What is the first step to wean a patient with a history of long-term benzodiazepine (benzo) use off their medication?

First Step in Weaning a Patient Off Long-Term Benzodiazepines

The first step is to determine whether the patient is at risk for withdrawal by assessing the duration and dose of benzodiazepine use, then deciding if gradual tapering is necessary—which it almost certainly is for any patient on long-term therapy. 1

Initial Risk Assessment

Before initiating any taper, you must evaluate several critical factors:

• Duration of use: Patients on benzodiazepines for more than 14 days will require a weaning protocol to prevent withdrawal symptoms 2
• Current daily dose: Document the total daily benzodiazepine dose in diazepam equivalents 1
• History of withdrawal seizures: Any prior seizure history mandates immediate specialist referral rather than office-based management 1
• Psychiatric comorbidities: Screen for depression, anxiety disorders, and substance use disorders that may complicate withdrawal 1
• Concurrent medications: Check the Prescription Drug Monitoring Program (PDMP) to identify all controlled substances, particularly opioids 1

A critical safety consideration: If the patient is taking both opioids and benzodiazepines, taper the benzodiazepine first, as benzodiazepine withdrawal carries greater risks including seizures and death. 1 This represents updated guidance that supersedes older recommendations to taper opioids first.

Patient Engagement and Education

Obtain patient agreement and interest in tapering using shared decision-making—this is a key component of success. 1 Without patient buy-in, forced withdrawal attempts typically fail.

Provide specific education about:

• Risks of continued use: Cognitive impairment, falls, fractures, respiratory depression (especially with concurrent opioids), and potential dementia with prolonged use 1
• Benefits of discontinuation: Improved psychomotor and cognitive functioning, particularly memory and daytime alertness 1
• Realistic timeline: The taper will likely require 6-12 months minimum, possibly longer—emphasize that the goal is durability, not speed 1
• Withdrawal symptoms to expect: Anxiety, insomnia, tremor, sweating, muscle tension, perceptual hypersensitivity, and in severe cases, seizures 1, 3

Contraindications to Immediate Tapering

Do not initiate tapering if:

• The patient is pregnant—benzodiazepine withdrawal can cause spontaneous abortion and premature labor; specialist consultation is mandatory 1
• The patient has unstable psychiatric comorbidities requiring stabilization first 1
• There is active substance use disorder requiring concurrent treatment 1

Common Pitfalls to Avoid

Never abruptly discontinue benzodiazepines—this can cause seizures and death, making it as dangerous as suddenly stopping antihypertensives or antihyperglycemics. 1 The FDA label explicitly warns against abrupt discontinuation 4.

Do not substitute another benzodiazepine or Z-drug (zolpidem, zaleplon) as a "safer alternative"—these carry similar risks, particularly in older adults. 1

Do not abandon the patient if tapering is unsuccessful—maintain the therapeutic relationship and consider maintenance therapy while addressing barriers to successful withdrawal. 1

Setting Up for Success

Once you've completed the risk assessment and obtained patient agreement, the actual tapering protocol can begin. This involves:

• Switching to a long-acting benzodiazepine (typically diazepam) for most patients, though elderly patients may benefit from staying on shorter-acting agents like lorazepam due to reduced fall risk 1, 5
• Calculating baseline diazepam equivalents to establish the starting taper dose 1
• Establishing a monitoring schedule with at least monthly follow-up, more frequently during difficult phases 1
• Integrating cognitive behavioral therapy (CBT) during the taper, which significantly increases success rates 1

The evidence strongly supports that the first concrete action after assessment is transitioning to a long-acting formulation and establishing the baseline dose from which to begin percentage-based reductions. 1 However, this transition itself must be done carefully and is technically the beginning of the taper process, not a separate preliminary step.