Tapering Benzodiazepines

Nearly 50% of prescriptions for benzodiazepines are prescribed during primary care visits. Almost one-fifth of prescriptions are misused, and 0.2% of patients​ develop benzodiazepine use disorder. Assessment of ongoing indications and identifying patients who would benefit from tapering benzodiazepine use, discontinuing benzodiazepine use, or both is important to detect misuse and reduce the risks associated with long-term use. Reassessment is recommended every 3 months. Risk of adverse effects and physiologic tolerance​ of benzodiazepines increase with time.

Benzodiazepines are indicated for short-term use​ (2 to 4 weeks) for treatment of acute stress reactions, initial or bridging treatment for severe agoraphobia or panic disorder, insomnia, alcohol withdrawal, and acute seizures. Short-term use is recommended due to diminished benefits within days to weeks and persistent risks associated with long-term use. Indications for long-term use include severe treatment-resistant generalized anxiety disorder, bipolar spectrum disorders, spasticity, complex seizure disorders, catatonia, and sleep disorders with abnormal movements (eg, rapid eye movement sleep disorder).

Risks associated with benzodiazepine use​ include sedation, falls, cognitive impairment, fatal/non-fatal overdose, sleep disturbances, motor vehicle accidents, medication interactions, medication diversion, suicidality, fetal harm, and hip fractures and orthostatic hypotension in older adults.

Benzodiazepine use disorder falls under substance use disorder in the Diagnostic and Statistical Manual of Mental Disorders​. Signs of the disorder include taking benzodiazepines in greater amounts or over a longer period than recommended, cravings for the medication, unsuccessful attempts to reduce use, and social impairment (eg, affecting job).

Tapering benzodiazepines is generally recommended when risks of ongoing use outweigh benefits. Indications include benzodiazepine use disorder, age 65 years or older, and resolution or management of the condition for which treatment was initially indicated (eg, insomnia). Risks of tapering include withdrawal symptoms, recurrence of the original treatment condition, and transition or return to illicit use. Underlying psychiatric conditions, including substance use disorder, should be treated prior to tapering. Patients taking benzodiazepines for less than 1 to 3 months have a low risk of withdrawal and a taper may not be necessary.

According to a joint guideline from the American Society of Addiction Medicine, American Academy of Family Physicians, and nine other medical societies, tapering may take months to years depending on how long or how much of a dose of benzodiazepines patients have been taking. An initial reduction of 5%-10% of the original dose is recommended every 2 to 4 weeks with the goal to discontinue use or reduce the dose to a point where benefits outweigh risks. The dose should not be reduced by more than 25% every 2 weeks.

Patients taking short-acting benzodiazepines may be transitioned to a long-acting benzodiazepine dose equivalent to aid in tapering. This is contraindicated in patients with hepatic impairment and in older adults due to reduced hepatic clearance of metabolites. A taper is generally safe to conduct as an outpatient; however, hospitalization for closer monitoring is recommended for tapering in patients with a history of complicated withdrawal (eg, seizures), alcohol use disorder, or significant comorbidities.

If a patient begins to withdraw​ during a taper, the taper may be paused or slowed down. Concomitant cognitive behavioral therapy may improve success in tapering. Medications to treat or reduce the risk of withdrawal symptoms are generally not recommended due to lack of demonstrated benefit.

The risk of long-term benzodiazepine use in patients initially prescribed benzodiazepines may be reduced​ by prescribing short-acting benzodiazepines if possible and prescribing a shorter course of treatment.