Benzodiazepine Tapering Guidelines
Benzodiazepine withdrawal should be managed through a planned, gradual tapering approach over 8-12 weeks with conversion to long-acting benzodiazepines, along with appropriate psychosocial support to minimize withdrawal symptoms and prevent severe complications. 1
Tapering Approach
General Principles
- Never discontinue benzodiazepines abruptly unless there are life-threatening issues (confusion, sedation, slurred speech) 2
- Convert short-acting benzodiazepines to equivalent doses of long-acting benzodiazepines (preferably diazepam) before tapering 1
- Diazepam is preferred for most patients due to its long half-life, with lorazepam preferred for patients with liver disease, respiratory issues, or advanced age 1
Tapering Schedule
- For short-term users (< 1 month): Taper over 4 weeks on an outpatient basis 3
- For long-term users (≥ 1 year): Tapers of 10% per month or slower are better tolerated than more rapid tapers 2, 1
- Standard recommendation: Reduce dose by 10% of the original dose per week 1
- For high-dose users (> 40mg diazepam equivalent daily for > 8 months): Consider inpatient management with 10% reduction per day 3
- For alprazolam specifically: Titrate at a rate of 0.5 mg three times a day regardless of whether tapering for low- or high-dose withdrawal 3
Monitoring and Follow-up
- Follow up frequently (at least monthly) with patients during tapering 2
- Weekly contact during active tapering is recommended to monitor withdrawal symptoms, mood changes, anxiety, suicidal ideation, and medication adherence 1
- Team members (nurses, pharmacists, behavioral health professionals) can support through telephone contact, telehealth, or face-to-face visits 2
Managing Withdrawal Symptoms
Common Withdrawal Symptoms
- Anxiety, insomnia, abdominal pain, vomiting, diarrhea, diaphoresis, mydriasis, tremor, tachycardia, piloerection 2
- More severe symptoms: seizures, delirium, hallucinations, psychosis 4
Adjusting the Taper
- If clinically significant withdrawal symptoms emerge, slow the taper rate 2
- Return to the previous dose and resume tapering at a slower rate if symptoms become intolerable 1
- Tapers might need to be paused and restarted when the patient is ready 2
- Slow the taper further as patients reach low dosages 2
Adjunctive Treatments
Pharmacological
- Carbamazepine may have promise as an adjunctive therapy, particularly for patients on higher doses (≥20 mg/d diazepam equivalents) 5, 6
- Consider antidepressants if the patient is depressed before withdrawal or develops depression during withdrawal 6
Non-pharmacological
- Cognitive-behavioral therapy, relaxation techniques, and patient education improve success rates 1
- Supportive psychotherapy and integrative strategies are recommended for managing withdrawal 1
Special Populations
High-risk Patients
- Patients with history of seizures, delirium, or concurrent substance use require inpatient management 1
- Use structured taper approach with long-acting benzodiazepines and symptom-triggered dosing for breakthrough symptoms 1
Elderly Patients
- Use medications with caution due to increased sensitivity to adverse effects 1
- Consider more gradual tapering approach to minimize risks 1
Pregnant Patients
- Consult appropriate expertise before tapering due to risks to both mother and fetus 1
- Consider more gradual tapering approach to minimize risks 1
Pitfalls and Caveats
- Psychological dependence risk increases at doses greater than 4 mg/day and with longer-term use 7
- Risk is further increased in patients with history of alcohol or drug abuse 7
- Withdrawal symptoms may be difficult to distinguish from recurrence of the original condition 7, 4
- Protracted withdrawal syndrome may persist beyond 4-6 weeks after initial withdrawal 4
- Patients may require antidepressant therapy for depression or panic that emerges during or after withdrawal 5
By following these guidelines, clinicians can help patients successfully discontinue benzodiazepines while minimizing withdrawal symptoms and maintaining quality of life.