What is the recommended protocol for withdrawing from Klonopin (clonazepam)?

Klonopin (Clonazepam) Withdrawal Protocol

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

Critical Safety Considerations

Never discontinue clonazepam abruptly - this carries significantly greater risks than opioid withdrawal and can result in life-threatening complications including:

• Seizures (potentially fatal) 1, 2
• Delirium tremens 1
• Hallucinations 1
• Rebound anxiety 1
• Death (rare but documented) 1, 3

The FDA label explicitly warns that "abrupt discontinuation or rapid dosage reduction may precipitate acute withdrawal reactions, which can be life-threatening (e.g., seizures)." 2

Standard Tapering Protocol

Recommended Taper Schedule

Reduce the dose by 25% of the current dose every 1-2 weeks - this is the most commonly used and safest tapering schedule with moderate success rates. 1, 3

For patients on intermediate-term use (3+ years), reduce by 0.25 mg per week once reaching 1 mg/day:

• Decrease by 0.5 mg every 2 weeks until reaching 1 mg/day 4
• Then decrease by 0.25 mg per week 4
• This protocol achieved 68.9% medication-free status at 4 months, with an additional 26% requiring 3 more months 4

Alternative Slower Approach

For elderly patients or those with higher risk factors, consider more gradual reductions:

• Reduce by 10% or less of the most recent dose per month 1
• Some patients may require tapering over many months to years 1
• Each new dose should be 90% of the previous dose (not a straight-line taper) 1

Withdrawal Symptom Management

Expected Withdrawal Symptoms

Common mild-to-moderate symptoms include: 4

• Anxiety (most common)
• Tremor/shaking
• Insomnia/nightmares
• Nausea/vomiting
• Excessive sweating
• Tachycardia/palpitations
• Headache
• Muscle aches and weakness

Severe withdrawal symptoms requiring immediate attention: 2

• Seizures
• Delirium tremens
• Hallucinations
• Catatonia
• Severe depression or suicidal ideation
• Psychosis

Adjunctive Treatment Strategies

Cognitive Behavioral Therapy (CBT) significantly increases tapering success rates and should be offered to all patients, particularly those struggling with the taper. 1, 3

For anxiety management after benzodiazepine discontinuation, offer: 1

• Evidence-based psychotherapies (especially CBT)
• Specific antidepressants approved for anxiety
• Other non-benzodiazepine medications for anxiety

Special Circumstances

Concurrent Opioid Use

If the patient is taking both benzodiazepines and opioids that require tapering, taper the opioid FIRST - benzodiazepine withdrawal carries greater mortality risk than opioid withdrawal. 1, 3

The combination of benzodiazepines and opioids increases overdose death risk nearly four-fold compared to opioids alone. 1

Patient Abandonment Concerns

Abrupt withdrawal or major dose reduction constitutes unacceptable medical care except in extreme cases such as confirmed diversion or serious medical toxicity. 1

Clinicians are obligated to either:

1. Offer a comfortable and safe tapering regimen
2. Obtain agreement from another physician to provide care
3. Provide alternative treatment options

"Sudden cessation is no more appropriate with benzodiazepines than with antihypertensives or antihyperglycemics." 1

Protracted Withdrawal Syndrome

Some patients develop protracted withdrawal lasting weeks to more than 12 months after initial discontinuation, characterized by: 2

• Persistent anxiety
• Cognitive impairment
• Depression
• Insomnia
• Motor symptoms (weakness, tremor, muscle twitches)
• Paresthesia and tinnitus

This syndrome persists beyond 4-6 weeks after initial withdrawal and requires ongoing monitoring and support. 2

Monitoring Requirements

Close observation and support during the taper are critical: 1

• Clinician availability to treat symptoms and manage fears
• Regular assessment for withdrawal symptoms
• Monitoring for return of original anxiety symptoms
• Assessment for depression or suicidal ideation 2

Set patients up for success by: 1

• Communicating individualized goals and expectations at the start
• Addressing patient fears
• Establishing contingency plans if problems arise (e.g., pause taper, slow the rate)
• Implementing very small dose decreases initially to build patient confidence

Common Pitfalls to Avoid

• Never taper too rapidly - this increases risk of seizures and treatment failure 1, 3
• Do not dismiss withdrawal symptoms as "just anxiety" - they represent real physiological changes requiring management 2
• Avoid "cold referrals" to other clinicians without confirmed acceptance of care 1
• Do not assume all patients can tolerate the same taper rate - adjust based on individual tolerance 1
• Never stop monitoring after successful discontinuation - protracted withdrawal can emerge months later 2