Pushback from other clinicians with benzo tapers

[Attending1985]

Last year a local independent psychiatrist retired who was heavy handed when it comes to poly pharmacy and controlled substances. I inherited a patient on 12 mg of Klonopin. Made it very clear at initial appointment my plan would be taper and she was free to seek a second opinion. She wanted to move forward. Without getting into specifics it came to my attention that another provider she sees was telling her to advocate for herself and push back on my taper plan. I have been tapering slowly at 25% every 1-2 months. In another case from this provider there’s a 67 year old on Xanax and Valium. Same scenario with letting her know what I would recommend and offering a second opinion. Got her off the Valium without too much trouble and over 8 months have reduced Xanax by 0.5 mg. Now I get a note from her therapist saying they spent the majority of the session discussing how she wants more Xanax and he recommends she be more assertive with me. I did send a message to the provider in the first case asking for follow up on their statement but they have not responded. Trying to decide how to handle things with this therapist and seeking input.

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[Ironspy]

Last year a local independent psychiatrist retired who was heavy handed when it comes to poly pharmacy and controlled substances. I inherited a patient on 12 mg of Klonopin. Made it very clear at initial appointment my plan would be taper and she was free to seek a second opinion. She wanted to move forward. Without getting into specifics it came to my attention that another provider she sees was telling her to advocate for herself and push back on my taper plan. I have been tapering slowly at 25% every 1-2 months. In another case from this provider there’s a 67 year old on Xanax and Valium. Same scenario with letting her know what I would recommend and offering a second opinion. Got her off the Valium without too much trouble and over 8 months have reduced Xanax by 0.5 mg. Now I get a note from her therapist saying they spent the majority of the session discussing how she wants more Xanax and he recommends she be more assertive with me. I did send a message to the provider in the first case asking for follow up on their statement but they have not responded. Trying to decide how to handle things with this therapist and seeking input.

I tell patients that my opinion is that the risk of chronic benzodiazepines>>>benefit. There are other practitioners who disagree with me and many of them are accepting new patients.

 

[Stagg737]

If this is a therapist within your group then I would contact them asking not to attempt to guide medication management or to just message you directly with questions or concerns about medications. If this is someone in the community then good luck. You can contact them and attempt to educate them on your treatment plans and why a benzo taper/minimizing their use is necessary, but good luck. I'm all for therapists helping certain patients be more assertive, but if they're sending you letters about the patients complaining about benzos and how you not giving them "the right meds" is interfering with therapy I wouldn't hold my breath that they'll listen.

 

[Bartelby]

If there is a therapist who is a particularly bad offender in this regard I would consider screening patients for who work with this provider and not taking those patients. We are still responsible for the overall outcome of "split treatment" and this therapist's judgment seems questionable. I would contact them for a conversation first, but their conduct so far raises red flags.

 

[Merovinge]

Therapist overstep on discussion with their "clients" around psychopharmacology has got to be in the top 2-3 pet peeves of mine on Earth. Masters level therapists typically have one hour of psychopharmacology during their entire training, I know because I have been the lecturer to give that didactic instruction.

I think you just have to know that people who spend their time in a field get the idea that they know more about neighboring fields than they do. I am sure there are optometrists who fancy themselves ophthalmologists, physical therapists who feel like they should comment on orthopedic surgery, etc. To me, this is a pretty clear case of Dunning-Kruger and people not understanding they don't know what they don't know.

As to what I do, I discuss the difference in training between fields when people seem to genuinely not understand, I may explain how I have navigated a similar situation approx 100 (or whatever) number of times. I explain the rationale again and how someone could mistake the recommendation the therapist is making. Sometimes discussing more in-depth the pharmacologic rationale (e.g. how tolerance works, how half lives work etc) will show a clear difference in your understanding vs the conversation they had with the therapist.

Then I finish that, smash my head into a wall, and move forward with my day.

 

[clausewitz2]

I will push back very slightly and say that it is possible that at least the second therapist acting appropriately. A patient who spends much of their therapy session complaining about how their doctor won't listen to them and they are unhappy with the situation who also doesn't breathe a word of this to their physician directly are not demonstrating interpersonal effectiveness. They probably should be pushed to actually address their discontent directly. Maybe that second therapist was telling this person they should have more Xanax, I don't know, but worth considering this message may be more in the spirit of "so heads-up here's what she's going to be asking you about and why she will be doing it." This would be a standard DBT kind of move.

 

[FlowRate]

Sounds like you've tried the thing that needs to happen next--a real-time dialog with the therapist. Hopefully you can make that happen but it sounds like the therapist isn't making that easy.

And, like clausewitz was saying, sometimes this is the therapist "doing" for the patient in a misguided/inappropriate way. (Rather than advocating for the patient to speak with you more directly.)

I'm curious why you decided to taper diazepam before alprazolam?

