Benzodiazepine Tapering & Deprescribing
in Hollywood, FL

What does a benzodiazepine taper feel like from the inside?

Dr. Leeds, an osteopathic physician whose practice is built around deprescribing, has his office in Fort Lauderdale, about ten miles north of Hollywood, and he sees Hollywood patients by secure video or, for those who want it, in person. Tapering benzodiazepines and z-drugs (sleep medications such as Ambien) is the lead service, and psychiatric medication deprescribing comes second. The subject here is the part of a taper that no dosing chart shows: what it feels like week by week, and what to do when a bad night arrives.

In short:

• Hollywood patients are seen mostly by weekly video visit, with the Fort Lauderdale office a short drive up I-95 or US-1 for anyone who wants to be seen in person.
• Visits are weekly and often up to an hour, always with Dr. Leeds himself, and urgent questions reach him by text at any hour.
• The taper follows the Ashton Manual, with steps that get smaller as the dose comes down, often on diazepam with liquid or compounded doses, over a year to 18 months or longer.
• Physical dependence is not addiction. Symptoms set the pace, a hold is a normal tool, and a wave is not a failure.

Hollywood lies between Fort Lauderdale to the north and Miami to the south on the Broward County coast, with the Broadwalk and Hollywood Beach on one side and quieter residential streets west of Dixie Highway on the other. In fact, much of a taper is lived in ordinary places, the kitchen at 6 AM, the car on Sheridan Street, the bedroom at 2 AM, and a familiar setting is a real asset when the nervous system is unsettled. Telemedicine lets the taper happen there.

What Hollywood patients often arrive with is a long prescription history and a short list of answers: a benzodiazepine started years ago for a reasonable reason, taken as directed, by a doctor who had no plan for stopping it. That is the point at which this page begins.

Why do symptoms often begin before the first dose is cut?

The strangest part of benzodiazepine dependence is that the trouble frequently starts while the dose has not changed at all. For example, a person who has taken Xanax (alprazolam), Klonopin (clonazepam), or Ativan (lorazepam) daily for years begins to feel a new kind of anxiety unlike the original problem, along with muscle tension, a sense of unreality, or early waking with a pounding heart. This is tolerance withdrawal: the brain has adapted so completely to the drug, by turning down its own gamma-aminobutyric acid type A (GABA-A) receptors, that the same dose no longer holds it steady, and withdrawal leaks through between doses.

It helps to name what this is and what it is not. Physical dependence is not addiction. The patient in tolerance withdrawal is not chasing a high and is not misusing anything. A prescribed medication, taken as directed, has changed the nervous system that takes it. In fact, in 2020 the U.S. Food and Drug Administration (FDA) revised the boxed warning on every benzodiazepine label to say that physical dependence develops even at prescribed doses, that withdrawal can be serious and sometimes prolonged, and that the drug should be tapered gradually.

Unfortunately, many patients spend a long time being told these symptoms are their anxiety coming back. The answer is not simply a higher dose, and it is never a sudden stop, which after long daily use can cause seizures. The answer is a slow, supervised taper that starts from wherever the patient is.

What do the first weeks of a taper feel like?

Fortunately, the first weeks are usually quieter than patients expect, because they begin with stabilization rather than cutting. A patient on Xanax or Ativan is often moved in stages onto diazepam (Valium), which stays in the body far longer, and the first thing many people notice is that the hours between doses stop feeling like a cliff.

Then comes the first cut, and the body answers on its own schedule. The days right after a reduction often feel ordinary, and then, a few days later, the symptoms arrive: lighter sleep, a tight chest on waking, a jittery current under the skin, and a mood that tilts toward dread for no reason the day can explain. Of course, the nervous system is registering the smaller dose, and that is expected. The symptoms usually crest and ease over a week or two, leaving a stretch of nearly normal days before the next step.

That rhythm, a flare and then a lull, is the pattern patients call windows and waves. A window is a run of hours or days in which a person feels close to themselves again. A wave is the return of symptoms, often without any new cut to explain it. So, Dr. Leeds describes the pattern in advance, because a patient who was never warned reads the first wave as proof that the taper is going wrong.

What should you do when a wave hits at 10 PM?

Waves have a habit of arriving at the worst time: the house is quiet, the day’s distractions are gone, and the next appointment is days away. If you are in one at 10 PM, a wave is not an instruction to take extra medication or to skip the next dose. Both responses swing the nervous system harder, and an unplanned jump down is a common way a taper turns into a crisis.

