Reader Question: Xanax Withdrawal

I am looking for a withdrawal protocol for benzos. I have patients that have been on Xanax 2mg for 3-5 years and now I need to detox them. We all know how difficult this is with people in the community let alone in the correctional setting. PLEASE HELP !!!!
Thank You, Doris

Well, Doris, you have come to the right place! I, and many other JailMedicine readers, are happy to share our strategies for dealing with benzodiazepine withdrawal. And this is a common dilemma in county jails. Believe it or not, Xanax is the single most-prescribed psychiatric drug in the United States. My experience is that Xanax is highly addictive and yet handed out like candy by some community practitioners. Some community prescribers I have talked to do not even realize that Xanax is addictive!  Strange but true.GABA-Production

And unfortunately, there is very little written in the medical literature about the process of benzodiazepine withdrawal—or at least, pertaining to what we do in jails. There is some mention in the psychiatric literature about weaning patients off of benzodiazepines, but these references talk about incredibly long tapering regimens that literally take months, for example, by reducing the benzodiazepine dose by 10% every 4 weeks. The reason that psychiatrists taper the benzodiazepines this slowly is so that the patient will feel no (or minimal) withdrawal symptoms. We can call this “tapered discontinuation.”

But this is much different from what we do in jails. What we are doing in correctional facilities instead is “benzodiazepine detoxification.” Our goal is not to eliminate any and all symptoms, but instead to withdraw the medication safely.

Unlike outside psychiatrists, we also have to take into account the security implications of having a controlled substance like a benzodiazepine in our jail. We want the withdrawal process to be safe for the patient but as short as possible to minimize the risk to the safety and security of the institution.

Since there is little, if anything, written about the benzodiazepine detoxification procedure in the medical literature, what follows is simply how I do it at my jails. I have developed my practice based on my experience with (literally) hundreds of patients, but also after discussing my practice with addiction specialists. What I do is not too different from what is done in inpatient addiction treatment programs.

And of course, I make no claims that what follows is any kind of standard of care. Other jails may be just as successful with a different procedure. But this process has worked for me:

Step one: Substitute a long acting benzodiazepine for the Xanax.

The two benzodiazepines with the longest half-lives are Valium and Tranxene but clonazepam, Librium and Ativan work OK as well. I like to keep things simple, however, and so I use Valium for all of my benzodiazepine needs, including both alcohol withdrawal and benzodiazepine detoxification. Do not use Xanax itself for detoxification because it is too short acting and does not work well!  It is much better to substitute a long acting benzodiazepine and taper that.The longer acting benzos have the benefit of self-tapering, as I will discuss later.

Do NOT use hydroxyzine as the primary treatment agent for benzodiazepine withdrawal. Just as it is for alcohol withdrawal, hydroxyzine is an inappropriate agent to use for benzodiazepine detoxification. Use the proper agent, which is a long acting benzodiazepine. Like in alcohol withdrawal, hydroxyzine does not act on the GABA system involved in benzodiazepine withdrawal. Unlike alcohol withdrawal, however, hydroxyzine historically has never been used or advocated in the medical literature for the treatment of benzodiazepine withdrawal.

Step two: Using a benzodiazepine dosage equivalence chart, calculate the approximately equivalent Valium dose for the amount of Xanax that the patient is taking.

Note, however, that there is some variance between these charts as to what an equivalent dosage is. Here is one , for example, that says that Xanax 0.5mg equals Valium 10mg. Here is another that says that Xanax 1mg equals Valium 10mg. Most of the charts I have seen use the 1mg Xanax = 10mg Valium and so that is the conversion I use. However, remember that this is an estimate and you don’t have to be exact. If this patient has been taking Xanax 2mg po BID, then the approximate equivalent dosage of Valium would be around 40mg a day.

Step 3: Cut the daily dose in half every 7 days until gone.

