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07. Beyond Benzodiazepine Discontinuation: Understanding Life Effects and Support Strategies

Published on June 1, 2024 Certification expiration date: June 1, 2027

Alexis Ritvo, M.D., M.P.H.

Addiction Psychiatry Fellowship Program director and assistant professor - University of Colorado School of Medicine

Key Points

  • BIND can have a significant negative impact on relationships and jobs. 
  • Many individuals report suicidal thoughts or attempts because of suffering from BIND. 
  • In 2020, the FDA updated the benzodiazepine black box warning, highlighting the increased risk of physical dependence and protracted withdrawal. 
  • Keep in mind that patients suffering from BIND benefit from diverse sources of support, including empathy and validation. 

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Slides and Transcript

Slide 1 of 20

In this section, I want to discuss beyond benzodiazepine discontinuation, how we can understand the life effects and support strategies for our patients.
Beyond Benzodiazepine Discontinuation: Understanding Life Effects and Support Strategies Slide 1 of 20

Slide 2 of 20

So from the benzodiazepine experience survey that I mentioned in the last section, we found that individuals that were experiencing negative effects of long-term benzodiazepine use and tapering and discontinuation endorsed a myriad of significant life effects from the symptoms they had. These included effects on pretty much every aspect of their life from impacts on their careers, losing income, losing insurance, cost of healthcare, impacts on their relationship, involvement in judicial system, other disability and mobility issues and an overall impact on confidence, self-esteem, and personality.
References:
  • Reid Finlayson, A. J., Macoubrie, J., Huff, C., Foster, D., & Martin, P. R. (2022). Experiences with benzodiazepine use, tapering, and discontinuation: An internet survey. Therapeutic Advances in Psychopharmacology, 12, 204512532210823.
  • Huff, C., Finlayson, A. J., Foster, D. E., & Martin, P. R. (2023). Enduring neurological sequelae of benzodiazepine use: An internet survey. Therapeutic Advances in Psychopharmacology, 13, 204512532211455.
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Slide 3 of 20

When asked about consequences of withdrawal, you can see that a vast majority endorsed these significant life effects of, you know, not being able to enjoy their hobbies or recreational activities, impairing their social interaction and friends, their ability to take care of home and others, their work, their ability to drive or walk.
References:
  • Reid Finlayson, A. J., Macoubrie, J., Huff, C., Foster, D., & Martin, P. R. (2022). Experiences with benzodiazepine use, tapering, and discontinuation: An internet survey. Therapeutic Advances in Psychopharmacology, 12, 204512532210823.
  • Huff, C., Finlayson, A. J., Foster, D. E., & Martin, P. R. (2023). Enduring neurological sequelae of benzodiazepine use: An internet survey. Therapeutic Advances in Psychopharmacology, 13, 204512532211455.
Beyond Benzodiazepine Discontinuation: Understanding Life Effects and Support Strategies Slide 3 of 20

Slide 4 of 20

I think of particular note is how many individuals endorse that their symptoms were so debilitating and had such a negative impact on their life that they had suicidal thoughts or attempted suicide. So 54% of the individuals, over half reported that at some point in their process of benzodiazepine use, tapering or discontinuation, they had suicidal thoughts or attempted suicide.  
References:
  • Reid Finlayson, A. J., Macoubrie, J., Huff, C., Foster, D., & Martin, P. R. (2022). Experiences with benzodiazepine use, tapering, and discontinuation: An internet survey. Therapeutic Advances in Psychopharmacology, 12, 204512532210823.
  • Huff, C., Finlayson, A. J., Foster, D. E., & Martin, P. R. (2023). Enduring neurological sequelae of benzodiazepine use: An internet survey. Therapeutic Advances in Psychopharmacology, 13, 204512532211455.
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Slide 5 of 20

So when looking at the life effect of suicidality, another study done by Dodds in 2017 reviewed 17 studies and found that benzodiazepines can be associated with increased suicide risk. The possible causes for this could be that the suicidal ideation is a side effect or withdrawal symptom contributing to intrusive thoughts about not wanting to live or taking one’s own life.
References:
  • Reid Finlayson, A. J., Macoubrie, J., Huff, C., Foster, D., & Martin, P. R. (2022). Experiences with benzodiazepine use, tapering, and discontinuation: An internet survey. Therapeutic Advances in Psychopharmacology, 12, 204512532210823.
  • Dodds T. J. (2017). Prescribed benzodiazepines and suicide risk: A review of the literature. The Primary Care Companion for CNS disorders, 19(2), 10.4088/PCC.16r02037.
Beyond Benzodiazepine Discontinuation: Understanding Life Effects and Support Strategies Slide 5 of 20

