Clonazepam discontinued in my country - please advice

/apologies, I deleted this same message from another thread/

 

Dear all

 

Clonazepam (0.5mg) is permanently out of stock in my country (Spain). The authorities do not expect it to be back anytime soon.

 

I've been taking 0.5mg clonazepam every night for 7 years for myofascial pain following a botched major surgery. 2 unsuccessful and quick attempts at dry tapering. I'm severely sensitized to even micro reductions to the pill now.

 

I need a clonazepam refill in 2 months, but doctors are now asked to prescribe another treatment. My doctor is 100% benzo unwise and I don't know how to have this conversation with him. I'm truly scared to death he will simply CT me or put me on an incorrect dose of another benzo/SSRI. I don't think he will be open to discussing the Ashton Manual (which he surely hasn't heard of) and it can be risky to simply suggest to him that he crosses me over to diapezam (and how much would he prescribe?)

 

--> I have a supply of 60 pills Clonazepam 0.5mg from my last refill, but 8 weeks is a super rapid taper I will not risk.

Then, I also have 60 pills of 5mg Diazepam prescribed from lumbago pain last year that I never took.

 

Should I start myself on a diazepam crossover? If so, for how long? I'm thinking diazepam because my doctor prescribed it in the past for the lumbago, so maybe I could talk to him about prescribing it in the absence of Clonazepam? (although again I don't know how much he will prescribe, if any).

 

I'm really grateful for any comments/ideas, and I'd like to thank you all for your time reading my message.

You say .5 mg is out of stock, are other dose sizes available?  Before we discuss specifics, have you seen this tool? https://clincalc.com/benzodiazepine/default.aspx

Thanks for your reply and link to the calculator! I am also aware of Ashton's recommendation (0.5 clonazepam = 10mg diazepam).

 

No Clonazepam can be found in any pharmacy in Spain. It has sadly made the news these days. Both Rivotril (brand by Roche) and the generic brand (by other pharmaceutical company) are out of stock and not expected to be back as per the Government's official announcement.

 

There are no 0.5mg pills and there are no 2 mg pills either- these are the only two dry doses approved in the country. I know there is liquid Clonazepam (2,5mg/ml) but it's such a high dose that it's impossible by doctor would ever consider it. Doctors have actually been officially advised to prescribe other treatment to patients, or in extreme cases, (not mine) request the clonazepam internationally.

 

Hello, abbyL. 

 

I’m sorry to learn about the shortage of regular clonazepam tablets in your country.  Has a reason/explanation been given for the shortage?  If so, please let us know.  Drug supply issues are a topic of great interest to our members.

 

Are you aware that we have multiple members who have used the 2.5mg/mL Rivotril liquid to taper?

 

My understanding is that it is supplied with a calibrated dropper; 1 drop equals 0.1mg of clonazepam.  So if your dose is 0.5mg a night, you would take 5 drops.

 

We recently had a member who was able to taper directly using the Rivotril drops.  We also have members who dilute the drops with water to achieve a less concentrated liquid (e.g. 0.1mg/mL or 0.01mg/mL).  This allows them to make smaller reductions in dose using a calibrated oral syringe as the measuring device.

 

Hello Libertas and thanks so much for your reply.

 

No reason has been given for the shortage of Clonaezepam in Spain. It's officially out of stock (and other drugs too, including synthetic insulin) and no timeframe has been given by the authorities for the supply to return. I'll keep you posted if the situation changes, or if I get any further information about it.

 

I was not aware of the calibrated dropper supplied with the liquid Rivotril, and I appreciate this info very much. It's great to hear that all these buddies were able to taper using it, or diluting it further.

 

My problem is that I don't know if my doctor will prescribe the liquid Rivotril in 2 month's time when I return for a refill. This liquid presentation might go out of stock again (it has been on shortage for a month already this year) and even more so if doctors start prescribing it as no equivalent pills are available.

You’re most welcome, abbyL.

