Is it safe to continue long-term Temazepam (temazepam) in a 64-year-old male?

Long-Term Temazepam Use in a 64-Year-Old Male: Discontinuation Strongly Recommended

Long-term temazepam use in a 64-year-old male is not safe and should be discontinued through a gradual taper, as benzodiazepines in older adults are associated with cognitive impairment, falls, fractures, dementia risk, and loss of functional independence. 1

Why Continuation is Inappropriate

Age-Related Risks

• The 2019 American Geriatrics Society Beers Criteria explicitly recommends avoiding all benzodiazepines, including temazepam, in older adults due to increased sensitivity and substantial risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes. 1
• Benzodiazepines are associated with reduced mobility, unsafe driving skills, decline of functional independence, and addiction in elderly patients. 1
• Observational data demonstrates that benzodiazepines with prolonged use are associated with dementia, with the effect being greatest for higher-dose hypnotics. 1

Limited Long-Term Efficacy

• Guidelines universally recommend benzodiazepines solely on a short-term basis (ideally 4 weeks maximum, occasionally 2-4 weeks for anxiety). 1, 2
• Temazepam shows effectiveness with short-term use but evidence for continued efficacy with long-term administration is lacking. 3
• Around half of patients dispensed benzodiazepines have been treated continuously for at least 12 months, often beyond guideline recommendations. 4

Recommended Tapering Protocol

Initial Assessment Before Tapering

• Check the Prescription Drug Monitoring Program to identify all controlled substances the patient is receiving. 5
• Assess for concurrent substance use disorders, psychiatric comorbidities, and history of withdrawal seizures. 5, 6
• Screen for depression, anxiety, and substance use disorders that may emerge during tapering. 5

Standard Tapering Schedule

• Reduce by 10-25% of the current dose (not the original dose) every 1-2 weeks. 5, 6
• For patients on benzodiazepines for more than 1 year, consider extending the taper to 10% per month rather than 10-25% every 1-2 weeks. 5
• The taper rate must be determined by the patient's tolerance, not a rigid schedule, and pauses are acceptable when withdrawal symptoms emerge. 5, 6
• Expect a minimum duration of 6-12 months for the complete taper. 5

Example Tapering Schedule for Temazepam

If the patient is on temazepam 30 mg nightly:

• Weeks 1-2: Reduce to 22.5 mg (25% reduction) 5
• Weeks 3-4: Reduce to 17-18 mg (20-25% of current dose) 5
• Weeks 5-6: Reduce to 13-14 mg (20-25% of current dose) 5
• Continue reducing by 10-25% of the current dose every 1-2 weeks until reaching the lowest available dose. 5
• Once the smallest dose is reached, extend the interval between doses before complete discontinuation. 5

Critical Safety Warnings

• Abrupt discontinuation can cause seizures and death—never stop suddenly. 1, 5, 6
• Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must always be conducted gradually. 5
• Monitor for withdrawal symptoms including anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion, and seizures. 5, 4

Adjunctive Strategies to Improve Success

Non-Pharmacological Support (Essential)

• Cognitive-behavioral therapy (CBT) during the taper significantly increases success rates and should be incorporated. 1, 5, 4
• Patient education about benzodiazepine risks and benefits of tapering improves outcomes and engagement. 1, 5
• For sleep issues during temazepam tapering, provide sleep hygiene education rather than substituting another medication. 5
• Additional supportive measures include mindfulness and relaxation techniques, exercise, and fitness training. 5

Pharmacological Adjuncts (Optional)

• Gabapentin can help mitigate withdrawal symptoms: Start with 100-300 mg at bedtime or three times daily, increasing by 100-300 mg every 1-7 days as tolerated. 5, 6, 4
• Carbamazepine may assist benzodiazepine discontinuation, though it may affect metabolism of some benzodiazepines. 1, 4
• Pregabalin has shown potential benefit in facilitating benzodiazepine tapering. 1, 4
• SSRIs (particularly paroxetine) may help manage underlying anxiety during tapering. 1, 4

Monitoring Requirements

Follow-Up Schedule

• Follow up at least monthly during the taper, with more frequent contact needed during difficult phases. 5, 4
• Monitor for withdrawal symptoms, mood changes, and suicidal ideation at each visit. 5
• Assess withdrawal symptoms and their severity systematically. 5

What to Monitor

• Anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion, or altered mental status. 5, 4
• Screen for depression, anxiety, and substance use disorders that may emerge during tapering. 5
• Advise patients of increased overdose risk if they return to previous doses after tolerance is lost. 5, 6

When to Refer to a Specialist

Immediate specialist referral is indicated for: 5, 6, 4

• History of withdrawal seizures (never manage in primary care)
• Unstable psychiatric comorbidities
• Co-occurring substance use disorders
• Previous unsuccessful office-based tapering attempts

Common Pitfalls to Avoid

• Never taper too quickly: Research shows that even a 10% reduction every 3 days resulted in only 24% of patients completing withdrawal successfully. 5
• Never abandon the patient: Even if tapering is unsuccessful, maintain the therapeutic relationship and consider maintenance therapy. 5
• Never calculate reductions as a percentage of the original dose: This creates disproportionately large final reductions that trigger severe withdrawal. 5, 6
• Do not substitute another benzodiazepine or Z-drug (zolpidem, zaleplon) as these carry similar risks in older adults. 1

Realistic Expectations

• The taper will likely take 6-12 months minimum, possibly longer. 5
• Patient agreement and interest in tapering is a key component of success. 5
• Tapers may be considered successful as long as the patient is making progress—the goal is durability of the taper, not speed. 5
• Research demonstrates that withdrawal from chronic benzodiazepine use can improve perceived sleep, reduce daytime fatigue, alleviate stress, and improve quality of life within 6 months. 7