Prescribing drugs of dependence in general practice

Part B - Benzodiazepines - Chapter 5

Discontinuing benzodiazepines

Last revised: 06 Nov 2019

Discontinuing after short-term use

For patients on less than 4 weeks of benzodiazepine therapy, it should be possible to stop medication without tapering. Caution should be exercised with patients who are at risk of seizures.

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.

Table 4. Acute withdrawal symptoms

Table 4.

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

  • anxiety
  • depression
  • diarrhoea, constipation, bloating
  • insomnia
  • irritability
  • muscle aches
  • poor concentration and memory
  • restlessness
  • 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

If dependence on benzodiazepines has become established, it is often difficult to treat and can become a long-term, distressing problem.25 All patients with dependence should be encouraged to discontinue the drug and offered a detoxification program at regular intervals. For some patients, discontinuation will be difficult, but the effort should be made. For other patients, a reduction in dose, rather than discontinuation, will be the first goal.

Evidence-based recommendations for general practice management of benzodiazepine withdrawal are difficult due to a lack of data. The following are general principles:

  • Review the patients’ prescription records and discuss the situation to those receiving long-term benzodiazepines.
  • Send patients letters suggesting methods of tapering off benzodiazepines (this may be enough to motivate them to withdraw).
  • Teach patients ways to deal with anxiety and insomnia (either as primary conditions or due to withdrawal).
  • Acknowledge that withdrawing from benzodiazepines can be stressful.
  • Encourage family and friends to provide encouragement and practical help during withdrawal.
  • Refer patients to appropriate services (eg psychologist or support groups). Only refer to drug or alcohol dependence services if the service has shown specific interest in benzodiazepine dependence or the patient also has a drug or alcohol problem.
  • Advise patients to make changes in lifestyle such as regular exercise.
  • Advise patients to avoid alcohol.
  • Advise patients to avoid mild stimulants (eg coffee and chocolate [theobromine]) as these can cause anxiety, panic and insomnia.
  • Postpone advice on smoking cessation until after the benzodiazepine has been withdrawn.189

Benzodiazepine reduction requires a team approach with regular communication between the prescriber and other practitioners involved in the patient’s care (eg pharmacist, counsellor, psychiatrist, addiction services).

Resources

Specialist services such as Reconnexion offer free telephone support (1300 273 266) to help with benzodiazepine withdrawal.

The clearest strategy for withdrawing benzodiazepines in primary care is to taper the medication.189

Slow discontinuation of benzodiazepines is recommended to avoid withdrawal symptoms (eg rebound anxiety, agitation, insomnia or seizures) particularly when use exceeds 8 weeks. However, clear evidence for the optimal rate of tapering is lacking. The British National Formulary recommends a minimum of 6 weeks,190 while Lader recommends a maximum of 6 months.189 The exact rate of reduction should be individualised according to the drug, dose and duration of treatment (refer to Table 5).

Two-thirds of patients can achieve cessation with gradual reduction of dose alone. Others need additional psychological therapies and a limited number of patients benefit from additional pharmacotherapy.191 CBT performed in a single, extended (20-minute) consultation with a GP, with a handout, has been shown to increase non-use at 1 year from 15% to 45%.192 A systematic review comparing routine care to brief interventions, gradual dose reduction and psychological interventions found all interventions increased benzodiazepine discontinuation over routine care, with gradual dose reduction plus psychological interventions the most effective.191

All patients on a reduction regime must obtain prescriptions from one prescriber and through one pharmacy, where time-limited dispensing may be required (eg once or twice a week at a specified time). Plans should be in place to cover absences of the usual prescribing doctor from the practice. Consider working closely with the patient’s pharmacist with staged supply or supervised dosing to assist the patient with dose reduction and cessation, if they are unable to manage this themselves.

Table 5. Recommendations for tapering benzodiazepines

Table 5.

Recommendations for tapering benzodiazepines

Copyrighted 2015. Frontline Medical Communications. 117258:0515BN
A common first step in withdrawal is to substitute diazepam for the benzodiazepine being taken.189 The slower elimination of diazepam creates a smoother taper in blood level.102

Refer to Resource D.2B for withdrawal protocols.

Pharmacotherapy interventions have limited use in benzodiazepine withdrawal. Generally, other drugs are used to address symptoms rather than substitute for benzodiazepines.

Carbamazepine – Carbamazepine has shown some usefulness, however, there is not enough evidence to recommend its use.193

Antidepressants – There is limited evidence that antidepressants help in benzodiazepine withdrawal, unless depression (or anxiety disorders/panic disorders) are present or emerge during withdrawal.191,193

Melatonin – Melatonin may help benzodiazepine reduction in older people with insomnia.194

There may be a small number of patients whose quality of life improves with the stable use of benzodiazepines. This may justify long-term therapy. The decision to continue long-term benzodiazepine treatment needs to be clearly documented. The decision may also involve a second opinion by a specialist in an area relevant to the patient’s needs. These patients still require regular, ongoing review and re-assessment of the risks and benefits of benzodiazepine use.

Attempts at withdrawal are more likely to succeed if the patient is able to contemplate the ultimate goal of cessation, and the doctor and patient are able to work together in a productive therapeutic relationship to achieve this.

Some patients struggle to reduce and cease benzodiazepine use. However, this group can often reduce their daily dose markedly and this is accompanied by a decrease in risk and side effects. They may continue on low-dose benzodiazepines (eg 2–5 mg diazepam daily) for an extended period. Continued regular review may assist in the majority who will successfully cease benzodiazepines in the longer term. This decision should be made on a case-by-case basis.

For patients who have complex, multiple morbidities, GPs should seek advice from mental health and addiction specialists, as well as other relevant specialists (eg neurologists) to assist with development of the best plan to assist the patient. 

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