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Welcome back to our Channel where we explore the side effects of psychiatric medication. Today, we're addressing a topic that doesn't receive enough attention: protracted benidipine withdrawal. So, what is it, and more importantly, how can you prevent it? Let's dive in.
Protracted withdrawal is a term used to describe a set of symptoms that can persist for months, sometimes even years, after stopping benzodiazepines. It differs from the initial withdrawal phase, which typically only lasts a few weeks. For a long time, protracted withdrawal from benzodiazepines was not recognized by the professional community. However, recently, more articles on this condition and its treatment have been published in the peer-review literature. Perhaps the most authoritative recognition of this condition was by the FDA in 2020, when they mandated that all drug companies making benzodiazepines finally include a description of the risk in the labels.
So, what is protracted benzodiazepine withdrawal? It's best understood as a neurological injury and not a normal withdrawal syndrome. In a typical withdrawal syndrome from other drugs like opiates, the symptoms resolve in about two to six weeks and they go away if you restart the drug. However, once protracted withdrawal develops, it can take years to resolve and does not go away even if you restart the drug. Although the condition is best known as protracted withdrawal, many advocate prefer to use the title benzodiazepine-induced neurological dysfunction since using the word "withdrawal" in the illness name can be confusing for doctors and families unfamiliar with the condition. Many people, when they hear the word "withdraw," assume the condition will resolve quickly or that the symptoms will simply disappear if you get back on the drug. But this is not the case, because protracted benzodiazepine withdrawal is more like a brain injury.
So, why does protracted benzodiazepine withdrawal injury, or BIND, occur? Well, it typically occurs in response to severe withdrawal symptoms, although some cases have gradually occurred in the setting of long-term chronic use. In these instances, it is hypothesized that the injury develops due to cumulative injury from interdose withdrawal. However, the most common development of this condition follows severe withdrawal syndromes after a rapid taper or a cold turkey detox. This suggests that severe withdrawal symptoms can be damaging to the nervous system and place people at risk of developing this condition. It is important to note that the majority of people who experience severe withdrawal symptoms from benzodiazepines do not develop protracted withdrawal, but it is currently unknown why it only happens to some.
Some theoretical risk factors for developing this condition would include any risk factors that might place someone at risk of a more severe acute withdrawal symptoms. These can be things like older age, due to the reduced neuroplasticity and less biological capacity for the brain to quickly readapt to the removal of the drug. Other risk factors may include being on the drug for decades or being on a very high dose, because these would suggest additional adaptations in the brain to accommodate the long use or also the high doses, and that would be more difficult to undo when the drug was removed. Other risks can be things like taking stimulant medications during the time of withdrawal, which are typically removed before withdrawing people, as the additional stimulation that's there can be damaging once you remove the sedative effect that is the benzodiazepine.
Symptoms of protracted withdrawal can be severe and disabling, and they can include a wide range of neurological and psychiatric symptoms, such as severe anxiety, intense pacing or restlessness known as akathisia, cognitive impairment, dissociation, neuropathic pain like numbness, tingling, or shock-like sensations, internal feelings of vibration, ear ringing or tinnitus, and light sensitivity. Because protracted withdrawal is a neurological injury rather than a simple withdrawal issue, the recovery time is unpredictable. While some recover in less than 12 months, many are still recovering several years after their injury.
The best way to prevent protracted withdrawal injury is to come off these medications with a slow taper. You want to avoid going into severe withdrawal because it's thought that these withdrawal symptoms are really the things that lead to the neuronal injury that causes protracted withdrawal. As a general rule of thumb, reducing the dose by five to ten percent of the previous dose per month and holding when moderate withdrawal symptoms emerge appears to be the safest strategy for most people to come off. This method will allow the brain to adapt gradually to the absence of the drug, minimizing the risk of having any severe withdrawal symptoms.
The most important piece to be aware of is that the highest risk period for severe withdrawal and potentially developing protracted withdrawal is at the lower doses of the drug. Dr. Mark Horowitz's research, which analyzed brain scans for drug receptor occupancy at the different doses of psychiatric medications, essentially showed that at lower doses, a small reduction in psychiatric medication can result in a large drop in receptor binding. This means that a seemingly smaller reduction can cause a significant increase in withdrawal symptoms. For example, reducing a dose of Xanax from six milligrams to four milligrams could be seen as a large two-milligram reduction, but it might only reduce receptor binding by ten percent. While reducing from one milligram to half a milligram may seem like a much smaller reduction, a half-milligram drop, but it might change in receptor binding by up to fifty percent. This could result in higher symptoms, even though the person doing the drop thinks that the reduction is much smaller. Mark's imaging findings have been further supported by the lived experience of many people who had increased difficulties tapering off the final few milligrams of their medications. So, consequently, the most important advice is to taper cautiously in a way that avoids severe withdrawal symptoms, and especially towards the end of the taper, where the risks of developing severe withdrawal symptoms are the highest. You need to really go slow.
Then, if you are already experiencing protracted withdrawal, the most important thing is to not lose hope. Although the condition can be severe and extremely uncomfortable, it has a good prognosis. The overwhelming majority of people gradually improve over several years and go on to live normal lives. This is due to the innate neuroplasticity of the brain, which really does have the capacity to heal during recovery. It is crucial to stay engaged with your support network, explore symptom management therapies, and focus on activities that keep you busy and distracted. Importantly, try to not overwhelm your caregivers, as caring for someone with protracted withdrawal can be very challenging. Ensure that they are also engaged in activities they enjoy to prevent burnout.
As we wrap up, remember that protracted withdrawal is an uncommon reaction, not a certainty of rapid tapering. If you have been through a rapid taper, it is very likely that you won't develop protracted withdrawal injury. Despite this, unless there's a really good reason for a rapid taper, like a serious side effect, a slow and symptom-free taper will reduce your risk of developing protracted withdrawal. If you are looking for more tips on the best way to taper while avoiding protracted withdrawal injury, we cover all of this here on our channel in the Tapering Tips of Psychiatric Medications playlist.
So, so that's it for today. If you found this video helpful, please give it a thumbs up. Share it with someone who might need it. And if you're looking for personal help with your taper, we work in several US states, and they're listed on my website, which is linked in the description below this video.