 

[Stagg737]

I will push back very slightly and say that it is possible that at least the second therapist acting appropriately. A patient who spends much of their therapy session complaining about how their doctor won't listen to them and they are unhappy with the situation who also doesn't breathe a word of this to their physician directly are not demonstrating interpersonal effectiveness. They probably should be pushed to actually address their discontent directly. Maybe that second therapist was telling this person they should have more Xanax, I don't know, but worth considering this message may be more in the spirit of "so heads-up here's what she's going to be asking you about and why she will be doing it." This would be a standard DBT kind of move.

Sure, I agree and said earlier that there's some patients where therapists encouraging assertiveness and more direct communication is completely appropriate and I welcome it. I wish there were more therapists who could appropriately provide positive reinforcement of effective communication skills.

However, there's a difference between encouraging assertive and effective communication and inappropriately guiding care. Given that the OP got a letter saying the patient complained about not getting enough Xanax and the therapist told the patient to be more assertive about meds definitely sounds more like the latter.

 

[TexasPhysician]

If other clinicians want to criticize, they can take over.

That said, dropping 3mg of Klonopin (25%) in 1-2 months is aggressive.

 

[clausewitz2]

Sure, I agree and said earlier that there's some patients where therapists encouraging assertiveness and more direct communication is completely appropriate and I welcome it. I wish there were more therapists who could appropriately provide positive reinforcement of effective communication skills.

However, there's a difference between encouraging assertive and effective communication and inappropriately guiding care. Given that the OP got a letter saying the patient complained about not getting enough Xanax and the therapist told the patient to be more assertive about meds definitely sounds more like the latter.

I agree that seems like overstepping, but I guess I read it as a message in an EMR or something rather than a formal letter.

 

[Attending1985]

Sounds like you've tried the thing that needs to happen next--a real-time dialog with the therapist. Hopefully you can make that happen but it sounds like the therapist isn't making that easy.

And, like clausewitz was saying, sometimes this is the therapist "doing" for the patient in a misguided/inappropriate way. (Rather than advocating for the patient to speak with you more directly.)

I'm curious why you decided to taper diazepam before alprazolam?

She was on a small dose of Valium at bedtime only. Didn’t want to transition over to Valium for a taper.

 

[Attending1985]

If other clinicians want to criticize, they can take over.

That said, dropping 3mg of Klonopin (25%) in 1-2 months is aggressive.

I am curious to see what others would do. I did collaborate with her neurologist who agreed with the 25% reduction. I also talked to the clinical pharmacist. I have never had a patient on over 6 mg of Klonopin before so it was new territory for me.

 

[TheRightMedication]

Strongly agree that the clonazepam taper is aggressive - in cases like this I would say "we'll have you off the clonazepam in 1 or 2 presidential administrations." However, its also our right to say we're not comfortable with a high absolute dose and we are offering an aggressive taper only. As tolerated of course, where vital signs and physical exam inform toleration more than subjective report. Furthermore I assume the strong taper is just an opening move and the rate of taper will decrease over time.

I am curious about just what this therapist said. If they offered a medical opinion about the appropriateness of the taper, yes, shame on them.

If they helped the patient articulate their feelings and encouraged them to speak up, or gently challenged them on their not telling their doctor how they felt, that seems like good work to me.

 

[calvnandhobbs68]

If this is a therapist within your group then I would contact them asking not to attempt to guide medication management or to just message you directly with questions or concerns about medications. If this is someone in the community then good luck. You can contact them and attempt to educate them on your treatment plans and why a benzo taper/minimizing their use is necessary, but good luck. I'm all for therapists helping certain patients be more assertive, but if they're sending you letters about the patients complaining about benzos and how you not giving them "the right meds" is interfering with therapy I wouldn't hold my breath that they'll listen.

I've had success with this before even in the community, I've called outside therapists and basically diplomatically said I'd love to hear their concerns around any medication directly but they can feel free to deflect any questions/concerns/opinions about the medication to me that are coming from the patient. They get the gist sometimes....I had one telling a patient that the only medication that they'd "ever seen work" for ADHD was multiple doses of short acting stimulant a day and telling the patient she should ask me to prescribe that instead.

I will also push back on this with patients directly and basically tell the patients that it's not the therapists place to decide or suggest anything about the medication since they've literally never written one prescription for one in their life and never will. I usually tell the patients that if the therapist has any concerns they should be contacting me directly rather than making the patient play telephone. I always tell patients right off the bat that I WANT them to bring up any concerns about the medication to me directly and to always feel comfortable telling me if they're not comfortable with med plans/changes/side effects, etc.

I agree this is one of my top pet peeves too, therapists commenting around literally anything about medication unless it's generic receptive information like "patient feels the medication has been helpful/unhelpful". I also agree some of this can get misinterpreted and it's best to clarify with the therapist directly but my general gist of this has been too many therapists feel way too comfortable giving opinions on medical stuff they have no idea about.