 

Please do keep us posted about the clonazepam shortage in Spain.  It would be very interesting to find out the cause(s).  We’re experiencing an amoxicillin shortage here in the US; one speculation is that it’s due to a surge in demand caused by an increase in upper respiratory infections, especially among pediatric patients.

 

You’ve identified two important questions about the Rivotril liquid — will your doctor be willing to prescribe it and will it be available.  Based on what you’d shared with us, it sounds like availability may be an issue so you are wise to consider alternatives.

 

Drug supply issues coupled with your drug history of two unsuccessful taper attempts, suggest you are wise to consider crossing over to diazepam.  (The last time I checked, diazepam was on the WHO’s essential medicines list so one would hope this would lowers the risk of a shortage.)

Thanks again for your reply, Libertas. I'll keep you all posted about the issue with Clonazepam in Spain.

 

I appreciate your insight and advice about my case- thanks for giving it your consideration. I also think crossing over to valium is the alternative I need to work with.

 

I have an appointment with doctor B (not my primary heath provider) to discuss the Rivotril issue. I'm going to prepare/rehearse this appointment writing a list of things to discuss- any suggestion would be welcome!

 

Thank you all and have a great day.

Tip of the hat for the thoughtful and thorough approach you are taking to preparing for and planning your next taper, abbyL.  Your idea of preparing a list of items to discuss with ‘Doctor B’ is spot on.  As I’m sure you’ve already surmised, sharing your benzodiazepine use history is also key.  The fact that you have had two unsuccessful taper attempts should signal your doctor that a cautious, slow, ‘taper as tolerable’ taper is indicated in your case.

 

Here are three resources you might find helping in preparing for your appointment:

 

(1) The Colorado Consortium for Prescription Drug Abuse Prevention, in cooperation with the University of Colorado Anschutz Medical Center in the US, has produced a benzodiazepine deprescribing guidance document, which collates many of the existing guidelines on this topic (including Ashton’s work).  Section 2: Preparing for Tapering includes a bullet point about substitution.  Section 3: Tapering Principles includes these bullet points:

 

Tapering Principles

● A symptom-based, patient-directed taper is the best approach.

● Initiate with a small test reduction (≤5% of current dose). Allow the patient to lead subsequent reduction amounts/intervals based on tolerability of withdrawal symptoms.

● Lived experience suggests ≤5%-10% reduction of the total dose monthly is best tolerated.

● Skipping doses, supplemental (“rescue”) doses, or up-dosing increase risk of kindling. Up-dosing may be necessary in case of over-rapid reduction and severe symptomatology (e.g.,akathisia, suicidality).

● Hyperbolic (exponential) dose reductions are better tolerated than fixed reductions; i.e., dose reductions should become smaller as the taper progresses.

● Complete discontinuation may take 12-18 months or longer.

● Nervous system hypersensitivity is common during withdrawal, and any foreign substance can have adverse effects. Caution is advised with any new supplement or medication.

 

Link:

Benzodiazepine Deprescribing Guidance Document (2022)

https://corxconsortium.org/wp-content/uploads/Benzo-Deperscribing.pdf

 

(2) Antidepressant Withdrawal Syndrome and its Management (the concepts in the video also apply to benzodiazepine withdrawal).

 

This video features Dr. Mark Horowitz, a training psychiatrist and research fellow at the National Health Service in the UK.  He completed a PhD in the neurobiology of depression and the pharmacology of antidepressants at the Institute of Psychiatry, Psychology and Neuroscience at King’s College London.  Horowitz’s approach to withdrawal from psychiatric medications is informed by how such medications interact with their biological targets (receptor binding).  He is a proponent of making small, gradual, hyperbolic dose reductions and (wonder of wonders) recognizes the need for dosage forms that support small reductions. In the video, he suggests the use of liquids or compounded ‘mini-tablets’ such as Tapering Strips (https://www.taperingstrip.com/).  Given that you reside in Spain/Europe, Tapering Strips might be an another option for you to consider.

