How Does a Short-Term Benzodiazepine Prescription Become Years on Several Medications?

How does a short-term benzodiazepine prescription become years on several medications?

It happens one refill at a time, and then one added prescription at a time. A benzodiazepine or a sleeping pill is started to get a person through a few hard weeks. The weeks pass, the refills continue, and nobody plans the stop.

Later, the problems that the medication itself causes are treated as new illnesses, each with a prescription of its own. Medicine has names for the result. Polypharmacy means taking several medications at once, and a prescription cascade is what happens when the side effect of one drug is treated with another drug.

None of this means that the patient did something wrong. A person who took alprazolam (Xanax), clonazepam (Klonopin), or lorazepam (Ativan) exactly as prescribed, and who now cannot stop without withdrawal symptoms, has physical dependence. Physical dependence is not addiction. In fact, it is the expected response of a nervous system that has adapted to a medication.

In September 2020, the United States Food and Drug Administration (FDA) required an updated boxed warning on all benzodiazepines. Its announcement stated that physical dependence can occur when these drugs are taken steadily for several days to weeks, even as prescribed. So, how does a prescription meant for a few weeks turn into ten years and four bottles on the kitchen counter?

The short prescription becomes long one refill at a time.

Benzodiazepines were not meant for years of daily use. The first chapter of the Ashton Manual, written by Professor C. Heather Ashton, repeats the long-standing advice that they should in general be reserved for short-term use, 2 to 4 weeks only.

Unfortunately, the first prescription rarely comes with an end date. The medication works well at first, the refill is easy, and the visits are short. Nobody decides that the patient will take it for years. It simply happens.

Meanwhile, the nervous system adapts. Professor Ashton wrote that tolerance to the sleep effect develops rapidly, within a few weeks of regular use, and that there is little evidence that benzodiazepines keep working for anxiety after a few months. When the drug seemed weaker, she noted, doctors often raised the dose or added a second benzodiazepine.

Then the patient tries to stop, and the symptoms come back harder than before. That is withdrawal, yet it is easily read as proof that the medication is still needed. Dependence can form sooner than most people expect, which is why the question of stopping cold turkey after only a few days or weeks needs a careful answer.

Unfortunately, the next prescriptions often treat the first one.

Chapter I of the Ashton Manual also describes what long-term use can look like. Anxiety gradually increases over the years despite the medication, panic attacks and agoraphobia may appear for the first time, and benzodiazepines may both cause and aggravate depression. Patients call this tolerance withdrawal, and with a short-acting drug it can arrive between doses.

A common pattern looks like this. A person is given a benzodiazepine for panic or sleeplessness during a hard stretch of life. A year or two later the mood is low and flat, and an antidepressant is added.

Then sleep falls apart as tolerance builds, and a sleeping pill is added. After that comes something for the daytime fog, the dizziness, or the upset stomach. Each prescription made sense in the visit where it was written.

Yet, nobody asked whether the first medication was causing the new symptoms. Chapter II of the Manual observes that many people who take benzodiazepines long-term were given a second prescription for depression that developed during chronic use or during withdrawal.

The sleeping pill deserves a second look. Z-drugs, such as zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata), are chemically different from benzodiazepines, but Table 1 of the Manual notes that they have the same effects on the body and act by the same mechanisms. A patient who takes both is, in effect, taking two drugs of the same kind.

Stacked prescriptions are sometimes presented as a requirement of treatment. Often they are an accumulation, and nobody ever looked at the whole list at once.

Why does a stack of medications make a benzodiazepine taper harder to read?

A taper is guided by symptoms. When a dose reduction is followed by a bad week, the patient and the physician need to know what the bad week means. With several medications in the picture, there is more than one possible answer.

It could be benzodiazepine withdrawal. It could be a side effect of another drug, or the result of a late or missed dose of something else. Chapter III of the Ashton Manual points out that the withdrawal symptoms of an antidepressant are not much different from those of a benzodiazepine, with more anxiety, poor sleep, flu-like symptoms, and an upset stomach.

Sedation adds up as well. The Manual’s first chapter lists additive effects between benzodiazepines and other sedating drugs, including other sleeping pills and sedating antihistamines. So, the drowsiness, the unsteadiness, and the mental fog may belong to the combination and not to any single drug.

Anyone who cooks knows the problem. If the salt, the heat, and the cooking time are all changed in the same pot on the same night, there is no way to know which change spoiled the soup. The rule is to change one thing at a time.

In a taper, that usually means that the benzodiazepine dose comes down in small steps while medications of other kinds are left where they are for the time being. Then each new symptom has one likely cause, and the next step can be planned with clear information.