Slide 6 of 20

The individuals in the survey, over 50% said they found support online and then support from a family or friend and much smaller percentages reported getting support from psychiatrists, general practitioners, therapists, or inpatient.
References:
  • Reid Finlayson, A. J., Macoubrie, J., Huff, C., Foster, D., & Martin, P. R. (2022). Experiences with benzodiazepine use, tapering, and discontinuation: An internet survey. Therapeutic Advances in Psychopharmacology, 12, 204512532210823.
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Slide 7 of 20

Again, when thinking about the survey overall, it bears repeating that we are aware a great limitation is this is a self-selected respondent group who were already on this online support forum, Benzo Buddies, and we need more research to look at individuals across the range of benzodiazepine users to see how they are all affected and try to identify what makes some individuals more susceptible to a severe BIND than others.
References:
  • Reid Finlayson, A. J., Macoubrie, J., Huff, C., Foster, D., & Martin, P. R. (2022). Experiences with benzodiazepine use, tapering, and discontinuation: An internet survey. Therapeutic Advances in Psychopharmacology, 12, 204512532210823.
  • Benzo Buddies. (2024). Benzodiazepine Withdrawal Support. https://benzobuddies.org/
Beyond Benzodiazepine Discontinuation: Understanding Life Effects and Support Strategies Slide 7 of 20

Slide 8 of 20

However, that being said, I think it’s extremely important that all prescribers are aware that the FDA did update their black box warning in 2020 for benzodiazepines in order to highlight that there is this risk not only of severe withdrawal but a protracted withdrawal or BIND. They didn’t use the, the word BIND but, ’cause it didn’t exist yet. So based on a report that the FDA completed after reviewing reports they’d received from individuals about harm from benzodiazepine, they updated the black box warning.
References:
  • FDA. (2020, October 2). FDA expands boxed warning to improve safe use of benzodiazepine drug. U.S. Food and Drug Administration. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class
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Slide 9 of 20

The FDA review that led to the black box warning had several common themes including harm from abrupt discontinuation, harm from rapid tapers, misdiagnosis of symptoms of withdrawal and protracted withdrawal and escalating doses to try to treat symptoms that were later identified as being part of a withdrawal or protracted withdrawal.
References:
  • FDA. (2020, October 2). FDA expands boxed warning to improve safe use of benzodiazepine drug. U.S. Food and Drug Administration. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class
Beyond Benzodiazepine Discontinuation: Understanding Life Effects and Support Strategies Slide 9 of 20

Slide 10 of 20

They also found that individuals that had been harmed by long-term benzodiazepine use were rarely ever cautioned about the potential long-term consequences which again highlights the need to utilize a good informed consent process with patients about the short and long-term risks of these medications just like we should be doing with other medications.
References:
  • FDA. (2020, October 2). FDA expands boxed warning to improve safe use of benzodiazepine drug. U.S. Food and Drug Administration. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class
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Slide 11 of 20

And that the report found there was a real lack of medical support, that there was a failure to recognize physical dependence and tolerance in individuals taking these medications long term. The report also found that most people were finding their support in online support forums.
References:
  • FDA. (2020, October 2). FDA expands boxed warning to improve safe use of benzodiazepine drug. U.S. Food and Drug Administration. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class
Beyond Benzodiazepine Discontinuation: Understanding Life Effects and Support Strategies Slide 11 of 20

Slide 12 of 20

Some alternative approaches and just to touch briefly on how to best provide support to our patients, we, certainly we know that as I mentioned before cognitive behavioral therapy has evidence for helping with benzodiazepine discontinuation. Cognitive behavioral therapy for insomnia has great evidence for helping with insomnia. Finding a therapist that is educated about protracted withdrawal is great, if not providing them with resources so they can educate themselves.
References:
  • Soyka, M. (2017). Treatment of benzodiazepine dependence. New England Journal of Medicine, 376(12), 1147-1157.
  • Pottie, K., Thompson, W., Davies, S., Grenier, J., Sadowski, C. A., Welch, V., Holbrook, A., Boyd, C., Swenson, R., Ma, A., & Farrell, B. (2018). Deprescribing benzodiazepine receptor agonists: Evidence-based clinical practice guideline. Canadian Family Physician, 64(5), 339–351.
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Slide 13 of 20

