What is the best approach to tapering benzodiazepines (BZD) in a patient with a history of long-term use?

How to Taper Benzodiazepines

Reduce benzodiazepines by 10-25% of the current dose every 1-2 weeks for short-term users (less than 1 year), or slow to 10% of the current dose per month for long-term users, always calculating reductions as a percentage of the current dose, not the original dose. 1

Critical Safety Framework

Abrupt discontinuation of benzodiazepines can cause seizures and death—never stop suddenly. 1, 2, 3 This risk is equivalent to suddenly stopping antihypertensives or antihyperglycemics and represents a life-threatening emergency. 1 Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must always be conducted gradually. 1

• Withdrawal symptoms can include anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion, and seizures. 1, 2, 3
• More severe reactions include delirium, hallucinations, psychosis, catatonia, and suicidality. 3
• Seizures have been reported even after brief therapy with doses within the recommended range (e.g., alprazolam 0.75-4 mg/day). 2

Pre-Taper Assessment

Before initiating any taper, assess for: 1

• History of withdrawal seizures (requires immediate specialist referral)
• Concurrent substance use disorders
• Psychiatric comorbidities (unstable conditions require specialist involvement)
• Concurrent opioid use (if both need discontinuation, taper benzodiazepines first due to higher withdrawal risks)
• Check the Prescription Drug Monitoring Program (PDMP) to identify all controlled substances the patient is receiving

Recommended Tapering Protocol

For Short-Term Users (Less Than 1 Year)

Reduce by 10-25% of the current dose every 1-2 weeks. 1 For example, if a patient is on diazepam 20 mg/day:

• Weeks 1-2: Reduce to 15 mg/day (25% reduction)
• Weeks 3-4: Reduce to 11-12 mg/day (20-25% of current dose)
• Continue reducing by 10-25% of the current dose every 1-2 weeks 1

For Long-Term Users (More Than 1 Year)

Slow the taper to 10% of the current dose per month. 1 This more conservative approach minimizes withdrawal symptoms and improves completion rates. The entire taper will likely take 6-12 months minimum, and possibly longer. 1

Critical Tapering Principles

• Always calculate reductions as a percentage of the current dose, not the original dose. 1 This prevents disproportionately large final reductions that can cause severe withdrawal.
• The taper rate must be determined by the patient's tolerance to withdrawal symptoms, not a rigid schedule. 1 Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge.
• Once the smallest available dose is reached, extend the interval between doses before complete discontinuation. 1

Specific Benzodiazepine Considerations

For alprazolam (a triazolobenzodiazepine): Consider converting to diazepam first using a gradual cross-taper protocol, as diazepam's longer half-life provides more protection against seizures and withdrawal symptoms. 1 If tapering alprazolam directly, reduce by 0.25 mg every 1-2 weeks for patients on the medication for months. 1

For clonazepam: Reduce by 0.25 mg per week after intermediate-term use. 4 In one study, patients successfully discontinued clonazepam by reducing 0.5 mg per 2-week period until 1 mg/day was reached, followed by 0.25 mg per week. 4

For elderly patients or those with hepatic dysfunction: Use lower doses and more gradual tapers. 1 Consider short/intermediate-acting benzodiazepines like lorazepam over long-acting agents like diazepam to reduce sedation and fall risk. 1

Adjunctive Pharmacological Support

Gabapentin

Start with 100-300 mg at bedtime or three times daily, increasing by 100-300 mg every 1-7 days as tolerated. 1 Gabapentin can help mitigate withdrawal symptoms during tapering. Adjust dosage in patients with renal insufficiency. 1

Other Medications

• Carbamazepine may assist discontinuation, though it can affect alprazolam metabolism. 1
• Pregabalin has shown potential benefit in facilitating benzodiazepine tapering. 1
• SSRIs (particularly paroxetine) may help manage underlying anxiety during tapering. 1
• Trazodone 25-200 mg can be used for short-term insomnia management without abuse potential. 1

Non-Pharmacological Interventions

Integrate cognitive-behavioral therapy (CBT) during the taper—this significantly increases success rates. 1 Additional supportive measures include: 1

• Mindfulness and relaxation techniques
• Sleep hygiene education
• Exercise and fitness training
• Patient education about benzodiazepine risks and benefits of tapering (improves outcomes and engagement)

Monitoring Requirements

Follow up at least monthly during the taper, with more frequent contact during difficult phases. 1 At each visit, assess for: 1

• Withdrawal symptoms and their severity
• Depression, anxiety, and substance use disorders that may emerge during tapering
• Suicidal ideation
• Mood changes

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

When to Refer to a Specialist

Immediate specialist referral is indicated for: 1

• History of withdrawal seizures
• Unstable psychiatric comorbidities
• Co-occurring substance use disorders
• Previous unsuccessful office-based tapering attempts
• Pregnant patients (benzodiazepine withdrawal during pregnancy can cause spontaneous abortion and premature labor)

Common Pitfalls to Avoid

• Never use straight-line percentage reductions from the starting dose—this subjects patients to disproportionately large final decrements. 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
• Never abandon the patient, even if tapering is unsuccessful—maintain the therapeutic relationship and consider maintenance therapy. 1
• Never prescribe additional CNS depressants during the tapering period. 1
• Never force unwilling patients to withdraw—patient agreement and interest in tapering is a key component of success. 1, 5

Special Considerations for Concurrent Opioid Use

If a patient is taking both opioids and benzodiazepines and both need discontinuation, taper the benzodiazepines first due to higher withdrawal risks. 1 Maintain the buprenorphine or other opioid dose stable during benzodiazepine tapering. 1 Avoid prescribing opioids and benzodiazepines simultaneously whenever possible due to increased risk of respiratory depression and death. 1

Realistic Expectations

Tapers are considered successful as long as the patient is making progress—the goal is durability of the taper, not speed. 1 Success rates with gradual tapering and psychological support are high and are unaffected by duration of usage, dosage, type of benzodiazepine, rate of withdrawal, symptom severity, psychiatric history, or personality disorder. 5 Following successful withdrawal, patients typically experience improved psychomotor and cognitive functioning, particularly in memory and daytime alertness. 1