This is the situation the concierge model exists for. A patient frightened by a surge of symptoms at 10 PM is not left waiting for the next open appointment slot, because urgent questions go to Dr. Leeds by text at any hour, and a cut that is not working can be reconsidered before it does harm. Fortunately, the options are simple. A short hold, meaning the dose stays put for an extra week or two before the next cut, is often the answer on a diazepam taper, and everybody is different: some patients do better continuing at a steady pace than waiting a long time to feel stable. In some cases a modest step back up to the last dose that felt tolerable, decided with Dr. Leeds, is the better move.

Hollywood is a coastal city, and a hurricane watch can upend a week on short notice. When an evacuation or any other emergency disrupts a taper, the guidance from Dr. Leeds is to hold rather than cut, since the stress of the emergency is load enough, and it is sensible to keep a reserve of medication ready for a natural disaster. Of course, some symptoms are emergencies of their own: a seizure, chest pain, or thoughts of suicide call for 911 or the closest emergency room before anything else, and the 988 Suicide and Crisis Lifeline answers around the clock for anyone having suicidal thoughts.

What does benzodiazepine-induced neurological dysfunction (BIND) feel like, and does it mean the taper has failed?

BIND names the group of symptoms that can surface while a person is still taking the drug, during the taper, or after the last dose. Patients describe it in remarkably similar words: skin that burns or crawls, ringing in the ears, an inner vibration like a phone buzzing in the chest, a bloated and painful gut, and a restlessness so intense that sitting still is unbearable. These symptoms are real and neurological. They are not the original anxiety returning, and they are not a psychiatric illness coming back.

Unfortunately, many patients arrive having had exactly these symptoms waved away, sometimes with a new prescription for the very drug they were trying to leave. Dr. Leeds takes BIND seriously and treats the problems that travel with it, such as a racing heart on standing, as part of the taper rather than as reasons to stop it.

BIND does not mean the taper has failed. It means the nervous system needs more time between steps, so the reductions are paced to the symptoms and the plan is adjusted rather than abandoned. When symptoms outlast the final dose, the term is protracted withdrawal. It tends to improve with time. However, no honest physician can say how much, and the practice’s page on BIND goes further into what recovery looks like.

How is the taper built, and where do the doses come from?

The method is the crossover taper that the late Professor C. Heather Ashton set out in the Ashton Manual: a gradual switch to diazepam for those who tolerate it, then reductions that shrink as the dose falls. The Maudsley Deprescribing Guidelines explain why the steps must shrink, a hyperbolic relationship between dose and effect in which the last milligrams carry far more of the drug’s effect than the first. Still, a patient who does poorly on diazepam tapers on the medication already in hand, and the sleep medications Ambien (zolpidem) and Lunesta (eszopiclone), which work at the same receptors, are tapered by the same rules, and the benzodiazepine dependence and tapering service page sets out the method in full.

Small steps call for a dose measured in fractions of a milligram, and that is where the pharmacy matters. Diazepam is made as a 1 mg/mL oral solution with its own FDA label. Few pharmacies keep it in stock. Yet, a Hollywood patient’s usual chain or neighborhood pharmacy in Florida can order it in, and the prescription goes there electronically after a video visit. For a different benzodiazepine or an even finer step, compounding pharmacies in Florida prepare liquids or capsules to the prescribed strength and ship them.

At the end of a diazepam taper Dr. Leeds goes further than the Ashton Manual, which advises stopping at 0.5 mg daily: on the 1 mg/mL solution he continues below that, down to about 0.1 mg, and he generally reduces the evening dose last. Stopping at 0.5 mg remains an option for a patient who is doing well and chooses it. None of these figures is a schedule for anyone to follow alone, and a taper that runs past 18 months is not a failed one. It is a taper.

What does coming off an antidepressant, gabapentin, or Seroquel feel like week to week?

Patients often arrive on several psychiatric medications at once and want to know whether they can come off any of them. The medications Dr. Leeds helps patients come off include the selective serotonin reuptake inhibitors (SSRIs) such as Lexapro (escitalopram), Zoloft (sertraline), and Paxil (paroxetine), the serotonin-norepinephrine reuptake inhibitors (SNRIs) such as Effexor (venlafaxine), the gabapentinoids, Lyrica (pregabalin) and gabapentin (Neurontin), and the antipsychotics Seroquel (quetiapine) and Zyprexa (olanzapine). One medication is tapered at a time, and his role with these drugs is to bring patients off them, as the psychiatric drug tapering hub explains medication by medication. He typically does not add a new one of these drugs to ease a taper from something else.

