Transcription
I'd like to talk about issues relating to filling prescriptions for tapering medication for patients who are tapering off of benzidines. So, for a long time, the gold standard of tapering guidelines was the Ashton manual, written by Dr. Heather Ashton, a British physician who had studied hundreds of patients and discovered how to taper patients in just such a way, at a very gradual pace, where they're able to come off of benzodiazepines safely and comfortably with minimal withdrawal symptoms and minimal risk of protracted long-term withdrawal.
The Ashton manual, the way that it works is that the patient will start. They start with one benzodiazepine and then transition gradually from that benzodiazepine to diazepam or Valium. And that transition may happen gradually over a period of weeks. And then, once the transition is complete, the patient will continue to reduce on a regular basis, which could be weekly, every two weeks, or even every month. And they'll reduce by a, you know, small amount that they can tolerate.
The Ashton manual is filled with tables that show samples of this transition of how it can be done. And these tables are meant to be examples. In fact, in the very beginning, on the first page of the manual, Dr. Ashton wrote a note saying that the benzodiazepine tapers should always be patient-directed. It should be what the patient can tolerate, and doctors should not push the patient to taper faster than what they're comfortable with. So, doctors should not take these guidelines that are found in the tables and use that as a rule, saying you need to be at this stage by this point in time.
So, you know, while we can make plans for tapering at a certain rate, we can plan for 2.5% per every two weeks or every month, they 5% at every tapering point, or even 10 or 15% as we're going along the way. If the patient becomes uncomfortable and begins to exhibit symptoms of withdrawal and they're not comfortable with going forward, uh, we can plateau for a while. We can go more gradually. We can try using a, a microtaper plan where we taper little by little, tiny amounts every day.
And there's also other ways of tapering besides the Ashton manual. Many patients are more comfortable tapering on the benzodiazepine that they're currently taking, which might be clonazepam, which is Klonopin, or Ativan, or lorazepam. And so the patient is taking one of these benzodiazepines and they're not comfortable with the idea of switching to Valium. Another way is a liquid taper, where the doctor can order a compound from a compounding pharmacy, where the medication is a liquid suspension, and they can start, for example, with the dose the patient is taking every day and put that in, for example, a milligram or, sorry, a milliliter. And then the patient would use an oral syringe, you know, like a, a 1 ml syringe and draw it up to, um, the level that they're tapering at. You know, one milliliter would be the full dose, and as they reduce, they can reduce by tenths of a milliliter or even hundreds of a milliliter.
So, one issue, a serious issue with tapering is dealing with pharmacies and dealing with a pharmacist who's not comfortable with filling the prescription, because it can be a little unusual when we prescribe, according to the Ashton manual, especially in the beginning during that transitional period. Suppose a patient is taking Klonopin and we're transitioning to Valium. We may be giving the patient both things in the first month at the same time, Klonopin and Valium. And it is unusual to get prescriptions for two different benzodiazepines at the same time. Although I have known psychiatrists to do that, to prescribe, uh, two benzodiazepines together. But a pharmacist may be very uncomfortable. They see Klonopin and diazepam and they're like, either there's a mistake or something unusual going on.
Now, the doctor, you can put in the memo of the prescription that this is a tapering prescription. You know, that this is our plan, where you're following the Ashton manual, where transitioning from Klonopin to diazepam. And so, some pharmacists are aware of the Ashton manual, many are not. Some will be interested and they'll call the doctor and ask, you know, what are you doing? I'm fine with it as long as it's well documented. And unfortunately, there's many pharmacists who will be completely against it. In fact, there's a pharmacist that I dealt with recently, where they had, they looked at the prescription. I did document that we're following the Ashton manual, and this pharmacist went and looked the Ashton manual, read through it, and they said, you're not following it properly because at this point, you should be on stage 10 or whatever.
And so, so she had looked, she must have flipped through and looked at some of the tables where they do have different stages, where maybe stage one, you're beginning your transition to Valium, stage two, you're further along and you're replacing, you know, in the Ashton manual, they show it as taking morning, afternoon, and evening dose, and you replace one at a time. You know, you work on maybe the, the midday dose, and then you might work on the morning dose. Hours laid out. But those tables are all, uh, guidelines. They're not meant to be, this is the only way to do it. In fact, some patients can do that transitional phase a lot faster than others, and some will take more time for it. There's a lot of variability. So, it's every patient is different. You know, it's not a, it's not meant to be a one-size-fits-all treatment.