 

[smalltownpsych]

If I was to communicate to a psychiatrist I would offer my perspective on how the patient is doing with the taper and appreciate that psychiatrist is helping them with that and keep up the good work while I continue to help them to expose themselves to anxiety provoking situations. Maybe I would suggest that if the patient is too anxious to discuss during psychiatry sessions, then we could meet together. I would be more likely to continue working on empowering the patient to speak for themselves and reinforce that it is hard to deal with anxiety and I am so glad they are going on the right direction by tapering for a substance that is temporarily effective but will make it worse in the long run. The one thing I would be cautious about is splitting and me be the nice parent and the psychiatrist be the strict parent.

 

[Sushirolls]

I'm blunt with patients and keep it simple. The chemical pull on benzos isn't readily amendable to the various therapy techniques; and it wastes time in appointment, goes in a loop and finishes right at "doc I want the benzo... I need the benzo... Its the only thing that works."

Bluntly remind, the taper is happening.
This is the outline, monthly prescriptions, 10% reduction at most 20%. [25% is fine at 2 months]
Each step down is going to suck.
Patients are going to have nostalgia for up to a year after stopping... rembering the good ol' days of benzos, or even forever.
Remind them directly as long as they are working with you this taper will not deviate.
They are welcome to find another clinician, there are ample others who will hit refill.
But you won't want your own family on this and will be happy to continue treating with the care you'd off to your own aunt/mother/grandmother/sister, whatever.

If the taper fails outpatient - inpatient drops down 10% per day... remember that, remind patients that.

 

[Attending1985]

I appreciate everyone’s input on the taper. Where I trained a 25% reduction per month was considered slow so it’s good to see different perspectives.

 

[smalltownpsych]

I'm blunt with patients and keep it simple. The chemical pull on benzos isn't readily amendable to the various therapy techniques; and it wastes time in appointment, goes in a loop and finishes right at "doc I want the benzo... I need the benzo... Its the only thing that works."

Bluntly remind, the taper is happening.
This is the outline, monthly prescriptions, 10% reduction at most 20%. [25% is fine at 2 months]
Each step down is going to suck.
Patients are going to have nostalgia for up to a year after stopping... rembering the good ol' days of benzos, or even forever.
Remind them directly as long as they are working with you this taper will not deviate.
They are welcome to find another clinician, there are ample others who will hit refill.
But you won't want your own family on this and will be happy to continue treating with the care you'd off to your own aunt/mother/grandmother/sister, whatever.

If the taper fails outpatient - inpatient drops down 10% per day... remember that, remind patients that.

No wonder the patient is anxious to communicate a different opinion with you. 😂
Seriously though, direct communication is more helpful than avoidant communication and I would help the patient learn the difference. Might not be that the patient is uncomfortable speaking their mind, it might be that the psychiatrist already heard them and told them no.

 

[TheRightMedication]

People quote the "Ashton Method" which as near as I can tell is just a ten percent reduction every one or 2 weeks, maybe with conversion to Valium.

I assume we're all assuming that the plan is individualized, but for the benefit of any youngsters reading this - the plan is individualized. If a patient on a huge dose of benzos for a long time is without side effects, is functional, and there's low concern for abuse and diversion, then go ahead and taper ten percent per month. Then even slower as you approach the end. Why not make it painless?

If, however, they're older, having potential effects like cognitive dysfunction, and have a few hospital admits for otherwise unexplained falls, then maybe you go as fast as you can without causing severe withdrawal.

So, there's no method or standard. It depends. The only benefit I see in being rigid is if there's a strong personality component and the structure is a must-have.

 

[Attending1985]

People quote the "Ashton Method" which as near as I can tell is just a ten percent reduction every one or 2 weeks, maybe with conversion to Valium.

I assume we're all assuming that the plan is individualized, but for the benefit of any youngsters reading this - the plan is individualized. If a patient on a huge dose of benzos for a long time is without side effects, is functional, and there's low concern for abuse and diversion, then go ahead and taper ten percent per month. Then even slower as you approach the end. Why not make it painless?

If, however, they're older, having potential effects like cognitive dysfunction, and have a few hospital admits for otherwise unexplained falls, then maybe you go as fast as you can without causing severe withdrawal.

So, there's no method or standard. It depends. The only benefit I see in being rigid is if there's a strong personality component and the structure is a must-have.

Do you typically switch over to Valium from Klonopin?

 

[TheRightMedication]

I do not, personally. As I write this I'm reminded that Valium comes in 2 mg tabs which can make it easier to use so perhaps I will someday.

 

[vanfanal]

Starting a bit of topiramate or VPA half way through the taper can be helpful too for wds and also some anxiolytic effects.

 

[Attending1985]

I've had success with this before even in the community, I've called outside therapists and basically diplomatically said I'd love to hear their concerns around any medication directly but they can feel free to deflect any questions/concerns/opinions about the medication to me that are coming from the patient. They get the gist sometimes....I had one telling a patient that the only medication that they'd "ever seen work" for ADHD was multiple doses of short acting stimulant a day and telling the patient she should ask me to prescribe that instead.

