Getting Off Xanax or Klonopin

Benzodiazepine drugs such as Xanax, Valium, Ativan, Klonopin and other compounds presents a significant challenge.  The benzodiazepines quickly reduce anxiety in a variety of anxiety disorders such as panic disorder and social anxiety disorder.  They can also be effective adjuncts to other agents in providing symptom relief.

However, these agents to have the potential to produce significant withdrawal symptoms.  The withdrawal symptoms appear to be most severe for patients who have needed higher doses for longer periods of use.  Withdrawal can also produce a rebound in the underlying anxiety disorder making discontinuation an even greater challenge.

A variety of pharmacological strategies exist for lessening withdrawal symptoms.  A switch from shorter half-life agents to longer half-life agents can reduce withdrawal.  Using a very slow protracted taper can also increase success rates.  One additional strategy is to use cognitive behavioral therapy (CBT) during withdrawal to address breakthrough anxiety symptoms.

Michael Otto and colleagues from Boston University and Harvard University have recently published research examining the effect of CBT in benzodiazepines in a series of 47 patients.  This randomized clinical trial had the following key design features:

• Primary outcome measure: successful discontinuation of benzodiazepine
• Three randomized treatments: treatment as usual, individual relaxation therapy, cognitive behavioral therapy (8 one-hour weekly sessions plus 3 booster sessions)
• Subjects: majority were women with average age of about 40 years with a diagnosis of panic disorder
• Benzodiazepine use history: 10 had taken alprazolam (Xanax) with average dose about 2.5 mg/day, 37 had taken clonazepam (Klonopin) with an average dose of about 1.2 mg
• Benzodiazepine taper schedule: gradual taper over an average of about 6 weeks (up to 9 weeks for subjects taking 6 mg of alprazolam)

Outcome for the three groups:

• CBT: 56% benzodiazepine free after intervention, 63% benzodiazepine free at 6 month follow up
• Individual relaxation therapy: 31% success after intervention, 13% success after 6 months
• Treatment as usual: 40% success after intervention, 27% success after six months

The overall effect of treatment on successful outcome was statistically significant at the 6 month follow up time period. 

The authors note that CBT during benzodiazepine discontinuation appears to have an enduring effect on patient's ability to manage both withdrawal symptoms as well as panic disorder symptoms.  CBT appears to offer specific strategies that help patients manage withdrawal above and beyond the effect of relaxation training.

This study provides evidence that the success rates for benzodiazepine discontinuation improves with concurrent CBT.  There is a need for a larger randomized trial to confirm this finding.  CBT practitioners would benefit from learning about the adaptation of this technique for this clinical population.

3D Molecular Model of Alprazolam (Xanax) from Wikipedia Commons created by Ccroberts.

Otto MW, McHugh RK, Simon NM, Farach FJ, Worthington JJ, & Pollack MH (2010). Efficacy of CBT for benzodiazepine discontinuation in patients with panic disorder: Further evaluation. Behaviour research and therapy, 48 (8), 720-7 PMID: 20546699