Diazepam Taper Schedule for 20-Year Clonazepam 2 mg Daily Use
For a patient on clonazepam 2 mg daily for 20 years, convert to diazepam 20 mg daily (using a 1:10 equivalence ratio), then reduce by 10% of the current dose per month over a minimum of 12–18 months, with the understanding that this taper may require several years to complete safely. 1
Step 1: Convert Clonazepam to Diazepam
Convert clonazepam 2 mg daily to diazepam 20 mg daily using the standard 1:10 equivalence ratio. 1 Diazepam is preferred for tapering because its long half-life (20–100 hours) provides more protection against seizures and withdrawal symptoms compared to clonazepam's 30–40 hour half-life. 1, 2
- Stabilize on diazepam 20 mg daily for 2–4 weeks before beginning the taper to ensure the patient tolerates the cross-taper and to establish a stable baseline. 1
- Divide the daily dose into 2–3 administrations (e.g., 10 mg morning, 10 mg evening, or 7 mg morning, 7 mg afternoon, 6 mg evening) to maintain steady plasma levels and minimize interdose rebound anxiety. 3
Step 2: Implement the 10%-Per-Month Taper
For patients on benzodiazepines longer than 1 year—especially 20 years—reduce by 10% of the current dose per month, not the original dose. 1 This prevents disproportionately large final reductions that cause severe withdrawal. 1
Month-by-Month Schedule:
| Month | Daily Dose | Reduction | Notes |
|---|---|---|---|
| 1 | 20 mg → 18 mg | 2 mg (10% of 20 mg) | First reduction [1] |
| 2 | 18 mg → 16.2 mg | 1.8 mg (10% of 18 mg) | Round to 16 mg for practicality [1] |
| 3 | 16 mg → 14.4 mg | 1.6 mg (10% of 16 mg) | Round to 14.5 mg [1] |
| 4 | 14.5 mg → 13 mg | 1.45 mg (10% of 14.5 mg) | Round to 13 mg [1] |
| 5 | 13 mg → 11.7 mg | 1.3 mg (10% of 13 mg) | Round to 12 mg [1] |
| 6 | 12 mg → 10.8 mg | 1.2 mg (10% of 12 mg) | Round to 11 mg [1] |
| 7–18+ | Continue 10% reductions monthly | Variable | Expect 12–18 months minimum, possibly several years [1] |
- Use liquid diazepam or split tablets to achieve precise doses (e.g., 14.5 mg = one 10-mg tablet + one 2-mg tablet + half of a 5-mg tablet). 1
- Once the smallest available dose (2 mg) is reached, extend the interval between doses (e.g., 2 mg every other day, then every third day) before complete discontinuation. 1
Step 3: Monitor and Manage Withdrawal Symptoms
Follow up at least monthly during the taper, with more frequent contact (weekly or biweekly) during difficult phases. 1 Monitor for:
- Withdrawal symptoms: anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion, and seizures. 1
- Psychiatric symptoms: depression, panic attacks, suicidal ideation, and emergence of substance use disorders. 1
- Functional decline: inability to maintain daily activities, which signals the need to pause the taper. 1
If clinically significant withdrawal symptoms emerge, pause the taper at the current dose for 2–4 weeks while optimizing non-pharmacologic therapies and adjunctive medications. 1 Do not increase the dose unless withdrawal is severe and life-threatening (e.g., seizures, delirium). 1
Step 4: Integrate Cognitive-Behavioral Therapy (CBT)
Incorporate CBT during the taper to significantly increase success rates. 1 CBT addresses the psychological dependence on benzodiazepines and teaches coping strategies for anxiety and insomnia without medication. 1
- Start CBT at the beginning of the taper, not after the patient has already failed. 1
- Additional supportive measures include mindfulness, relaxation techniques, sleep hygiene education, and exercise. 1
Step 5: Consider Adjunctive Medications for Withdrawal Symptoms
Gabapentin can mitigate withdrawal symptoms. Start with 100–300 mg at bedtime or three times daily, and increase by 100–300 mg every 1–7 days as tolerated (adjust for renal insufficiency). 1
Carbamazepine may assist discontinuation, though it can affect alprazolam metabolism (less relevant for diazepam). 1
Trazodone 25–200 mg can be used for short-term insomnia management without abuse potential. 1
SSRIs (particularly paroxetine) may help manage underlying anxiety during tapering. 1
Do not substitute another benzodiazepine or Z-drug (zolpidem, zaleplon) during the taper, as these carry similar risks. 1
Step 6: Identify High-Risk Features Requiring Specialist Referral
Refer immediately to a specialist if the patient has: 1
- History of withdrawal seizures (benzodiazepine withdrawal carries higher seizure risk than opioid withdrawal). 1
- Unstable psychiatric comorbidities (e.g., active suicidal ideation, severe depression, psychosis). 1
- Co-occurring substance use disorders (e.g., alcohol, opioids). 1
- Previous unsuccessful office-based tapering attempts. 1
- Concurrent use of multiple CNS depressants (e.g., opioids, alcohol, gabapentinoids). 1
Step 7: Set Realistic Expectations and Define Success
The taper will likely take a minimum of 12–18 months, and possibly several years. 1 The goal is durability of the taper, not speed. 1
Both complete discontinuation and attainment of a reduced, functionally acceptable dose are considered acceptable outcomes. 1 If the patient cannot complete the taper despite optimal support, maintenance therapy at a lower dose is a legitimate outcome—do not abandon the patient. 1
Advise the patient of increased overdose risk if they return to previous doses after tolerance is lost. 1
Critical Pitfalls to Avoid
- 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 reduce by a fixed percentage of the original dose (e.g., always 2 mg per month), as this subjects patients to disproportionately large final decrements. 1
- Never abruptly discontinue benzodiazepines, as this can cause seizures, delirium, and death—equivalent to suddenly stopping antihypertensives or antihyperglycemics. 1, 3
- Never abandon the patient if tapering is unsuccessful; maintain the therapeutic relationship and consider maintenance therapy. 1
- Never prescribe additional CNS depressants (e.g., opioids, alcohol, Z-drugs) during the taper. 1
Special Considerations for 20-Year Use
Patients on benzodiazepines for 20 years have developed profound physical dependence and may require an even slower taper than 10% per month. 1 Consider:
- Reducing by 5% per month if 10% reductions cause intolerable withdrawal. 1
- Pausing the taper for 1–2 months at difficult dose thresholds (e.g., when reaching 10 mg, 5 mg, or 2 mg diazepam). 1
- Extending the total taper duration to 2–3 years if necessary. 1
Patient agreement and interest in tapering is a key component of success. 1 Use shared decision-making and explain the risks of continued use (cognitive impairment, falls, fractures, dementia risk) versus benefits of discontinuation (improved psychomotor and cognitive functioning, particularly memory and daytime alertness). 1
Example Taper Schedule (First 6 Months)
| Week | Daily Dose | Divided Dosing Example |
|---|---|---|
| 1–4 | 20 mg | 10 mg AM, 10 mg PM |
| 5–8 | 18 mg | 9 mg AM, 9 mg PM |
| 9–12 | 16 mg | 8 mg AM, 8 mg PM |
| 13–16 | 14.5 mg | 7 mg AM, 7.5 mg PM |
| 17–20 | 13 mg | 6.5 mg AM, 6.5 mg PM |
| 21–24 | 12 mg | 6 mg AM, 6 mg PM |
Continue this pattern, reducing by 10% of the current dose every 4 weeks, until complete discontinuation or a stable maintenance dose is reached. 1