From the inside, an antidepressant cut has its own signature. A few days after a reduction of an SSRI or SNRI, patients describe brief electrical jolts in the head when they move their eyes, dizziness on standing, nausea, vivid dreams, and an irritability that feels borrowed from someone else. A week or two later it usually fades, and the next step waits until it has. Paxil and Effexor, which leave the body quickly, tend to make themselves felt sooner and harder than Prozac (fluoxetine), which lingers.

A gabapentinoid reduction feels different: sweating, anxiety that may run higher than the original, sleep that will not come, and a restless, keyed-up sensation much like benzodiazepine withdrawal. And, a patient coming down from Seroquel taken for sleep usually meets rebound insomnia first, and sleep returns in stages over weeks rather than nights. The Maudsley Deprescribing Guidelines give hyperbolic reductions for the antidepressants and gabapentinoids. Antipsychotics may be tapered in a similar way, and compounded liquids make the final steps possible.

To be clear, Dr. Leeds typically does not add a gabapentinoid to smooth a taper, and in general he avoids adding any new medication that carries a dependence of its own, because it only adds a second taper to the first.

What about opioid dependence, alcohol, and other problems?

Opioid dependence is the secondary service, treated with buprenorphine, the medication in Suboxone and ZubSolv and in generic buprenorphine products. Visits for buprenorphine are monthly, weekly when needed, and the plan, long-term maintenance or a gradual taper, belongs to the patient.

Alcohol use disorder is treated with naltrexone under the Sinclair Method: a dose roughly an hour ahead of drinking, so that across months the reward of alcohol can fade and drinking often tapers with it, with no requirement to stop on day one. Or, for a patient who must stop drinking altogether, alcohol withdrawal can be supervised at home, with a nurse present around the clock.

Other substance problems, including stimulants, can be discussed at a consultation. Dr. Leeds also offers low dose naltrexone, a compounded preparation, for autoimmune-related pain conditions.

How does concierge telemedicine work from Hollywood?

The practice is concierge rather than insurance-based. Every medical visit is with Dr. Leeds, weekly for a taper and often up to an hour, by secure video from home in Hollywood or the neighboring cities, with text access for urgent questions between visits. Prescriptions travel electronically to the pharmacy the patient names when that works out, and a family member is welcome to sit in on a video visit if the patient wants one there.

Dr. Leeds prescribes for patients in Florida. For someone outside Florida, a consultation may still be possible. Hollywood is close enough that in-person care is a real option rather than a day trip: the office is at 3290 NE 33rd Street, Fort Lauderdale, about ten miles away, 15 to 25 minutes on I-95 or US-1 depending on traffic, and it takes calls Monday to Friday from 10 AM to 2 PM.

The first step is a consultation, and the concierge telemedicine page describes the model in more detail. Dr. Leeds also serves on the medical advisory board of the Benzodiazepine Information Coalition.

Frequently asked questions

What does the first week after a dose cut usually feel like?

Often nothing for a few days, then a rise in symptoms: lighter sleep, a tight chest, a jittery feeling, and anxiety that seems to come from nowhere. The flare usually crests and settles within a week or two, and the next reduction waits until it has.

What is a wave, and how long does one last?

A wave is a return of withdrawal symptoms during or after a taper, often without a new cut to explain it, and a window is the stretch of better days between waves. A wave can last from a few hours to a couple of weeks, and over a taper the windows usually grow longer and the waves shorter.

Does BIND mean the taper has failed?

No. BIND can appear in someone who has done everything right, including before any cut has been made. It calls for more time between steps and treatment of the symptoms that come with it, not for abandoning the taper. Whether a higher dose would help is decided case by case with Dr. Leeds.

When does Dr. Leeds hold a dose, and is a small increase a step backward?

A hold is used when a step has produced more than the patient can carry, when illness, travel, or an emergency such as a hurricane takes over the week, or when a patient wants a longer breath between steps. Going back up by a small amount, under Dr. Leeds’ guidance, to the last dose that felt manageable is a legitimate tool as well. Neither undoes the taper.

Are benzodiazepines addictive?

Rarely, in the sense that word is usually meant. Few people who take a prescribed benzodiazepine develop compulsive use. Yet, physical dependence after months or years of taking it exactly as directed is common, which is why a person on the drug for years cannot simply stop. The dependence is a physical adaptation, treated with a slow taper and never with a sudden stop.

A Hollywood patient who wants to come off a benzodiazepine, a sleeping pill, or a psychiatric drug with a physician who is reachable at night once care begins can start with a consultation requested through the contact form. Contact the office today.

This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.