How to safely taper off benzodiazepines (benzos)?

How to Safely Taper Off Benzodiazepines

Benzodiazepines must be tapered gradually using a 25% reduction of the current dose every 1-2 weeks, as abrupt discontinuation can cause seizures and death. 1

Critical Safety Warnings

Never abruptly discontinue benzodiazepines - this can precipitate life-threatening withdrawal including seizures, delirium, and rarely death. 1, 2, 3 Benzodiazepine withdrawal carries greater risks than opioid withdrawal and requires more cautious management. 1, 2

Seizure Risk

• Withdrawal seizures can occur even after brief therapy (as short as 15 days) at therapeutic doses. 4
• Grand mal seizures are the most common type reported, with severity ranging from single episodes to coma and death. 4
• Risk increases significantly at doses above 4 mg/day diazepam equivalent. 3
• Patients with history of withdrawal seizures must be referred to a specialist rather than managed in primary care. 1

Pre-Tapering Assessment

Before initiating any taper, assess for: 1

• Concurrent substance use disorders
• Psychiatric comorbidities (especially unstable conditions requiring specialist involvement) 1
• History of withdrawal seizures
• Concurrent opioid use (if present, taper benzodiazepines first due to higher withdrawal risks) 1, 2

Standard Tapering Protocol

Reduction Schedule

Reduce by 25% of the CURRENT dose (not the original dose) every 1-2 weeks. 1 This prevents disproportionately large final reductions that occur when calculating from the original dose. 1

For patients on benzodiazepines >1 year, slow the taper to 10% per month rather than the standard 25% every 1-2 weeks. 1

Example Tapering Schedule

For a patient on diazepam 20 mg/day: 1

• Weeks 1-2: Reduce to 15 mg/day (25% reduction)
• Weeks 3-4: Reduce to 11-12 mg/day (20-25% of current dose)
• Continue reducing by 10-25% of current dose every 1-2 weeks

Critical Principle

The taper rate must be determined by the patient's ability to tolerate reductions, not by a rigid schedule. 1 Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge. 1

Choice of Benzodiazepine for Tapering

Diazepam is convenient for tapering due to available dosage strengths and long half-life, but tapering can be carried out directly from any benzodiazepine without switching. 5

Special Consideration for Alprazolam

Alprazolam requires special handling - taper at 0.5 mg three times daily regardless of whether low-dose or high-dose withdrawal. 6

Adjunctive Medications to Ease Withdrawal

Evidence-Based Options

• Gabapentin: Start 100-300 mg at bedtime or three times daily, increase by 100-300 mg every 1-7 days as tolerated; adjust for renal insufficiency. 1
• Carbamazepine: Can help mitigate withdrawal symptoms (note: may affect alprazolam metabolism). 1
• Pregabalin: Has shown potential benefit in facilitating tapering. 1
• SSRIs (particularly paroxetine): May manage underlying anxiety during tapering. 1

Caution with Adjunctive Medications

Start gabapentin at lower doses and titrate cautiously to avoid dose-dependent dizziness and sedation. 1

Psychological Support (Essential Component)

Cognitive-behavioral therapy (CBT) during the taper increases success rates and should be offered to all patients, particularly those struggling with discontinuation. 1, 2 However, one high-quality study found that while tapering alone achieved 62% success vs 21% with usual care, adding group CBT did not further increase success rates (58% vs 62%). 7

Additional psychological interventions to incorporate: 1

• Patient education about benzodiazepine risks and benefits of tapering
• Mindfulness and relaxation techniques
• Psychotherapy as needed

For Sleep Issues

If tapering temazepam, provide sleep hygiene education rather than substituting another medication. 1

Monitoring Requirements

Follow-Up Schedule

• At least monthly contact during the taper 1
• More frequent contact may be needed during difficult phases 1

What to Monitor

• Withdrawal symptoms (anxiety, depression, seizures, altered mental status) 1
• Mood changes and suicidal ideation 1
• Screen for depression, anxiety, and substance use disorders that may emerge 1
• Warn patients of increased overdose risk if they return to previous doses after tolerance is lost 1

Special Populations

Elderly Patients

Consider a more gradual taper with smaller dose reductions to minimize adverse effects. 1, 2

Patients with Renal Insufficiency

Adjust gabapentin dosage if used as adjunct; exercise caution with clonazepam as metabolites are renally excreted. 1, 3

When to Refer to a Specialist

Mandatory specialist referral for: 1

• History of withdrawal seizures
• Unstable psychiatric comorbidities
• Co-occurring substance use disorders
• Failed office-based tapering attempts
• Significant medical comorbidities

Concurrent Opioid Use

If a patient is taking both opioids and benzodiazepines requiring discontinuation, taper the benzodiazepines first due to higher risks associated with benzodiazepine withdrawal. 1, 2 The combination significantly increases risk of respiratory depression and death. 2, 3

Alternative Inpatient Protocol

For high-dose abusers (>40 mg diazepam equivalent daily for >8 months), consider inpatient tolerance testing with diazepam followed by tapering at 10% per day. 6 A fixed-dose phenobarbital protocol over 3 days has also shown safety and effectiveness in inpatient settings. 8

Common Pitfalls to Avoid

• Never calculate reductions from the original dose - always use the current dose to prevent excessively large final reductions 1
• Don't force unwilling patients to withdraw - success requires patient engagement 5
• Don't use rigid schedules - flexibility based on patient tolerance is essential 1
• Don't ignore protracted withdrawal syndrome - symptoms can last weeks to >12 months in some cases 3