 

Link and time stamps:

 

Antidepressant Withdrawal Syndrome and its Management

 

20:30 introduction to the concept of hyperbolic tapering

27:16 discussion of dependence and withdrawal

49:42 main take home messages by Horowitz

 

(3) 10 Tips to Find Medical Help with Benzodiazepine Cessation

 

This video includes tips for talking to a doctor.  It features Dr. Christy Huff, director of the Benzodiazepine Information Coalition.  Huff is also a medical doctor who has personal experience with benzodiazepine withdrawal.

 

Link:

10 Tips to Find Medical Help with Benzodiazepine Cessation

Wow, Libertas, I cannot thank you enough for your fantastic reply full of excellent links and resources! 

 

I had seen the video by Dr. Huff, and I wrote down in my journal many tips to communicate with "Dr. B". I will be studying the rest of the material you so kindly provided this afternoon.

 

I'm worried, however, about how flexible 'Dr. B' might be- it's always hard to come to a doctor's appointment with documents that (I know) he has never seen. I don't want to hurt his ego or appear as if I'm seeking new pills. ALSO- I'm terrified of tapering clonazepam again and considering the crossover to diazepam as a result of the shortage of the drug nationwide.

 

I feel very happy to count with all this great info, but sadly skeptical about how 'Doctor B' will take it. My appointment is tomorrow, so I'll keep you posted about what he says and how it goes.

 

Have a lovely day!

You are welcome, abbyL.

 

In my opinion, you are doing exactly the right thing by meeting with Dr B tomorrow.  First, you will discover if he is receptive to the idea of helping you implement a cautious, slow, ‘taper as tolerable’ patient-led taper (perhaps with Rivotril but you could also ask about diazepam).  Second, he may have additional information and/or insights to share regarding the clonazepam shortage as well as strategies prescribers and patients are using to cope with this.

 

Please do keep us posted.

 

Ok, so it seems Rivotril 2mg is back on stock. Officially, as stated on the official website, the 0,5 pill is also back, but I didn't confirm this asking in a pharmacy. No reasons for these (dis)continuations have been given.

 

'Doctor B' confirmed that Rivotril is a medication that is sometimes not available. That he prescribed it the other day to a patient but that said patient could not find it and that he needed to prescribe something else. I feel this patient might have dodged a bullet, tbh.

 

As for me; he wrote a report suggesting to my primary health provider that I updose Rivotril to 1mg at night and also add Lexapro. -_- Plus quite a few other things (pain medication and other stuff such as Gabapentin) as I'm a chronic pain patient and under medicated in his opinion -_-

 

So. I'm not taking any.single.thing. Since it looks like the alert on Rivotril is over, no plans to switch over to Diazepam for the moment.

 

I'll think and plan my next micro taper soon, I'll keep you posted. Love <3

Thank you for the update, abbyL.  That’s good news that the clonazepam shortage appears to be easing.  Is your next step to ask your primary health provider if s/he would be willing to (a) help you do a conservative, symptom-informed taper and (b) prescribe the 2.5mg/mL Rivotril drops as long as needed?

Hi Libertas.

 

For the moment, I'm going to stay on 0.5 Rivotril. I know I'm probably in tolerance withdrawal from my last unsuccessful taper attempt in October (I have insomnia + tinnitus) but I really need to think this very thoroughly.

 

1-I will not discuss a taper with my primary health provider. The rule given by top psychiatrists in Spain is to cut the pill in quarters and be done in 4 days. If/when I do a microtaper, I'll be on my own.

 

2-I'm very wary to ask *anything* concerning the Rivotril pills (change to liquid formulation included). Not just because of the recent  shortage, but because there is a huge black market for this substance and the legislation about prescribing it is more severe now.

 

As the 0.5mg/2mg pills are back in stock, I understand my primary doctor will continue prescribing them, even more now with this other doctor's report suggesting the updose. So I think I can count with the chronic Rx for the 0.5 pill.

 

I'm not in a situation I like, but not ready yet to start the microtaper.