So, for this patient, half of 40mg of Valium is 20mg a day.  I use this as the starting dose in the taper, then: 10mg po BID for 7 days then 10mg qHS for seven days then 5mg po qHS for 7 days then stop. Note that this withdrawal protocol still will take three weeks to complete. An addiction specialist I know steps down the taper after 5 days instead of 7. Also, remember that Valium has such a long half life that even after the finish of the taper, the patient will continue to have Valium and active metabolites in her bloodstream for weeks afterward. This is the “prolonged self-taper mentioned in this quote from a psychiatric textbook:

The simplest approach to detoxification is a gradual reduction in dose that may be extended over several weeks or months; under no circumstances should benzodiazepines be stopped abruptly. When a more rapid detoxification is desired, inpatient dosage reduction can be completed within 2 weeks. . . . (The proper)approach is to switch to a high-potency, long-acting benzodiazepine (such as clonazepam). Most patients seem to tolerate detoxification on clonazepam quite well. Because of the prolonged self-taper after completion of detoxification with clonazepam, patients experience a smoother course of withdrawal with a minimum of rebound anxiety.
Stern: Massachusetts General Hospital Comprehensive Clinical Psychiatry, 1st ed.19950328

Step 4: Monitor the patient to make sure she is doing well.

I usually start off getting vital signs daily for the first several days. If the patient is tachycardic or even if the nurse thinks that the patient is not doing well, I will see the patient back in clinic and sometimes I will increase the dose or extend the taper. Some patients need more TLC than this, for example, those who are simultaneously withdrawing from Xanax and opioids like oxycontin, those who are older or in poor general health or those who just look rough.

Some jails use the CIWA Alcohol Withdrawal Assessment Tool (CIWA) to try to objectively score the severity of patients’ benzodiazepine withdrawal symptoms. I do not do this, myself, for three reasons. First, there is no mention in the medical literature of CIWA being used in this way.  There is no foundation for the practice.  Second, in my experience, it doesn’t work!  The symptoms of alcohol withdrawal begin within 12-24 hours of incarceration. The symptoms of benzodiazepine withdrawal begin much later. For the long acting benzos, like Valium, the patient may not show withdrawal symptoms for literally 2 to 3 weeks. Using CIWA within the first few days may lead to a false sense of security: “This guy is doing great. We don’t have to treat him for withdrawal.” Then, at week three, boom, he has a withdrawal seizure and a bad outcome. Third, in my experience, patients withdrawing from benzodiazepines do not have the same constellation of predictable symptoms as do patients withdrawing from alcohol. Take tremor, for example. All alcohol withdrawal patients have a hand tremor, 100% (or as close to 100% as there is in this life). But not all benzodiazepine withdrawal patients have tremor. Some do–but others do not.  Same with sweating, tactile hallucinations, and, well, just about all of the CIWA scoring criteria.

Step 5: Consider alternative treatments for anxiety.

Most of these patients will benefit from a visit with a mental health counselor. And many also should be prescribed an alternative, non-addictive, medication for anxiety.

If you follow these five steps, Doris, you will do fine.  In my experience, benzo-detox patients who are treated with a (relatively) short taper of a long acting benzodiazepine do very well and are not the complicated medical “problem children” that alcohol withdrawal patients tend to be.

How do you treat benzodiazepine withdrawal in your facility? Please comment!

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21 thoughts on “Reader Question: Xanax Withdrawal

  1. Sue Burkhalter

    I don’t change medications if the patient is on Xanax. I leave them on Xanax and decrease by 30% per week until eliminated. I have never had any problems with this taper.

    Reply
    1. Jeffrey Keller MD Post author

      Thanks for the comment, Sue! I know of other practitioners who just taper the Xanax, as well.

      Reply
  2. Lisa

    Here is our protocol for benzodiazepine tapers:

    C. Benzodiazepine taper protocol:

    1 week benzodiazepine taper:
    Klonopin 0.5 mg PO QHS x 7 days THEN stop

    2 week benzodiazepine taper:
    Klonopin 0.5 mg PO BID x 7 days THEN Klonopin 0.5 mg PO QHS x 7 days THEN
    stop

    3 week benzodiazepine taper:
    Klonopin 0.5 mg PO QAM AND Klonopin 1 mg PO QHS x 7 days THEN Klonopin 0.5 mg BID x 7 days THEN Klonopin 0.5 mg PO QHS x 7 days THEN stop

    4 week benzodiazepine taper:
    Klonopin 1 mg PO BID x 7 days THEN Klonopin 0.5 mg PO QAM AND Klonopin 1 mg PO QHS x 7 days THEN Klonopin 0.5 mg BID x 7 days THEN Klonopin 0.5 mg PO QHS x 7 days THEN stop

