Communicating with Patients About Physiological Dependence and Withdrawal

First of all, it is not just a matter of speaking with patients, but more importantly it is essential to listen to them.  Often, their story will reveal solutions that are more beneficial than those that are traditionally identified by means of a diagnosis alone.  Patients are experts in the nature of their challenges and often have a very sophisticated understanding as well as solution opportunities as well.

It is helpful to understand the language used, so here is an introduction to common terms commonly used by patients who are aware of the problems with benzodiazepines (see also the Terminology page and the Withdrawal page).  “Benzowise” is what clinicians should seek to be.  “Benzo brain” refers to the array of symptoms – a good descriptor for the condition which does not have a formally accepted term in medicine.  “Benzodiazepine brain injury” is another, though this might not represent the complete picture once we understand how peripheral benzodiazepine receptors are involved.  Patients may use the terms “waves” and “windows” to describe accelerated exacerbations and relative pauses in symptom severity respectively.  This pattern is common during periods of continued benzodiazepine use, withdrawal, and post-withdrawal recovery, and it is important to understand this when developing a treatment plan.

Involved individuals may call themselves “benzodiazepine survivors” which accurately implies the severity of the problem and should be respected.  Their experience can have a catastrophic functional effect related to benzodiazepine exposure and should not be simply attributed to a separate new or worsening medical condition.  It is very rare that the diagnosis of Benzodiazepine Use Disorder (addiction) is applicable, because there is generally no craving to use them for non-indicated reasons.  On the contrary, the vast majority struggle because benzodiazepines were continued too long, and both patients and medical providers have not had the tools for a safe, effective withdrawal process.

Not all patients recognize that benzodiazepines or Z-drugs are the source of the problems they are experiencing. They may have even been told by other providers that they have a physical need for benzodiazepines, although there are no peer-reviewed studies supporting this assertion.   For many patients, the symptoms of benzodiazepine withdrawal persist for many years after discontinuance, which is a diagnostic challenge.  It is important to take a thorough history and have a high suspicion that these medications may be the cause of issues presented by patients and not simply attribute them to other etiologies, though it is possible that that could be the case.  It is also important to understand that even in the absence of overt problems, these agents are typically no longer effective, and therefore trial discontinuation should be offered.

Clinical skills involve the provision of information paired with the use of motivational interviewing for patients taking benzodiazepines.  If there are no overt, potentially related symptoms, discuss the likelihood of loss of efficacy over time.  If there are overt, potentially related symptoms, discuss the likelihood of their relationship to the use of benzodiazepines.  It is helpful to objectively measure cognitive and psychomotor function as well as overnight oxygenation profile to determine actual current status for these parameters that can relate to benzodiazepine use.  Ask the patients then to outline their goals and relate the (lower) likelihood of goal achievement in the context of continued benzodiazepine use.   The aim here is for the patient to understand the likely connection and become interested in making a change.

A supported tapering process should be recommended.  If the patient declines the offer, continue to monitor for efficacy / risks / adverse outcomes and employ motivational interviewing in a non-judgmental and non-shaming manner.  If accepted, employ specific strategies outlined in the Withdrawal page of this website .  Educate the patient and have them access The Ashton Manual, which is a very readable guide for patients and providers alike.  Manage expectations with informed consent to include a discussion that tapering is a very individual process, it may take 18 months or even longer to complete, and there will be a recovery period after the taper completes.  With the patient build a team of support: family, friends, coaches.  Build the therapeutic alliance through shared decision-making and by responding to the patient’s reported experiences.  Make the first dose reduction small since most patients fear that you might “throw me under the bus”.  As much as possible, ensure the patient has pauses in withdrawal intensity by altering the amount of or interval between dose reductions based on the patent’s status.  Continuous high-level withdrawal is especially hard to tolerate.  Expect multiple adjustments to the plan which require listening carefully to the actual experience of the patient and be open to their ideas about withdrawal management.  These strategies are not only the right thing to do but will enhance the therapeutic relationship with the patient who needs to feel safe throughout this process.

COLLABORATING WITH COLLEAGUES

Ideally, medical practices integrate behavioral health and employ a team-based approach.  It is important to knit together a multi-disciplinary team.  More than referral and communication, this means coordination and collaboration.  This can present challenges as less-informed medical providers may not share the same perspective on the use of benzodiazepines and Z-drugs.  On initial contact with other involved colleagues, stating your concerns and recommendations for a specific patient should be direct and respectful.  It is helpful to provide any objective information you have, such as cognitive, psychomotor, and mood status and overnight oxygenation studies.  Lay out your concerns about loss of efficacy and development of adverse side effects over time.  Make clear who will be prescribing and managing the withdrawal (if accepted) going forward.  If you are met with a difference of opinion or approach, acknowledge that in a respectful manner and consider carefully the manner of communicating this to the involved patient.