In the past week, I have seen three patients that complained about their difficulties in attempting to taper off medications prescribed for sleep. In every case, the story had remarkable similarities. The drugs were prescribed years ago, and the patients were offered no other options for their insomnia. Not much instruction was given at the time of prescribing in terms of how to use the medication to avoid dependency. And, in several instances, the need to increase the dosage of medication was never addressed as a potentially harmful problem.
The drugs in question are familiar to anyone who knows about prescription sleeping pills: zolpidem (Ambien); alprazolam (Xanax); and clonazepam (Klonopin).
While each of these cases has more similarities than differences, I want to walk you through several features of each case to show you how maddening this process of tapering can be for many patients who receive treatment from medical professionals with scant experience in the field of sleep medicine. As always, I will leave out details of age and sex so that no patient could be identified were they reading about the descriptions.
The first patient (we’ll give the moniker P1) reported some difficult and stressful life experiences having to do with work and relationships a few years back. When discussing with a primary care physician P1 received the option of Ambien as the best way to proceed. P1 took a while to become dependent on the drug, but after a year or so was using the medication every night. In the world of the healthcare merry-go-round regarding primary care physicians, P1 lost a PCP due to an insurance change. Upon meeting a new PCP (a young physician barely out of residency), P1 was immediately informed that Ambien is a horrible and dangerous drug, after which the physician informed the patient no further prescriptions would be forthcoming. The patient being a reasonable person listened to the new PCP, accepted the instructions and after using the last of the medication, promptly developed rebound insomnia lasting 7 days and nearly ended up in an emergency room for help. Another physician started P1 back on Ambien to resolve the acute crisis during which the patient was seen at our sleep center.
After P1 discovered the diagnosis of sleep apnea had been missed by other physicians, this patient was motivated to move forward with PAP therapy. The patient has continued on the device for several months, slowly increasing time on the mask, and in the process, gaining improvements in insomnia by the elimination of sleep fragmentation with PAP therapy. P1 is now ready to initiate a tapering process on Ambien, and we are working on a strategy to help plan out the formal steps of the tapering program during the next few months.
P2 has a much more chronic condition, all starting after a major life disruption from the death of a spouse. Levels of depression and anxiety persisted long after the grieving process, and eventually the patient was placed on Xanax in sizeable dosages to be taken throughout the day. Xanax of course is a highly addictive medication for patients who suffer chronic anxiety, because when anxiety becomes so uncomfortable if not frightening, the individual’s need to eliminate all anxiety feelings expands to unrealistic levels. Clinically, although Xanax will come close to achieving this objective in a fair number of individuals for extended periods of time, eventually breakthrough anxiety almost always arises. Among those who use Xanax throughout the day, it is nearly impossible for them to taper off without receiving intense professional help from an expert in psychology or psychiatry who has the skills and experience to achieve such goals. Interestingly, once the patient tapers off the daytime Xanax, even though there is only one final dosage to taper from at bedtime, this night time pill creates its own special addiction or dependency related to insomnia, which then creates its own special tapering considerations that prove most difficult in the largest proportion of patients.
Our P2 patient was diagnosed with both sleep-disordered breathing and leg jerks and had tried gabapentin for leg jerks in the past with mixed results at lower dosages, but when attempting to raise the dosage P2 developed side-effects, including dizziness and weakness, after which the patient discontinued the med. Frustrated with having to take medication for sleep, P2 began tapering efforts and dropped from 3 mg of Xanax down to 0.75 mg, but life stressors again led to a downturn in mood and an upturn in anxiety, so the patient renewed the larger dosages of Xanax.
Our current efforts are focused on guiding P2 in using the PAP device on a regular basis, resolving any vitamin or mineral deficiencies affecting leg jerks, and finding the best medication without side effects to treat these leg jerks. Once all these steps are in place, and the breathing and movement problems are effectively addressed, then we will begin the tapering of Xanax. The problem however that arises in these scenarios is the extent to which the individual can tolerate emotional distress (namely anxiety) when attempting to reduce the medication. Many patients hooked on Xanax never come off the drug.
To understand this phenomenon, picture a chronic pain patient who is not addicted to his opiates, but who does indeed experience pain when the pain pills are not used. In time, the patient can become so sensitive to pain that he no longer chooses to accept any pain and instead starts taking a dosage of opiate on a regular basis to prevent pain from emerging at all. But, if for other reasons the patient needed to taper off the opiates, it would no doubt prove distressing, because the pain would emerge again and again as the dosage decreases. This same scenario plays out for the anxiety patient trying to taper of Xanax, because the anxiety emerges again and again as the dosage is lowered. Thus, the real trick to tapering off Xanax is helping the patient find new ways of coping with or tolerating anxiety to more manageable levels in the face of decreasing dosages of the medication. Successful tapering in this type of patient can take from one to two years or longer.
Patient P3 is very similar to P2 in having been prescribed large doses of Klonopin more than 10 years ago as high as 2 mg four times a day for severe anxiety and depression. We originally saw the patient 5 years ago, but at that juncture P3 was dead set against moving forward with anything to do with the diagnosis of sleep-disordered breathing. Then, just a year ago P3 met a very persuasive psychiatrist who also happened to be a regular user of PAP therapy. That doctor greatly encouraged P3 to start PAP about 6 months ago, and the patient has been thrilled with noticeable treatment gains, so much so that under the psychiatrist’s direction, P3 was able to reduce Klonopin to bedtime dosing only and is currently alternating between 1.00 and 0.75 mg dosages every night of the week. P3 is highly motivated to continue tapering but realizes slow and steady wins the race and acknowledges there are many more months ahead in the tapering process.
