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Now Available: Maudsley Deprescribing Guidelines


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The first edition of The Maudsley Deprescribing Guidelines for Antidepressants, Benzodiazepines, Gabapentinoids, and Z-drugs is now available! Discover more about this crucial work, including details on ordering your copy and our suggestions on how to help ensure broader access to this important resource. BIC's medical director, Christy Huff, MD, and our Medical Advisory Board member, Nicole Lamberson, PA, played key roles as contributors, offering their knowledge and guidance. Learn how to order and our ideas for spreading the word about this important guideline on our blog here

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A clarification for our US members …

As of the day/time of this post, the print edition of The Maudsley Deprescribing Guidelines has not been released in the US and is not available via Amazon.  However, the Kindle (electronic) version is available from Amazon for $49.00.  Here’s the table of contents for Chapters 1 and 3 (Chapter 2 covers antidepressants, Chapter 4 covers gabapentinoids):

Chapter 1 Introduction to Deprescribing Psychiatric Medications 
Deprescribing as an intervention 
The context for deprescribing
Why deprescribe?
Barriers and facilitators to deprescribing
Withdrawal Effects from Psychiatric Medications
Mis-diagnosis of withdrawal effects as relapse
Pathophysiology of psychiatric drug withdrawal symptoms
Clinical aspects of psychiatric drug withdrawal
Specific issues in psychiatric drug withdrawal
How to Deprescribe Psychiatric Medications Safely
The neurobiology of tapering
Practical options for prescribing gradually tapering doses
Psychological aspects of tapering
Tapering psychiatric drugs in practice
Further topics

Chapter 3 Safe Deprescribing of Benzodiazepines and Z-drugs
When and Why to Stop Benzodiazepines and Z-drugs
Discussing deprescribing benzodiazepines and z-drugs
Withdrawal Symptoms from Benzodiazepines and Z-drugs
Physical dependence vs addiction in use of benzodiazepines and z-drugs
Pathophysiology of benzodiazepine withdrawal syndrome
Variety of withdrawal symptoms from benzodiazepines and z-drugs
Protracted benzodiazepine withdrawal syndrome
Distinguishing benzodiazepine withdrawal symptoms from return of an underlying condition
Withdrawal symptoms during benzodiazepine maintenance treatment
How to Deprescribe Benzodiazepines and Z-drugs Safely
Tapering benzodiazepines and z-drugs gradually
Hyperbolic tapering of benzodiazepines and z-drugs
Switching to longer-acting benzodiazepines to taper
Making up smaller doses of benzodiazepines and z-drugs practically
Other considerations in tapering benzodiazepines and z-drugs
Psychological aspects of tapering benzodiazepines and z-drugs
Tapering benzodiazepines and z-drugs in practice
Management of complications of benzodiazepine and z-drug discontinuation
Tapering Guidance for Specific Benzodiazepines and Z-drugs

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Good news!  Amazon has just updated the US release information for the print version.  It’s changed from ‘not released’ to:

“This title will be released on February 21, 2024.”

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[98...]

Thanks for posting this @[Li...]

Mark Horowitz was on THE PROJECT (TV) Australia last night bringing everything into the light. 

I was just saying to @[Sc...] that his column in the Guardian newspaper drew 300 emails from people asking for help tapering their medications, and of those 300, 6 were psychiatrists themselves asking for help tapering off their own medications.

He told the show that he was provided absolutely no information in deprescribing these medications in his training, hence the emails from other psychiatrists asking for guidance with their own personal medication issues. 

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[98...]

I should clarify… that was 300 emails he received immediately after the BBC documentary aired mid last year. 

I’ve been advised that all this information is on his website, so most members will most likely already be aware of all of this. 

Though, I was very pleased to see him airing at prime time on a very popular show in Australia 

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That's great but why have all these psychiatrists not been using the Ashton Manual all these years, available since the 90's. And if these psychiatrists didn't know about it then the GP's definitely don't know

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Are you considering buying the book, guys? It seems to be a massive source of knowledge on the "medication injury" topic. It really fills a gap, I mean, there are very important topics here. 

Will you purchase it? I am seriously considering... 

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[98...]
31 minutes ago, [[W...] said:

That's great but why have all these psychiatrists not been using the Ashton Manual all these years, available since the 90's. And if these psychiatrists didn't know about it then the GP's definitely don't know

Most have never even heard of The Ashton Manual @[WU...]

I know! It’s staggering! 

 

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Hello @[Re...].  I pre-ordered the print version back when the book was first announced!  

My understanding is that the book contains the unique binding curves (i.e. graphs showing the relationship between receptor occupancy and drug dose) for each of the benzodiazepines addressed. My thinking is that these graphical representations would be easier to view in print vs the small, relatively low-resolution screen of my Kindle.  Also, as I’m sure you know, we don’t really own the ebooks we purchase from retailers like Amazon but rather license them. 

I also plan to order print copies for my prescriber and primary care physician. 