I will also push back on this with patients directly and basically tell the patients that it's not the therapists place to decide or suggest anything about the medication since they've literally never written one prescription for one in their life and never will. I usually tell the patients that if the therapist has any concerns they should be contacting me directly rather than making the patient play telephone. I always tell patients right off the bat that I WANT them to bring up any concerns about the medication to me directly and to always feel comfortable telling me if they're not comfortable with med plans/changes/side effects, etc.

I agree this is one of my top pet peeves too, therapists commenting around literally anything about medication unless it's generic receptive information like "patient feels the medication has been helpful/unhelpful". I also agree some of this can get misinterpreted and it's best to clarify with the therapist directly but my general gist of this has been too many therapists feel way too comfortable giving opinions on medical stuff they have no idea about.

The other provider was not a therapist. I would welcome direct feedback about the speed of the taper as I’ve gotten here but I just think badmouthing me to a patient is poor form.

 

[TexasPhysician]

At 12mg, I would have reduced to 11mg. Remember that they survived 12mg for awhile, so 11mg isn’t crazy at the moment. At follow-up, I’d assess how they are doing and reduce 0.5-1mg. It’s going to take 1-4 years to get them off, but this gives me time to find a better option and make the taper tolerable.

 

[clausewitz2]

People quote the "Ashton Method" which as near as I can tell is just a ten percent reduction every one or 2 weeks, maybe with conversion to Valium.

I assume we're all assuming that the plan is individualized, but for the benefit of any youngsters reading this - the plan is individualized. If a patient on a huge dose of benzos for a long time is without side effects, is functional, and there's low concern for abuse and diversion, then go ahead and taper ten percent per month. Then even slower as you approach the end. Why not make it painless?

If, however, they're older, having potential effects like cognitive dysfunction, and have a few hospital admits for otherwise unexplained falls, then maybe you go as fast as you can without causing severe withdrawal.

So, there's no method or standard. It depends. The only benefit I see in being rigid is if there's a strong personality component and the structure is a must-have.

I would say it's less a ten percent reduction necessarily than making very small changes at any given step. Conversion to valium is done because you can realistically decrease a valium dose by much tinier increments than you can, say , clonazepam. Definitely second the individualization in most cases.

I have had several chronic BZD patients come to me specifically wanting to find someone to implement the Ashton method, and it has been quite successful for them. Note the confounding factors but it has also gone well with some patients who had never heard of it.

Details here: benzo.org.uk : Benzodiazepines: How They Work & How to Withdraw, Prof C H Ashton DM, FRCP, 2002

 

[Merovinge]

The other provider was not a therapist. I would welcome direct feedback about the speed of the taper as I’ve gotten here but I just think badmouthing me to a patient is poor form.

If it's a PCP, neurologist, IM sub specialist etc, I would speak to them directly to see what their concerns are and if there is a rational reason for it. It may come out that they just don't know what they are talking about and don't want any education on the topic, but I think that is a sizeable minority of those interactions. When docs talk directly to docs about a patient they are both taking care of, I think the conversation goes well at least 90% of the time in my clinical experience.

 

[FlowRate]

I appreciate everyone’s input on the taper. Where I trained a 25% reduction per month was considered slow so it’s good to see different perspectives.

FWIW I don't think 25% in 2 months is aggressive, as long as the individual increments were small (e.g. 0.5mg TDD reduction every 2 weeks.) If a patient has never tried a reasonable taper before, I think it's worth it to give them the opportunity to taper off in a somewhat motivating timeframe. You can always reassure them that, if there are any issues, you can bump the dose back to whatever was tolerable and slow things down. Some patients actually start to see cognition improvements (although that's usually as they get down to much lower doses) which can motivate completing the taper.

 

[Candidate2017]

The dirty, open little secret is patients don't care about our plan. "Doc, you want me to taper my benzo from thrice daily to twice daily, and come back in a month to continue to taper? Sure!"... picks up bottle of #60 tabs, takes thrice daily, finishes supply early, comes back, "Doc, this taper is terrible, I can't eat, can't sleep, I'm so anxious and depressed!"

I've learned to give sequential scripts of 7 day supply, rather than 30 days. This way, controlled sub is controlled, and patients are better able to regulate themselves when they have a scant supply in hand. At most, if they overconsume, they will only be out of pills for a day or two.

Last year a local independent psychiatrist retired who was heavy handed when it comes to poly pharmacy and controlled substances. I inherited a patient on 12 mg of Klonopin.

This is not an inheritance I'd want. Get thee to inpatient detox, bye.

Now I get a note from her therapist saying they spent the majority of the session discussing how she wants more Xanax and he recommends she be more assertive with me. I did send a message to the provider in the first case asking for follow up on their statement but they have not responded. Trying to decide how to handle things with this therapist and seeking input.

Give the "therapist" a call. When you speak to them, given your training and experience, they will naturally understand your reasoning and any misconceptions will be cleared up, and everyon will be on the same page in the best interest of the patient.

