Kaiser Permanete's guidelines in the management of chronic BZD patients

[[Ba...]]

Lorazepam (patients aged 65 and over)

Switching to diazepam in patients aged 65 and over is not recommended, as case reports suggest that it

may be associated with delirium. For older adults, lorazepam, oxazepam, and temazepam are the safest

options because they don’t have metabolites that can accumulate. Of these, lorazepam is the best in

terms of dosing options—available as 0.5, 1, and 2 mg tabs, and as 2 mg/mL oral solution.

 

I don't believe this at all. Ativan is a VERY POTENT drug and should be discontinued slowly. It causes a great deal of anxiety.

 

Well, there are some things I just don't agree with, but someday they'll hopefully get it right...

 

A sleep dr once told me ditch the valium, take temazepam.  Maybe he was right!

 

 

Edit: Fixed quote box

[[Ms...]]

Yes, I agree, Libertas! I think it would be a good idea! How about it, MAB?

 

Otherwise doctors are going to follow this, and some of it is definitely off.

 

They're probably going to follow it either way. It's possible we can get a volunteer to respond appropriately, time permitting. We are SWAMPED and most BIC is still very sick.

[[Te...]]

Thank you so much, MAB!!

 

I'm sorry you and your colleagues are still sick :'(, but you are all doing a fantastic job and we so appreciate it!!!  :thumbsup: :thumbsup:

[[Li...]]

I join Terry38 in saying thanks to you and your colleagues at BIC.  The work you are doing is vitally important ... especially for us “taken as prescribed” folks.

[[Ba...]]

So are peopke agreeing, or not,with the over 65 don't go to valium, better on the shorter acting drugs?

I don't see clonopin mentioned....

[[Li...]]

So are peopke agreeing, or not,with the over 65 don't go to valium, better on the shorter acting drugs?

I don't see clonopin mentioned....

This is one of the issues I have with the guidelines.  What evidence is there to support this “one size fits all” recommendation?

[[Ms...]]

I join Terry38 in saying thanks to you and your colleagues at BIC.  The work you are doing is vitally important ... especially for us “taken as prescribed” folks.  If it would help, I would be willing to take a first pass at identifying points in the KP guidelines that should be clarified/modified and then seek input/feedback from other Buddies ... Terry38 will be at the top of my list.

 

sure if you want to help with this that would be great!! feel free to message me about it!

[[Lo...]]

Lorazepam (patients aged 65 and over)

Switching to diazepam in patients aged 65 and over is not recommended, as case reports suggest that it

may be associated with delirium. For older adults, lorazepam, oxazepam, and temazepam are the safest

options because they don’t have metabolites that can accumulate. Of these, lorazepam is the best in

terms of dosing options—available as 0.5, 1, and 2 mg tabs, and as 2 mg/mL oral solution.

 

I don't believe this at all. Ativan is a VERY POTENT drug and should be discontinued slowly. It causes a great deal of anxiety.

 

Well, there are some things I just don't agree with, but someday they'll hopefully get it right...

 

I don't believe  in this either. Ativan is very frequently prescribed to people over 65 years old, and it is an extremely potent benzodiazepine. It had injured many people who are/were younger than 65, so I do not see why it would somehow be "safe" in patients over 65. Ativan is not a "mother's little helper". It's a GABA-A binding hammer. It hits the brain hard and fast and makes it out for a quick exit. The feeling of it not being very strong is either just a medication spellbinding illusion or a sign of tolerance and dependence or injury from it.

[[Li...]]

sure if you want to help with this that would be great!! feel free to message me about it!

AOK. Will do.  I will read through the guidelines again to refresh my memory on the questions/issues I had before I PM.  My general take is that although there are many positives there are also some potential red flags.  I hope other Buddies will share their perspectives as well.

[[Do...]]

for those of you upset that it is saying ativan is safer for older people, they are referring to the fact that ativan will build up less in the system due to it's shorter half life.  While some of us have issue with that because of interdose withdrawal, if a person is metabolizing it slowly, having a faster acting one would help prevent this from happening.

[[si...]]

Lorazepam (patients aged 65 and over)

Switching to diazepam in patients aged 65 and over is not recommended, as case reports suggest that it

may be associated with delirium. For older adults, lorazepam, oxazepam, and temazepam are the safest

options because they don’t have metabolites that can accumulate. Of these, lorazepam is the best in

terms of dosing options—available as 0.5, 1, and 2 mg tabs, and as 2 mg/mL oral solution.

 

I don't believe this at all. Ativan is a VERY POTENT drug and should be discontinued slowly. It causes a great deal of anxiety.

 

Well, there are some things I just don't agree with, but someday they'll hopefully get it right...

