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Reader Question: Xanax Withdrawal
By Jeffrey E. Keller MD
Published: 11/02/2015


I am looking for a withdrawal protocol for benzos. I have patients that have been on Xanax 2mg for 3-5 years and now I need to detox them. We all know how difficult this is with people in the community let alone in the correctional setting. PLEASE HELP !!!!
Thank You, Doris

Well, Doris, you have come to the right place! I, and many other JailMedicine readers, are happy to share our strategies for dealing with benzodiazepine withdrawal. And this is a common dilemma in county jails. Believe it or not, Xanax is the single most-prescribed psychiatric drug in the United States. My experience is that Xanax is highly addictive and yet handed out like candy by some community practitioners. Some community prescribers I have talked to do not even realize that Xanax is addictive! Strange but true.

And unfortunately, there is very little written in the medical literature about the process of benzodiazepine withdrawal—or at least, pertaining to what we do in jails. There is some mention in the psychiatric literature about weaning patients off of benzodiazepines, but these references talk about incredibly long tapering regimens that literally take months, for example, by reducing the benzodiazepine dose by 10% every 4 weeks. The reason that psychiatrists taper the benzodiazepines this slowly is so that the patient will feel no (or minimal) withdrawal symptoms. We can call this “tapered discontinuation.”

But this is much different from what we do in jails. What we are doing in correctional facilities instead is “benzodiazepine detoxification.” Our goal is not to eliminate any and all symptoms, but instead to withdraw the medication safely.

Unlike outside psychiatrists, we also have to take into account the security implications of having a controlled substance like a benzodiazepine in our jail. We want the withdrawal process to be safe for the patient but as short as possible to minimize the risk to the safety and security of the institution.

Since there is little, if anything, written about the benzodiazepine detoxification procedure in the medical literature, what follows is simply how I do it at my jails. I have developed my practice based on my experience with (literally) hundreds of patients, but also after discussing my practice with addiction specialists. What I do is not too different from what is done in inpatient addiction treatment programs.

And of course, I make no claims that what follows is any kind of standard of care. Other jails may be just as successful with a different procedure. But this process has worked for me:

Step one: Substitute a long acting benzodiazepine for the Xanax.

The two benzodiazepines with the longest half-lives are Valium and Tranxene but clonazepam, Librium and Ativan work OK as well. I like to keep things simple, however, and so I use Valium for all of my benzodiazepine needs, including both alcohol withdrawal and benzodiazepine detoxification. Do not use Xanax itself for detoxification because it is too short acting and does not work well! It is much better to substitute a long acting benzodiazepine and taper that.The longer acting benzos have the benefit of self-tapering, as I will discuss later.

Do NOT use hydroxyzine as the primary treatment agent for benzodiazepine withdrawal. Just as it is for alcohol withdrawal, hydroxyzine is an inappropriate agent to use for benzodiazepine detoxification. Use the proper agent, which is a long acting benzodiazepine. Like in alcohol withdrawal, hydroxyzine does not act on the GABA system involved in benzodiazepine withdrawal. Unlike alcohol withdrawal, however, hydroxyzine historically has never been used or advocated in the medical literature for the treatment of benzodiazepine withdrawal.

Step two: Using a benzodiazepine dosage equivalence chart, calculate the approximately equivalent Valium dose for the amount of Xanax that the patient is taking.

Note, however, that there is some variance between these charts as to what an equivalent dosage is. Here is one , for example, that says that Xanax 0.5mg equals Valium 10mg. Here is another that says that Xanax 1mg equals Valium 10mg. Most of the charts I have seen use the 1mg Xanax = 10mg Valium and so that is the conversion I use. However, remember that this is an estimate and you don’t have to be exact. If this patient has been taking Xanax 2mg po BID, then the approximate equivalent dosage of Valium would be around 40mg a day.

Step 3: Cut the daily dose in half every 7 days until gone.

So, for this patient, half of 40mg of Valium is 20mg a day. I use this as the starting dose in the taper, then: 10mg po BID for 7 days then 10mg qHS for seven days then 5mg po qHS for 7 days then stop. Note that this withdrawal protocol still will take three weeks to complete. An addiction specialist I know steps down the taper after 5 days instead of 7. Also, remember that Valium has such a long half life that even after the finish of the taper, the patient will continue to have Valium and active metabolites in her bloodstream for weeks afterward. This is the “prolonged self-taper mentioned in this quote from a psychiatric textbook:
The simplest approach to detoxification is a gradual reduction in dose that may be extended over several weeks or months; under no circumstances should benzodiazepines be stopped abruptly. When a more rapid detoxification is desired, inpatient dosage reduction can be completed within 2 weeks. . . . (The proper)approach is to switch to a high-potency, long-acting benzodiazepine (such as clonazepam). Most patients seem to tolerate detoxification on clonazepam quite well. Because of the prolonged self-taper after completion of detoxification with clonazepam, patients experience a smoother course of withdrawal with a minimum of rebound anxiety. Stern: Massachusetts General Hospital Comprehensive Clinical Psychiatry, 1st ed.

Step 4: Monitor the patient to make sure she is doing well.

I usually start off getting vital signs daily for the first several days. If the patient is tachycardic or even if the nurse thinks that the patient is not doing well, I will see the patient back in clinic and sometimes I will increase the dose or extend the taper. Some patients need more TLC than this, for example, those who are simultaneously withdrawing from Xanax and opioids like oxycontin, those who are older or in poor general health or those who just look rough.

Some jails use the CIWA Alcohol Withdrawal Assessment Tool (CIWA) to try to objectively score the severity of patients’ benzodiazepine withdrawal symptoms. I do not do this, myself, for three reasons. First, there is no mention in the medical literature of CIWA being used in this way. There is no foundation for the practice. Second, in my experience, it doesn’t work! The symptoms of alcohol withdrawal begin within 12-24 hours of incarceration. The symptoms of benzodiazepine withdrawal begin much later. For the long acting benzos, like Valium, the patient may not show withdrawal symptoms for literally 2 to 3 weeks. Using CIWA within the first few days may lead to a false sense of security: “This guy is doing great. We don’t have to treat him for withdrawal.” Then, at week three, boom, he has a withdrawal seizure and a bad outcome. Third, in my experience, patients withdrawing from benzodiazepines do not have the same constellation of predictable symptoms as do patients withdrawing from alcohol. Take tremor, for example. All alcohol withdrawal patients have a hand tremor, 100% (or as close to 100% as there is in this life). But not all benzodiazepine withdrawal patients have tremor. Some do–but others do not. Same with sweating, tactile hallucinations, and, well, just about all of the CIWA scoring criteria.

Step 5: Consider alternative treatments for anxiety.

Most of these patients will benefit from a visit with a mental health counselor. And many also should be prescribed an alternative, non-addictive, medication for anxiety.

If you follow these five steps, Doris, you will do fine. In my experience, benzo-detox patients who are treated with a (relatively) short taper of a long acting benzodiazepine do very well and are not the complicated medical “problem children” that alcohol withdrawal patients tend to be.

How do you treat benzodiazepine withdrawal in your facility? Please comment!

Corrections.com author, Jeffrey E. Keller is a Board Certified Emergency Physician with 25 years of practice experience before moving full time into the practice of Correctional Medicine. He is the Chief Medical Officer of Centurion. He is also the author of the "Jail Medicine" blog

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