    1. Inmates on Valium/ Diazepam
    Total daily dose of 5mg or below: No taper
    10mg: 1 week taper
    20mg: 2 weeks taper
    30mg: 3 weeks taper
    40mg: 4 weeks taper

    2. Inmates on Lorazepam/ Ativan / Klonopin
    Total daily dose of 0.5mg or below: No taper
    1mg: 1 week taper
    2mg: 2 weeks taper
    3mg: 3 weeks taper
    4mg: 4 weeks taper
    6mg: Start Klonopin 1.5 mg bid x 7 days THEN 4 weeks taper
    Above 6mg: Call Psychiatrist

    3. Inmates on Alprazolam/Xanax
    Total daily dose of 0.5mg: 1 week taper
    1mg: 2 weeks taper
    2mg: 3 weeks taper
    3mg: 4 weeks taper
    4mg: Start Klonopin 1.5 mg bid x 7 days THEN 4 weeks taper
    6mg: Start Klonopin 2mg bid x 7 days/ Klonopin 1.5mg po bid x 7 days THEN 4 weeks taper
    Above 6mg: Call Psychiatrist

    Inmates will be referred for Psychiatry appointment

    CONVERSION: 1MG OF KLONOPIN= 1MG OF ALPRAZOLAM= 2MG OF LORAZEPAM= 20MG OF DIAZEPAM

    Reply
      1. Lisa

        Yes it has… our only difficulty and I wouldn’t mind suggestions are those people who take Benzo’s off the streets. We test their urine on intake and they test positive… Can’t really go on the “dose” they say they are taking. It is hard to get an idea of where to start a taper protocol on them.

        Reply
  3. BJF

    Jeff,
    I’m curious, Is your protocol being started based on an inmates word saying they are taking benzos either prescribed or off the streets? If that is the case probably half my jail would be on withdrawal protocol.
    We utilize Librium for ETOH and Benzo withdrawal with two different tapered protocols along with parental Lorazapam PRN. We place all potential withdrawal patients on daily checks and a bottom bunk and start the protocol if they show signs or symptoms of early withdrawal. Those with a known hx of previous withdrawal or patients with co-morbidities as well as the elderly are started sooner and monitored in the infirmary. It is my experience that the majority (95+ %) of patients do fine without any detox and have very mild or no withdrawal symptoms or sequela. We do have the benefit of 24/7 RN staffing, and a well trained jail staff which helps in picking up the potential problem patients.
    BJF

    Reply
    1. Jeffrey Keller MD Post author

      The protocol I wrote about is based on verified prescribed benzodiazepines. I am told by narcotics detectives that Xanax and the other benzos are so easy to obtain from a practitioner (they are schedule 4 rather than schedule 2 like Oxycontin) and so cheap to purchase that people do not buy them on the street, at least very much. It is cheaper and easier to walk into a Doc-in-the-Box and walk out with an alprazolam prescription that you can get filled for less than ten bucks. So we probably should tend to be skeptical of people who say they buy it on the street. I am told that alprazolam is thrown in with methamphetamine purchases sometimes to help with tweaking.

      Reply
      1. kevin stout

        I never got any treatment, when I got locked-up…..I have been on differant drugs all my life…prison numerous times…only rehab is Prison…..

        Reply
  4. susan

    We do the exact opposite of what I was trained for while working on an acute detox unit prior to a position at the jail. The PA and MD elect to shorten the whole detox experience and the nurses stand between a rock and a hard place. Sometimes blaming the pt. for using when I know physicians are actually prescribing this stuff. We do at times a 9 day detox with Clonazepam. 1 mg. Bid times three days then 0.5 mg bid times three days then 0.5 mg. qd times three days and D/C. I have tried to enlighten them but alas I am only a nurse with a LADAC and experience from a fabulous Doc in the past. I have no say or control. Most of the patients go bizerk. Oh well.

    Reply
    1. Jeffrey Keller MD Post author

      9 days seems pretty dang short to me, as well. And both you and the prescribers then have “the hassle factor” to deal with, which is the complaining, repeat visits to the clinic, grievances, etc. I started out using a shorter benzodiazepine taper than I use now, but I have lengthened it over the years in response to the hassle factor. Maybe you can get the practitioners to lengthen their taper if you present it as a time management issue!

