It is posted here to educate viewers about safe tapering. It answers many questions about why to taper slowly, how to taper slowly, and when to slow down even more. Full text, with notes and bibliography, here.
Your Drug May Be Your Problem
Chapter 8: How to Stop Taking Psychiatric Drugs
You may feel in a rush to stop taking psychiatric drugs. Perhaps you are experiencing distressing side effects or feel "fed up" with being sluggish and emotionally numb. Beware! It's not a good idea to abruptly stop taking drugs without first making sure that there's no danger involved in doing so. In our opinion, it is almost always better to err in the direction of going too slowly rather than too quickly. In rare cases, the development of a severe adverse reaction may require an immediate withdrawal; but if you are having a serious drug reaction, you should seek help from an experienced clinician.
Once you have begun to withdraw from psychiatric drugs, don't let anyone—not even your doctor—rush you. Especially if there's a chance that you are going too fast, pay careful attention to how you feel physically, emotionally, and spiritually. At the same time, however, you should take into account the warnings of professionals, family members, or friends who believe that withdrawal is causing you more problems than you realize. You may not be the best judge of your emotional condition as you come off drugs, so you should take into consideration the concerns of people you trust.
Gradual Withdrawal Is Its Own Protection
When people take psychiatric drugs, their decision-making faculties may function less effectively. Their feelings are numbed. At these times, if their thinking were expressed in words, it would likely communicate indecision, apathy, or confusion. Or they may experience different feelings in rapid succession, almost as if they were out of control. Because people generally want to think more clearly, to "feel fully" again, and to be more in control of themselves, they are motivated to stop taking psychiatric drugs.
Coming off drugs gradually helps to "contain" the emotional and intellectual roller-coaster that sometimes accompanies withdrawal. Indeed, a slow, gradual tapering serves as a discipline upon the withdrawal process. This discipline is backed by available knowledge and sound clinical experience. In the absence of a trusted friend or ally to provide feedback on your progress, in the absence of a support network, gradual withdrawal is likely to be the wisest strategy—especially if you are unsure as to how quickly you should proceed. Even if a medical doctor or other health professional is assisting you or monitoring your withdrawal, a gradual taper is usually the safest strategy.
Why Gradual Withdrawal Is Better Than Sudden Withdrawal
The minute a psychiatric drug enters your bloodstream, your brain activates mechanisms to compensate for the drug's impact.1 These compensatory mechanisms become entrenched after operating continuously in response to the drug. If the drug is rapidly removed, they do not suddenly disappear. On the contrary, they have free rein for some time. Typically, these compensatory mechanisms cause physical, cognitive, and emotional disturbances—which are collectively referred to as the withdrawal syndrome.
The simplest way to reduce the intensity of withdrawal reactions is to taper doses gradually, in small increments. This way, you are giving your brain appropriate "time" and "space" to regain normal functioning. Unless it is clearly established that you are suffering an acute, dangerous drug-induced toxic reaction, you should proceed with a slow, gradual withdrawal. The longer the withdrawal period, the more chances you have to minimize the intensity of the expected withdrawal reactions.
Interestingly, there is some evidence that "gradual discontinuation tends to shorten the course of any withdrawal syndrome."2 In other words, the actual duration of all expected symptoms from drug withdrawal is likely to be shorter if you withdraw slowly than if you withdraw abruptly.
In one early study of withdrawal from tricyclic antidepressants, 62 percent of those withdrawn in less than two weeks experienced withdrawal reactions, compared to only 17 percent of those withdrawn over a longer period.3 Because unpleasant withdrawal reactions are one of the main reasons you might be tempted to abort your withdrawal, a gradual taper increases your chances of succeeding and remaining drug-free.
In addition, it appears that people who gradually reduce their drug intake find a renewed vigor and energy that they now can learn to reinvest. In contrast to a sudden, unplanned cessation, a gradual withdrawal allows them to find constructive ways to use this energy, to appreciate the new confidence in their abilities that they will develop, and to consoli¬date the new emotional and behavioral patterns that will be learned in the process.
