How to safely taper off benzodiazepines after long-term use?

Benzodiazepine Tapering After Long-Term Use

Direct Answer

For patients on benzodiazepines for years, implement a gradual taper reducing by 10-25% of the current dose every 1-2 weeks, with the understanding that this will require a minimum of 6-12 months and potentially much longer, while integrating cognitive-behavioral therapy to significantly improve success rates. 1

Critical Safety Framework

Never discontinue benzodiazepines abruptly—this can cause seizures and death, making it as dangerous as suddenly stopping antihypertensives or antihyperglycemics. 1 Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must always be conducted gradually. 1

Life-Threatening Withdrawal Symptoms to Monitor

• Grand mal seizures can occur, ranging from single episodes to coma and death 2
• Seizures have been reported even with less than 15 days of use at therapeutic dosages, though they are more common in long-term, high-dose users 2
• Other serious withdrawal symptoms include anxiety, tremor, insomnia, sweating, tachycardia, confusion, altered mental status, and perceptual hypersensitivity 1

Tapering Protocol

Standard Approach for Long-Term Users

• Reduce by 10-25% of the current dose (not the original dose) every 1-2 weeks 1
• For patients on benzodiazepines for more than 1 year, consider extending to 10% per month rather than the faster schedule 1
• The taper rate must be determined by the patient's tolerance to withdrawal symptoms, not by a rigid schedule 1, 3
• Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge 1

Example Tapering Schedule

• If starting at diazepam 20 mg/day: reduce to 15 mg/day (25% reduction) in weeks 1-2, then to 11-12 mg/day (20-25% of current dose) in weeks 3-4, continuing to reduce by 10-25% of the current dose every 1-2 weeks 1
• Once the smallest available dose is reached, extend the interval between doses before complete discontinuation 1

Realistic Timeline

• Expect a minimum of 6-12 months for the taper, and possibly much longer 1
• Some patients may need to extend their taper over many months to years to avoid debilitating withdrawal symptoms 3
• The goal is durability of the taper, not speed—tapers are considered successful as long as the patient is making progress 1

Adjunctive Strategies to Maximize Success

Cognitive-Behavioral Therapy (Essential)

• Integrating CBT during the taper significantly increases success rates and should be incorporated 1, 4
• In a randomized trial, 77% of patients receiving CBT plus tapering achieved complete benzodiazepine discontinuation immediately post-treatment versus only 38% with tapering alone (OR 5.3), with benefits sustained at 12 months (70% vs 24%, OR 7.2) 4
• CBT can be provided in weekly small-group sessions over 8 weeks 4

Additional Non-Pharmacological Support

• Patient education about benzodiazepine risks and benefits of tapering improves outcomes and engagement 1
• Mindfulness and relaxation techniques should be incorporated 1
• Sleep hygiene education rather than substituting another medication for sleep issues 1
• Exercise and fitness training 1

Pharmacological Adjuncts for Withdrawal Symptoms

Gabapentin (First-Line Adjunct)

• Start with 100-300 mg at bedtime or three times daily 1, 3
• Increase by 100-300 mg every 1-7 days as tolerated 1
• Adjust dosage in patients with renal insufficiency 1
• Helps mitigate withdrawal symptoms during tapering 1

Other Adjunctive Medications

• Carbamazepine: May assist discontinuation, particularly in patients receiving ≥20 mg/day diazepam equivalents 1, 5; in one study, significantly more patients receiving carbamazepine remained benzodiazepine-free 5 weeks after taper compared to placebo 5
• Pregabalin: Has shown potential benefit in facilitating tapering 1, 3
• SSRIs (particularly paroxetine): May help manage underlying anxiety during tapering 1, 3
• Trazodone: Can be used for short-term management of insomnia during tapering 1
• NSAIDs or acetaminophen: For muscle aches 1

Important Caveat About Adjunctive Medications

• Antiseizure medications themselves require tapering to avoid substituting one drug dependence for another 1

Monitoring Requirements

Follow-Up Schedule

• Follow up at least monthly during the taper, with more frequent contact needed during difficult phases 1, 3
• Monitor for withdrawal symptoms at each visit 1
• Screen for depression, anxiety, and substance use disorders that may emerge during tapering 1
• Monitor for mood changes and suicidal ideation 1

Prescription Drug Monitoring

• Check the Prescription Drug Monitoring Program (PDMP) to identify all controlled substances the patient is receiving 1

Post-Taper Warning

• Advise patients of increased overdose risk if they return to previous doses after tolerance is lost 1

Special Populations and Situations

Elderly Patients

• Use lower doses and more gradual tapers due to increased risks of sedation, cognitive impairment, falls, and fractures 1
• Long-acting agents like diazepam pose particular concerns in this population 1
• Benzodiazepines are associated with cognitive impairment, reduced mobility, unsafe driving, decline of functional independence, falls, fractures, and addiction in elderly patients 1

Pregnant Patients

• Should not taper benzodiazepines during pregnancy without specialist consultation, as withdrawal can cause spontaneous abortion and premature labor 1

Patients on Concurrent Opioids

• When both opioids and benzodiazepines need to be discontinued, taper the benzodiazepines first due to higher withdrawal risks 1
• Maintain the opioid dose stable during benzodiazepine tapering 1
• Avoid prescribing additional CNS depressants during the tapering period 1

When to Refer to a Specialist Immediately

• History of withdrawal seizures 1
• Unstable psychiatric comorbidities 1
• Co-occurring substance use disorders 1
• Previous unsuccessful office-based tapering attempts 1
• Patients with medical comorbidities requiring specialized management 1

Key Pitfalls to Avoid

Never Abandon the Patient

• Maintain the therapeutic relationship even if tapering is unsuccessful 1
• Consider maintenance therapy if complete discontinuation proves impossible 1
• Research shows that even a 10% reduction every 3 days resulted in only 24% of patients completing withdrawal successfully—this is too fast 1

Never Taper Too Quickly

• Approximately one-third of long-term users experience symptoms and signs on attempting to withdraw 6
• The usual method of slow tapering may not obviate problems completely, but it is essential 6

Do Not Substitute Other Problematic Medications

• Do not substitute another benzodiazepine or Z-drug (zolpidem, zaleplon) as these carry similar risks 1

Pre-Tapering Assessment

Before initiating the taper, assess for:

• Concurrent substance use disorders 1
• Psychiatric comorbidities 1
• History of withdrawal seizures 1
• Current benzodiazepine dose and duration of use 1
• All controlled substances the patient is receiving via PDMP 1