 

I don't believe  in this either. Ativan is very frequently prescribed to people over 65 years old, and it is an extremely potent benzodiazepine. It had injured many people who are/were younger than 65, so I do not see why it would somehow be "safe" in patients over 65. Ativan is not a "mother's little helper". It's a GABA-A binding hammer. It hits the brain hard and fast and makes it out for a quick exit. The feeling of it not being very strong is either just a medication spellbinding illusion or a sign of tolerance and dependence or injury from it.

 

This recommendation is made by KP in the context of tapering only, crossing over slowly & dosing 2x/day (see pages 10-11 for further details).

 

sierra 

[[Li...]]

Just checking, according to the doc linked in the initial post to this thread, these guidelines are for the “Kaiser Foundation Health Plan of Washington.”  Are there other/different KP guidelines for other states and/or health plans?  If so, please share the links to same!

 

Addendum ... from the root URL (https://wa.kaiserpermanente.org):

 

About Kaiser Permanente Washington

In 2017, Kaiser Permanente acquired Group Health Cooperative and its subsidiaries, which have been caring for members in Washington since 1947. Now Kaiser Permanente Washington, we serve more than 710,170 members and support the health of communities in Northwest Washington, Central Washington, Eastern Washington, the Coastal and Olympic region, and Puget Sound.

[[Lo...]]

I do understand that what is talked about is tapering guidelines, but even when a patient is tapering, there's far more to these drugs than half-life, duration of action, accumulation, or interdose withdrawal. Ativan is a very strong anti-convulsant (it's a favorite in ER to give for seizures in IV form), much more so than diazepam. If a patient has developed full tolerance to its anti-convulsive effects, it's going to be one heck of a drug to taper from for someone over 65. If I were having so much trouble in my early 40's, how is someone going to do it when they are over 65? If diazepam is seen as undesirable in elderly, at least crossing a patient over to clonazepam seems like a more humane practice to me than trying to taper from a high potency, short-acting, strong anti-convulsant benzo such as ativan.

 

I still feel that the stigma surrounding diazepam that dates back to 1970's is still somewhat behind what's guiding a lot of these guidelines. One has to ask all the UK patients who have suffered mightily on ativan in the 1980's.

[[se...]]

I do understand that what is talked about is tapering guidelines, but even when a patient is tapering, there's far more to these drugs than half-life, duration of action, accumulation, or interdose withdrawal. Ativan is a very strong anti-convulsant (it's a favorite in ER to give for seizures in IV form), much more so than diazepam. If a patient has developed full tolerance to its anti-convulsive effects, it's going to be one heck of a drug to taper from for someone over 65. If I were having so much trouble in my early 40's, how is someone going to do it when they are over 65? If diazepam is seen as undesirable in elderly, at least crossing a patient over to clonazepam seems like a more humane practice to me than trying to taper from a high potency, short-acting, strong anti-convulsant benzo such as ativan.

 

I still feel that the stigma surrounding diazepam that dates back to 1970's is still somewhat behind what's guiding a lot of these guidelines. One has to ask all the UK patients who have suffered mightily on ativan in the 1980's.

 

Why do you think the anti convulsants effects of Ativan especially matter in this context, LF?  I get that it’s potent but I think the point is accumulation is more a factor in older adults who have more difficulty clearing longer acting benzos.

[[Lo...]]

I do understand that what is talked about is tapering guidelines, but even when a patient is tapering, there's far more to these drugs than half-life, duration of action, accumulation, or interdose withdrawal. Ativan is a very strong anti-convulsant (it's a favorite in ER to give for seizures in IV form), much more so than diazepam. If a patient has developed full tolerance to its anti-convulsive effects, it's going to be one heck of a drug to taper from for someone over 65. If I were having so much trouble in my early 40's, how is someone going to do it when they are over 65? If diazepam is seen as undesirable in elderly, at least crossing a patient over to clonazepam seems like a more humane practice to me than trying to taper from a high potency, short-acting, strong anti-convulsant benzo such as ativan.

 

I still feel that the stigma surrounding diazepam that dates back to 1970's is still somewhat behind what's guiding a lot of these guidelines. One has to ask all the UK patients who have suffered mightily on ativan in the 1980's.

 

Why do you think the anti convulsants effects of Ativan especially matter in this context, LF?  I get that it’s potent but I think the point is accumulation is more a factor in older adults who have more difficulty clearing longer acting benzos.

 

The rebound convulsive effects while tapering Ativan can cause shakiness and instability on legs, which can contribute to falls in elderly rather easily. Also, with ativan being a strong muscle relaxant, the rebound muscle issues can cause falls and unsteadiness in those over 65. The interdose withdrawal effects could cause the weakening of the leg muscles, which can make walking more difficult, also increasing the risk of falls and fractures.

[[se...]]

