From the Guidelines
Long-term benzodiazepine use should be avoided and gradual tapering is recommended for patients already on long-term therapy to minimize withdrawal symptoms and reduce the risk of dependence, tolerance, cognitive impairment, and increased risk of falls and accidents. The risks associated with long-term benzodiazepine use are significant, and alternative treatments should be considered 1. For patients who have been on benzodiazepines for years, a slower tapering approach may be necessary, with dose reductions of 5-10% every 1-2 weeks 1.
Key Considerations for Tapering Benzodiazepines
- Gradual tapering is essential to minimize withdrawal symptoms, including anxiety, insomnia, irritability, and rarely seizures 1.
- Alternative treatments for anxiety and insomnia should be considered, including SSRIs or SNRIs for anxiety disorders and cognitive behavioral therapy for both conditions 1.
- Elderly patients are particularly vulnerable to adverse effects, including falls, fractures, and cognitive impairment 1.
- The EMPOWER trial demonstrated success in tapering benzodiazepines by targeting education about benzodiazepine risks and benefits of tapering, with 62% of independent seniors expressing interest in benzodiazepine changes, and 27% of patients stopping benzodiazepines compared with 5% in the control group 1.
Monitoring and Support During Tapering
- Patients should be monitored for withdrawal symptoms during tapering 1.
- A supportive approach, including education and self-empowerment, can help patients succeed in tapering benzodiazepines 1.
- Clinicians should collaborate with patients and share decision-making about whether and how to taper benzodiazepines 1.
- Open discussion between the clinician and patient should take place to determine the goal of the taper, whether it is stopping benzodiazepines or reducing them to a point where benefits outweigh risks 1.
From the FDA Drug Label
Abuse and misuse of benzodiazepines may lead to addiction Dependence Physical Dependence Diazepam may produce physical dependence from continued therapy. To reduce the risk of withdrawal reactions, use a gradual taper to discontinue diazepam or reduce the dosage
Long-term benzodiazepine use can lead to physical dependence and addiction.
- Abuse and misuse of benzodiazepines may occur even when taken as prescribed.
- Physical dependence can develop from continued therapy, and withdrawal reactions can occur with abrupt discontinuation or rapid dosage reduction.
- A gradual taper is recommended to reduce the risk of withdrawal reactions when discontinuing or reducing the dosage of diazepam 2.
- Tolerance to diazepam may also develop from continued therapy 2.
- Adverse reactions associated with long-term benzodiazepine use include cognitive impairment, depression, insomnia, and motor symptoms 2 2.
From the Research
Long-term Benzodiazepine Use
- Long-term benzodiazepine use can lead to severe, harmful psychological and physical dependence, resulting in withdrawal symptoms similar to those of alcohol withdrawal 3.
- The risks of overuse, dependence, and addiction with benzodiazepines are low in relation to the massive exposure in society, but benzodiazepine addiction can occur when doses within the clinical range are taken regularly over about 6 months 4.
- Many patients continue to derive benefit from long-term treatment with benzodiazepines, but attitudes strongly against the use of these drugs may be depriving many anxious patients of appropriate treatment 4.
Factors Associated with Long-term Use
- Long-term benzodiazepine use increases with age, with 20.7%, 41.0%, and 57.4% of incident users becoming long-term users in the 0-17,18-64, and ≥65-year-old age groups, respectively 5.
- Prescribing-related factors, such as multiple benzodiazepines at initiation and concurrent dispensing of other medications, are associated with increased risks of long-term use 5.
- Four benzodiazepine use trajectories have been identified: 'discontinued', 'decreasing', 'slow decreasing', and 'maintained', with the proportion of 'discontinued' trajectory members decreasing with age 5.
Treatment Options
- Benzodiazepines, such as diazepam and clonazepam, are used to treat parasomnias, but data on efficacy are limited, and most information comes from anecdotal case reports, case series, or small open-label trials 6.
- Combining selective serotonin reuptake inhibitors and cognitive behavioral therapy has been shown to be effective in treating youth with depression and anxiety, with the added value of cognitive behavioral therapy occurring late in treatment 7.