How to Deprescribe Benzodiazepines
Critical Safety Warning
Abrupt discontinuation of benzodiazepines is never appropriate and can cause seizures and death—always use a gradual taper. 1, 2, 3 Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must be conducted with extreme caution. 1, 2
Pre-Taper Assessment
Before initiating any taper, evaluate the following:
- Check the Prescription Drug Monitoring Program (PDMP) to identify all controlled substances the patient is receiving 1
- Screen for concurrent substance use disorders, as these patients require specialist referral 1
- Assess for psychiatric comorbidities (depression, anxiety disorders, panic disorder) and determine if they are stable or unstable 1
- History of withdrawal seizures is an absolute indication for specialist referral rather than primary care management 1
- Concurrent opioid use: If both medications need tapering, taper benzodiazepines first due to higher withdrawal risks 1, 2
- Pregnancy status: Pregnant patients should not taper without specialist consultation, as withdrawal can cause spontaneous abortion and premature labor 1
Tapering Protocol
Standard Taper Schedule
Reduce by 10-25% of the CURRENT dose (not the original dose) every 1-2 weeks. 1, 3 This percentage-based reduction prevents disproportionately large final reductions. 1
For patients on benzodiazepines >1 year, slow to 10% per month to improve tolerability and success rates. 1
Specific Example for Diazepam 20mg/day:
- Weeks 1-2: Reduce to 15 mg/day (25% reduction) 1
- Weeks 3-4: Reduce to 11-12 mg/day (20-25% of current 15mg dose) 1
- Continue: Reduce by 10-25% of current dose every 1-2 weeks 1
- Final stages: Once the smallest available dose is reached, extend the interval between doses before complete discontinuation 1
Critical Tapering Principles
- The taper rate must be determined by the patient's tolerance, not a rigid schedule 1
- Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge 1
- Tapers may take 6-12 months minimum, possibly longer—the goal is durability, not speed 1
- Clinically significant withdrawal symptoms signal the need to slow the taper rate 1
Switching to Diazepam
Consider converting to diazepam before tapering, as it is available in liquid formulation allowing precise dose adjustments. 4 Diazepam's longer half-life may also reduce withdrawal severity compared to short-acting agents. 5
Monitoring Requirements
Follow up at least monthly during the taper, with more frequent contact during difficult phases. 1
Monitor for Withdrawal Symptoms:
- Anxiety, panic attacks, tremor 1
- Insomnia, sweating, tachycardia 1
- Headache, weakness, muscle aches 1
- Nausea, confusion, altered mental status 1
- Seizures (medical emergency) 1, 2
- Depression and suicidal ideation 1
Additional Monitoring:
- Screen for depression, anxiety, and substance use disorders that may emerge during tapering 1
- Advise patients of increased overdose risk if they return to previous doses after tolerance is lost 1
Adjunctive Pharmacological Support
Evidence-Based Medications:
- Carbamazepine (200-800 mg/day): May assist discontinuation, particularly for patients on ≥20mg diazepam equivalents daily 1, 6 Note: May affect alprazolam metabolism 1
- Gabapentin: Start 100-300mg at bedtime or TID, increase by 100-300mg every 1-7 days as tolerated; adjust for renal insufficiency 1
- Pregabalin: Has shown potential benefit in facilitating tapering 1
- SSRIs (particularly paroxetine): May manage underlying anxiety during tapering 1
- Trazodone: For insomnia during taper (short-term use) 1
- NSAIDs or acetaminophen: For muscle aches 1
Important caveat: Antiseizure medications themselves require tapering to avoid substituting one dependence for another. 1
Non-Pharmacological Interventions (Essential for Success)
Cognitive-behavioral therapy (CBT) during the taper significantly increases success rates and should be incorporated. 1, 2, 4 This is one of the most evidence-based interventions.
Additional Supportive Measures:
- Patient education about benzodiazepine risks and benefits of tapering improves outcomes and engagement 1, 2
- Mindfulness and relaxation techniques 1
- Sleep hygiene education (especially for temazepam tapering—do not substitute another medication) 1
- Exercise and fitness training 1
- Problem-solving therapy or brief CBT-based interventions for acute distress 1
Special Populations
Elderly Patients:
- Use lower doses and more gradual tapers due to increased risks of sedation, cognitive impairment, falls, fractures, and loss of functional independence 1
- Long-acting agents like diazepam pose particular fall risks in elderly patients 1
- Benzodiazepines are associated with dementia risk, with greatest effect for higher-dose hypnotics 1
Patients with Depression:
- Offer evidence-based psychological therapies (CBT) and/or SSRIs as alternatives during the reduction process 1
- Monitor closely for worsening depression and suicidal ideation 1
- Antidepressants may be needed if depression emerges during withdrawal (28% of patients in one study required antidepressant therapy) 6
Concurrent Opioid Use:
- Avoid prescribing opioids and benzodiazepines simultaneously due to increased risk of respiratory depression and death 1, 3
- If both need tapering, taper benzodiazepines first 1, 2
- Keep buprenorphine dose stable if patient is on medication-assisted treatment 1
- Monitor for excessive sedation, dizziness, confusion, and respiratory depression at every encounter 3
When to Refer to a Specialist (Immediate Referral Indicated)
- History of withdrawal seizures 1
- Unstable psychiatric comorbidities 1
- Co-occurring substance use disorders 1
- Previous unsuccessful office-based tapering attempts 1
- Patients requiring both opioid and benzodiazepine tapering with complex medical issues 1
Key Pitfalls to Avoid
- Never taper too quickly: Even a 10% reduction every 3 days resulted in only 24% completion rates 1
- Never abandon the patient: Even if tapering is unsuccessful, maintain the therapeutic relationship and consider maintenance therapy 1
- Never reduce by a percentage of the original dose: Always reduce by a percentage of the current dose 1
- Never substitute another benzodiazepine or Z-drug (zolpidem, zaleplon) in elderly patients, as these carry similar risks 1
- Do not use rigid schedules: Patient tolerance must guide the taper rate 1
If Tapering is Unsuccessful
- Maintain the therapeutic relationship 1
- Establish goals for continued benzodiazepine therapy 1
- Maximize non-pharmacologic treatments 1
- Consider maintenance therapy at the lowest tolerable dose 1
- Reassess readiness for future taper attempts 1
Team-Based Approach
Involve pharmacists and pain specialists when benzodiazepines are prescribed with other CNS depressants. 1 Team members including nurses, pharmacists, and behavioral health professionals can support patients through telephone contact, telehealth, or face-to-face visits. 1