What is the recommended taper schedule for temazepam (Restoril) and how should I discontinue trazodone and initiate low‑dose doxepin for insomnia?

Tapering Temazepam and Transitioning to Doxepin for Insomnia

Taper temazepam gradually over 2–4 weeks using 25% dose reductions every 1–2 weeks, discontinue trazodone immediately without tapering, and initiate low-dose doxepin 3 mg at bedtime concurrently with Cognitive Behavioral Therapy for Insomnia (CBT-I).

Temazepam Tapering Protocol

Benzodiazepine hypnotics like temazepam require gradual tapering to prevent withdrawal reactions including rebound insomnia, anxiety, seizures, and delirium. 1, 2

Recommended Taper Schedule:

• Week 1–2: Reduce temazepam dose by 25% (e.g., if taking 15 mg → reduce to 11.25 mg or approximately 10 mg) 1, 2
• Week 3–4: Reduce by another 25% of the original dose (e.g., 15 mg → 7.5 mg) 1, 2
• Week 5–6: Reduce to 3.75 mg or discontinue, depending on tolerance 1, 2
• Monitor closely for withdrawal symptoms (anxiety, tremor, insomnia worsening, irritability); if these occur, pause the taper or slow the reduction rate 1, 2

The FDA explicitly recommends using a gradual taper to discontinue temazepam or reduce dosage, and if withdrawal reactions develop, consider pausing the taper or increasing the dosage to the previous level before decreasing more slowly. 1

Trazodone Discontinuation

Stop trazodone immediately without tapering—it does not require gradual dose reduction when used at hypnotic doses (25–50 mg). 2

• Trazodone is explicitly NOT recommended for insomnia treatment by the American Academy of Sleep Medicine due to minimal benefit (only ~10 min reduction in sleep latency, ~8 min reduction in wake after sleep onset) with no improvement in subjective sleep quality and harms outweighing benefits 3, 4
• At low hypnotic doses (25–50 mg), trazodone does not produce significant withdrawal symptoms upon abrupt discontinuation 2
• There is no need to taper trazodone when discontinuing, unlike benzodiazepines 2

Initiating Low-Dose Doxepin

Start doxepin 3 mg at bedtime immediately, even while tapering temazepam—there is no need to wait for complete benzodiazepine discontinuation. 3, 2

Doxepin Dosing and Titration:

• Initial dose: 3 mg at bedtime (take within 30 minutes of bedtime with ≥7 hours remaining before planned awakening) 3
• Mechanism: Selective H₁-histamine receptor antagonism at low doses, with minimal anticholinergic effects and no abuse potential 3
• Efficacy: Reduces wake after sleep onset by 22–23 minutes, improves sleep efficiency, total sleep time, and sleep quality 3
• Titration: If 3 mg is insufficient after 1–2 weeks, increase to 6 mg 3
• No tapering required when discontinuing doxepin 2

Why Doxepin Over Other Options:

• Low-dose doxepin (3–6 mg) is the preferred first-line agent specifically for sleep-maintenance insomnia according to the American Academy of Sleep Medicine and American College of Physicians 3
• It has no abuse potential, no DEA scheduling, and minimal side effects compared to benzodiazepines 3
• Minimal anticholinergic burden at hypnotic doses (3–6 mg), unlike higher antidepressant doses 3

Concurrent Cognitive Behavioral Therapy for Insomnia (CBT-I)

Initiate or optimize CBT-I immediately alongside the medication transition—it is the standard of care and provides superior long-term outcomes compared to medication alone. 3, 2

Core CBT-I Components:

• Stimulus control therapy: Go to bed only when sleepy; use bed only for sleep and sex; leave bed if unable to sleep within 15–20 minutes 3
• Sleep restriction therapy: Limit time in bed to actual sleep time + 30 minutes to consolidate sleep 3
• Relaxation techniques: Progressive muscle relaxation, guided imagery, breathing exercises 3
• Cognitive restructuring: Address maladaptive beliefs about sleep (e.g., "I must get 8 hours or I'll be dysfunctional") 3
• Sleep hygiene education: Avoid caffeine/alcohol in evening, maintain consistent sleep-wake times, optimize bedroom environment 3

CBT-I can be delivered via individual therapy, group sessions, telephone, web-based modules, or self-help books—all formats show effectiveness. 3

Monitoring and Reassessment

• Reassess after 1–2 weeks of doxepin initiation to evaluate efficacy on sleep-onset latency, total sleep time, nocturnal awakenings, and daytime functioning 3
• Monitor for adverse effects: Morning sedation, headache, cognitive impairment (though rare at low doses) 3
• Screen for complex sleep behaviors (sleep-driving, sleep-walking) at every visit; discontinue immediately if these occur 3
• Evaluate for underlying sleep disorders (sleep apnea, restless legs syndrome, circadian rhythm disorders) if insomnia persists beyond 7–10 days despite treatment 3

Common Pitfalls to Avoid

• Do NOT abruptly stop temazepam—this can precipitate severe withdrawal, including seizures 1, 2
• Do NOT continue trazodone—it lacks efficacy for insomnia and has an unfavorable risk-benefit profile 3, 4
• Do NOT use over-the-counter antihistamines (diphenhydramine, doxylamine) as alternatives—they lack efficacy, cause anticholinergic effects, and develop tolerance within 3–4 days 3
• Do NOT prescribe doxepin without initiating CBT-I—behavioral therapy provides more durable benefits than medication alone 3, 2
• Do NOT combine multiple sedating agents (e.g., adding another hypnotic to doxepin during the temazepam taper)—this markedly increases risk of respiratory depression, falls, and cognitive impairment 3

Special Population Considerations

• Elderly patients (≥65 years): Start doxepin at 3 mg and do not exceed 6 mg; monitor closely for falls and cognitive impairment 3
• Hepatic impairment: Doxepin remains safe at low doses, but monitor for increased sedation 3
• History of substance use: Doxepin is ideal due to no abuse potential; avoid benzodiazepines entirely 3