Possible med interactions with benzo taper and bruxism

[cduggles]

Hi. I would appreciate help from this venerated forum.
Background: stopped taking oxycodone at 80 mg in November. No relapse.
Started 300mg bupropion after oxycodone taper in November and added 75mg venlafaxine for PAWS-related depression.

Benzos:
Began taking alprazolam in 2010, increased to 4mg per day for anxiety until end of 2016. (Insurance issue.)
Switched from alprazolam to clonazepam at the beginning of this year, 2017.
Currently dropping 0.25mg clonazepam per 10 days and am now tapered down to 1.25mg per day from original 4mg.
Questions:
1. Is clonazepam or diazepam better to finish the taper? (I've read the Ashton method and I have read threads here regarding half-life versus duration of activity and there doesn't seem to be a clear choice.)

2. Are 300mg bupropion and 75 mg venlefaxine pharmaceutically good choices? They have worked well in the past for me. I didn't want to increase bupropion while tapering clonazepam due to seizure risk.

3. I am experiencing clonazepam withdrawal-related bruxism and have moderate TMJ as well. Any suggestions regarding something to help tone the bruxism down? I've seen propanol, clonidine, neurontin and magnesium suggested. I don't believe I have a Mg deficiency.

Also if anyone wants to comment on the speed of the taper, please do. My symptoms were limited to bruxism, although the anxiety has increased as I dropped below 1.5mg.
To be honest, I just don't want to mess up my glutamate or anything else. If I could CT I would, but it seems like a bad idea.

Thank you! CD

 

[Tranced]

1. Both are considered the go to benzos for tapering as far as I'm aware. It may differ between countries from what I can see; I notice a lot of UK blers taking diazepam, whereas certain other countries seem to sometimes go for clonazepam.

3. Whenever I had bruxism from benzo withdrawal it was because my body was close to a seizure. You're not experiencing any brain zaps or hypnogergic jerks are you? Not to freak you out or anything, but maybe it's worth discussing with a doctor... Especially if it came on quite recently/rapidly.

If you're having withdrawals then maybe you need to slow the taper? Again, it's something to discuss with your doctor. Perhaps it's unavoidable and perhaps it's partially caused by anxiety. Propranolol will reduce the symptoms of physical anxiety to some degree, and magnesium is effective at reducing bruxism. It certainly wouldn't hurt to try some magnesium.

Both could help, but maybe the issue needs addressing directly. I'm unsure though because I have no experience of benzo withdrawal bruxism apart from, like I say, when I was in a pretty severe, borderline, seizure state.

 

[cduggles]

I think I should address #3 now: no brain zaps or hypnagogic jerks.
I've had bruxism for weeks it's just getting annoying.
Oh, and I have a tiny bit of RLS where my feet dance around. It's not unbearable.
Knock on wood.
I will discuss it with my doctor, although he'd never heard of Ashton and didn't know what to prescribe for RLS.
He is a nice doctor though and I think he will work with me.
Thanks! CD

 

[d1nach]

I put food in my mouth and try to suck on it without chewing it help me relax my jaw and keeps salvia forming . I take effexor too i think it is some kind of autoimmune problem where my immune system attacks my mouth because it feels like there is a war going on inside me also i drink alot of whole milk to coat my mouth

 

[Cotcha Yankinov]

Mindfulness to enhance bodily awareness can help with clenching, in addition some jaw pain can be caused by improper breathing mechanics - try to let the breath flow deeply through the stomach.

 

[adder]

My guess is that antidepressants add to your symptoms of anxiety and bruxism. If they can cause such side effects by themselves, surely they can exacerbate symptoms of benzodiazepine withdrawal. I don't understand this recent trend of mixing antidepressants, quite a few of such threads I've seen recently and there is no good point in that in my opinion. If you have to take an antidepressant, I suppose it's always safer and easier to control side effects with one antidepressant as opposed to two or more even if the dose needs to be increased. I myself would avoid anything increasing noradrenaline and adrenaline during tapering, I myself avoid antidepressants in general as they only add another problem in my opinion.

