This is about medical ethics. It’s a blatant conflict-of-interest matter that I’ve never heard mentioned, and so I’d like to mention it.
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Let me start by telling what’s been happening to my girlfriend, to illustrate the situation, because it’s a sure bet that her experience isn’t unique.
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Zoloft and Xanax were prescribed for Janet about 3 years ago. She was having anxiety-attacks that turned out to have a medical cause, which no longer remains.
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But because she was left on those drugs for so long, she’d addicted to them. As you might know, drugs such as those are highly addictive.
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She tried to just quit, and the symptoms were too harsh. We’ve since read that overly fast withdrawal of those drugs can be fatal. When she mentioned to her doctor that she wanted to quit the drugs, he put her on a taper of his devising. It started with an abrupt 25% reduction in the Zoloft dosage-rate. Again, the withdrawal symptoms were harsh and alarming, and the doctor agreed to stopping the taper.
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So I suggested, to Janet and to the doctor, a genuinely gradual taper. …a smooth exponential taper.
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The doctor agreed to it, and we began. On that taper, Janet has reduced her Zoloft dosage-rate by 43%, with no symptoms whatsoever.
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It’s based on an ideal continuously exponentially decreasing dosage-rate. An exponentially-decreasing function decreases by the same percentage each day (or for any equal duration).
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Each day, Janet’s number of pills is such that, for each day, it puts her at, rounded up to the nearest integer, the cumulative (non-integer, of course) total pill number that is the integral of the exponential rate-function, up to that day.
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As I said, we, so far, have thereby reduced her Zoloft dosage-rate by 43% with no symptoms whatsoever.
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For the exponential function’s constant, k, in exp(kt), we chose a (negative) value that would (gradually of course) halve Janet’s dosage-rate every year. That gradualness seems necessary, because she’s been habituated to the drugs for years, and so the halving should happen on a commensurate time-scale.
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So far so good, but then Janet’s doctor retired, and his successor told us. “I don’t do it that way.” He insisted on abruptly reducing the Xanax by half, saying that we could raise her Zoloft dose-rate back up to 75% of its initial value if we want. Her previous doctor had told us to taper the Zoloft first, and that’s what we’d been successfully doing.
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We immediately got a different doctor, but she refused to prescribe more than 75% of Janet’s initial Xanax dose-rate, thereby imposing a 25% reduction like the one that had caused Janet harsh symptoms when we tried it before. Result: Convulsions in sleep, and difficulty sleeping.
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We’ve asked these doctors, “Why is a gentle, symptom-free taper a problem to you??”. No answer.
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Yeah? Well here’s a clue:
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The doctors of course say, “If there’s any problem with this taper, be sure to make an appointment to come in.” …so that the doctor can offer counsel, maybe tinker with his hard-“taper”, and maybe prescribe this or that palliative drug to ease the ordeal.
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Visit-appointments, and money, are made when there’s a problem that needs treating. If the patient is on a symptom-free taper, that doesn’t generate any appointments, or any money for the doctor. So (for some doctors at least) there’s a monetary motive to make a problem for the patient to keep coming in to be treated for.
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Thus, the old saying, “Follow the money” provides the explanation for why a gentle, symptom-free taper is a problem to some doctors.
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I’m not saying that all doctors are unethical, but, in Janet’s experience, some are.
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I’d like to put my taper-program around. As programs go, it’s very brief. So let me describe it here:
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First, a few symbols and what they stand for:
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t is the day-number in the taper. t = 1 on the taper’s 1st day.
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k is the constant in the expression “exp(kt). (I’ll later tell how to choose k)
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r is the initial dosage rate, in pills (or half-pills) per day.
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S is the number of the pills (or half-pills) taken so far.
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d is the number of pills or half-pills to be taken on a particular day.
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Maybe “pseudocode” is the word for the following program-description:
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r is the number of pills (or half-pills) being taken daily before the beginning of the taper.
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Set S to 0.
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Set t to 1.
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[line-label] d = 1 + INT((r/k)(exp(kt) - 1) - S)
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if d < 1 then exit
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print t, d
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linefeed
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S = S+d
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t = t+1
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go to labeled line
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end of program listing
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To determine what k should be:
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Suppose you want to reduce the dosage rate by a factor of F, in t days:
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k = ln(F)/t
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(“ln” stands for “natural logarithm”)
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Because F is less than 1, k will be negative.
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For example, say you want to reduce the dosage-rate by half, every year:
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k = ln(.5)/365.25 = - .001897734
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I suggest that k value, for a halving-time of one year, as a general 1st-trial tentative tapering suggestion, when the person has been habituated to the drug for just a few years. …because the halving-time should be commensurate with the habituation-time.
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As I said, my girlfriend, using that k value, reduced her Zoloft dosage-rate by 43%, from 100 mg. to 57 mg., with no symptoms whatsoever.
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But some people have been smoking for lots of decades, and, for them, maybe the halving-time should be longer than a year. …likewise for any substance that have been used for more than just a few years.
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For such a longer habituation-period, it might be best to cautiously start with a halving period that’s at least a large fraction of the habituation-time. …and of course regard it as just a cautious tentative first trial taper.
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Obviously, if there are withdrawal symptoms, the dosage-rate should be returned to its pre-taper value, and a taper with a longer halving-period should be cautiously tried. This is intended as a completely symptom-free gentle taper.
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…and of course a doctor should be consulted (but preferably not a cold-turkey doctor).
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I emphasize that I’ve never heard of, or found any Internet reference of, a doctor suggesting a taper as gentle as the one with a one year halving-period.
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In fact, of course any taper should be done cautiously, while watching for withdrawal symptoms.
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Equivalent years:
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How much of the substance will be taken during the taper? I speak of “equivalent-years”, by which I mean number of years at the initial (pre-taper) dosage-rate, that would result in the same amount of the substance that is taken during the taper.
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Equivalent Years = (-1/k) * (1/365.25)
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For example, for the k that gives a 1 year halving-period, the equivalent-years is 1.44 years.
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…meaning that the amount of the drug that’s taken during the taper is equal to the amount that would be taken during 1.44 years at the initial (pre-taper) rate.
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Feel free to use, share, post or publicize the above-described taper-program anywhere, anytime.
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(In fact, please do !!)
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Michael Ossipoff