Psych Wards are not Helpful for People With Benzodiazepine Dependence and Benzodiazepine Protracted Withdrawal Syndromes

Why are psych wards not helpful for benzodiazepine dependence and protracted withdrawal?

A psychiatric ward is built for one job. It keeps a person safe through an acute crisis, usually over a stay of days. Benzodiazepine dependence and protracted withdrawal are a different kind of problem.

They are physical conditions of the nervous system, caused by a prescribed medication such as alprazolam (Xanax), clonazepam (Klonopin), lorazepam (Ativan), or diazepam (Valium). They settle slowly, over months and sometimes longer. A unit organized around short stays and psychiatric diagnoses has no slow taper to offer.

So, what happens when a person who is dependent on a benzodiazepine is admitted? And, what should happen instead?

How does a person in benzodiazepine withdrawal end up on a psychiatric unit?

Patients often describe the same sequence. A benzodiazepine was taken as prescribed for years. Then the dose was cut, a refill was missed, or the medication stopped working the way it once did.

Within days, there is panic that does not let up, no sleep, a pounding heart, and a restlessness that makes sitting still impossible. Sometimes, there are dark thoughts the person has never had before. A frightened family drives to the emergency room.

What does the emergency room see? It sees a psychiatric emergency. In Chapter III of the Ashton Manual, Professor C. Heather Ashton wrote that “nearly all the acute symptoms of withdrawal are those of anxiety.” Unless someone asks about the prescription, withdrawal and a psychiatric crisis look the same at the door.

Withdrawal symptoms are read as psychiatric illness.

On the unit, each symptom tends to get a psychiatric name. Akathisia, the inner restlessness that drives a person to pace, is often charted as agitation. Sleeplessness and racing thoughts can be charted as mania, and the perceptual changes and hallucinations that withdrawal can cause as a psychotic illness.

Burning skin, ringing in the ears, muscle jerks, and the gut symptoms that patients call benzo belly may be recorded as anxiety about health. The patient who says that the medication caused all of it may be told that this belief is part of the illness.

The staff are not the villains here. They are doing the work the unit was built for, and that work rarely includes a slow benzodiazepine taper. Yet, the result for the patient is the same.

Unfortunately, the benzodiazepine is often stopped or cut quickly.

A stay is short, and the benzodiazepine may be seen as the cause of the trouble. So, it is stopped on admission, or reduced over a few days. For a physically dependent person, that is the step that carries the most risk.

In 2020, the United States Food and Drug Administration (FDA) required an updated boxed warning for every benzodiazepine. The agency stated that stopping abruptly or reducing the dosage too quickly can result in withdrawal reactions, including seizures, which can be life-threatening.

Professor Ashton gave the same warning in Chapter II of the Manual: “Abrupt or over-rapid withdrawal, especially from high dosage, can give rise to severe symptoms (convulsions, psychotic reactions, acute anxiety states) and may increase the risk of protracted withdrawal symptoms.”

On a psychiatric unit, those psychotic reactions and that acute anxiety arrive a few days after the medication is taken away, and they are read as proof of the psychiatric diagnosis. The treatment has produced its own evidence.

More medications are added, and no taper is offered.

A psychiatric unit treats with medication. New diagnoses arrive with new prescriptions, perhaps one for mood, one for sleep, and one for agitation. Patients often go home with a longer medication list than they brought in.

A nervous system in benzodiazepine withdrawal is sensitized, and it can react unpredictably to new medications. Some of those medications also cause physical dependence of their own, which means another taper later. Which medications make sense during withdrawal is a decision for a physician who understands the condition, made for one patient at a time.

What is missing at discharge is the one thing the dependence called for. There is no gradual taper, and often there is no benzodiazepine prescription at all.

The addiction label follows the patient home.

The discharge paperwork may say misuse or addiction, and it may include a referral to an addiction program. Yet, the patient took a prescription as directed. Does that make it an addiction? It does not.

