Withdrawal is possible for most patients on longer term benzodiazepines, although the process of reduction may be difficult and lengthy. The withdrawal process is aided by a good therapeutic alliance between the GP and patient, with specialist support where needed. Discontinuation is usually beneficial as it is followed by improved psychomotor and cognitive functioning, particularly in the elderly.189 Up to 15% of patients who experience withdrawal will go on to have protracted symptoms lasting months to years.2
Withdrawal strategies will vary with the type of dependence (therapeutic dose, prescribed high dose, recreational high dose or polydrug). Withdrawal symptoms are highly variable and each patient will need tailored withdrawal management that will also address any underlying problems. Withdrawal symptoms may appear in 1–2 days for agents with shorter half-lives, but may not appear until 3–7 days for agents with longer half-lives.
Acute withdrawal symptoms
Reproduced with permission from Ford C, Law F. Guidance for the use and reduction of misuse of benzodiazepine prescribing and other hypnotics and anxiolytics in general practice. 2014.38
Protracted benzodiazepine withdrawal symptoms include:30
- diarrhoea, constipation, bloating
- muscle aches
- poor concentration and memory
- less commonly, perceptual disturbances and panic attacks
- occasionally, seizures and symptoms of psychosis.
The symptoms and duration of benzodiazepine withdrawal can vary, mostly impacted by the level of dose reduction. Although, other contributing factors can include a history of polydrug dependence, seizures, anxiety, depression or trauma, or when the total daily dose is not clear (due to doctor shopping or illegal purchase).
Patients taking ‘therapeutic doses’
For patients who have early/mild dependence, minimal interventions such as advisory letters, other information provision or GP advice should be offered. Where dependence is established, gradual dose reduction of prescribed benzodiazepine is recommended (both grade A recommendations from the British Association for Psychopharmacology).153
Switching from a short half-life benzodiazepine to a long half-life benzodiazepine before gradual taper should be reserved for patients having problematic withdrawal symptoms on reduction (grade D recommendation from the British Association for Psychopharmacology).153
Additional psychological therapies increase the effectiveness of gradual dose reduction, particularly in patients with insomnia and panic disorder. Consideration should be given to targeted use of these interventions (grade B recommendation from the British Association for Psychopharmacology).153
Patient taking high doses of benzodiazepines or who are users of illicit drugs (polydrug users)
So called ‘harm-reduction dosing’ or maintenance prescribing of benzodiazepines for patients using polydrugs cannot be recommended on the basis of existing evidence, as prescribing benzodiazepines does not appear to prevent use of other drugs.153 There are some evidence that maintenance dosing of benzodiazepines may reduce high-dose problematic benzodiazepine use in some patients (grade D recommendation from the British Association for Psychopharmacology).153