Patients not appropriate for offering benzodiazepine

North Bradford Prescribing Support Team – Benzodiazepine
withdrawal guidelines
North Bradford has a very high use of benzodiazepines. Most patients take these
agents as sleeping tablets and had them initiated decades ago. The problems
associated with long term use are shown in figure 1. Many patients may be happy to
continue with their treatment. We do not know which patients are happy with
treatment and which would like to be weaned off. There is therefore a need to contact
all appropriate patients and to offer them the opportunity to come off
benzodiazepines. Those patients considered not appropriate for offering withdrawal
are shown in figure 2.
Figure 1: Risk of long-term use of benzodiazepines 1
The risks out-weigh the benefits in long-term use.
Psychological adverse effects
 Drug dependence
 Sedation (in day time)
 Paradoxical release of anxiety and hostility
 Psychomotor impairment
 Memory disruption
 Build up of R.E.M sleep causing nightmares
Physical adverse effects
 Drug dependence
 Vertigo
 Dysarthria
 Ataxia with falls (and subsequent fractures in elderly)
Figure 2: Patients not appropriate for offering benzodiazepine withdrawal 2
Those experiencing a current crisis
Having an illness for which the drug is required at the current time e.g.
Diagnosis of psychosis or dementia
Known to have alcohol abuse
Documented evidence in the clinical record that patient does not wish to
come off or reduce the dose
Strategies for benzodiazepine withdrawal
The key to successful withdrawal is;
Patient motivation
Gradual dosage reduction
Anxiety management
Method 1 : Benzodiazepine withdrawal – self management of withdrawal
Asking patients, either verbally, or by letter (see example) will result in around 1660% either stopping or substantially reducing the dose by themselves.3,4,5 The
following points need to be considered:
This method works best for patients taking low doses (the higher the dose the
greater the likelihood of dependence).
Emphasis the benefits of withdrawal.
Needs the patient to be motivated.
Withdrawal may need to occur over a several months or longer
Ask patient to cut down the dose very gradually by reducing the number of
tablets and then, if necessary, halving the last tablet
Warn patients of benzodiazepine withdrawal syndrome (see box)
40% of patients can stop with no difficulty. About 40% may experience
benzodiazepine withdrawal syndrome. Patient who experience benzodiazepine
withdrawal syndrome may need a slower reduction in dose. In which case method 2
is recommended.
Box : Benzodiazepine withdrawal syndrome
Recurrence of the underlying disorder
Rebound symptoms lasting only a few days after drug discontinuation
Withdrawal symptoms e.g. excess sensitivity to light and sound, tremulousness,
sweating, insomnia, abdominal discomfort, tachycardia (and mild systolic
hypertension).2 Abrupt withdrawal can cause convulsions, panic attacks and
confusional states
Method 2: Benzodiazepine withdrawal – conversion to diazepam with support.
This method is particularly important for patients on high doses and those
experiencing difficulty in reducing the dose of their current benzodiazepine.
1. Convert patient to equivalent daily dose of diazepam preferably taken at night.
Diazepam is a long acting benzodiazepine and makes the dose reduction much
easier. It does not produce the “kick” often experienced after larger doses of
temazepam, but its calming effect may last up to 24 hours.
2. The rate of withdrawal needs to be tapered for each individual patient. Patients on
an initial dose of diazepam 20mg daily or less may need a dose reduction of 1mg
every 1 to 2 weeks. Patients on initial doses of 40mg of diazepam can usually
tolerate larger dosage reductions of 2mg every 1 to 2 weeks. Once a daily dose 45 mg has been reached then dose reduction may need to be 0.5mg every 1 to 2
weeks. If withdrawal symptoms occur, maintain at this dose until symptoms
improve (it may be necessary to step back up the dose for a short while). It is
better to reduce too slowly rather than too quickly.6
3. Diazepam is available as 2mg and 5 mg tablets or liquid 2mg/5ml (for very
gradual reduction e.g. 1ml is 0.4mg.
4. Stop completely. Withdrawal may take 6-8 weeks or even up to 1 year.
5. Once treatment has stopped continue to provide cognitive treatments to support
patient if necessary (see method 3).
Equivalent doses of benzodiazepines (from BNF)
Approximate equivalent doses, diazepam 5mg
chlordiazepoxide 15mg
lorazepam 500 micrograms
lormetazepam 0.5-1mg
nitrazepam 5mg
oxazepam 15mg
temazepam 10mg
Method 3: Anxiety management 6
Patients withdrawing from benzodiazepines may suffer from anxiety. Many patients
are anxious anyway. Whether the anxiety is due to withdrawal or another cause it
needs managing.
The degree of support required will vary from simple encouragement to formal
cognitive, behavioural therapies. Support may need to be given during the withdrawal
stage and for prolonged periods afterwards.