So, this particular pharmacist, looked at the Ashton manual and the way we're prescribing and said, you're not following the Ashton method. And I, I took out the Ashton manual and I said, let's read along together. I'll read it to you. And I read that first page where Dr. Ashton says, um, this is a guideline and it must be patient-directed. And unfortunately, the, the pharmacist told me she was going to document and she wrote apparently pages of documentation and ultimately, unfortunately, she refused to fill the prescription, forcing the patient to leave a pharmacy where he'd already been going, was fine, and was happy, everything was working fine. But one pharmacist out of several that worked there, kind of ruined it for him and, you know, forced him to leave. And we had a little difficulty finding another pharmacy.
There's also the issue that prescriptions now, at least in Florida, have to be electronically submitted. It used to be we could give them a paper prescription and a patient could go to a pharmacy and as long as they don't write all over the prescription, the pharmacist could refuse to fill it for whatever reason, and the patient could take that piece of paper back and bring it to another pharmacy. And now with e-prescribing, um, the prescription must be sent directly to a, a specific pharmacy. And if they refuse to fill it, we now have to confirm that it's canceled. You know, that even though the pharmacist refused, it could still be in the system and might get filled, and now the patient has multiple prescriptions out there, which we have to make sure that doesn't happen. So we have to make sure it's canceled, which often involves a phone call just to verify that. And then we have to electronically submit it to another pharmacy.
Now, suppose the other pharmacy has an issue, and now we end up repeating this time-consuming, frustrating process over and over again. And now, ideally, to minimize all these issues of a pharmacy causing trouble, ideally, it's good when a doctor has relationships with local pharmacies and the pharmacist. And which is not always easy because, you know, with the large chain pharmacies, you can get to know the, the head pharmacist or you can get to know different pharmacists who work at a, for example, at Walgreens. But Walgreens tend to hire floater pharmacists who may work more on the weekends or in the evening. And you can have that same situation. You can have everything working out well and you get a, a floater pharmacist, for example, and they, they often make up stuff. They'll say like, well, we don't have the medication. We don't have the medication in stock. You know, come back tomorrow. You know, and and that's just putting it off. So another pharmacist will take care of it the next day. Or they may say, I'm not comfortable. I'm going to flag this in the system. We don't want to fill this anymore.
And one pharmacist again can cause a problem where a patient had no problem for sometimes even months or years at that one pharmacy. Now they have to go look elsewhere because one pharmacist took it upon themselves to, um, document in such a way that they can't go there anymore. So, but yeah, it can help to, you know, working with an independent pharmacy, sometimes resolves that because you may have the owners, a pharmacist, and hopefully, you know, they have maybe just the one pharmacist or or a few of them. But that, that one issue that I described where we had a problem where the pharmacist questioned the Ashton manual, that was an independent pharmacy, and I didn't expect that to happen there. But, you know, they did cause a significant difficulty for that particular patient.
So, now it is understandable that that pharmacists are, you know, that they, they, I, I understand why they're uncomfortable because pharmacists do get inspected regularly. Inspectors will look at prescriptions and, and, and a lot of these inspectors are not healthcare professionals. They are government inspectors, and they look at prescriptions and they say, well, I'm not comfortable with this. Why, why is the doctor doing this? You know, can you explain it? And that's why it is important to communicate with the pharmacist and to document things carefully. But, you know, it can be, uh, disconcerting to have those interactions with inspectors. So I can see why a pharmacist, especially one who's just working part-time, would just be uncomfortable and refuse to fill a prescription.
Now, as far as the liquid taper, you know, we get a compound liquid. There's a lot of compounding pharmacies, but a lot of them would probably be uncomfortable with doing a liquid taper with a benzodiazepine. But there are certain ones that are very, uh, comfortable, that they're accustomed to it and they do it routinely, and those are good pharmacies to work with. And, uh, you know, they can ship the medication directly to the patient. And so, that unfortunately, with compounds, usually insurance will not cover them. So that's, that's one of the downsides.
One benefit of the Ashton manual method is that diazepam tablets are very inexpensive. And the reason why they use diazepam is that it's a very weak benzodiazepine. It's actually the weakest. And so it comes in 10 milligram and 2 milligram tablets. And being weak, it actually makes it easier to taper. Which you can imagine, if if a patient is taking 2 milligrams of Xanax or alprazolam, that would actually convert to 40 milligrams of diazepam. So imagine if a person had 10 milligram tablets of diazepam, they can go from, you know, four 10 milligram tablets a day and then break one of the tablets and now you have go from 40 to 35 milligrams. As you taper lower, you have to go more gradually. And and then you can use the 2 milligram tablet. So you can taper by steps of 2 milligrams or even 1 milligram by breaking it in half at a time. And so, but by using that lower strength diazepam, it actually helps you to to make do those gradual reductions where it'd be harder to do with, um, with the more, the highly potent benzodiazepines where where Xanax, Klonopin, Ativan, those are all very potent, uh, high potency benzodiazepines. And you can't really break the tablets enough to, you know, if you take a, a 1 milligram Xanax and break it in half, maybe you can break it in quarters. A quarter of a 1 milligram Xanax is equal to 5 milligrams Valium, which is, you know, so so clearly. And they do make 5 milligram Valium tablets, but clearly it's easier to use the weaker one. And now you have more flexibility with the, you know, the tablet strengths and breaking it down and tapering gradually.
