Medication

The chances of success are improved when a person’s physical and psychological health and personal circumstances are stable.

Withdrawal effects can emerge while patients are taking medication due to the process of tolerance (sometimes called ‘tolerance withdrawal’), most often seen with short-­ acting ben-
zodiazepines (often observed as inter-­ dose withdrawal)….inter-­ dose withdrawal can be improved by more frequent dosing.

In 2020 the FDA updated the boxed warning on all marketed benzodiazepines to re-­ emphasise the risk of physical dependence,addiction and withdrawal effects, including the warning that withdrawal syndromes could persist for more than 12 months after stopping.
It is estimated that up to 15% of patients who stop long-­ term benzodiazepines will
experience a protracted withdrawal syndrome, which can last months and sometimes
years.
Short-­ acting benzodiazepines are associated with more severe acute withdrawal
symptoms on discontinuation than longer-­ acting drugs such as diazepam

In order to reduce benzodiazepine effects at their major target by equal amounts,hyperbolically reducing doses are required
A hyperbolic pattern of reduction means that the size of dose reductions should become smaller and smaller as the total dose reduces. Final doses before complete cessation will sometimes need to be very small.
Patients often report that 10% reductions (calculated on the last dose, so that they become increasingly small) or less every 2–4 weeks are tolerable

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Lorazepam
The manufacturer in the UK states that the duration of treatment should not be longer than 4 weeks, and in the USA the manufacturer recommends that duration of treatment should be limited to the ‘minimum required’
Half-­ life: The mean half-­ life is 12 hours and there are no major active metabolites.3 The
manufacturer recommends lorazepam to be given 2–3 times a day in divided doses.
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Withdrawal Symptoms
Psychological symptoms (like anxiety or panic attacks) that emerge after stopping the medication that were not present before taking medication (or are much greater in severity) are likely to
be withdrawal symptoms

Physical symptoms of withdrawal are more distinctive. Benzodiazepines have muscle
relaxant effects in the short term; conversely on cessation stiffness, muscle spasm, fas-
ciculations, rigidity and trembling can be experienced.

Benzodiazepine withdrawal also involves a number of sensory symptoms…. changes to vision, sound, taste, touch and smell. This can involve severe and sometimes intolerable sensory hypersensitivity, tinnitus, photophobia and dysosmia.

Increased sensitivity can also lead to pain, with allodynia and hyperaesthesia recognised: this can include shooting, twisting, burning and searing pains.

Effects on cognition can range from impaired memory and concentration, that can
impair decision making, to delirium and profound sedation, especially in older patients

One of the most distressing consequence of benzodiazepine withdrawal is akathisia, a
neuropsychiatric condition characterised by severe agitation,restlessness and a sense of terror.

Withdrawal symptoms persisting beyond 6–8 weeks are variously called protracted, prolonged or persistent or termed the ‘post-­ acute withdrawal syndrome’ (PAWS).
The FDA highlighted the following symptoms of protracted withdrawal:
■ anxiety,
■ cognitive impairment,
■ depression,
■ insomnia,
■ formication,
■ motor symptoms (e.g. weakness, tremor, muscle twitches),
■ paraesthesia, and
■ tinnitus.