Providing information
Clear information about how best to withdraw treatment needs to be given at the
outset. Emphasis the fact that withdrawal will be tailored to the individual; it will be
gradual and can stop at any stage. Explain that the specific symptoms that may be
experienced are temporary and not a sign of physical or mental disease. Try and
dispell any inappropriately held beliefs’ patients have about withdrawal.
Dealing with specific symptoms
 Give reassurance
 Advise on avoiding stimulants such as tea, coffee and alcohol at bed time
 Use of relaxation tapes and anxiety management techniques
Panic attacks
 Panic attacks can occur for the first time during withdrawal.
 Give an explanation of the physical mechanism of panic
 Keeping a diary can help to pinpoint precipitating factors
 Patients can exercise control by using relaxation techniques, breathing exercises,
being trained in anxiety management, through yoga etc.
 Discovering that panic attacks can be managed without having to take a tablet can
be a boost to self-confidence.
 Agoraphobia and social phobia may occur for the first time during withdrawal (it
may have been the underlying reason for prescribing the benzodiazepine in the
first instance).
 Formal therapy can be offered but in most cases the phobia disappears along with
other symptoms after drug withdrawal.
 Clinical depression requires treatment with antidepressants
 Highly motivated patients can usually manage their own withdrawal
 Less motivated patients can be encouraged by pointing out the advantages of
withdrawal and offering a reducing in dose (rather than a complete withdrawal).
Enforced withdrawal will not work and is inappropriate. Many patients may
simply choose to reduce the dose rather than stopping completely.
Outcome of withdrawal
 Symptoms characteristically wax and wane, varying in severity and type.
 Typically “windows” of normality appear and over time these “windows” become
longer whilst discomfort slowly regresses.
 However patients remain vulnerable to external stresses for some time and the
clinical course after drug cessation can be protracted.
Lader MH. Limitations on the use of benzodiazepine in anxiety and insomnia:are
they justified. Eur. Neuropsychopharmacol 1999;suppl 6:S399-405
Anon . Managing hypnotic and anxiolytic withdrawal in primary care. Regional
Drug and Therapeutic Centre. Drug Update.2001;number 14.
Hopkins D,sethi K, Mucklow J. Benzodiazepine withdrawal in general practice.
Journal of the Royal College of General Practitioners. 1982;32:758-762.
Cormack M, Owens RG, Dewey ME. The effects of minimal interventions by
general practitioners on long-term benzodiazepine use. Journal of the Royal
College of General Practitioners. 1989;39:408-411.
Holden J. benzodiazepine prescribing and withdrawal for 3234 patients in 15
practices. Family Practice 1994;11:358-362.
Ashton H. The treatment of benzodiazepine dependence. Addiction 1994;89:15351541.
Procedure for writing out to all patients in a practice on benzodiazepines
Identify patients prescribed benzodiazepines chronically (i.e. 3-4 months)
Identify patients who are appropriate for benzodiazepine withdrawal
Ask each appropriate patient if they would like to discontinue treatment
(see letter)
If yes
If no
Ask patient to try and quit
by themselves (method 1)
if would like to quit
Try and opportunistically talk
to the patient
Explain risks of chronic treatment
and benefits of quiting
If patient has problems in
withdrawing or reducing
the dose too fast then increase
the dose again and re-continue
with gradual withdrawal
If unable to quit or wants support
Then offer reduction strategy using
Diazepam and support
(method 2 and 3)
Once drug withdrawal has begun offer
Anxiety management (method 3). Continue
To offer this support if necessary after
If still not willing to quit
record that the patient
is not willing or able
to withdraw despite counselling
Use a Read code such as “chronic
benzodiazepine user”
Example letter (to be amended by each practice if necessary)
I have noticed in your record that you have been taking …………. for some time
now. I am writing to you because, recently, family doctors have become concerned
about this kind of tranquilizing medication when it is taken over long periods.
Research has shown that the body can become used to repeated use of this sort of
medication so the tablets no longer work properly. The tablets may also cause anxiety
and sleeplessness and they can be addictive.
I am writing to ask you to consider cutting down on your dose of these tablets and
perhaps stopping them at some time in the future.
It is best to cut down very gradually because you will be less likely to have unpleasant
withdrawal symptoms. The best way to cut down is to take these tablets only when
you feel they are absolutely necessary. For example, take them only when you know
you have to do something that might be difficult for you. Once you have begun to cut
down, you might be able to think about stopping them completely.
If you would like to talk to your doctor or the practice pharmacist about this then
please make an appointment. Please indicate on the attached slip whether you would
like to try and come off these tablets or not.
Yours sincerely
Dr and Partners
Patient ……………………
I would like to try and reduce the dose of my sleeping tablet with a view to possibly
stopping them some time in the future
I do not want to stop my sleeping tablets and do not need any help
Please return this slip with your next repeat prescription request. Your response will
be treated in strict confidence.