Nah, who are we kidding. Best to not engage stupid.

 

[kookfu]

Starting a bit of topiramate or VPA half way through the taper can be helpful too for wds and also some anxiolytic effects.

You find these more useful for benzo taper withdrawal than clonidine, in general?

 

[clausewitz2]

The dirty, open little secret is patients don't care about our plan. "Doc, you want me to taper my benzo from thrice daily to twice daily, and come back in a month to continue to taper? Sure!"... picks up bottle of #60 tabs, takes thrice daily, finishes supply early, comes back, "Doc, this taper is terrible, I can't eat, can't sleep, I'm so anxious and depressed!"

I get what you're saying, but there is a significant overlap between the people who end up on high doses of chronic benzodiazepines and the people who are extremely conscientious and exacting about observing medication plans right down to details that really don't matter. Being super clear in any taper that you are happy to pause the taper but you will never, ever, ever go up helps with this.

 

[Stagg737]

At 12mg, I would have reduced to 11mg. Remember that they survived 12mg for awhile, so 11mg isn’t crazy at the moment. At follow-up, I’d assess how they are doing and reduce 0.5-1mg. It’s going to take 1-4 years to get them off, but this gives me time to find a better option and make the taper tolerable.

Eh, I've found that at the very large doses quicker cuts are tolerated much better unless it's someone using Xanax more than QID (had a lady legit taking it Q3h including waking up to take overnight doses). I don't think going from 12mg to 9mg in 2 months is aggressive. If it's 4mg TID you could drop to 4-3-4, then 3-3-4 in 4 weeks, then 3-3-3 at 2 months. That's pretty slow for such high doses and less than 10% decrease each month. Going slower than that seems to be much less about addressing physical symptoms of a taper and more about psychological/control issues.

In residency our outpt clinic had a pharmacist embedded who would handle clozapine stuff and assist with tapers and her policy was that a 25% reduction every 2 weeks was medically "safe" and pretty much always recommended that plan. Imo that is overly aggressive and I saw plenty of patients have problems with that, especially once we get down to doses that are actually more reasonable and not the larger, less safe doses.

 

[Sushirolls]

No topamax. No VPA.
Yes gabapentin to adjunct.
No on clonidine - bp issues.

@Candidate2017 I preface patients they get a month. And from day one, ff they run short, that let's us know they have "failed" outpatient taper/detox and need inpatient. I won't deviate from the outlined monthly ~10% drop. Having this discussion up front, makes it easier to point to a detox facility, and have charting in my notes to support the facility (if they request records or call for collateral) to get the insurance to cover it.

 

[Sushirolls]

What's with people citing pharmacists as reference? They know nothing. It's our job to know these things.
Every rounding pharmd I've been around was a complete waste and could have been replaced by an epocrates drug checker.
Man, don't get me going on PharmD rant right now. Complete waste of resources expanding their clinical role. A field ruined by retail (and oversaturation, and degree creep) and now trying to find any nail they think they can hammer by lobbying. Not often I say this, but plug an ARNP into their duties (outside of a pharmacy), or PA before the PharmD.

 

[clausewitz2]

Eh, I've found that at the very large doses quicker cuts are tolerated much better unless it's someone using Xanax more than QID (had a lady legit taking it Q3h including waking up to take overnight doses). I don't think going from 12mg to 9mg in 2 months is aggressive. If it's 4mg TID you could drop to 4-3-4, then 3-3-4 in 4 weeks, then 3-3-3 at 2 months. That's pretty slow for such high doses and less than 10% decrease each month. Going slower than that seems to be much less about addressing physical symptoms of a taper and more about psychological/control issues.

I mean, yes, that is probably the case most of the time. Still seems highly relevant for getting someone off and making sure they stay off if they are actually in a position to have options in terms of who they see.

 

[annoyedpsychiatrist]

I disagree with some of the opinions on here. I dont think 25% reduction every 1-2 months is aggressive at all. If anything, sometimes making the taper prolonged can be more painful for the patient. I think low to moderate doses of medium-long acting benzos, you can taper off in three months sucessfully in 3 months, perhaps a bit longer once you get towards the end. If you look at the evidence, people often struggle the most towards the end of the taper, rather than the beginning, and it becomes harder once you taper to the smaller doses. Some people may take may take 4-6 months, but often I think you can do a 3 month taper successfully. Granted 12mg of klonopin is an absolutely absurd dose, but years sounds like a very long and painful process to taper. The fact that the patient is standing, and able to speak with 12mg of klonopin makes you think the patient is either diverting the medication or has built up a complete tolerance to it.

Normally I agree with texasphysician on 100% of things, but I actually disagree with 25% being aggressive. Multiple sources state that you can do 25% reductions, in most people, every two weeks in fact, in the beginning of the taper. The second half of the taper may require 10-25% reductions. Typically the start of the taper the reductions are larger, with smaller reductions towards the end.

