Tranquilliser withdrawal

People have looked to alternative medicine, herbal remedies, homoeopathy, acupuncture and hypnotherapy, and other therapies as alternatives to tranquillisers to help them withdraw. These may be valid and useful in their way but they are not all that is required. Switching to an alternative therapy fails to pay proper attention to physical dependence. A pharmacological understanding of tranquilliser withdrawal is also required. 

Clients who describe having seen psychiatrists, psychologists, and other professionals in the past, and have found it useful, may be involved in a longer process of more fundamental change of which tranquilliser withdrawal is a part. Sometimes the client is aware of needing something more man a short-term withdrawal course. Statements which indicate that the client is aware of some personal issue, such as relationship difficulties or other dependencies, that they need to look at in order to come off tranquillisers are also an indication that more than a short course is appropriate. If a short... 

We have had clients who have previously withdrawn too abruptly and sought help in desperation for acute depression or other severe symptoms. The syndrome may be difficult to recognise if the client does not connect her symptoms with abrupt tranquilliser withdrawal. Alternative medication for symptomatic relief may confirm the client s and her family s fears that she is going mad or is about to die. 

WITHDRAW Project (1986) Aspects of Withdrawal from Benzodiazepines— A guide for those who work with tranquilliser withdrawal, WITHDRAW Project, North Birmingham Health Authority. 

With the use of major tranquillisers, for example, thioridazine, chlorpromazine, or perphenazine, it is possible to withdraw opiate dependents who are highly motivated. The dosages can be titrated to the degree of clinical symptoms and this can be monitored with key carers through an out-patient clinic. The use of hypnotics should be restricted to short-term use due to their own dependency problems, but they can be a useful addition, particularly in the early phases of the treatment programme. 

It is for those already dependent on tranquillisers, for a few weeks or over twenty-five years, that attention is now being directed towards finding a safe effective way to help those who wish to withdraw. Increasingly it is being recognised that tranquillisers were only ever of use as a temporary measure of symptomatic relief (Committee on the Review of Medicines 1980). Those who withdraw from them may also require further help to deal with psychosocial problems, of which anxiety was an indication. 

We have found that people who have withdrawn from tranquillisers may report that they are still experiencing the withdrawal syndrome months or even years after they have stopped taking tranquillisers. It is both puzzling and frustrating when they continue to request help from their doctors and others for unspecific symptoms which appear to resist treatment ... 

WITHDRAW Teaching Pack currently being prepared for publication. Throughout, the client is referred to as she as the majority of tranquilliser clients are women. The worker is referred to as he for balance it may be understood that in both cases men and women are included. 

The advantage of an integrated approach is that it deals with all aspects of withdrawal from the start. It must clearly be better practice to consider the frequently described forms of agoraphobia, for example, in conjunction with withdrawal, rather than leaving the client drug free but afraid to leave the home alone. In withdrawing from tranquillisers the client has an implicit hope that the quality of life will improve. 

The WITHDRAW Project was established to offer a clinical psychological service to people who wanted to withdraw from tranquillisers. It is unique in that it has a research study running parallel with it which allows for the research findings to influence the development of the clinical service and for clinical impressions to be investigated by research. It aims to identify those people who may successfully withdraw from tranquillisers, to assess the severity of the psychological problems before and after treatment, and to evaluate the WITHDRAW three-tier model of intervention. 

The first option for treatment is one of information and advice only. For some clients who prefer to withdraw on their own, advice, written material, and support either through telephone counselling or one to two appointments may be all they require. Clients who may benefit from this level of treatment may (a) not have been taking tranquillisers for very long, (b) have received other help from elsewhere, or (c) have almost completed withdrawal. 

A third possibility may be to offer one or two individual sessions following the course to discuss issues which have arisen for the client as a result of her withdrawal from tranquillisers. It may also be helpful for clients who are looking for their next step to have a chance to discuss with the worker additional treatment or a referral elsewhere. 

Although withdrawal from tranquillisers is the main aim of people attending groups, the approach adopted is to focus on theissues underlying and maintaining tranquilliser use. Each session deals with a separate topic, and by the end of the... 

The third option of a longer-term group is reserved for those who need more than the first two levels. Clients may have all the facts and information needed on how to withdraw may understand what they can do instead of taking tranquillisers they may even have the skills, and yet still fail to give up tranquillisers. More intensive therapy is needed to look at the fundamental issues which may be maintaining tranquilliser use. 

Agoraphobia is fairly common as a side-effect of tranquillisers and also as part of the withdrawal syndrome for those who have been reducing on their own, and may be part of the reason why a client may say that she cannot come for an assessment. Persuasion is rarely effective, but recognition of the fears, reassurance that others have coped with their fears and come, and an invitation to bring a friend or discuss travel arrangements may help the client to make this important step. 

Tranquilliser users may already have watched television programmes, read several books, and received quite a lot of help and advice. Rather than a solely intellectual approach, what they may need is an experience which addresses their thinking, feeling, and behaviour, in an integrated way. The WITHDRAW group uses a variety of... 

It is possible to categorise tranquillisers by the duration of action (Trickett 1986) the duration of action affects the length of time before withdrawal symptoms occur, and also the length of time the withdrawal is experienced (see Table 7.1). 

Managing benzodiazepine withdrawal Table 7A Duration of action of various tranquillisers... 

How soon the withdrawal syndrome starts is partly dependent upon the half-life of the tranquilliser being taken, and whether other benzodiazepines are also being used (for example, hypnotics). If the half-life is shorter (that is, less than twelve hours), then a person may experience withdrawal between doses. However, if the tranquilliser is longer acting, then withdrawal can start within three to ten days of any reduction (Committee on the Review of Medicines... 

In practice, there is such a wide individual variation that at least fourteen days should be allowed before consideration is given to any further reduction. If the withdrawal syndrome does occur, then no further reduction should be made until the symptoms of withdrawal have passed. An exception to this occurs when taking shorter-acting tranquillisers in very low dose, when almost constant withdrawal is experienced. The final reduction to coming off completely can usually be considered after about three weeks from the previous reduction. 

One way of estimating the likelihood and severity of the withdrawal syndrome (which should affect time taken to withdraw) is to use the Cumulative Benzodiazepine Exposure Index developed by Busto et al. (1986) which measures a person s total tranquilliser... 

If tranquillisers are no longer seen as a long-term solution to anxiety and stress-related problems, then what is Much of the experience gained in managing withdrawal points to fruitful areas of investigation in the search for alternatives. Alternative medication... 

Hamlin, M. (1988) An integrated cognitive behavioural approach to withdrawal from tranquillisers , in Dryden, W. and Trower, P. (eds) Developments in Cognitive Psychotherapy, London Sage Publications. 

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