Transcription
Hi Dr. Mark Aggress. This is a follow-up video to my previous video, "How to Detox from Klonopin." This video, "How to Detox from Benzodiazepines like Klonopin, Xanax."
What are benzodiazepines? There are a host of different types. Klonopin is clonazepam. Out of ham is lorazepam. Xanax is alprazolam. Valium is diazepam. Those are probably the four most common types.
These drugs are used in panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, insomnia. They're also used recreationally to get high.
One thing with these drugs, they affect the GABA receptor. There's another class of drugs, non-benzodiazepines, sedative hypnotics like Ambien, Lunesta, Sonata. And Ambien being zolpidem, Lunesta is eszopiclone, and Sonata is zaleplon.
There's other drugs which are benzodiazepines. I don't know. Halcion, which is triazolam, and Restoril, temazepam. Dalmane, flurazepam. Versed is used to induce anesthesia and makes you forget that you underwent a procedure.
They're all, they all work basically the same. The benzodiazepines affect GABA. It's a receptor on the cell, the GABA receptor, and it's an inhibitory receptor. When it's stimulated, it slows the body down, calms it, makes you sleepy, decreases anxiety. The non-benzodiazepines work on a subunit of the GABA receptor on the cell.
These benzodiazepines can also be used for seizures. Now, the different types are all related to how long it takes the body to break them down. The longer the half-life, which is a measurement of how long it takes the body to break down the drug, the longer the drug lasts. For example, Klonopin may last 60 hours a half-life, where something like Xanax may last 11 hours. The shorter the half-life, the quicker the drug leaves your system.
Coming off these drugs can be dangerous because they form a dependency. Coming off may result in seizures, tremors, severe anxiety, sleep problems, a panic disorder worsening, a post-traumatic stress, obsessive compulsive disorder. You may get just delirious. It is very dangerous to come off these drugs, so it has to be done right.
And I stress upon everyone. I get a lot of questions, "How should I come off Klonopin? How should I come off Xanax?" It is not formulaic. There are some general guidelines here. Klonopin, two milligrams twice a day, you should come off about 0.5 milligrams every 7 to 10 days. It is not formulaic, meaning there's no magic number. Depending on how you are clinically, should depend on how you come off the drug and what time frame.
Xanax is not a good one to come off of. What you should do with the Xanax is to convert it to Klonopin over a two-week period of time, 10 days to 14 days, and then come off the Klonopin. Ativan, you can taper off Ativan and then come off the Ativan. Roughly coming off 0.5 milligrams every 7 to 10 days. And then when you get the 0.5 milligrams, do 0.25 milligrams for 10 days, and then maybe 0.25 milligrams every other day for 10 days. The slower the better.
When you're coming off benzodiazepines like Klonopin, Xanax, Ativan, things may happen. The first thing that may happen, your blood pressure may go up, and you may feel a severe sense of withdrawal. It's tormenting. Xanax being the worst in class for the worst withdrawal and the most dangerous. It's one, it's one that's most prevalent to cause seizures, and it's extremely dangerous. That's why don't come off Xanax. Convert it to Klonopin and then come off the Klonopin.
But when you're coming off and you're slowly tapering down 0.5 milligrams every week, every 7 to 10 days, your blood pressure may go up. You will feel incredibly anxious, and you will experience tremors and feel a sense of malaise, a sense of uneasiness.
So what I recommend is clonidine. Clonidine is an alpha-2 receptor blocker and a stimulator. I mean, and that stimulation of that part of the system is inhibitory. What it does, it blocks the body's flight-or-fight response, the peripheral, everything from your neck down. It stops the body's trembling, anxiousness, height and blood pressure, rapid heart rate. It will slow things down.
Clonidine can be used 0.1 milligrams four times a day up to 0.3 milligrams four times a day. You can use it as tolerated. Watch out you don't bottom your blood pressure out. It helps with the anxiety of withdrawal. It helps with elevations in blood pressure. It helps with sleep. It's short acting. It needs to be given frequently, every four hours. Any detox from benzodiazepines usually involves clonidine for those reasons.
Other things that could happen is restlessness, tremor, uneasiness. There is a drug which a modulator at the GABA receptor called Neurontin, gabapentin. You can use that between 1 and 800 milligrams three times a day. It's adjunct in the treatment of benzodiazepine withdrawal. So when it also helps block the risk of seizure. I pre-treat everyone with Neurontin prior to starting the detox from benzodiazepines like Klonopin, Xanax, Ativan, Valium. Those are the four most common. So I put three to 600 milligrams three times a day of Neurontin. It helps decrease anxiety. It prevents tremor. It prevents the peripheral uneasiness and it risks, it decreases the risk of seizure. It is also an anti-seizure medication.
So clonidine helps with blood pressure and anxiety. Neurontin can help with anxiety, risk of seizure, and tremor. The third drug I use, quetiapine, Seroquel. There's also severe sleep and agitation problems. Not to mention people can become delirious. When we're slowly tapering, at some point people become delirious and out of control. I use Seroquel, 25 milligrams, 250 milligrams at bedtime to help them sleep, or four times a day, three times a day, two times a day to control agitation and delirium. It's critical. It is extremely dangerous.
So just to decide you're going to do this just by stopping the benzodiazepine, it's extremely dangerous. I don't advise that because we're holding death. 0.5 milligrams every 7 to 10 days, pre-treating with Neurontin, using quetiapine, Seroquel for sleep, agitation, anxiety, delirium, and using clonidine for anxiety, blood pressure, restlessness.
The next drug, Remeron, mirtazapine, is used at night. They block associated decrease in appetite. It blocks from the benzodiazepine withdrawal. It blocks anxiety and it helps with sleep. It has an overall calming effect. 30 milligrams, 15 to 30 milligrams at bedtime.