The ashton method is fine for someone with strong insight, and strong desire to get off of benzos. The issue is I would say that is roughly 30-50% of people on high doses of chronic benzos. The other issue with that is you're giving two benzos at once ultimately, which one may argue contributes towards polypharmacy. I personally don't use it routinely, and they advocate for letting the patient control the taper, but the issue with that is by letting the patient have they want, is often what got them into this mess to begin with. That and/or stupid doctors.

People often say switching to a long acting benzo to taper is ideal, but id argue that isnt always the case for many reasons. For one, the exact conversion between benzodiazepines is far from exact, is really a range so its never an exact science. Second thing is, people don't always tolerate the alternative benzo as well as the original, and the third thing is that I think people who are already psychologically dependent on benzos, the idea of abruptly taking it away and replacing it with something else is kind of scary. Sometimes tapering down from a short acting benzo, even like xanax, can be fine. I think the important thing is trying to ensure the frequency is at least in a realistic manner, and you're not tapering it to where the patient is taking xanax once daily, but rather equal taper of each different dose (morning, noon, evening, etc). Really its more patient dependent, i feel, the decision to switch to a long acting benzo or stay on the current one.

Ultimately I think the success of the taper is dependent on patient insight, therapeutic relationship, and CBT probably strongly improves the outcome to deal with the psychological dependence and the uncomfortable physical sensations.

 

[annoyedpsychiatrist]

Eh, I've found that at the very large doses quicker cuts are tolerated much better unless it's someone using Xanax more than QID (had a lady legit taking it Q3h including waking up to take overnight doses). I don't think going from 12mg to 9mg in 2 months is aggressive. If it's 4mg TID you could drop to 4-3-4, then 3-3-4 in 4 weeks, then 3-3-3 at 2 months. That's pretty slow for such high doses and less than 10% decrease each month. Going slower than that seems to be much less about addressing physical symptoms of a taper and more about psychological/control issues.

In residency our outpt clinic had a pharmacist embedded who would handle clozapine stuff and assist with tapers and her policy was that a 25% reduction every 2 weeks was medically "safe" and pretty much always recommended that plan. Imo that is overly aggressive and I saw plenty of patients have problems with that, especially once we get down to doses that are actually more reasonable and not the larger, less safe doses.

Completely agree with first part. So I personally think its fine to go quicker (sometimes 25% every two or so weeks) in the beginning, but I prefer the the VA method of holding at the halfway point for a month, then continuing the reduction. Towards the end is where I tend to be more compassionate and may go slower, because I agree, I think the start is usually harder than the finish for patients. Towards the second half i usually go 10-25% reduction depending on how patient is tolerating it.

 

[Stagg737]

I mean, yes, that is probably the case most of the time. Still seems highly relevant for getting someone off and making sure they stay off if they are actually in a position to have options in terms of who they see.

My point there is that it doesn't matter if you decrease from 12mg to 10mg or from 12mg to 11.5mg. Many of those patients are going to be reporting anxiety and discomfort either way. I'd rather do a bit more early as long as it's not causing too much of a physiologic response so that when we're farther along it can be used as encouragement of to continue even with smaller gross decreases. May just be personal experience, but when I've gone very slow early (like 0.25mg decreases or even 0.5 with doses OP is talking about) the patient becomes far more resistant with any changes later. Especially true for those in less stable social situations where they may be fine for a few weeks then have a major social stressor. The patients typically give more weight to the taper causing the anxiety over the social stressor or pull out the "I need the benzo to get through this" card. When that happens being you don't have room to slow the taper down temporarily and patients look for more social excuses to delay or stop the taper if you decide to continue a dose for more than one appointment.

Obviously that's all dependent on the individual patient. That said, patients are usually terrible at determining if their discomfort is actually because of physiologic effect of the taper or if it's just psychologic due to a perceived change, so may as well get as much momentum/bang for your buck while if you can.

 

[FlowRate]

What's with people citing pharmacists as reference? They know nothing. It's our job to know these things.
Every rounding pharmd I've been around was a complete waste and could have been replaced by an epocrates drug checker.
Man, don't get me going on PharmD rant right now. Complete waste of resources expanding their clinical role. A field ruined by retail (and oversaturation, and degree creep) and now trying to find any nail they think they can hammer by lobbying. Not often I say this, but plug an ARNP into their duties (outside of a pharmacy), or PA before the PharmD.

Our clinical pharmacy specialist is extraordinarily helpful, up to date on latest research across the range of psychopharm, and I consult her roughly once a week to get a quick, nuanced, and accurate answer to something that would otherwise take me longer to look up. She absolutely earns her salary and is an asset to our team. She also helps with clozapine titrations, starting LAI's, and doing additional long-form nuanced pregnancy med discussions when women want more than we can offer in the duration of a typical appointment.

