What is the best way to taper off lorazepam (Ativan) in a patient with a history of long-term use?

Lorazepam Tapering Protocol

For patients with long-term lorazepam use, reduce the dose by 10% of the most recent dose per month (not the original dose), continuing this hyperbolic reduction pattern until complete discontinuation, which will typically require 6-12 months minimum. 1, 2

Critical Safety Framework

Abrupt discontinuation of lorazepam can cause seizures and death—never stop suddenly. 1, 3 Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must always be conducted gradually. 1, 2

Special Priority for Concurrent Opioid Use

• If the patient is taking both opioids and benzodiazepines, taper the lorazepam first due to higher withdrawal risks associated with benzodiazepine discontinuation. 1, 2
• The FDA warns that concomitant use increases risk of respiratory depression and drug-related mortality. 3

Standard Tapering Schedule

For Long-Term Users (≥1 year)

• Reduce by 10% of the current dose per month. 1, 2
• Example: If starting at 2 mg/day, reduce to 1.8 mg/day in month 1 (10% reduction), then to 1.62 mg/day in month 2 (10% of 1.8 mg), then to 1.46 mg/day in month 3 (10% of 1.62 mg). 1
• Always calculate reductions as a percentage of the current dose, not the original dose, to prevent disproportionately large final reductions. 1

For Shorter-Term Users (<1 year)

• Reduce by 10-25% of the current dose every 1-2 weeks. 1, 2
• This faster schedule is only appropriate for patients without prolonged exposure. 2

Final Doses Before Complete Cessation

• Final doses may need to be as small as 1/40th of a therapeutic dose to prevent large decreases in receptor occupancy when stopped. 4
• Once the smallest available dose is reached, extend the interval between doses before complete discontinuation. 1

Managing the Taper Process

Patient Engagement

• Obtain patient agreement and involvement in the tapering plan—this is a key component of success. 1, 2
• Use shared decision-making and explain risks of continued use versus benefits of discontinuation. 1
• Set realistic expectations: the taper will likely take 6-12 months minimum, possibly longer. 1

Monitoring Requirements

• Follow up at least monthly during the taper, with more frequent contact during difficult phases. 1
• Monitor for withdrawal symptoms including: anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion, and seizures. 1, 5
• Screen for depression, anxiety, and substance use disorders that may emerge during tapering. 1
• Clinically significant withdrawal symptoms signal the need to further slow the taper rate or pause the reduction. 1

Flexibility in Tapering

• 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 be considered successful as long as the patient is making progress—the goal is durability of the taper, not speed. 1

Adjunctive Pharmacological Support

Gabapentin for Withdrawal Symptoms

• Start gabapentin 100-300 mg at bedtime or three times daily, increasing by 100-300 mg every 1-7 days as tolerated. 1, 2
• Adjust dosage in patients with renal insufficiency. 1
• Gabapentin can help mitigate withdrawal symptoms including anxiety, tremor, and insomnia. 1

Other Symptomatic Medications

• Carbamazepine may assist benzodiazepine discontinuation, though evidence is limited. 1, 6
• Pregabalin has shown potential benefit in facilitating benzodiazepine tapering. 1
• For insomnia during tapering, use trazodone 25-200 mg for short-term management without abuse potential. 1
• For underlying anxiety, consider SSRIs (particularly paroxetine) rather than substituting another benzodiazepine. 1
• For muscle aches, use NSAIDs or acetaminophen. 1

Medications to Avoid

• Do not substitute another benzodiazepine or Z-drug (zolpidem, zaleplon) as these carry similar risks. 1
• Avoid prescribing additional CNS depressants during the tapering period. 1

Non-Pharmacological Interventions

Cognitive Behavioral Therapy

• Integrating CBT during the taper significantly increases success rates and should be incorporated. 1, 2, 6
• CBT is particularly helpful for patients struggling with benzodiazepine discontinuation. 1
• Group therapy may provide additional peer support. 6

Additional Supportive Measures

• Patient education about benzodiazepine risks and benefits of tapering improves outcomes and engagement. 1, 2
• Incorporate mindfulness and relaxation techniques. 1
• Provide sleep hygiene education for insomnia concerns. 1
• Encourage exercise and fitness training. 1

When to Refer to a Specialist

Immediate specialist referral is indicated for: 1, 2

• Patients with a history of withdrawal seizures
• Unstable psychiatric comorbidities
• Co-occurring substance use disorders
• Previous unsuccessful office-based tapering attempts
• Unreliable history about amount being taken
• Poor motivation or adherence

Special Populations

Elderly Patients

• Use lower doses and more gradual tapers in elderly patients to minimize adverse effects. 1, 2
• Benzodiazepines in elderly patients are associated with cognitive impairment, reduced mobility, falls, fractures, and loss of functional independence. 1
• Long-acting agents like diazepam pose particular concerns due to sedation and fall risk. 1

Pregnant Patients

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

Expected Outcomes

During and After Successful Withdrawal

• Successful withdrawal is typically followed by improved psychomotor and cognitive functioning, particularly in memory and daytime alertness. 1, 6
• Improvement in anxiety symptoms and general well-being is maintained during both the taper and follow-up phases. 5
• Most withdrawal symptoms are mild and transient when tapering is done gradually. 5

Realistic Success Rates

• With gradual tapering and psychological support, success rates of withdrawal are high (approximately 70-90% completion). 7, 5
• Success is unaffected by duration of usage, dosage, or type of benzodiazepine when proper tapering methods are used. 7

Critical Pitfalls to Avoid

• Never taper too quickly—even a 10% reduction every 3 days resulted in only 24% of patients completing withdrawal successfully. 1
• Never abandon the patient, even if tapering is unsuccessful—maintain the therapeutic relationship and consider maintenance therapy. 1
• Do not force unwilling patients to withdraw. 7
• Advise patients of increased overdose risk if they return to previous doses after tolerance is lost. 1