      Reply
  5. Al Cichon

    Two thoughts:
    Depending on the verified amount of benzodiazepine dispensed and the ‘apparent’ rate of consumption we will decrease the dose until it is approximately equivalent to 1 mg Clonazepam bid. The first decrease is about 50% unless the initial dose is so high that would be unreasonable.
    Our Protocol starts at :
    1 mg Clonazepam bid x 4 days, then we decrease by 0.5 mg per dose every 4 days
    Example:
    1 mg bid x 4 days; then
    0.5 mg AM and 1 mg HS; then
    0.5 mg bid and so on.
    Basically we administer a taper for 16 days.
    Then we place the individual on Dilantin taper for another 6 – 10 days.

    Now comes the other side of the coin (Part A & B)
    a. We do not empirically discontinue benzodiazepines unless the individual is determined to be misusing them in community / jail – rather, we contact the prescriber and ask for information to help understand if there is a true need.

    b. There are risks with many withdrawals: ETOH, barbiturates, opiates, etc. but we do not taper for beer, heroin, etc.; nor do we taper Suboxone / Methadone when the individual cannot arrange for the taper. I would submit that a rapid taper and a medication supported withdrawal is not a bad thing. (Heading for my foxhole now 😉

    Reply
  6. Pingback: Supplements Accelerate Benzodiazepine Withdrawal | The Health Rebel

  7. Paul Glynn, D.O.

    Experience always is the best teacher. I’ve been doing correctional med in county jails for about 20 yrs. For better or for worse, there are many factors to consider. Of course number one is the safety of the patient/inmate. And remembering that MOST of them are “pre-adjudicated”. But that includes NOT allowing them to finagle benzos when they don’t need it. Unfortunately, there are few warning signs that someone is actually at risk for benzo withdrawal seizures. Xanax is claimed by virtually every person incarcerated for drugs, and those who are familiar with the system, especially return visitors to a particular jail, are familiar with the protocols. It’s great, I guess, to know you can get a five or six day buzz after you are arrested, if you work it right. And yet, there is the, not totally rare, person who, for their own reasons, won’t admit to Xanax use, and four days after arrest starts having seizures. Rarely does anyone enter a county jail with only benzos as a drug problem. So I try to err on the side of caution and treat on suspicion of use as well as claim of use. I use a nine to twelve day Librium taper, and I have not had any treatment failure seizures. In my experience, many people who can document prescriptions for 2 mg xanax qid do not have any in their urine on intake. And those who get it on the street are usually “bolus” users, not taking it regularly. So it is an individual decision on each person. It is important enough that it should not be left to a nurse, an aide or a jailer to decide if the protocol should or shouldn’t be started. A physician had to sign off on the protocols, and a physician has the liability. I get a lot of calls on my cell phone.
    One additional item. I would like to see some research on how heavy cannabinoid use affects the risks and outcomes of other substance withdrawals.

    Reply
    1. Jeffrey Keller MD Post author

      Thanks for the comment, Paul! I agree with everything you said. Err on the side of caution, even if this means some people finagle benzos they don’t need. The medical director should be called about the initiation of withdrawal protocols every time–and the patient should be seen in the very next sick call clinic. That is and interesting question about marijuana use and how it affects withdrawal from other substances. When heavy marijuana users come to jail, they absolutely do go through a withdrawal period . . . I’ve seen it happen plenty of times.

      Reply
  8. Cheralee Worrall

    We have a protocol that we use for our withdrawal patients. Each withdrawal protocol starts out with standardized orders including a UDS. For opiates we use clonidine, meth we use propranolol for tachycardia, have found gabapentin to be very useful in benzo and alcohol withdrawal. Our psych provider is the one who brought the benzo withdrawal protocol to us. We use gabapentin 300mg PO TID x 3 days then, gabapentin 300mg PO BID x 1 day then, gabapentin 300mg PO x 1 day. We also use gabapentin for our ETOH withdrawal with a lot of success. We still have to use Librium for some of our long-term alcoholics that also use mouthwash, cough syrup, etc. We complete a CIWA BID x 7 days so are able to monitor the withdrawal – some we start on gabapentin but then need to change to Librium depending on how they are doing. I really appreciate using the gabapentin vs other controlled substances.

