To the Editor:
The article about benzodiazepine use disorder by Robertson, et al.1 did not mention the most effective way to wean patients from short-acting benzodiazepines. I successfully have used a rapid taper of phenobarbital over 6 days. Phenobarbital has a duration of action of 80 to 120 hours vs 6 to 8 hours for lorazepam.2,3 A 6-day taper of phenobarbital allows patients to immediately discontinue benzodiazepines without experiencing withdrawal symptoms. I recommend the following tapering protocol:
- Days 1 and 2: 64.8 mg three times daily
- Days 3 and 4: 64.8 mg twice daily
- Days 5 and 6: 64.8 mg at bedtime
Using this simple protocol, short-acting benzodiazepines can be safely discontinued.
In Reply:
Thank you for your suggested approach of prescribing phenobarbital for benzodiazepine withdrawal. Most published evidence supports the use of phenobarbital for treating alcohol withdrawal in a hospital setting, with only case reports available for its use in benzodiazepine withdrawal.1,2 The retrospective observational study referenced in your letter offers valuable insights into the use of phenobarbital for acute detoxification from benzodiazepines in hospitalized patients.3 On average, these patients were administered phenobarbital, 220 mg daily, stayed in the hospital for 8 days, and underwent treatment for 18 days. In addition, 42% of these patients supplemented their phenobarbital treatment with long-acting benzodiazepines. Although the efficacy and safety profile of phenobarbital for benzodiazepine discontinuation in the hospital setting are promising, it may be premature to extrapolate these findings to an outpatient setting. Additional studies would be beneficial to determine the safety and efficacy of phenobarbital and establish optimal dosing and weaning protocols in the outpatient setting.
