I think your ideas are healthy, and clonazepam withdrawal at 0.125 per month would be possible on condition you could bank on compliance by your patient. Should one consider using diazepam instead, because of it long half life and therefore an absence of rebound anxiety ?

The tapering schedule that both you and Jean Blom suggest is reasonable. HOWEVER, I would want to know a little more about your patient, such as: (1) given that he has a hx of substance use disorders what abusable psychotropics does he now use (either by prescription or "self-medication"; (2) does he have a past/current history of sedative-hypnotic abuse (including either the benzodiazepines and/or alcohol); (3) why was he originally prescribed clonazepam; (4) why does he want to reduce the clonazepam dosage; and (5) does he have a past history, or family history, of seizure disorders???

Hope this helps . . .

Lou

Hi Darryl and Lou,

Lou's remark just demonstrates the need of a full assessment. This includes an Axis II specification.. which, in the presence of a clear Axis i diagnosis, is never very authentic. Pehaps we could hear a little more about the 46 year old male, as Lou suggested.

Greetings,

Jean.

I think in a substance use disorder pt there is another important consideration - increasing risk of relapse.  Our data shows that there's a pretty direct correlation between discontinuation of neuroleptics and return to active substance use.  In short, I would ask pt whether she wants to take the risk - the clonazepam may very well be keeping her SUD in remission.  As you know, clonazepam is a safe and old medication without any material adverse side effects in long-term use, especially at the 2mg level.  Not knowing anything else about your pt, my opinion would be to strongly weigh the risks of discontinuation (e.g. relapse to active SUD) vs the benefits (if any).  

If pt insists on discontinuation, I might also suggest pregabalin (Lyrica) instead of divalproate/valproic acid as it is the emerging "standard of care" for benzodiazepine detox/discontinuation/substitution.  There is also emerging evidence that it helps patients stay in remission from opioid use disorder.  Pregabalin is essentially a much stronger version of gabapentin in terms of its pharmacokinetics that directly enhances GABA levels in the amygdala.