It would be helpful to understand that recommendation a little better with data to back it up.  A bit of an aside, I "tapered" off alprazolam in a detox with phenobarbital over 10 days and that was EASIER than the month long clonazepam taper I did over a year after that.  I had longer lasting symptoms after the CT detox compared to the clonazepam.

[[Li...]]

It would be helpful to understand that recommendation a little better with data to back it up.

 

Me too,  Seltzerer.  I also would like to see evidence regarding the recommendation to dose 2 times a day for lorazepam. Per the Benzodiazepine Information Coalition:

 

“Those who choose or are required to taper using a shorter-acting benzodiazepine may find it particularly helpful to take their dose several times per day, depending on the half life of the medication. For example, patients taking Klonopin may benefit from dosing 3-4x per day, whereas those taking Ativan may need to dose 4-5x per day.  Some patients on Xanax may require 5-6 doses per day just to maintain steady serum levels. Patients who dose at regular intervals are more likely to successfully complete a benzodiazepine taper because they do not experience severe ‘drops’ throughout the day between doses that make discontinuation intolerable. These symptoms are commonly referred to as ’interdose’ withdrawal.”

[[si...]]

It would be helpful to understand that recommendation a little better with data to back it up.

 

Me too,  Seltzerer.  I also would like to see evidence regarding the recommendation to dose 2 times a day for lorazepam. Per the Benzodiazepine Information Coalition:

 

“Those who choose or are required to taper using a shorter-acting benzodiazepine may find it particularly helpful to take their dose several times per day, depending on the half life of the medication. For example, patients taking Klonopin may benefit from dosing 3-4x per day, whereas those taking Ativan may need to dose 4-5x per day.  Some patients on Xanax may require 5-6 doses per day just to maintain steady serum levels. Patients who dose at regular intervals are more likely to successfully complete a benzodiazepine taper because they do not experience severe ‘drops’ throughout the day between doses that make discontinuation intolerable. These symptoms are commonly referred to as ’interdose’ withdrawal.”

 

That's a really important point.  In my experience tapering Ativan, I've found dosing 4x/day provides me the necessary cover from interdose withdrawals.  Perhaps their thinking was metabolism slows down with age, so less frequent dosing is possible?  I agree that it would be good to know the details as to how this recommendation was concluded. 

 

It's encouraging though that KP endorses patient led tapering, "Tapering should be guided by individual choice and severity of withdrawal symptoms. Drug discontinuation may take 3 months to a year or longer. Some people may be able to discontinue the drug in less time." (pg. 10)

 

sierra 

[[Li...]]

Just checking, according to the doc linked in the initial post to this thread, these guidelines are for the “Kaiser Foundation Health Plan of Washington.”  Are there other/different KP guidelines for other states and/or health plans?  If so, please share the links to same!

 

Addendum ... from the root URL (https://wa.kaiserpermanente.org):

 

About Kaiser Permanente Washington

In 2017, Kaiser Permanente acquired Group Health Cooperative and its subsidiaries, which have been caring for members in Washington since 1947. Now Kaiser Permanente Washington, we serve more than 710,170 members and support the health of communities in Northwest Washington, Central Washington, Eastern Washington, the Coastal and Olympic region, and Puget Sound.

Just checking one more time ... has anyone found guidelines for other Kaiser Permanente entities in other states or at the national level?

[[Lo...]]

It would be helpful to understand that recommendation a little better with data to back it up.

 

Me too,  Seltzerer.  I also would like to see evidence regarding the recommendation to dose 2 times a day for lorazepam. Per the Benzodiazepine Information Coalition:

 

“Those who choose or are required to taper using a shorter-acting benzodiazepine may find it particularly helpful to take their dose several times per day, depending on the half life of the medication. For example, patients taking Klonopin may benefit from dosing 3-4x per day, whereas those taking Ativan may need to dose 4-5x per day.  Some patients on Xanax may require 5-6 doses per day just to maintain steady serum levels. Patients who dose at regular intervals are more likely to successfully complete a benzodiazepine taper because they do not experience severe ‘drops’ throughout the day between doses that make discontinuation intolerable. These symptoms are commonly referred to as ’interdose’ withdrawal.”

 

That's a really important point.  In my experience tapering Ativan, I've found dosing 4x/day provides me the necessary cover from interdose withdrawals.  Perhaps their thinking was metabolism slows down with age, so less frequent dosing is possible?  I agree that it would be good to know the details as to how this recommendation was concluded. 

 

It's encouraging though that KP endorses patient led tapering, "Tapering should be guided by individual choice and severity of withdrawal symptoms. Drug discontinuation may take 3 months to a year or longer. Some people may be able to discontinue the drug in less time." (pg. 10)

 

sierra 

 

At one point, I had to dose ativan 5x a day, as that was the only way I could have survived. I wish I had not attempted the crossover to valium and had switched to klonopin instead. It would have saved me from a lot of harmful stigma (valium stigma, being on 2 benzos stigma), which actually made me feel even worse when all I needed was support. But , if it were not for valium and if Ativan was all I had, I would have probably had to maintain 4x or 5x dosing to survive taper.

