What are the guidelines for benzodiazepine (BZD) refills?

Guidelines for Benzodiazepine Refills

Benzodiazepine refills should be limited to short-term use (2-4 weeks maximum) with careful monitoring for dependence, and long-term prescriptions should be avoided due to significant risks of tolerance, dependence, and withdrawal symptoms. 1, 2

General Principles for Benzodiazepine Prescribing

• Benzodiazepines should generally be prescribed for the shortest duration possible, ideally limited to 2-4 weeks, to minimize risks of dependence and withdrawal 1, 2
• Long-term prescribing contradicts clinical guidelines, as approximately 50% of patients prescribed benzodiazepines continue them for at least 12 months, despite recommendations against this practice 3
• Regular use, even at low therapeutic doses, can lead to tolerance, addiction, depression, and cognitive impairment 1
• Maximum recommended dose is 2 mg/day of any high-potency benzodiazepine when given for more than 1 week 4

Specific Refill Guidelines

• For anxiety disorders: Benzodiazepines should be used in conjunction with other treatments (psychological interventions, antidepressants) and limited to:

  • Single doses for acute stress reactions
  • Very short courses (1-7 days)
  • Short courses (2-4 weeks)
  • Rarely for longer-term treatment 2

• For insomnia: Prescriptions should be limited to:

  • A few days
  • Occasional or intermittent use
  • Courses not exceeding 2 weeks 2

• For patients already on long-term therapy:

  • Assess for signs of dependence before each refill (tolerance, withdrawal symptoms between doses) 5
  • Document clear justification for continued therapy beyond 4 weeks 1, 2
  • Consider gradual dose reduction for patients on long-term therapy 5

Risk Assessment Before Refills

• Higher risk of dependence is associated with:

  • Doses greater than 4 mg/day (alprazolam equivalent)
  • Treatment duration exceeding 12 weeks 5
  • History of substance use disorders 6
  • Female gender and age 45-74 years 3
  • Higher levels of socioeconomic deprivation 3

• Contraindications for refills:

  • Signs of misuse or diversion
  • Concurrent use with opioids (increased risk of respiratory depression) 3
  • Pregnancy or nursing 1

Special Population Considerations

• Elderly patients:

  • Require lower doses due to increased sensitivity and risk of falls 1, 7
  • Should preferentially receive short-acting benzodiazepines that are not oxidized (e.g., lorazepam, temazepam) 7
  • Duration should not exceed 2-3 months 7

• Patients with substance use disorders:

  • Benzodiazepine use should be strictly limited and dispensing supervised 6
  • Higher risk of complications including overdose and suicide attempts 6

Monitoring and Documentation Requirements

• Before each refill, document:

  • Continued therapeutic benefit
  • Absence of adverse effects
  • No signs of misuse or diversion
  • Ongoing plan for eventual discontinuation 1, 8

• Implement a tracking system to identify patients at risk of dependence, as the main prescribing physician can identify patient risk level in 80-90% of cases 8

Alternative Approaches

• For anxiety: Consider buspirone, SSRIs, or SNRIs as alternatives with lower dependence potential 9
• For insomnia: Consider non-benzodiazepine options such as:
  • Cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment
  • Melatonin receptor agonists (e.g., ramelteon)
  • Low-dose doxepin (3-6 mg)
  • Non-benzodiazepine BZRAs (e.g., zolpidem, zaleplon, eszopiclone) at lowest effective doses 1, 9

Withdrawal Management

• Patients on long-term therapy may experience significant withdrawal symptoms including:

  • Heightened sensory perception
  • Impaired concentration
  • Paresthesias
  • Muscle cramps
  • Anxiety and insomnia 5

• Tapering is essential for discontinuation after long-term use:

  • 71-93% of patients on alprazolam can successfully taper completely off therapy 5
  • Duration of treatment (3 vs 6 months) does not affect ability to taper to zero dose 5