4.10.3 Benzodiazepines addiction and withdrawal

ChoiceDrugDosage
1st choiceDiazepam tablets 2mg, 5mg, 10mg

Dose:
See prescribing notes and suggested protocol below

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 withdrawal

  • Dosage should generally be tapered gradually in long-term benzodiazepine users. Abrupt or over-rapid withdrawal, especially from high dosage, can give rise to severe symptoms.
  • Benzodiazepine withdrawal should be flexible and carried out at a reduction rate that is tolerable for the patient. The rate should depend on the initial dose of benzodiazepine, duration of use, and the patient’s clinical response. Short-term users of benzodiazepines (2-4 weeks only) can usually taper off within 2-4 weeks. However, long-term users should be withdrawn over a much longer period of several months or more.
  • For people withdrawing from short-acting drugs it is advisable to switch to a long-acting benzodiazepine such as diazepam.
  • Exceptions to the general rule of slow reduction are zolpidem and zalepon. These drugs are eliminated quickly and can generally be stopped abruptly without substitution of a long-acting benzodiazepine. However, caution is advised with high doses or prolonged use. If withdrawal symptoms occur, patients can be given a short course of diazepam starting at about 10mg daily, decreasing the dose gradually.
  • It is inappropriate for patients to be prescribed more than one benzodiazepine at the same time. Patients already in receipt of a prescription of more than one type of benzodiazepine should normally be converted to diazepam only.
  • 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.

A suggested protocol for withdrawal for prescribed long-term benzodiazepine patients is as follows:

  1. Transfer the patient stepwise, one dose at a time, over about a week, to an equivalent daily dose of diazepam(1) preferably taken at night. Please note large doses at night may increase risk of falls or respiratory difficulties so it may be advisable to split doses to twice or three times daily in some cases.
  2. Reduce diazepam dose, usually by 1–2 mg every 2–4 weeks (in patients taking high doses of benzodiazepines, initially it may be appropriate to reduce the dose by up to one-tenth every 1–2 weeks). If uncomfortable withdrawal symptoms occur, maintain this dose until symptoms lessen.
  3. Reduce diazepam dose further, if necessary in smaller steps; steps of 500 micrograms may be appropriate towards the end of withdrawal. Then stop completely.
  4. For long-term patients, the period needed for complete withdrawal may vary from several months to a year or more.

Withdrawal symptoms for long-term users usually resolve within 6–18 months of the last dose. Some patients will recover more quickly, others may take longer. The addition of beta‐blockers, antidepressants and antipsychotics should be avoided where possible. Counselling can be of considerable help both during and after the taper.

Approximate equivalent doses, diazepam 5 mg

≡ alprazolam 250 micrograms

≡ clobazam 10 mg

≡ clonazepam 250 micrograms

≡ flurazepam 7.5–15 mg

≡ chlordiazepoxide 12.5 mg

≡ loprazolam 0.5–1 mg

≡ lorazepam 500 micrograms

≡ lormetazepam 0.5–1 mg

≡ nitrazepam 5 mg

≡ oxazepam 10 mg

≡ temazepam 10 mg

Note – dose equivalents of benzodiazepines are only a guide on the effect of single doses and do not account for dose accumulation effects of long acting benzodiazepines in comparison to shorter acting benzodiazepine.