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Oh I absolutely agree @[Li...], books are way better to have "physically" in general , I enjoy them very much! 

Thank you so much for bringing my attention to the digital version, that skipped my mind for a second 😊👍

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@[Li...] "graphs showing the relationship between receptor occupancy and drug dose"

Can you explain to a simpleton what the above means please?  

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@[WU...]At a given dose of medication, for example 0.25 mgs of alprazolam (or whatever benzo, SSRIs or SNRIs) what percentage of the receptors are bound to the medication.

What is interesting about psychiatric drugs, is that quite low dosages bind to reasonable amount of receptors already (in this case some 30-40 %, but maybe my memory is false). 

So even at small dosages quite a lot of receptors are "filled" with medication. This is causing misconception about "small doses" and that is why tapering at lower doses becomes especially difficult. 

(There are certain imaging procedures to detect this binding). 

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Thanks @[Re...]  It is hard to grasp exactly what is going on. And can they tell which receptors are affected i.e. why are only some GABA receptors affected and others aren't?

I seem to remember in Mark Horowitz's interview with Angie Peacock he talked about how cutting from high doses was fairly straightforward and only became more difficult when it got down to the lower doses. It is quite a fascinating subject if it wasn't so painful! 

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46 minutes ago, [[W...] said:

"graphs showing the relationship between receptor occupancy and drug dose"

Can you explain to a simpleton what the above means please?  

@[WU...] Figure A in the image below shows the binding curve for the antipsychotic haloperidol (binding curves for the benzodiazepines are also hyperbolic). 

The-effect-of-linear-or-hyperbolic-reduc

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Thanks @[Li...] I'm afraid those graphs mean absolutely nothing to my frazzled brain ! Does it mean that  the damage is being done at a lower dose and that higher doses don't really make any difference?

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@[WU...] 

The graphs I shared upthread show the relationship between the dose of the drug (given on the horizontal axis) and the percent of receptors occupied by the drug (given on the vertical axis).  

The resulting binding curve is in the shape of a hyperbola. It is steep at the beginning when the dose is low and then flattens out and becomes almost horizontal at the top when the dose is high.

Look at Graphs B and C.

At a high dose of 6mg haloperidol, about 80% of the receptors are occupied.  At 4mg, the percent of receptors occupied is about the same (80%).  In other words, a 2mg change in dose at higher doses of this drug does not produce much change in receptor occupancy. 

However, at the lower doses, small changes in dose produce large changes in receptor occupancy.  For example, at 1mg approximately 55% of the receptors are occupied. At 0.5mg, 40% of receptors are occupied. At around 0.18mg, 20% of the receptors are occupied.

What Horowitz and other clinicians/researchers (e.g. Gøtzsche, Sørensen) advocate is that the withdrawal process should follow the shape of the binding curve for the drug being tapered.  For example, individuals who are taking a high dose of a drug may be able to make larger reductions in dose at the start of a taper when the effect on receptor occupancy is small. However, when they reach lower doses (i.e. the steep part of the hyperbolic binding curve), they would be wise to follow the principle of ‘Go slow when you get low.’

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Thanks for the explanation @[Li...]  So it looks like even taking higher doses doesn't result in more than 80% occupancy, is that right? 

Do you know where I can find the graph for diazepam? It is a bit academic for me now as I went CT but it would still be interesting. 

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You’re welcome @[WU...].  The basic principle is that binding curves reach a plateau where an increase in dose has minimal impact on receptor occupancy.  My understanding is that the book includes the binding curve for diazepam.  If memory serves, Horowitz shared a slide with the curve in his interview with Angie Peacock as well as his interview with Benzo Warriors.

 

 

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Ah thanks again @[Li...] I will go back and check that interview on YT. It is very interesting that the body doesn't allow more than 80% occupancy so we must have an innate protection mechanism

 

P.S. Just checked the interview and it only shows the graph for anti-depressants. 

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58 minutes ago, [[W...] said:

It is very interesting that the body doesn't allow more than 80% occupancy so we must have an innate protection mechanism

Hmm …. are you aware of research that supports this conjecture, @[WU...]?  If so, I’d be interested in reading it. 

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Thank you for this information. Please help me with this question. If I’m down to 1mg of Klonopin, what cut amount and frequency would you recommend. I’d like to safely finish this taper off with as little discomfort as possible..Sincerely!

Rich

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@[Ri...] Hello! 😊 Please do start your own thread under Benzodiazepine Taper Strategies. 

I see you are down to 1 mg, that is a huge accomplishment, congratulations! As this thread reflects, you are getting lower in your dose, so the right planning in your reduction will make it a lot easier. 

I did not follow this, sadly. 

Here is where to post :

https://benzobuddies.org/forum/120-benzodiazepine-taper-strategies/

:mybuddy:

 

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@[Li...] I was just going by the graph showing the occupancy level plateauing at 80%, at least for this drug anyway. Which is why I would like to see the graph for diazepam.

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