Reader Questions Benzo Withdrawal and Inhaler Abuse

(With regard for The Rules for Treating Benzodiazepine Withdrawal) I practice in a jail on the East Coast. I totally agree that Benzo’s must be used, but I can’t find anything in the literature concerning length of treatment to avoid life-threatening vs. annoying symptoms. The months-long tapers are not well accepted by either Correctional Healthcare companies or Correctional institutions. Most providers here go with a week of tapering diazepam. I usually go with 10-14 days. I would like to try your general formula of choosing the dose of diazepam, then tapering down every 4-6 days. Do you have any literature or expert panel opinion on how long to taper in order to avoid life-threatening consequences? Do you see any benefit to using other meds after the benzo taper simply to decrease annoying symptoms from withdrawal?  Steven Wilbraham MD

Thanks for the question, Dr. Wilbraham!  Yes, the psychiatry literature talks about tapering benzodiazepines very gradually over many months or even years. But what they are doing is different than what we are doing.  They are treating benzodiazepine addiction and we are treating withdrawal with a detoxification protocol.  It is analogous to the difference between treating opiate addiction in a methadone clinic (which also can last for months or years) versus what we do when we treat opiate withdrawal for at most a couple of weeks. 

The problem is this: compared to opiate withdrawal, there is very little literature about the optimum strategy for treating benzodiazepine withdrawal.  The best article I have found on the subject is also the one with the shortest recommended treatment time:  The Oregon State Drug Review: Benzodiazepine safety and tapering.  One addiction specialist who practices in jails told me that he tapers by 25-50% each week.

The basic rules are:  1.  Treat everyone at risk.  2.  Substitute a long-acting benzo for short acting benzos, like Xanax.  3.  Taper slowly: no more rapidly than 25-50% per 5-7 days.  It’s OK to go more slowly but be leery of going more rapidly.  Tapering someone taking really large doses of Xanax (like, say, 2mg of Xanax four times a day) in one week is probably too fast.

How long a benzo taper lasts should depend on how much the patient has been taking.  A patient taking small amounts can perhaps be tapered using Valium 5mg po qHS for a week.  A patient who has been takin large doses for a long time may require several weeks of tapering and monitoring. Be cautious. You can get into trouble going too fast.  It is safer and better to go more slowly. 

I personally do not use any other medications on a regular basis in treating benzo withdrawal. I certainly would consider something else based on a particular patient’s complaints, but the vast majority of my patients do fine on just a benzo taper. If a patient has more than mild symptoms from benzo withdrawal, the best and most effective therapy is just more benzos, so I usually either increase the dose by a little or extend the taper or both.

Respimat abuse

I work in the WA DOC. We currently have restrictions on certain inhalers because they have components that could be used for illicit means if taken apart. One example would be Respimat. I am curious if others have had issues such as this. I am not sure if this was a hypothetical concern or there have been cases where these devices have been used to this detriment.  William Aurich, DO, FMD, CBCC

The short answer, Dr. Aurich, is Yes! Respimat components can be repurposed for other uses, such as giving prison tattoos.  Caution is warranted. There are two easy solutions to this particular problem:

  1. Since tiotropium in a Respimat inhaler is a scheduled drug rather than a prn drug, don’t allow patients to keep it on person (KOP). The patient would have to go to the pill call line once a day for their inhalation. If the patient is already going to pill call anyway (which most patients taking tiotropium will be), there should be no problem doing this.
  2. Prescribe a different medication that does not carry the same risk.  The published guidelines on asthma and COPD therapy offer several alternative meds and treatment pathways.

The list of seemingly benign medications that are diverted, sold, and abused in jails and prisons is long.  Practitioners in correctional settings need be careful about prescribing potential problematic drugs, like the Respimat inhaler. We do not want to unintentionally harm our patients!

What I have written here is my opinion, based on my training research and experience. I could be wrong!

Please comment!

How long do you taper benzodiazepines at your facility?

What is your experience with diverted and abused drugs in your facility?

1 thought on “Reader Questions Benzo Withdrawal and Inhaler Abuse

  1. We are getting reports of patients emptying their SABA (Xopenex) onto a mirror, scraping off the residue and then snorting it. Have your heard of this? Is there any intoxicating effects that can be divided this way? We have had an increased demand for SABA inhalers. We are having patients that run out in days.

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