Fear of Relapse During a Benzodiazepine Taper: What the Fear Really Is

Is fear during a benzodiazepine taper really a fear of relapse?

No. Fear during a benzodiazepine taper is normal, and it can be planned for. The word attached to it is the problem. A person who took a medication as prescribed, and who is now lowering the dose with a doctor, is not relapsing.

Relapse is a word from addiction treatment, where it means a return to compulsive drug use. A patient who took alprazolam (Xanax), clonazepam (Klonopin), lorazepam (Ativan), or diazepam (Valium) the way the prescription said has no compulsive use to return to. What that patient has is physical dependence, and physical dependence is not addiction.

In fact, the United States Food and Drug Administration (FDA) lists the two as separate risks in its 2020 boxed warning update for the whole drug class. It also states that physical dependence can occur when a benzodiazepine is taken steadily for several days to weeks, even as prescribed.

So, what is the fear really? Underneath the word there are usually three fears: the withdrawal symptoms, not coping without the medication, and symptoms getting worse before they get better.

Each one is answered by the way a slow taper is built. Dr. Mark Leeds, an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida, works from two frameworks. They are the Ashton Manual, written by Professor C. Heather Ashton, and the Maudsley Deprescribing Guidelines.

The first fear is the withdrawal symptoms themselves.

This fear is reasonable, and it keeps many people on a medication longer than they wanted. The FDA’s 2020 update warns that stopping abruptly, or reducing the dose too quickly, can cause withdrawal reactions, including seizures, that can be life-threatening. A seizure, or any other medical emergency, means calling 911 right away.

Fortunately, the same update names the answer, which is a gradual taper planned for the individual patient. Chapter III of the Ashton Manual goes further, and says that withdrawal symptoms can be minimized and largely avoided by slow tapering, tailored to the person’s needs.

How slow? Chapter II suggests reductions of up to one tenth of the dose at each step, and the words “up to” matter. The Maudsley Deprescribing Guidelines add that the reductions should become smaller as the dose comes down, each one sized to the dose that remains. Professor Ashton also wrote that the patient should be in control of the schedule.

Chapter II speaks to the fear itself, too. With a sufficiently gradual and individualized schedule, it says, withdrawal can be “quite tolerable, even easy,” especially when the person understands the cause of any symptoms and is therefore not afraid. While that is not a promise of a symptom-free taper, small steps ask less of the nervous system.

The second fear is not coping without the medication.

What if the anxiety comes back? What if the insomnia that led to the first prescription returns? Some people who say they fear a relapse mean this, the return of the original condition.

Chapter III makes an observation that helps here. Benzodiazepines were developed to relieve anxiety, and as a consequence nearly all the acute symptoms of withdrawal are those of anxiety. So, in the middle of a taper, anxiety from the last dose reduction and anxiety from the original condition can look the same.

Nobody can promise how a patient will feel once the taper is finished. That question is better judged at a stable dose than in the week after a reduction.

While the fear imagines life with no medication all at once, a taper never asks for that. The medication is still taken every day, and the dose comes down one small step at a time. At each step the person finds out how they are doing before the next one is considered.

There is no fixed timeline to keep up with, either. Chapter II tells patients not to let a doctor impose a deadline, and it notes that many people have taken a year or more to finish.

The third fear is that symptoms will get worse before they get better.

Sometimes they do, for a while. After a reduction, symptoms can rise before they settle, as the nervous system catches up with the new dose. That rise is usually withdrawal, and it says something about the size of the last step or the time allowed after it.

This is what a hold is for. The dose stays where it is until things have settled, and the next step waits. The response to a hard stretch is a change to the plan, never a judgment of the person.

It helps to picture a taper as a staircase with a landing after every stair. Each stair is small, a person can stand on a landing for as long as they need, and nobody is pushed from behind.

And, a person can step back up one stair. The sources differ on how readily. When a reduction proves too large, the Ashton Manual prefers standing still for a few weeks and, as far as possible, not going backwards. The FDA’s 2020 update tells prescribers that it may be necessary to pause the taper for a time, or to raise the dose to the previous level and then proceed more gradually once the patient is stable.

A hold is usually the first move. Dr. Leeds also regards a small updose after a cut that proves too large as a legitimate adjustment, worked out with the prescriber. Going back up a step is a tool. It is not a failure, and it is not a relapse.

So, when a stair feels too steep, the patient stands still and tells the prescriber.

Why is a bad day not a warning sign?

Because bad days are part of the expected pattern. Chapter III describes symptoms that wax and wane from day to day, from week to week, and even within a single day. It also describes “windows” of feeling well that appear after some weeks, then become more frequent and last longer. Patients call the pattern windows and waves.

Patients often describe the same sequence. There are three good days, plans are made for the weekend, and then a morning arrives that feels like the first week all over again. The first thought is that everything has been undone.

It has not. Professor Ashton wrote that there is no need to be discouraged by these wave-like recurrences, because the waves become less severe and less frequent as time passes. A wave can arrive in the middle of a hold, with no change in dose at all, and it does not mean the taper is failing.

Unfortunately, much of what is written about fear during a taper borrows the addiction model, and tells the patient to watch for warning signs. A person who reads a hard week that way carries shame on top of the symptoms, and may hide them from the prescriber. A person who expects waves can say so, hold, and adjust.

Of course, knowing the pattern does not make a wave pleasant. The comforts for the bad days of a taper are modest, and the evidence behind most of them is limited.

When should the prescriber hear about it?

Early. The prescriber should hear when symptoms after a step are building instead of settling, when a hold has not helped, and before any change to the dose. If the pace is too fast, the doctor must advise slowing down.

Fear sometimes pushes the other way, toward speeding up or skipping doses to get the whole thing over with. That is a moment to call as well. A benzodiazepine should never be stopped suddenly.

Symptoms that feel unsafe are a reason to call the same day. A new symptom such as chest pain should not be assumed to be withdrawal, and it needs prompt medical attention of its own. Thoughts of suicide mean calling or texting the 988 Suicide and Crisis Lifeline, and any medical emergency means calling 911.

How should progress be measured?

In completed steps. A reduction that has been made and has settled is progress, and it stays progress through the hold that follows. A hold is not lost time. It is part of the method.

Days without medication are the wrong measure, because during a taper there are none until the stopping point that patient and doctor have agreed on in advance. When that point comes, the last step should feel like just another step.

Realistic goals are small and near. The next step, settled, is a goal. The finish date is not, because nobody knows it yet. Deadlines come from calendars and insurance forms, and neither one has a nervous system.

Fear rarely leaves before a taper starts. Yet, it tends to ease the way the dose comes down, a little at a time, with each settled step.

How does Dr. Leeds’ practice handle fear during a taper?

BenzoDoc is the website of Dr. Leeds’ medical practice in Fort Lauderdale, and a taper there is planned the way this article describes. He is one physician who works directly with each patient, by telemedicine throughout Florida, on a concierge basis and not through insurance. The pace belongs to the patient, holds are part of the plan from the start, and there is no deadline.

Dr. Leeds’ practice provides medically supervised benzodiazepine and z-drug tapering, and a conversation about it starts with the contact form. Contact Dr. Leeds to ask about a supervised taper in Florida.

This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.