    Reply
    1. Jeffrey Keller MD Post author

      Several anticonvulsants have been tried for the treatment of alcohol withdrawal, most notably carbamazepine and Depakote. They work, but as a rule, they are inferior in preventing serious withdrawal than are banzodiazepines. That is why UpToDate, for example, does not recommend them. I was not able to find much literature on the use of gabapentin for alcohol withdrawal. But it is an interesting topic! I’m glad it is working for you.

      Reply
  9. kitty berry

    I am a certified substance abuse nurse, practicing in detox, sobering, and corrections for 11 years; I am appalled that anyone would recommend Klonopin for BZO WD. Please see ASAM criteria: Librium 50 MG PO TID (CIWA-B scale dependent) plus Depakote (ADM per Pt WT) BID. Librium is used for generalized seizure initial risk coverage until Depakote (Valporic acid) therapeutic blood levels can be reached which, often is times when the patient is no longer under provider/nursing care. Depakote levels take a long time to reach therapeutic levels, so Librium is coverage until this occurs. Caution: Both Librium and Depakote have significant adverse effects on hepatic function; consider this with use. Serax and Gabapentin may be used in substitution if Cirrhosis or other end-stage liver conditions exist. Study ASAM Criteria. FYI: Klonopin is a long acting BZO. Detoxing from the longer acting BZOs takes a longer amount of time to detox.

    Reply
  10. Moses Quinones

    Kitty, please help me understand why you’re appalled at the use of Klonopin for benzo WD. Because it’s long acting and takes longer to detox? Long acting is what you want. Libirum’s half life is just a bit longer than Klonopin because of its active metabolites (100hrs librium v ~80 Klonopin).
    The ASAM Criteria “Treatment Intervention” recommends a “long acting” benzo. Where in the ASAM Criteria are you seeing that using Klonopin amounts to something appalling?
    Also, I’m not aware that Librium has “significant adverse affects on hepatic function.” In fact I was taught that all benzos rarely if ever affect transaminases/liver function. However benzos, especially Librium are affected by impaired liver function/disease (prolongs the half life of metabolite).
    Also consider what the ASAM Criteria says about itself: “The ASAM criteria do not purport to set a medical or legal standard of care . . .The criteria contained within are necessarily general in their approach and are not intended as, nor should be used as, a standard of care for the treatment of any individual. . .”
    Mo

    Reply
  11. Larry

    To the comment that xanax is not something that users tend to buy off the street since it is easily available in Dr. Offices and Pharmacies, this is far from the truth. Internet xanax purchases from oversees and the local sales have flooded the market in most of the US, as I know it has in my area. I have several clients that take benzos on a daily basis that do not get them thru legitimate channels. In contrast, these tend to be the ones on the highest dose, one case a client was using 8-10 mg of xanax per day! Since he was not getting it prescribed, he was not limited to the typical monthly supply of a prescription. Since the tolerance typically goes up for these type of meds, he was simply using more and more each time to get the desired effect. I would hate to see this individual get incarcerated in one of the jails that require a valid prescription to treat for withdrawal as he would be in for a very bad time.

    Reply
  12. JaneMD

    We are revising our benzo withdrawal policy now and are using a combination of a valium taper over 2 weeks (see details below) as well as monitoring of the patient Qshift with CIWA-B scale. Thoughts or experience with this approach?

    For all patients who are taking daily dose equivalent or greater to Valium 30 mg daily:
    Valium 10 mg TID x 5 days
    Valium 10 mg BID x 5 days
    Valium 10 mg Daily x 5 days
    Valium 5 mg daily x 5 days

    Reply
    1. Jeffrey Keller MD Post author

      My opinion is that CIWA should not be used to assess benzodiazepine withdrawal–mainly because it doesn’t work. Also, I tend to cut the benzodiazepine dose in half with each step of the withdrawal process. So if someone had been taking the equivalent of 30mg a day of Valium on the outside, I would not start them on 30mg a day–I’d start at approximately half of that. Then if five to seven days I’d cut that dose in half again, etc. So one approach to a patient taking 30mg a day of Valium on the outside would be: Valium 10mg po BID for ten doses (five days) then 10mg qHS for five doses then five mg HS for five days then DC. Remember that Valium has a VERY long half life and so is self tapering. This patient will still have active Valium metabolites in their blood stream for weeks after the taper ends.

      Reply

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