Physical dependence is not addiction. Dependence is the body’s adaptation to a medication taken steadily, and the FDA warning states that it can occur when a benzodiazepine is taken steadily for several days to weeks, even as prescribed. Addiction is a pattern of compulsive use despite harm. There is more on why the addiction label is wrong for a dependent patient.

The label matters because the care follows it. A program designed for addiction expects the medication to be gone quickly, and it has nothing to offer a nervous system that needs months.

Why is protracted withdrawal mistaken for psychiatric illness?

Protracted withdrawal means symptoms that continue for months, and occasionally years, after the last dose. A related and newer term is benzodiazepine-induced neurological dysfunction (BIND), which covers the neurological, physical, and psychological symptoms that can follow benzodiazepine use.

The mistake starts with reasoning that sounds sensible. The medication left the body weeks ago, so the symptoms cannot be withdrawal, so they must be mental illness.

Yet, a drug clearing the body is not the same as a nervous system finishing its readjustment. Over years of use, the nervous system adapts to the medication, and that adaptation appears to reverse far more slowly than the drug clears. Table 3 in Chapter III of the Ashton Manual lists anxiety, insomnia, tinnitus, tingling, muscle pain, and gastrointestinal symptoms, some of which may last a year or longer.

The FDA noted the same difficulty in the case reports it reviewed, which was telling withdrawal symptoms apart from a return of the symptoms the benzodiazepine was first prescribed for. A person admitted months after the last dose is therefore likely to leave with a new diagnosis.

The symptoms also come in windows and waves, so a bad stretch after a good month can look like a new episode of illness. Fortunately, Professor Ashton’s table describes these symptoms as gradually diminishing, receding, or improving. The nervous system is not broken.

None of this is a reason to avoid emergency care.

Safety comes first. Call 911 for a seizure or any other medical emergency. Anyone with thoughts of suicide can call or text 988, the Suicide and Crisis Lifeline, at any hour, and should call 911 if the danger is immediate.

In the emergency room or during an admission, the patient or a family member can state plainly the name of the benzodiazepine, the dose, and how long it has been taken. They can also ask that it not be stopped abruptly, and point to the boxed warning on the medication’s own label.

A hospital can keep a person safe for a few days. It cannot do the work of coming off a benzodiazepine, because that work takes months.

Fortunately, the alternative is a slow taper at home.

Professor Ashton addressed the choice directly in Chapter II. She allowed that withdrawal in a hospital or an inpatient center is medically safe and may suit a small minority of people. Yet, she wrote that it “usually involves a fairly rapid withdrawal,” and that such centers “often remove the control of withdrawal from the patient.” Slow withdrawal at home, in her words, “allows time for physical and psychological adjustments.”

Coming off a benzodiazepine is like landing an airplane. The safe way down is a long, gradual descent, and nobody lands by pointing the nose at the ground.

The dose comes down in small steps, each one sized to the dose that remains, so the steps get smaller as the dose gets lower. That is the hyperbolic pattern set out in the Maudsley Deprescribing Guidelines. Where it helps, a crossover taper to diazepam, a long-acting benzodiazepine, comes first, as the Ashton Manual describes.

The pace belongs to the patient. A step that proves too large is a reason to hold or to slow down, and it is never a failure.

What does a doctor who understands benzodiazepine dependence do differently?

Dr. Mark Leeds is an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida. His practice provides medically supervised tapering of benzodiazepines and z-drugs, the related sleep medications such as zolpidem (Ambien), for patients in Florida. The patient lives at home throughout. Dr. Leeds also helps patients taper other psychiatric medications.

He works directly with each patient. The taper is gradual and patient directed, and it is measured in months, sometimes longer. A flare of symptoms is information about the pace. It is not a new diagnosis.

A person who has been through a psychiatric admission during benzodiazepine withdrawal has often been told that the problem is in the mind. It is in the nervous system, it has a known cause, and in most cases it gets better with time. Dr. Leeds’ practice is built around a slow taper that gives the nervous system that time. 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.