 

[comp1]

Unless the OP and the therapist are communicating in real time on something like Teams, this isn't a conversation to be had through "messages." This is an unfortunately necessary phone call. I definitely second that there is no therapy replacement for benzo withdrawal. It just sucks and it's something we should all think about before writing that first benzo prescription. I really like that concept of "nostalgia" for benzos. That seems to capture it. The therapist advising the patient to be more self-efficacious is very different from the therapist saying your psychiatrist is bad, they should be giving you more benzos. But in anything other than real time conversation, that nuance will be lost. I also strongly support informing patients that inpatient tapers will be much more rapid than anything done outpatient, they will indeed.

 

[Fan_of_Meehl]

Last year a local independent psychiatrist retired who was heavy handed when it comes to poly pharmacy and controlled substances. I inherited a patient on 12 mg of Klonopin. Made it very clear at initial appointment my plan would be taper and she was free to seek a second opinion. She wanted to move forward. Without getting into specifics it came to my attention that another provider she sees was telling her to advocate for herself and push back on my taper plan. I have been tapering slowly at 25% every 1-2 months. In another case from this provider there’s a 67 year old on Xanax and Valium. Same scenario with letting her know what I would recommend and offering a second opinion. Got her off the Valium without too much trouble and over 8 months have reduced Xanax by 0.5 mg. Now I get a note from her therapist saying they spent the majority of the session discussing how she wants more Xanax and he recommends she be more assertive with me. I did send a message to the provider in the first case asking for follow up on their statement but they have not responded. Trying to decide how to handle things with this therapist and seeking input.

Sounds like a therapist with poor boundaries. I'm assuming that they're a non-prescriber. If so, they should stay in their lane. Aren't there state laws against practicing medicine without a license? Scope of practice?

To me, the therapist contacting you directly is clearly countertherapeutic in this sort of situation. I'm assuming the patient is an adult, can use a telephone, and could reach out to you to discuss their medication plan (which is YOUR plan with the patient and falls within YOUR scope of practice). The therapist could help the client explore the issue and could offer any number of appropriate/helpful therapeutic interventions, including:

(a) utilize Socratic questioning, collaborative empiricism, and examining the evidence after identifying likely cognitive distortions around their 'need' for the benzo

(b) I've heard that there's this thing called applied relaxation and all kinds of these things called psychological interventions to address many common conditions (such as anxiety/panic) that are often the clinical targets of benzos

Relatedly, I have been seeing a sharp increase over the past several years of clinical practice (as a psychotherapist) of what we probably need to nominate as a clinical disorder for further study in the next version of the DSM, namely, 'Adult Maturation Deficit Disorder.'

(c) assertiveness/communication training, teaching the client to clearly but respectfully articulate what they see as their needs/opinions/boundaries and to assert their opinion ('I NEEEED BENZOOOS') as an opinion and not an incontrovertable fact and to do so properly with their prescribing provider while inhabiting the patient role

From what you wrote, the gist of the note from the therapist was...'the patient whom we share in common spends the majority of the session discussing how she wants more Xanax and he recommends she be more assertive with [you],' I dunno...if you respond at all, I'd imagine you could/should just say, 'Thanks for keeping me in the loop. I'll be glad to discuss Mr./Mrs. X's medication treatment plan with him/her at our next clinical encounter.'

 

[annoyedpsychiatrist]

you guys are a lot nicer than me. If a therapist told a patient to be more assertive with me in terms of obtaining xanax, i would recommend to the patient that he gets a therapist who isnt a *****.

 

[TexasPhysician]

you guys are a lot nicer than me. If a therapist told a patient to be more assertive with me in terms of obtaining xanax, i would recommend to the patient that he gets a therapist who isnt a *****.

We don’t get to see the wording of the letter. The taper was aggressive. If the letter specifically says “the patient requires more Xanax for treatment and I recommend the patient be more assertive with discussing this with you”, it’s a problem. If the letter states “I’ve been working with this patient on being more assertive in life and self-advocacy but it is a work in progress. We are currently discussing the speed of the taper, and the patient has found it so uncomfortable that prior coping skills aren’t working. Can the dose be temporarily increased?” - this is fair and should be properly addressed.

A lot can be lost in translation.

 

[annoyedpsychiatrist]

We don’t get to see the wording of the letter. The taper was aggressive. If the letter specifically says “the patient requires more Xanax for treatment and I recommend the patient be more assertive with discussing this with you”, it’s a problem. If the letter states “I’ve been working with this patient on being more assertive in life and self-advocacy but it is a work in progress. We are currently discussing the speed of the taper, and the patient has found it so uncomfortable that prior coping skills aren’t working. Can the dose be temporarily increased?” - this is fair and should be properly addressed.

A lot can be lost in translation.

More helpful details would be the speed of the taper and original dose of xanax she was on. From what im reading, in the span of 8 months he only decreased xanax by .5mg? if so that, then thats not necessarily a taper, just a small dose reduction. Helps knowning too if it was 1mg->.5mg or 4mg-->3.5mg. Also knowing when the valium was tapered off in comparison, and how much the valium dose is.