One published account describes the case of a woman who wanted to stop Paxil after taking 20 mg daily for six months. Her doctor abruptly cut this dose in half, to 10 mg daily, and gave her the new dose for one month. Then, during the following two weeks, he gave her 10 mg every other day. On alternate, nondrug days, the woman experienced severe headaches, severe nausea, dizziness and vertigo, dry mouth, and lethargy. The dose was reduced to 5 mg daily but, convinced that this only prolonged her agony, she stopped abruptly. She is reported to have experienced two weeks of various withdrawal symptoms and then to have fully recovered.4
A more gradual taper, rather than an abrupt 50 percent reduction at the start, might have reduced the severity of this woman's overall withdrawal reactions. Granted, many users of psychiatric drugs do cease them suddenly, without experiencing any significant withdrawal pains. Our experience, however, suggests to us that abrupt withdrawal is chosen by people who are not properly informed or supervised, who cannot tolerate their drug-induced dysfunctions any longer, or who act impulsively because they perceive that no one is listening to them or understanding their suffering.
Remove Drugs One at a Time
Many people, perhaps yourself among them, take several psychiatric drugs simultaneously. Common psychiatric drug combinations include an antidepressant and a tranquilizer; a stimulant and a tranquilizer; lithium and an anticonvulsant; or a neuroleptic, an antiparkinsonian, and a tranquilizer.
You can withdraw from several drugs simultaneously, but this is a risky strategy. It should be reserved for cases of acute, serious toxicity. In addition, since drugs taken together (such as neuroleptics and antiparkinsonians) often have some similar effects, withdrawing them together can make withdrawal reactions worse. If you intend to withdraw simultaneously from two or more drugs, you should do so under the active supervision of an experienced physician or pharmacist.
When you take two drugs, your brain tries to compensate not only for the effects of each one separately but also for the effects of their interaction. The physical picture gets even more complicated with each additional drug. The increasing complexity goes far beyond our actual understanding, creating unknown and unpredictable risks during both drug use and withdrawal. In cases of multidrug use, withdrawal is like trying to unravel a thick knot composed of many different strings—without cutting or damaging any of the strings. In this analogous situation, you would have to proceed quite carefully indeed, gradually disentangling one string and continually adjusting the others in response to the ongoing progress.
It is usually best to reduce one drug while continuing to take the others. The process begins anew once you've eliminated the first drug completely and have gotten used to doing without it.
Which Drug Should Be Stopped First?
If you want to get off more than one drug, there are some considerations in deciding which drug to stop first. Let's say you're taking drug "A" to counteract the side effects of drug "B"; in this case, you should probably start withdrawal with drug "B." For example, if you're taking a sleeping pill for insomnia caused by Prozac or Ritalin, you may want to delay withdrawal from the sleeping pill until you have begun to reduce the Prozac or Ritalin. Similarly, if you're taking Cogentin or Artane or some other drug to suppress movement disorders caused by neuroleptics, you should probably first reduce your neuroleptic before you attempt to withdraw from the Cogentin or Artane.
Because benzodiazepine tranquilizers often provoke unpleasant, lengthy, and potentially dangerous withdrawal reactions, some people choose to withdraw from their use last, after they've experienced withdrawal from other drugs and strengthened their resolve and gained confidence.
The 10 Percent Method
Pharmacy textbooks often describe the 10 percent withdrawal method, especially with regard to benzodiazepine tranquilizers. It may be applied to any psychiatric drug. If you wish to stop taking psychiatric drugs, the 10 percent method (or variations on it) can be a good starting point.
This method generally stipulates that withdrawal be carried out in approximately ten steps, or 10 percent at a time. Sometimes, the very last step is itself divided into a series of smaller steps. The duration of each step may vary from a few days to several weeks or months. Thus, if an individual stops a decade-long use of tranquilizers or neuroleptics, each step could sensibly last two or three months, barring any major difficulties. Many older persons have been taking tranquilizers daily for over twenty years. In these cases, a withdrawal period of two years is not unusual.
