Gradual Reduction is Best For Coming Off Meds: But In All Situations?
This post has generated a surprising number of concerned responses from readers. In order to avoid misunderstanding I decided to change the title, which was originally “Is “Medication Tapering” The Best Term For Withdrawal?” and making a few clarifying changes to the text. I also am adding a link to my Coming Off Medications Guide:
Unfortunately I don’t have the time availability to keep re-expressing my point of view. It’s in the Guide I wrote, which was just revised in a second edition and which continues to be open to any suggestions for changes in upcoming editions.
The phrase “medication tapering” is being used more and more as the preferred term for the psychiatric medication withdrawal or coming off process. Based on my years of work educating many people around coming off medications — clients, support groups, and in workshops and trainings — I think that term is misleading, and let me explain why.
Gradual withdrawal is a sound guideline supported by a growing body of research literature as well as personal accounts, but should not be elevated to a firm rule: tapering is one possible strategy, but not the only one or even always the best one. Abrupt withdrawal can create severe and even life threatening consequences, but at the same time many people do successfully withdraw abruptly, and abrupt withdrawal, even with its risks (including unknown risks), may be a more advisable course of action and better choice in some circumstances.
As I write with Dr. Neil Falk and Dr. Dan Fisher in the upcoming “Textbook of Modern Community Mental Health Work”
While this slow and tapering approach to reduction and discontinuation is generally advisable and has a growing body of research evidence in support of it, in practical settings this is only a guideline. For example, clinicians and clients sometimes face circumstances where abrupt withdrawal is indicated. Medication toxicity such as liver and kidney problems, signs of tardive dyskinesia, rash associated with lamotrigene, neuroleptic malignancy syndrome, serotonin syndrome, or acute reactions such as heart arrhythmia, suicidality, self-injury, or mania call for either immediate withdrawal or transfer to another medication with a different adverse effect profile. In such instances the risks associated with withdrawal are outweighed by the physical danger posed by medication continuation. Abrupt withdrawal should be cautiously considered, however, as some medications, such as benzodiazepines, can be life-threatening during abrupt discontinuation (Ashton, 2005). Clients may also choose abrupt withdrawal when adverse effects are subjectively experienced as intolerable. In these cases, clinicians should ensure that clients are informed about the possible consequences of abrupt withdrawal, while also acknowledging the motivation and concerns behind it, and any difficulties encountered met are treated as a learning process.
Medication withdrawal is not a medical procedure like surgery: it is driven by the subjective meaning of the medications and the human relationships surrounding them. Because of this, there is a lot of diversity in coming off. Though I would never recommend it, I have met people who did just throw their meds away (often just after coming out of the hospital) and reported no withdrawal effects at all. Many people who begin with “I want to come completely off my meds” may, in the process of reduction, discover new usefulness to their medications or face withdrawal obstacles that lead them to rethink their initial goals. Others do better breaking with their prescriber and leading the process on their own (the UK charity MIND did a study of coming off medications and, because it found physicians were so often unhelpful in the process, changed its policy, and now no longer recommends physicians always guide withdrawal). A surprising number of people “just forget” to take a medication, and find this is the starting point for successful withdrawal. And we should remember that “psychiatric drugs” encompasses a vast range of possible medication situations, from the occasional Ambien on trans-atlantic flights to long term life-threatening polypharmacy. We need to understand this diversity and recognize that people have unique life stories just as they have unique relations to medications.
“Medication tapering” implies that like any medical procedure, there is a standard practice for physicians to follow. It’s certainly true that there should be guidelines and protocols around medication withdrawal, as this information is greatly needed and sorely lacking. There needs to be research into the physical risks of medication withdrawal and how to avoid those risks, including understanding drug interaction, supportive therapies like supplements, and the chemistry of different medications in the body. And too often people who have problems with an abrupt withdrawal are told this shows they need to stay on the medications, not try more slowly next time. But assuming that gradual withdrawal is more than a general principle, or that physicians are the ones who should always be making the decisions, risks making the process more difficult and potentially more harmful.
To meet the complexity and unpredictability of medication withdrawal, we need a more flexible approach. Calling the process “medication tapering” overlooks the need for that flexibility.