for things to settle down and then I want you to slow down the rate of the taper. So maybe you are removing like 10 lines. The next time you do a reduction, you might want to squeak down to six lines and see how you do. See if you can get yourself back into that green zone.
And the final traffic light is the red traffic light. This is when you do a reduction and you have severe withdrawal symptoms. You're unable to work. Maybe you're taking days off. You can't fulfill your domestic duties. This is when you need to updose immediately. So you don't sit there and wait for it to die down. You go back to the last dose where you didn't have those symptoms and you hold until the symptoms resolve and then you're going to slow down the taper rate. And so maybe you're doing 15 lines at a time. You're going to drop that down to 10 and that's what you're going to try the next time. And so that's essentially how you optimize your tapering rate throughout your taper so you're always at that perfect zone where you're moving at the fastest rate that is both safe and comfortable for you.
Now there is one area that trips up the most people when it comes to drug tapering and that is the end of the taper. Now the reason for this is a little bit technical but I'm going to make it really easy for you to understand. The end of the taper is really challenging because even small reductions in dose can have big changes at the receptor level which can unexpectedly throw people into withdrawal and then they get very confused and then they jump off the medication or they give up entirely. But I want to show you some graphics right now to explain why this happens.
Now what you're looking at on screen right now are two neurons next to each other. All these little circles between them are essentially the drug, the sedative. These little U's here, these are receptors. What I want you to notice is that when you are on a high dose of the drug, there's essentially a lot of that drug floating around that's residual in the brain. You could remove 20% and you're still binding most of the receptors and so the person doesn't experience a lot of withdrawal. You may even remove another 20% and you're still binding most of the receptors because there's so much residual drug floating around. You may even remove another 20% and then there's only minor withdrawal. But then once you get down to the lower doses of the drug, I'm talking about like the lowest available dose that the drug comes in, what we find is that there's not a lot of residual drug floating around in the brain anymore. You could do that same reduction that you had tolerated the last four times and all of a sudden you uncouple a whole bunch of the receptors and you experience a lot of withdrawal.
This graphic here is just another way of demonstrating this. This is with the drug fluoxetine. It's an anti-depressant but it is relevant for all sedatives. All psychiatric drugs follow this same pattern. On the y-axis here is receptor occupancy. On the x-axis is dose. Now for context 60 milligrams of fluoxetine is the top dose that you would prescribe and 20 milligrams or 10 milligrams are usually the starting doses that people give. What I want you to see is that receptor occupancy hardly changes between 10 milligrams and 60 milligrams. That's because the brain is already flooded with the drug and it's having most of its effect. But once you get below 10 milligrams, you kind of fall off this cliff and the drug disconnects from the receptor at a very, very fast rate.
Now, why could something like this be a problem? Well, it could be a big problem because if you're tapering with fluoxetine tablets, you might say, "Oh, I'm on 60. I'm just going to drop down 10 milligrams and 10 milligrams and 10 milligrams and 10 milligrams and that's so easy. I'm not having a lot of problems." Then you drop down another 10 milligrams and then you have the last 10 milligram tablet. You say, "Well, I guess I'm going to have it." Okay, so you go to five. Maybe you have some withdrawal, but you've really just gone from about 70 to 60%. And maybe you quarter that again and you go to 2.5 and you just say, you know, what am I doing? This is like a tiny crumb in my hand. I'm just going to stop it. I'm just going to jump off. And then all of a sudden instead of doing more gradual reductions after that, you plunge from 50% receptor occupancy all the way down to zero and you get hit with really really bad dangerous withdrawal symptoms that totally confuse you because you say, "Wow, you know, I've been tolerating 10 milligram cuts each time and why can't I do this now? You know, there must be something wrong with my brain and I can't come off these drugs."
And so here are the rules that I want you to have for finishing the taper. So you just have realistic expectations about what this is like and you don't panic. That's the most important thing. Do not panic at the end. I want you to expect that the last 25% of the taper is going to take as long as the first 75%. I want you to expect that reductions are often going to get smaller over time. I want you to use liquid formulations if you can. Guys, I've said this a lot. Don't taper with the tablets if you can avoid that. Find a doctor to write you a liquid formulation because just think about it. There's those 100 small lines on the side of the syringe. That gives you so much precision and accuracy in lowering that drug down safely. You can essentially edge your way down that cliff and come off smoothly. It's a lot more accurate than using a scale and a razor and all of the like the weight fluctuations there. So, use a liquid. And the last thing is to avoid getting to the end and just being like, "This is stupid. This is just a crumb of the drug. I'm just going to drop off." That little crumb in your hand is a lot stronger than you think it is. I hope that makes sense.
Now, before we continue, I just want to pause for a second and share this. A lot of really smart, super capable people really struggle when they try to come off these sedative medications. And that's because there's a lot of information out there. It's not really organized and it's just very easy to get overwhelmed. And after helping hundreds of patients, I have seen something consistently. People who succeed in getting off these medications safely and doing it right the first time, they do it because they have the right strategy and the right support. What that means is that they have a taper that is tailored to their specific situation. They have a knowledgeable team on call guiding all of their reductions and they also have a team that's helping them build the skills to deal with the anxiety or the insomnia or whatever led to them getting on the drugs in the first place.
Now, that's why we built the taper clinic because we recognize this can be one of the hardest things that people do. There is nothing scarier than trying to navigate this when your brain is on fire with anxious thoughts and you're feeling unwell. You do not need to do this on your own. You wouldn't do brain surgery on yourself or manage like an autoimmune condition by yourself. And so, you don't need to. And so if you would like our support in applying a framework just like this to your specific situation and having us hold your hand through the whole thing and get you through it safely, below this video there's going to be a link to our drug tapering practice where you can learn a little bit more about what we do. And if it seems like we're a good fit for you, you can book a call and we can help you handle this once and for all.
And if you want to learn how something like this has affected prominent, well-known people, you're not going to miss this next video where I break down the problems that Dr. Jordan Peterson had with the benzoazipene Adavan.