 

In my personal experience, any sort of dosing that was more than 2x a day made my doctors very alarmed, except for my original prescriber of ativan who wrote I could take it up to x4 times a day.

 

The only thing I can say is that my impression I got from the doctors that treated me/treat me is that there was/is this belief that these medications offered me a much more steady state relief than they really did. I don't know where this is coming from, but that's the belief I am up against. The belief that a patient can be on 2x dosing for a long time and taper like that just fine. If anyone can chime in and voice their thoughts where that belief comes from, I'd be very interested.

[[Te...]]

I don't think you would have liked Klonopin, Loraz. It is a very strong drug and the cognitive effects are far worse, I think, than on Valium. Most people seem to have problems exercising as well, even lasting for years. As I said before, most of the people in protracted were on Klonopin, Ativan, and Xanax. Very few on Valium.

[[Lo...]]

Yes. it seems to me that some of the weaker benzodiazepines are either not being prescribed, or people are just not having problems with them. I'd seen very few people here have problems with Serax or Tranxene or Librium as an original drug. Most seem to struggle with Ativan, Xanax and Klonopin. Why start people with the heaviest tranquilizers out there? Makes no sense. It feels like doctor-enabled drug dependence to go and prescribe the most potent benzos right off the bat. The surrogate parent whips out a script and prescribes the most powerful, most mind-bending benzos of them all. And then the patient gets so much blame in the end.

 

Wish I'd gone to a CoDA meeting instead of taking those wretched pills.

 

 

[[Te...]]

I know, I have TONS of regret, too, Loraz!  :'(

[[to...]]

Kaiser Permanete's guidelines in the management of chronic BZD patients is a good start

but they are seriously misinformed on this point below (or purposely "not going there")

 

I think they are covering their ass as prescribers.

 

https://wa.kaiserpermanente.org/static/pdf/public/guidelines/benzo-zdrug.pdf

 

5.

Is there an association between benzodiazepine or Z-drug use in adults with insomnia

with or without anxiety and other comorbid conditions —and the risk of suicide?

 

There is insufficient evidence to determine whether the use of BZDs or Z-drugs increases

the risk of suicide among patients using the drugs to treat insomnia and/or anxiety.

 

 

http://w-bad.org/suicide/

 

It is important to note that some of the patients who have chronic depression, who feel suicidal or who attempt suicide while taking the benzodiazepines long-term, are completely unaware that the benzodiazepines are the actual cause. Sometimes they seek medical help because they feel so bad and are drugged further with more dependence- and withdrawal-causing psychotropic drugs, further compounding the problem. They are often misdiagnosed as having “refractory depression” when the real, true cause of their emotional distress is the benzodiazepine drug they’ve been prescribed.

 

Often times, ill-educated medical professionals will compound this issue by denying that the drugs are capable of causing the depression or by reinforcing to the patient that it’s their so-called “mental illness” (and not the BZ drug) causing depression and that that is a sign that they “need the drugs for life”. If the patient then tries to withdraw from the BZ (usually too quickly, due to personal or prescriber ignorance of the guidelines on how to properly and slowly withdraw) and their depression worsens or withdrawal symptoms emerge, patients are sometimes told by medical professionals that it’s “not withdrawal” and that the symptoms they noticed are “the underlying illness reoccurring” (this happens even in patients who didn’t have an underlying psychiatric illness prior to taking the BZs!).

 

The tip of the iatrogenic benzodiazepine iceberg

 

https://www.kevinmd.com/blog/2019/03/the-tip-of-the-iatrogenic-benzodiazepine-iceberg.html

 

Those of us involved in benzodiazepine safety and awareness efforts frequently find ourselves exasperated. The nature of our work leaves us surrounded by endless desperation, enduring suffering (in addition to our own) and countless suicides — all directly resulting from benzodiazepine misprescribing (>2-4 weeks, without informed consent about the real risks for physical dependence and withdrawal) and careless withdrawal practices (advising or forcing discontinuation much faster than is recommended or tolerated, setting patients up for severe and protracted syndromes)

 

 

[[Ja...]]

I have Kaiser insurance. My Pdoc didn't follow the guideline of only prescribing short term (up to two weeks) and not using benzos for insomnia. He prescribed me 1mg per night for insomnia for years. He also prescribed me 3mg per day for over a month when my anxiety was ramping up. I wish he DID follow these guidelines and kept me out of this mess in the first place....

 

He is, however, NOW following the tapering guidelines and allowing me to DLMT slowly. I'll bet he won't prescribe benzos the way he did for me with future patients. I told him I was angry he never warned me of dependence risk, etc.