INTERDOSE WITHDRAWAL:
Interdose withdrawal, where withdrawal symptoms emerge in between scheduled doses, is common in people who take BZs sporadically or who take BZs with a short half-life. That is not to say that interdose withdrawal cannot occur on the intermediate and longer half-life drugs—it can and does. Interdose withdrawal is often described anecdotally by iatrogenically dependent BZ patients in the withdrawal support communities as a physical or physiological ‘craving’ for the next dose before it is scheduled or due. This is different from cravings seen or described in addiction/drug abuse where people are craving a ‘high’ or another ‘hit’ from the drug—but it can certainly make someone dependent on a BZ feel like they’re an addict. They’re not. BZ tolerant patients or patients experiencing interdose withdrawal from taken-as-prescribed long-term BZ use are not looking to get high and often experience tolerance and interdose for the very reason that they haven’t increased their dose.
Some iatrogenic BZ-dependent patients who are experiencing tolerance and/or interdose may subconsciously find themselves taking ‘a little more’ (e.g., an extra quarter of a pill or taking their dose earlier than due) than usual here and there on some days. Many of them are confused as to why they’re so anxious or irritable and feeling like they need more ‘anxiety medicine.’ as they’re unaware of these possible effects (tolerance, interdose) from their BZ due to a lack of informed consent from their prescriber. If they take ‘a little more’ during a month’s prescription, they may run out of the drug and need a refill sooner than its due. This may appear to some prescribers to be ‘drug seeking behavior’ or ‘abuse,’ when in fact it is more likely a phenomenon described by The American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine as ‘pseudoaddiction’.
The pseudoaddiction phenomenon described in prescribed opiate dependence:
Pseudoaddiction is a term which has been used to describe patient behaviors that may occur when pain is undertreated. Patients with unrelieved pain may become focused on obtaining medications, may ‘clock watch,’ and may otherwise seem inappropriately ‘drug seeking’. Even such behaviors as illicit drug use and deception can occur in the patient’s efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated.
So, as opposed to abuse or a ‘substance-use disorder’, many patients experiencing BZ tolerance withdrawal or interdose withdrawal who increase their dose a small amount without prescriber direction are more likely experiencing ‘pseudoaddiction’. (Note: We do not advocate increasing the dose of BZs without prescriber cooperation, but just point out that it sometimes happens for the sake of this informative explanation). The ‘clock watching’ is the physical or physiological ‘craving’ described above that is often reported in interdose withdrawal.
These otherwise compliant patients are not looking for a ‘high,’ they are looking for relief (and most likely are seeking to function normally in the face of crippling interdose and tolerance withdrawal symptoms – that they may not even know they have, perhaps falsely attributing it to a misdiagnosed ‘disorder’—to continue to live their lives). If they were looking to get high or were badly abusing their BZ, they would be most likely taking a lot more than a handful of extra pills per month and wouldn’t be otherwise compliant in their scheduled follow-ups and the like. Any prescribing medical provider with a patient on long-term BZs should educate themselves on pseudoaddiction, tolerance, and interdose withdrawal and then use their best discretion when the evaluating a patient who is presenting requesting an increase in dose or a refill a few days before it is due.