A z-drug is the exception. It acts the way a benzodiazepine does, so it belongs inside the taper plan, and the slow withdrawal schedules in Chapter II of the Ashton Manual include one for a z-drug.

Which medication comes off first?

The Ashton Manual gives a plain answer for the most common pair. Chapter II says that when a person takes an antidepressant as well as a benzodiazepine, it is best to complete the benzodiazepine withdrawal before starting to taper the antidepressant. Schedule 13 of the same chapter adds a pause of at least four weeks after the benzodiazepine is stopped.

After that, Professor Ashton advised that the second medication be tapered gradually too, on a schedule agreed with the doctor, because it can cause a withdrawal reaction of its own. This is a starting point. The order is settled for one person at a time, with a physician who knows the whole list.

However, what should not happen is a sudden clearing of the shelf. Stopping the added medications all at once, to make things simple before the taper, trades one withdrawal for several.

A related mistake runs the other way. During a taper, new prescriptions are sometimes added to cover withdrawal symptoms, and the cascade begins again. Chapter III of the Manual notes that when the taper is slow enough, additional drugs are seldom needed.

What should a prescriber explain before the first prescription?

A cascade usually starts with a conversation that did not happen. Informed consent means that the risks come first, before the first tablet: tolerance, physical dependence, and withdrawal. Since the FDA’s 2020 update, physical dependence and withdrawal reactions have been part of the boxed warning required on every benzodiazepine label.

Next come the benefits and the alternatives, including the alternative of no medication at all. Then comes the part that is most often missing, which is the exit plan. A prescription for a benzodiazepine or a sleeping pill should come with an expected duration and a description of how it will be stopped, from day one.

The patient may decline. The patient may also agree and change their mind later, without penalty to the care relationship.

Consent is a conversation that continues at every refill. It is not a signature on a form, and it is never a technique for getting a patient to agree. The article on informed consent and psychiatric drugs goes into more detail.

What should you ask before starting a benzodiazepine or a sleeping pill?

Five questions cover most of it. First, what is this prescription for, and for how many weeks is it meant to be taken? The Manual’s figure of 2 to 4 weeks is a fair yardstick for the answer.

Second, what are the risks of tolerance, physical dependence, and withdrawal, and how soon can they begin? Third, what are the alternatives, including waiting, and including no medication? Fourth, how will the medication be stopped, and who will supervise the taper if stopping turns out to be hard?

The fifth question is for anyone who already takes one of these drugs and is offered another prescription. Could the new symptom be coming from a medication that is already on the list? That is the question that interrupts a cascade.

A prescriber who welcomes these questions is a good sign, and a patient who asks them is not being difficult. The same questions apply at any refill. Consent that was never asked for at the start can still be asked for in year five.

What if you are already taking one, or several?

Do not stop suddenly. The FDA’s 2020 warning states that stopping a benzodiazepine abruptly, or reducing the dose too quickly, can cause withdrawal reactions, including seizures, which can be life-threatening. For a seizure or any other medical emergency, call 911.

Fortunately, there is a safer way down. A gradual taper, supervised by a physician and directed by the patient, gives the nervous system time to adapt at each step. It usually takes months, and sometimes longer, and the same FDA update tells prescribers that no standard tapering schedule suits all patients.

Where it helps, the Ashton Manual describes a crossover taper to diazepam (Valium), a long-acting benzodiazepine that allows small, smooth reductions. The Maudsley Deprescribing Guidelines describe hyperbolic tapering, in which the steps get smaller as the dose gets lower. Chapter II of the Manual says the person tapering should be in control of the schedule, which is why the pace belongs to the patient.

A person in this position can ask for a taper, and can bring one useful thing to that visit: a list of every medication in the order it was started, with over-the-counter sleep aids included. The order often shows where the cascade began.

The list did not build in a day, and it does not have to come down in a hurry.

With time, and with a taper that is slow enough, the nervous system adapts back. In Chapter III, Professor Ashton wrote that a steady decline in symptoms almost invariably continues after withdrawal, though it can take a long time.

Dr. Mark Leeds is an osteopathic physician and deprescribing specialist in Fort Lauderdale. His practice provides medically supervised benzodiazepine and z-drug tapering for patients in Florida, with telemedicine visits throughout the state. Dr. Leeds also helps patients taper other psychiatric medications.

In Dr. Leeds’ practice, consent for a taper works the way consent for a prescription should have worked. The risks come first, then the alternatives, then a plan agreed in advance, and the patient keeps the right to slow down, hold, or decline at any point. A patient’s other medications are part of the planning from the first conversation. Contact the office to ask about a gradual, medically supervised benzodiazepine 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.