The 10 percent method is not absolute. It should be adapted to individual situations and changing circumstances. As we mentioned, withdrawal needs to be sensitive to each individual's developing situation as the process unfolds. Overall, however, the 10 percent method provides three benefits: (1) an easily applied schedule; (2) the sensible suggestion that it is best to stay roughly within such decrements, even if the first steps turn out to be uncomplicated; and (3) in cases where withdrawal difficulties manifest themselves after most of the dose has been reduced,5 a framework in which the individual can avoid compounding such difficulties by not rushing through the remaining steps of withdrawal.
As noted, this method suggests that 10 percent of the initial dose be removed at each step. Thus, a person taking 200 mg of a drug would re¬duce it by 20 mg (10 percent of 200) at each step of the withdrawal.
Seven to ten days is a reasonable length for each step if the duration of drug use has not exceeded one year.
- The first step involves going from 200 mg to 180 mg and taking the latter dose for seven to ten days.
- The second step involves going from 180 mg to 160 mg, and again staying on this dose for seven to ten days.
The other steps are similar, involving a 10 percent reduction until you are down to 0 mg. However, the very last step may be the most difficult, even if the original amount of the drug has now been reduced by 80 percent or more. In that case, you could reduce the remaining quantity itself gradually. You could progress, say, by 25 percent decrements, over two weeks or more. This would mean, in our example, going from 20 mg to 15 mg, then to 10 mg, then to 5 mg, then to zero. (As described in Chapter 7, some people benefit from prolonged use of tiny doses during the last phase of withdrawal.) Each substep could last four or five days, or more, based on your ongoing assessment of your progress—ideally, validated by feedback from your doctor and from trusted friends or relatives.
How to Divide Dose Reductions During the Day
Perhaps you are taking drugs in divided doses throughout the day. For instance, you might be taking a dose in the morning, at noon, and before bedtime. One way to reduce this kind of intake is to use the 10 percent method to progressively decrease the morning doses until these are eliminated; then move on in a similar manner to the noon doses and, ultimately, to the evening doses.
Alternatively, you could reduce the morning dose during the first step of the 10 percent method, then reduce the noon dose during the second step, then reduce the evening dose during the third step. Once this cycle was finished, you would begin the fourth step with a further reduction of the morning dose, and so on, until the withdrawal is completed.
Sometimes there will be obvious reasons to choose the morning or evening dose as the first one to reduce. When taking tranquilizers such as Xanax or Klonopin, for example, many people find that they awaken in the morning in a state of anxiety or agitation due to withdrawal from the previous evening dose. Therefore, they may feel more comfortable beginning with a reduction of the afternoon dose. Others may find that they become excessively sleepy in the afternoon. They might want to begin by reducing that dose. Still others may be concerned about difficulty sleeping if they stop the evening dose of a tranquilizer. In that case, they would be wise to begin reducing a dose that is given earlier in the day.
There are no hard and fast rules about which doses to reduce first. In general, however, you should consider initially reducing the dose that's causing the most side effects, such as the afternoon dose that makes you too sleepy. Conversely, you may want to initially keep the dose that seems to be helping you the most, such as the evening dose if you have insomnia.
How to Fraction Individual Doses
To follow the above steps, you may have to use smaller doses than those written on your prescription. Psychiatric drugs usually come in pills of varying doses, such as 200, 100, 75, 50, and 20 mg. You can request that your pharmacist provide you with pills of different strengths when you are filling your prescription, or help you determine which combinations of existing pill strengths you should use to decrease the dose by as close to 10 percent as possible. Most pills have a slit that allows them to be divided in half easily; you can also purchase a device for cutting pills, which is available at many pharmacies. Capsules, too, can sometimes be opened and their contents divided up. Your pharmacist can inform you about any problems involved in dividing your pills or the contents of your capsules. You should also discuss this process with your doctor.
* * *
In sum, the actual process of reducing your drug intake is not inherently complicated. For a prudent, minimal-risk withdrawal, it's a good idea, first, to adapt the withdrawal to your unique circumstances, both psychological and physical. Second, it's a good idea to proceed gradually— for example, by 10 percent reductions every seven to ten days or longer—depending on how long you've been taking drugs. Third, if you're taking several drugs simultaneously, it's best to remove one at a time, again in a gradual manner.