The Withdrawal After the Withdrawal: Managing Benzodiazepine Reduction and Post-Acute Withdrawal in Older Adults

Introduction Post-acute withdrawal, also described as protracted, extended or persistent withdrawal, refers to a syndrome that includes anxiety, irritability, hostility, mood instability, fatigue, insomnia and increased physical complaints often related to gastrointestinal symptoms, pain and weakness. Unlike acute withdrawal, where treatment guidelines and practices are highly predictable and protocol driven; post-acute interventions are highly symptom driven and individualized. Attention to co-occurring medical and psychiatric disorders is vital as well. It is well-known that benzodiazepines pose greater risks to older adults including confusion, ataxia, syncope, risk of falls, fractures, delirium and excess hospitalizations. Even with these known risks about 20-25% of all inappropriate prescriptions for benzodiazepines are given to older adults. There is limited literature on managing post-acute withdrawal syndromes in older adults, with few available guidelines for medication management of emerging symptoms. The additional challenges of the COVID-19 pandemic have increased both the stress on older adults in need of care and of providers seeking to engage patients in therapeutic relationships. We focus on representative cases of older adults seeking treatment related to benzodiazepines withdrawal and describe flexible treatment approaches for their evolving and complex needs. Methods Cases studies were identified from the patient population at Mount Sinai Beth Israel, an urban medical center serving a multicultural and socioeconomically diverse population that includes several NORC sites. Mount Sinai Beth Israel has been serving the population of lower Manhattan since 1889 and provides full service behavioral health care including opioid treatment programs. Patients were identified from those who presented to the ambulatory care center that offers adult, geriatric and dual-diagnosis services. A personalized treatment planning approach was developed in each case and included the time period of the COVID-19 quarantine. Results Mr A: 64 year old man with Generalized Anxiety Disorder, Panic Disorder, Opioid Use Disorder in sustained remission on Methadone 270mg daily and Sedative Hypnotic Use Disorder. The patient entered treatment for impending Benzodiazepine withdrawal after losing his provider. He was taking alprazolam 2mg, clonazepam 6m and zolpidem 10mg daily over the past 30 years. Following treatment for acute withdrawal and treatment with a slow taper of clonazepam the patient has been struggling with episodic anxiety and feelings of loss. Isolation and boredom related to COVID-19 quarantine conditions have contributed to this making the issue of worsening anxiety with protracted withdrawal symptoms difficult to delineate. Ms B:74 year old woman with Generalized Anxiety Disorder entered treatment after her provider closed his practice. The patient was prescribed diazepam 40mg, lorazepam 2mg and zolpidem 10mg daily for the past 5 years. In addition she was prescribed dextroamphetamine 20 mg daily for 3 years for fatigue. Over a 2 year period the medications were tapered using clonazepam; the dextroamphetamine was discontinued. While being maintained on clonazepam 0.5mg daily she started to complain of fearfulness, loneliness, insonia and chronic pain which increased with the onset of the COVID-19 quarantine. Mirtazpine 7.5mg was started at bedtime with improvement. Ms D: 59 year old woman with PTSD, Major Depressive Disorder, Alcohol Use Disorder, Cannabis Use Disorder and Cocaine Use Disorder treated with lorazepam 2 mg daily entered treatment after a previous provider was unable to administer Naltrexone LAI. The dose was reduces by 25% every 3 to 4 weeks while mirtazapine was utilized to manage emerging symptoms of depression and insomnia. Conclusions We found that patients often entered treatment as a result of prior providers either refusing to continue prescribing benzodiazepines or limiting their practice. Patients responded well to engagement but under the increased stress of COVID-19 quarantine conditions symptoms increasingly emerged. Our population included patients who were also receiving MAT for sustained remission of Opioid Use Disorder and faced greater risks related to benzodiazepine use. Patients were receptive to educational interventions regarding the risks of continuing use and were able to engage in treatment. Despite the proven negative outcomes of chronic use providers continue to prescribe benzodiazepines inappropriately to older adults. The need to care for patients treated with these agents is high. Post-acute withdrawal syndrome is poorly understood and under recognized in older adults. Efforts such as de-prescribing, patient centered approaches to rational prescribing and use remote education programs should be increased. COVID-19 pandemic conditions lead to an increase in overall symptoms reported but did not prevent patients from engaging in successful treatment.