How to taper an elderly patient with chronic pain on morphine (opioid analgesic) and gabapentin (anticonvulsant) off of Valium (diazepam) 20 mg daily?

Benzodiazepine Tapering in Elderly Patients on Concurrent Opioids and Gabapentin

Taper the diazepam first using a slow, gradual reduction of 10% of the current dose per month over 6-12 months minimum, while maintaining stable doses of morphine and gabapentin throughout the benzodiazepine taper. 1

Critical Safety Framework

When a patient is taking both opioids and benzodiazepines and both need adjustment, benzodiazepine tapering must take precedence due to the substantially higher risks associated with benzodiazepine withdrawal, including seizures and death. 1 This is the opposite of older guidance and reflects current best practice based on withdrawal risk profiles. 1

• Abrupt benzodiazepine discontinuation can cause seizures and death—this is equivalent to suddenly stopping antihypertensives or antihyperglycemics and is never appropriate. 1
• The concurrent use of opioids (morphine) and benzodiazepines (diazepam) dramatically increases respiratory depression and overdose death risk, making this taper medically urgent. 1
• In elderly patients specifically, diazepam poses particular concerns due to its long half-life causing sedation, cognitive impairment, and fall risk with fractures. 1

Recommended Tapering Protocol for Diazepam 20 mg Daily

Month-by-Month Reduction Schedule

Reduce by 10% of the current dose per month, not 10% of the original dose—this prevents disproportionately large reductions at the end of the taper. 1

• Month 1: Reduce from 20 mg/day to 18 mg/day (10% reduction) 1
• Month 2: Reduce to 16.2 mg/day (10% of 18 mg) 1
• Month 3: Reduce to 14.6 mg/day (10% of 16.2 mg) 1
• Month 4: Reduce to 13.1 mg/day (10% of 14.6 mg) 1
• Continue this pattern: Each month reduce by 10% of the previous month's dose 1

The taper will require a minimum of 6-12 months and possibly longer—this is not negotiable for safety. 1 For patients on benzodiazepines for more than 1 year (which is likely in this elderly patient with chronic pain), extending the taper to 10% per month rather than faster schedules is specifically recommended. 1

Practical Dosing Adjustments

Since diazepam is available in liquid formulation, use this to achieve precise dose reductions. 2 When tablets must be used:

• 20 mg = two 10 mg tablets
• 18 mg = one 10 mg + one 5 mg + three 1 mg tablets (or use liquid)
• As doses become smaller, liquid formulation becomes essential for accuracy 2

Managing the Concurrent Medications

Morphine Management During Taper

Keep the morphine dose completely stable throughout the benzodiazepine taper. 1 Do not attempt to adjust opioids simultaneously—this creates compounded withdrawal risks and makes it impossible to determine which medication is causing symptoms. 1

• The morphine provides the foundation for chronic pain management and should not be adjusted for anxiety or withdrawal symptoms that emerge during benzodiazepine tapering. 1
• After successful benzodiazepine discontinuation, if opioid tapering is desired, this can be addressed as a separate process months later. 3

Gabapentin Management During Taper

Maintain the current gabapentin dose stable throughout the benzodiazepine taper. 1 Gabapentin serves two critical functions in this scenario:

1. Pain management: Gabapentin is appropriately used as a coanalgesic with opioids for neuropathic pain components. 3
2. Benzodiazepine withdrawal support: Gabapentin can help mitigate withdrawal symptoms during benzodiazepine tapering. 1

Starting gabapentin dosing for elderly patients should be 100-300 mg nightly with slower titration, and dose adjustment is required for renal insufficiency. 3 If this patient is not already on an adequate gabapentin dose, consider optimizing it before or during the benzodiazepine taper, but do not taper gabapentin during the diazepam reduction. 1

Critical gabapentin caution: If gabapentin ever needs to be discontinued in the future, it must be tapered slowly over weeks to months (similar to benzodiazepines) to avoid withdrawal seizures, especially in elderly patients. 4, 5, 6 Gabapentin withdrawal after chronic use can present with severe symptoms including status epilepticus, even with gradual tapers. 6

Monitoring Requirements

Follow up at least monthly during the taper, with more frequent contact (weekly or biweekly) during difficult phases. 1

At each visit, assess for:

• Withdrawal symptoms: Anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion, altered mental status, and seizures 1
• Excessive sedation, dizziness, confusion, and respiratory depression from the morphine-diazepam combination 1
• Depression, anxiety, and substance use disorders that may emerge or worsen during tapering 1
• Suicidal ideation 1
• Fall risk and cognitive function in this elderly patient 1

Team members including nurses, pharmacists, and behavioral health professionals can provide support through telephone contact, telehealth visits, or face-to-face visits between physician appointments. 1

When to Pause or Slow the Taper

Clinically significant withdrawal symptoms signal the need to further slow the taper rate or pause temporarily. 1

• If the patient develops moderate to severe withdrawal symptoms, hold at the current dose for 2-4 weeks before attempting further reduction. 1
• Pauses in the taper are acceptable and often necessary—they do not represent failure. 1
• The taper rate must be determined by the patient's tolerance, not by a rigid schedule. 1
• Some patients may require extending the taper beyond 12 months, particularly at lower doses where each reduction represents a larger percentage change in receptor occupancy. 1

Adjunctive Strategies to Improve Success

Cognitive Behavioral Therapy

Integrating CBT during the taper significantly increases success rates and should be incorporated if available. 1 CBT helps patients develop coping skills for anxiety and insomnia that emerge during tapering. 1

Patient Education

Provide explicit education about benzodiazepine risks and the benefits of tapering—this improves outcomes and engagement. 1

Explain to the patient:

• The increased risk of falls, fractures, cognitive impairment, and respiratory depression with continued benzodiazepine use, especially combined with morphine 1
• That withdrawal symptoms are temporary and manageable 1
• That improved cognitive function, mobility, and reduced fall risk typically follow successful discontinuation 2
• The timeline: this will take 6-12+ months minimum 1

Symptomatic Management

For specific withdrawal symptoms that emerge:

• Insomnia: Sleep hygiene education, relaxation techniques, mindfulness; consider trazodone for short-term management if severe 1
• Anxiety: Maximize CBT and relaxation techniques; SSRIs (particularly paroxetine) may help manage underlying anxiety but require weeks to become effective 1
• Muscle aches: NSAIDs or acetaminophen 1

Do not substitute another benzodiazepine or Z-drug (zolpidem, zaleplon, eszopiclone) as these carry similar risks in elderly patients. 1

Critical Pitfalls to Avoid

1. Never taper too quickly. Research shows that even a 10% reduction every 3 days resulted in only 24% of patients completing withdrawal successfully. 1 The 10% per month schedule is evidence-based for tolerability.

2. Never abandon the patient. Even if tapering is unsuccessful, maintain the therapeutic relationship and consider maintenance therapy at a reduced dose rather than returning to 20 mg. 1

3. Never attempt to taper morphine simultaneously with diazepam. This creates compounded risks and confusion about symptom etiology. 1

4. Never reduce by a percentage of the original dose. Always calculate reductions based on the current dose to avoid disproportionately large final reductions. 1

5. Never abruptly discontinue if the patient becomes non-adherent to the taper schedule. Restart at a tolerable dose and slow the taper further. 1

When to Refer to a Specialist

Immediate specialist referral is indicated for: 1

• History of withdrawal seizures from any substance
• Unstable psychiatric comorbidities (active suicidal ideation, severe depression, psychosis)
• Co-occurring substance use disorders beyond the prescribed medications
• Previous unsuccessful office-based tapering attempts
• Development of seizures or severe confusion during the taper

Realistic Expectations and Goals

The goal is durability of the taper, not speed. 1 Success is defined as the patient making progress, even if the timeline extends beyond 12 months. 1

• Approximately 50-70% of patients can successfully discontinue benzodiazepines with gradual tapering and support. 2
• Improved psychomotor and cognitive functioning typically follows successful discontinuation, particularly in elderly patients. 2
• Some patients may achieve a reduced dose (e.g., 5-10 mg/day) where functional benefits outweigh risks, even if complete discontinuation is not achieved. 1
• Once the smallest available dose is reached, the interval between doses can be extended (e.g., every other day, then twice weekly) before complete discontinuation. 1

After successful taper, advise the patient of increased overdose risk if they ever resume benzodiazepines at the previous dose due to loss of tolerance. 1