But, you know, with the liquid taper, you can even be more flexible and more fine-tune in your gradual tapering or even micro tapering by using the, um, the syringe and just going little by little. Like I said, you can go by hundreds or or tens of a milliliter reductions every time you reduce or cut back.
So, that may be an issue of why not all doctors like to be involved in benzodiazepine taper because the doctor who decides to take on that responsibility now has to work with pharmacies and deal with pharmacies that are not, um, willing to cooperate. You know, so, you know, and then there's also the issue of a patient who takes a lot of a high dose of medication. Say, a patient that takes 4 milligrams of of Xanax, which is not an unusual dosage. There, there used to be an old prescribing manual, monthly prescribing manual book, which I don't know if it exists anymore, but I remember it said in it that doctors can prescribe up to 4 milligrams of Xanax a day. That works out to 80 milligrams of Valium a day. So, interestingly, it's a little unusual, but a pharmacist will not even blanket at pres at filling a prescription for Xanax, 4 milligrams daily. But they, will be shocked at and refuse to fill a prescription for 80 milligrams of Valium, which is exactly equivalent.
Another advantage of Valium is it's very long-acting. Valium has a long half-life, so you don't get the problem of interdose withdrawal, what you get with, especially Xanax. Xanax is very short-acting, has a very short half-life. So if you take Xanax, you know, in the morning, by the afternoon, even before it's already worn off to the level that the patient actually starts to withdraw symptoms. If they transition to Valium, Valium is longer lasting, so you have the levels are are more, you know, evenly, it's more of a level line of of dosage throughout the day, like it's not going up and down and dipping frequently throughout the day where they have withdrawal symptoms. So, that's also an advantage of switching to from something like Xanax to Valium.
So, the Ashton manual is all about the taper being gradual, being patient-directed, and in the case of the Ashton manual, of transitioning from a potent benzodiazepine to, um, to Valium for the advantages that we discussed. So, hopefully, more pharmacists will, um, become knowledgeable about tapering and make things easier for the doctors that want to get involved and help out, because it does turn out to be a lot of the, the work of helping a patient taper is dealing with pharmacies. And, um, it is always great to find a pharmacist who is knowledgeable and understanding and willing to fill the prescriptions. You know, so, um, that's always a good thing.
And there's also those difficult cases where a patient gets into a situation where a doctor has prescribed them very high doses of a benzodiazepine. For example, I just, um, met with a patient, actually a consult, we haven't started working together, a patient who was on, I think as high as 10 milligrams of Klonopin a day, which is mostly unheard of. That's, you know, extremely high dose. Klonopin and Xanax are equally potent, so you don't normally see over 4 milligrams of Klonopin. It would be probably nearly impossible to get a pharmacist to, uh, dispense a prescription for the equivalent amount of Valium. You go from 10, what would that be? Every milligram is equal to 20 of Valium, so would be, um, 200 milligrams of Valium daily for the person taking 10 milligrams of Klonopin. Either either one, whether they get Klonopin 10 milligrams or Valium 200 milligrams daily, is is pretty much unheard of and most pharmacists would refuse it, putting that patient in a difficult situation of how do they get treatment, how do they get tapered off of what this doctor put them on.
And, you know, in those cases, you may have to find a, a pharmacist willing to, you know, as long as there's a, a very good documentation. And, and fortunately, the tapering can go faster in the beginning as long as there's reductions on a regular basis early on, and hopefully you can get the patient to a level where it's, you know, more well accepted. And, you know, then at that point, if you need to, you can slow down. It, it becomes a, a difficult, um, balancing act of working with the patient with what they can tolerate and working with the pharmacist with what with what they're comfortable with. And, uh, you know, maybe one solution in some cases might be that, um, doctors who are experienced in doing benzodiazepine tapering might be able to dispense medication themselves. I don't know if that's allowed. I don't even know if that would be a good idea. There is a lot of issues with, um, doctors and clinics dispensing medication during the, um, pain clinic epidemic and, you know, about 10 to 15 years ago. And, and they put a stop to that, at least here in Florida. So, you know, doctors and pharmacies or or pharmacy wholesalers and government regulators may be understandably uncomfortable with the idea of doctors having medication on their office to give out to patients. So it makes sense in a way that there's kind of a system of checks and balances of having the doctor and the pharmacy separate. But sometimes that separation can get in the way of the patient getting the proper care that they need.
Okay, thank you for joining me.