So now we've discussed use of clonidine, which is called Catapres. Neurontin, gabapentin. Seroquel, quetiapine. Remeron, which is mirtazapine. Also to help with the anxiety, hydroxyzine. It's an antihistamine-like drug which can minimize anxiety. That can be given 25 to 50 milligrams three times a day.
So now I have discussed five drugs which are used to help with benzodiazepine withdrawal. I've discussed the taper which should be used. Keep in mind how you entered into this withdrawal. Did you start out with a panic disorder? Did you start out with anxiety disorder, insomnia, or were you using it recreationally?
If you start out with panic disorder, you may want to start a drug for panic disorder to prevent it from reoccurring because now you've pulled away the treatment. You may start getting panic. So an SSRI like Zoloft, sertraline, Paxil, paroxetine, or fluoxetine, which is Prozac, may be extremely helpful. If they have just generalized anxiety disorder, you can use Prozac, Paxil, Zoloft, Luvox, Celexa, and Lexapro to pre-treat for anxiety.
If there's a sleep disorder, you can use. I have used Ambien, Lunesta, Sonata. Trazodone is another drug which is a key component in helping people sleep as they're going through benzodiazepine withdrawal. Trazodone, 250 to 100 milligrams. Trazodone can also be used 50 milligrams three to four times a day to control agitation and anxiety. You can use the non-benzodiazepine sedative hypnotics like Ambien, Lunesta, and Sonata to help with sleep and minimize the effects of withdrawal.
Also with withdrawal, keep in mind, enter into this withdrawal state. Don't use any coexisting drugs of abuse, cocaine, alcohol. People who smoke metabolize drugs quicker and need more medicine. Keep your body hydrated. Make sure you get sunlight. Make sure you exercise every day. It's critical in this process.
So the drugs which I commonly use for the withdrawal, and I use them as symptoms appear, clonidine, Neurontin, and Seroquel, Remeron, hydroxyzine, and trazodone. You can use Ambien, Lunesta, and Sonata to help with sleep.
What else you can do? Make sure that that individual, if they have a pre-existing condition and you're pulling away the treatment, if they have panic disorder, make sure you treat with a panic disorder drug. OCD, obsessive-compulsive disorder, make sure they have something else to help with obsessive-compulsive disorder. If they have generalized anxiety disorder, make sure you have a drug for generalized anxiety as you're pulling away the Klonopin, which is or the Xanax, or the Ativan, or the Valium.
Also, what you need to do is if you're pulling away Klonopin or one of the benzodiazepines, people will develop sleep problems that they don't already have. Be careful with individuals when you're giving them these detox drugs. A lot of people start drinking more. That's not good because it'll throw off the dosing of the benzodiazepine taper and it'll make matters worse in terms of risk of seizure, risk of anxiety, risk of panic disorder, problems with post-traumatic stress and generalized anxiety disorder.
So we have to make sure these individuals don't drink alcohol, stay hydrated, get some light exercise, make sure we've pre-treated as we're pulling away the treatment for one of the anxiety disorders so they're treated for that. We use the six drugs I've named to minimize the effect of the benzodiazepine withdrawal and then make sure they don't see, they don't get tremors. We're not formulaic. We don't just randomly decrease the dose over time of the benzodiazepines.
If someone's not doing well, hold the dose where it is for maybe longer than a week, longer than two weeks. If someone's coming off a lot and they, they're on, let's say, ten milligrams of Klonopin a day, and you get to the point where on five milligrams, you're like, "I'm not doing well, very anxious, I'm tremulous, I feel light-headed," hold the dose for a week, two weeks, three weeks, as long as you can so that individual stabilizes. It's clinically determined when you go down on the dose of the benzodiazepine. It's not from your leg. You don't just randomly come down and force someone to come down. We use the coexisting drugs to minimize the effect of withdrawal and help the patient to come down.
The detox could take a month, three months, four months, whatever it takes. Use time in your favor. Time is not your enemy. Time is your friend. Longer is better. It's less risky. You're never in a point where that individual is uncomfortable having tremor. Tremor because that's a sign the body is not handling the withdrawal of the benzodiazepine well. The GABA, GABAergic system is not tolerant to sudden changes. It takes a long time. For example, coming off opiates, five days. Alcohol, you know, five to seven days. Not with benzodiazepines. It's a long-term thing. The GABA system doesn't rebound for months.
And people said, "Well, what do I feel normal?" You'll feel more normal every week, but you're looking at six to 12 months. Now, people say, "I'm gonna feel terrible like this for six to 12 months." No, each month and each week it'll get better, but you won't feel right. You'll still feel the anxiety of withdrawal, the sleep problems, and decreased appetite six months or 12 months into it. So there will be some fleeting symptoms where I think when you're coming off other drugs, that's not the case. This is a long-term problem. Think in terms of months. Six months, I think most people are 80% better. There's 10 to 20% fleeting symptoms for six months to 12 months after stopping benzodiazepines.
I get a lot of questions, people on a lot of different benzodiazepines for a lot of different reasons. Don't just write something down on a piece of paper. Listen to your body as you're coming down. And if your, your symptoms and anxiety, tremor, sleep and appetite, blood pressure and pulse change or get out of control, slow your taper down.
I hope that helps. I've had a lot of questions. I go into this in my blog, drgrassi.com. Also, I described how I've taken patients through benzodiazepine withdrawal in my book, "Tales from the Couch," on Amazon.com. I appreciate the comments. Hit that like button. Hit that subscribe button. I really appreciate it. Thank you. And I'm always open for questions and comments. I do respond. Dr. Mark Grassi.