As far as other alternative medicines to utilize, as we mentioned there’s not much that is evidence based and nothing that is approved. So folks will read online of a whole variety of options from supplements, vitamins or CBD, melatonin, acupuncture, massage, homeopathy, functional medicine. And really, it’s, you know, it takes a lot of trial and error, reports of what works for one person doesn’t seem to be helpful or maybe causes side effects or harms for another. So it’s really advising our patients to proceed cautiously, trying one thing at a time and doing so with a trusted practitioner.
References:
  • Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 2024. http://www.benzo.org.uk/manual/.
Beyond Benzodiazepine Discontinuation: Understanding Life Effects and Support Strategies Slide 13 of 20

Slide 14 of 20

I think the most useful thing we can do is really help provide and connect our patients to good peer support options as these are really the primary tool for ongoing support and can provide a lot of hope and validation. There’s a variety of types of groups. The ones I would most recommend are, there’s Benzo Warriors which is moderated by a group of individuals that have been affected including a psychologist and I think they do a really nice job of moderating who belongs and what is discussed in the forum.
References:
  • Benzo Warrior Resources and Support. (2024). About Benzo warrior — Benzo warrior. Benzo Warrior. https://www.benzowarrior.com/about-benzo-warrior
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Slide 15 of 20

The Benzodiazepine Action Work Group at benzoaction.org which is part of the state entity, the Colorado Consortium for Prescription Drug Abuse Prevention, has developed a peer support training program and is implementing that both within Colorado as well as now nationally. And you can find more information about that at benzopeertraining.org and that will hopefully really fill some of this gap of need for peer support that is trained and more knowledgeable about these long-term effects of benzodiazepines and benzodiazepine discontinuation.
References:
  • Benzodiazepine peer support training. (2024, January 25). Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/projects/benzo-peer-support/
Beyond Benzodiazepine Discontinuation: Understanding Life Effects and Support Strategies Slide 15 of 20

Slide 16 of 20

Other coping skills and lifestyle modifications include looking at how to manage anxiety, using acceptance, distraction, exercise, diet, sleep hygiene, meditation, yoga, and stress reduction.
References:
  • Wright, S. L. (2020). Limited utility for benzodiazepines in chronic pain management: A narrative review. Advances in Therapy, 37(6), 2604-2619.
  • Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf
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Slide 17 of 20

And my colleagues that have been individually impacted by this really reiterate that peer support and validation is often the most helpful thing we can do for our patients. And I will just call your attention that the Benzo Action Work Group does also have a peer support guidance document that you may find helpful in providing some resources for your patients.
References:
  • Benzodiazepine Action Work Group. (2022). Peer support guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Peer-Support.pdf
  • Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf
Beyond Benzodiazepine Discontinuation: Understanding Life Effects and Support Strategies Slide 17 of 20

Slide 18 of 20

So overall, the key points in this section are that benzodiazepine-induced neurological dysfunction or BIND, the protracted withdrawal syndrome from benzodiazepines can have significant negative impact on relationship and jobs. And unfortunately many individuals report suicidal thoughts or attempts as a result of suffering from BIND.
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Slide 19 of 20

In September 2020, the FDA updated the benzodiazepine black box warning based on a report that they created about the increased risk of physical dependence and protracted withdrawal from benzodiazepines and the need for better education of patients as well as a more gradual tapering.   And we should keep in mind that patients suffering from BIND benefit from diverse sources of support including empathy and validation from medical providers.
Beyond Benzodiazepine Discontinuation: Understanding Life Effects and Support Strategies Slide 19 of 20

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08. Clinical Case

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CME Information

Learning Objectives:

After completing this activity, the learner will be able to:

  1. Perform motivational interviewing techniques for effective benzodiazepine deprescribing.
  2. Develop individualized benzodiazepine tapering strategies tailored to patient needs.
  3. Recognize and manage benzodiazepine withdrawal symptoms.

Original Release Date: June 1, 2024

Expiration Date: June 1, 2027

Expert: Alexis Ritvo, M.D.

Medical Editor: Paz Badía, M.D. 

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None of the faculty, planners, and reviewers for this educational activity have relevant financial relationships to disclose during the last 24 months with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Contact Information: For questions regarding the content or access to this activity, contact us at support@psychopharmacologyinstitute.com

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Participants must complete the activity online during the valid credit period that is noted above.

Follow these steps to earn CME credit:

  1. View the required educational content provided on this course page.

  2. Complete the Post Activity Evaluation for providing the necessary feedback for continuing accreditation purposes and for the development of future activities. NOTE: Completing the Post Activity Evaluation after the quiz is required to receive the earned credit.

  3. Download your certificate.

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This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of Medical Academy LLC and the Psychopharmacology Institute. Medical Academy is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation Statement

Medical Academy designates this enduring activity for a maximum of 1.25 AMA PRA Category 1 credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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