However, at this point I wouldn't suddenly stop taking antidepressants either, the withdrawal from them is a nightmare too, not as much as opioid or benzodiazepine withdrawal in my experience but abrupt discontinuation without being stable on benzodiazepines might be more dangerous in this case. Nonetheless, I would consider dropping bupropion with your doctor.

A couple of articles so as not to leave my opinion completely not backed up by anything:

http://jaoa.org/article.aspx?articleid=2093332
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1894833
https://www.ncbi.nlm.nih.gov/pubmed/2500425
https://www.ncbi.nlm.nih.gov/pubmed/11144696
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0100-879X2002000400010

 

[Solipsis]

Agreed with adder on pretty much all accounts..

Doubtful if it's really worth switching to diazepam at this point if you can manage with your current clonazepam regimen and the ups and downs during the day, I guess you could split your clonazepam dose over two moments in the day. Diazepam may have a relatively disappointing duration of noticeable effects compared to it's halflife but as far as warding off withdrawals I think it's still very worthwhile to maintain with thanks to the long metabolism and ignoring that short window of proactive effects.

Avoid a chain reaction of remedying one side-effect with another pharmaceutical. These antidepressants probably do exacerbate restlessness and bruxism but the options you have are not clear. Try to avoid interactions including metabolic ones from adding new pharmaceuticals if you can.
It's to be expected that the last steps are heaviest and regarding some symptoms they may be hard to avoid in the end. Magnesium does work best if there is any kind of deficiency but possibly a lot of people have a benign deficiency and in most of those cases supplementing to maintain proper muscle tone can help and is a relatively minor effort/risk afaik. Effexor reduces the effects of clonidine anyway.

Gabapentinoids may help quite a number of your symptoms even beyond bruxism (is it sleep bruxism mostly? you could wear a brace although that might not help TMJ issues) but I would still be concerned about the number of interactions.

Indeed if anything taper/drop the bupropion as dropping effexor is potentially pretty heavy itself. Don't taper two things at the same time though, so you have a choice IMO: depending on whether your symptoms are only uncomfortable or actually damaging among other reasons, to possibly just opt for proceeding the taper as is. Maybe a little slower, I don't recall the Ashton manual by heart, it seems fine but I would not go faster than this.
Probably better to drop in dose a little faster initially and go slow at the end.

Not sure why the glutamate is a concern of "getting fucked up" but definitely don't CT as that bears more risks of longer PAWS etc. Which is not so much a glutamate problem as a glutamate vs. GABA problem due to GABA receptor dysfunction as you need to carefully recover from the tolerance effects like decoupling and even changed receptor conformation.
I'd first just get through the detox unscathed and with as few complications as possible (including making it more complicated pharmaceutically yourself) before seeing whether you have especially intolerable PAWS.

 

[cduggles]

Hello All,
Thank you. I have gratefully perused your comments multiple times.

d1nach You have given me some good ideas. Thanks!

CY I am doing CBT for anxiety and I will incorporate some deep relaxation/breathing techniques to help with the bruxism. Many thanks.

adder Thank you for the practical advice and the references. It might not seem like it, but I am a medical researcher (different area) and the references will be devoured.

Solipsis
Two practical points:
1) I am splitting the clonazepam into .25mg doses 5x a day because of the bruxism.
2) As implied, the bruxism is constant. I'm not sure if it's getting worse or just more annoying. I now have a mouth guard to try.

I am trying to avoid adding anything pharmaceutical, including baclofen or neurontin, particularly the latter due to tolerance buildup and another taper, as long as the bruxism is bearable.

(Apologies about the informal wording regarding glutamate getting "messed up". I ended in haste. I do understand radiating effects from altering pre/post synaptic regulation of an NT on others, so don't hold back!)

Again, thank you all. I value your time and consideration.
Best, CD