I get a huge number of benzo referrals so I try to stay up to date as I can with these medications and there are a lot of people who end up dependent on these medications because of poor prescribers/not their own fault. These people generally do fine with tapering, and I usually let the patient help direct the speed of the taper, provide reassurance, frequent f/us and try to be collaborative.

However there is also a significant portion of people who just want to snow themselves as much as humanly possible to avoid any sense of feeling and they aren't ready to accept the idea of not being numb and deal with their avoidance. Tapering with this group of people is usually a very different outcome and they are not mentally ready for a taper yet. Which is up to them, its their autonomy.

The first patient, 12mg of klonopin is just absurd, and I feel there is likely more to the story with this patient, as far his history/background.

Im not trying to disagree with you, as I know you're a seasoned/skilled psychiatrist. Its just my opinion when working with this, and dealing with the fallout of other prescribers overprescribing.

 

[Attending1985]

Thanks for the feedback everyone. I appreciate I can count on people taking the time with questions like these.

 

[SeniorWrangler]

A thankless job no matter how you parse it.

 

[esob]

I'm curious, b/c I see different attending with different approaches to benzos when pts come in on them. Suppose someone has been on them for some extended duration AND has a reasonable expectation of continuity. Why not start the alternative agent (SSRI, for example) and then give the SSRI time to work before starting the taper? There seems to be a focus on potential negative side effects when starting meds, so we do things (that drive some attendings mad) like starting sertraline at 25mg to avoid spooking the pt from the med. If the expectation is that some alternative agent is going to replace the pt's benzos, it seems like waiting for that agent to have a chance to kick in would also help alleviate spooking the pt that the new SSRI wont work when they have rebound anxiety on day 1 because the SSRI isn't doing much yet.

 

[docksan]

If a patient is telling their therapist they're concerned about the dose tapering, especially with a patient who has been on it a long time, chances are pretty good they have a better rapport with their therapist than you.

That being said, I tend to do longer tapers with my patients because I have to keep in mind they've been on their meds a long time and setting the expectation immediately that you're taking it away honestly sets them up for failure from the get go.

Telling them they're free to get a second opinion seems helpful but also undermines the amount of time it takes to get into a psychiatrist in the first place.

I'm sorry if this isn't a popular opinion, because I hate benzos too, but a good chunk of the time I've found patients sometimes will take themselves off when there isn't the lingering fear you're going to rip it away with no plan for what to replace it with.

Also, any time a therapist tells their patient to talk about something and advocate I call the therapist and talk. This is a team sport.

 

[Attending1985]

If a patient is telling their therapist they're concerned about the dose tapering, especially with a patient who has been on it a long time, chances are pretty good they have a better rapport with their therapist than you.

That being said, I tend to do longer tapers with my patients because I have to keep in mind they've been on their meds a long time and setting the expectation immediately that you're taking it away honestly sets them up for failure from the get go.

Telling them they're free to get a second opinion seems helpful but also undermines the amount of time it takes to get into a psychiatrist in the first place.

I'm sorry if this isn't a popular opinion, because I hate benzos too, but a good chunk of the time I've found patients sometimes will take themselves off when there isn't the lingering fear you're going to rip it away with no plan for what to replace it with.

Also, any time a therapist tells their patient to talk about something and advocate I call the therapist and talk. This is a team sport.

Unfortunately I’ve found that if I’m not clear with expectations initially people will really balk at reducing them because they are not interested in a taper they are interested in continuing them long term.

 

[annoyedpsychiatrist]

I'm curious, b/c I see different attending with different approaches to benzos when pts come in on them. Suppose someone has been on them for some extended duration AND has a reasonable expectation of continuity. Why not start the alternative agent (SSRI, for example) and then give the SSRI time to work before starting the taper? There seems to be a focus on potential negative side effects when starting meds, so we do things (that drive some attendings mad) like starting sertraline at 25mg to avoid spooking the pt from the med. If the expectation is that some alternative agent is going to replace the pt's benzos, it seems like waiting for that agent to have a chance to kick in would also help alleviate spooking the pt that the new SSRI wont work when they have rebound anxiety on day 1 because the SSRI isn't doing much yet.

Often times benzodiazepines are worsening the anxiety disorder through avoidance and reinforcement. I believe anxiety is more commonly rooted in the principles that CBT attempts to address moreso than just low serotonin, if that makes sense. SSRIs themselves dont decrease anxiety with the tapering of a benzo and trying to find an SSRI or medication that works is an important term...What does a medication that works mean to the patient? What should they feel? Because how they think they should feel may be based on their experience with xanax. Also one issue is that patients associate anxiety as a "bad" emotion that they shouldnt feel and forget that anxiety is sometimes the appropriate response in the right context of the situation. if you lose your car keys, anxiety is the appropriate response to this in many people. Ultimately exposure to anxiety to some degree is likely the best treatment to overcoming it, ideally without flooding the patient.

 

[Attending1985]

A thankless job no matter how you parse it.

You can say they again. Just got a message from another consulting physician relating to me that patient on Xanax is having falls due to polypharmacy.