There is also the similarity to patient P2 in that P3 suffers from leg movement symptoms as well, but P3 has also been diagnosed with neuropathy and was already in the low to medium range of dosages for gabapentin. While we will be looking at vitamin and mineral deficiencies that might be affecting leg jerks, P3 is eager to increase gabapentin dosages to more effectively treat the limb movement disorder. Moreover, P3 appreciates that anything decreasing sleep fragmentation and increasing sleep consolidation is likely to yield further sleep quality gains and ultimately make things much easier in tapering off Klonopin.
All three patients are highly motivated to eventually taper off these medications, but if we were to predict which patients have the best chance of doing so, the ranking would be strictly based on the medication. The Ambien user has the greatest chances of success, followed by the Klonopin user and bringing up the rear would be the Xanax user. All three patients may attain successful outcomes, but it is well known that some people actually stop Ambien cold-turkey with minor distress (although our P1 patient had horrible rebound insomnia); whereas, it is most unusual to go off Klonopin or Xanax cold-turkey without major or serious side-effects, including the potential of life-threatening seizures.
Summing up, it is worth reiterating some points about emotional distress and how it creates the single greatest barrier to the tapering process. As described above in the chronic pain example, emotional distress is often described and understood by both mental health professionals and their patients as “distress intolerance,” but without resorting to jargon, a better common sense term is used: the sensation or feeling of “emotional pain.” The parallel to chronic pain is even clearer, because this intolerance to emotional pain actually operates just like tangible bodily pain in chronic pain patients. Thus, these emotionally compromised individuals lack the ability to cope or effectively deal with emotions on a general basis ultimately prevents these individuals from handling acute situations of emotional discord. In fact, repeated episodes of emotional discord that the patient finds increasingly uncomfortable eventually causes this person to become an ineffective emotional processor.
Emotional processing, in a nutshell, means that you are not frightened by your feelings, you are able to feel them (and not just think about them), and when they arise, you use the emotional experience to learn about something that is usually important to your mental health and overall well-being. If over time, you lose this natural ability to experience clearly and successfully work through your emotions (a nearly universal problem in mental health problems and insomnia), then one of the most typical long-term effects is to develop a problem with anxiety or depression or both.
Now, many people think of anxiety and depression as problematic emotions, and on a superficial level this view is accurate, but it is also incomplete. Anxiety or depression, more often than not, are a sign that the individual has been unable to work with emotions. Instead, emotions become jumbled in mix of sensations including various feelings and thoughts, all of which confuse the individual to the point of being only able to recognize the feelings of anxiety or depression; whereas this mixture was really about deeper emotional states like grief, sadness, anger, embarrassment, shame or guilt. But, because the patient is unable to experience these deeper emotional states, they end up stuck with the feelings of anxiety and depression. Anxiety in particular flashes into someone’s consciousness often as a gatekeeper that prevents the individual from even recognizing there might be deeper emotions, and yet the irony is that the experience of anxiety is also a warning signal that deeper emotional experiences are lurking.
Patients with insomnia frequently experience overt anxiety issues or sometimes covert in the form of emotional tension in the body, such as headaches, stomachaches, and backaches. Howsoever individuals suffer from this anxiety, the bottom line is that they grow desperate to alleviate the feeling, because it is “too painful” for them to experience. Once they discover that a pill such as clonazepam or alprazolam will relieve these painful feelings, they believe they have successfully treated the problem.
I hope you can see how complex these issues become for individuals attempting to taper off medications either at bedtime or throughout the day. First and foremost, the individual at some conscious level will recognize that it will be painful to initiate and complete a tapering process. But, a large proportion of these individuals will not be able to go through the process to completion, because they just cannot figure out how to deal with the emotional pain. Their distress intolerance threshold, so to speak, is so low that once they reduce the dosage of medication, sooner or later the anxiety returns, after which they just do not possess the confidence to continue down this rocky road.
In three previous posts on the role of emotions and CPAP adaptation, I discussed how fear and shame, embarrassment and guilt as well as sadness and grief can each interfere with the individual’s ability to overcome obstacles that prevent use of the positive airway pressure device. These same emotional states affect the insomniac and prevent him or her from being able to taper off the medications.
Are there exceptions to the examples above? Yes, there are some people where the medication has become habit-forming in a more superficial way, which means in these cases, the person may be able to go through a fairly straightforward tapering process with only a small amount of emotional distress. Some of these individuals, remarkably, go through cold-turkey approaches and achieve success, but that is almost never advisable given the serious side-effects of some of these drugs in question.
Notwithstanding, there is a much larger contingency of insomniacs who have become hooked on their medications, because they simple cannot tolerate the emotional pain experienced in their minds and bodies. These individuals need much more time, coaching and psychotherapy to be able to successfully taper off the drugs.
In our clinical experience we find these patients fare much better when their underlying OSA/UAR or restless legs/leg jerks are treated prior to initiating the tapering process. As you might expect, if you can help someone to start sleeping better before they go off the meds, there is a greater potential for the insomniac to experience some optimism and thus gain motivation to take the necessary steps on the road to recovery.