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4.10.3 Benzodiazepine and Z drug withdrawal

Prescribing Notes

Polydrug users

  • Benzodiazepines have their own potential for misuse and dependence and are often taken in combination with opiates or stimulants. Many drug misusers misuse benzodiazepines but the majority do not require long-term replacement prescribing or high doses. For those who are benzodiazepine dependent, sudden cessation in their use can lead to a recognised withdrawal state
  • Good assessment and care planning and adherence to local protocols are prerequisites for considering prescribing benzodiazepines. Prescribing benzodiazepines to drug misusers requires competencies in this form of treatment and appropriate supervision. It is therefore more likely to be considered an appropriate approach in secondary care rather than in primary care
  • Only very rarely should doses of more than 30mg diazepam equivalent per day be prescribed

General advice on Benzodiazepine and Z drug withdrawal

  • The two potential approaches for withdrawal are slow dose reduction of the person’s current benzodiazepine or z-drug, or switching to an approximately equivalent dose of diazepam, which is then tapered down
  • Switching to diazepam should be considered for:
    • People using the short-acting potent benzodiazepines (that is, alprazolam and lorazepam)
    • People using preparations that do not easily allow for small reductions in dose (that is alprazolam, flurazepam, loprazolam and lormetazepam)
    • People experiencing difficulty or who are likely to experience difficulty withdrawing directly from temazepam, nitrazepam, or z-drugs, due to a high degree of dependency (associated with long duration of treatment, high doses, and a history of anxiety problems)
    • Seek specialist advice (preferably from a hepatologist) before switching to diazepam in people with hepatic dysfunction as diazepam may accumulate to a toxic level in these individuals. An alternative benzodiazepine without active metabolites (such as oxazepam) may be preferred
  • Refer to NICE CKS ‘Benzodiazepine and z-drug withdrawal’ for comprehensive information including suggested withdrawal schedules
  • The majority of patients on therapeutic doses are taking less than 20mg diazepam (or equivalent) daily. Only very rarely should doses of more than 30 mg diazepam equivalent per day be prescribed
  • Older people can withdraw from benzodiazepines just as successfully as younger people, even if they have taken the drug for years. There are more compelling reasons why older people should withdraw from benzodiazepines, e.g. risk of falls, confusion