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Benzodiazepine Withdrawal

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Benzodiazepine Withdrawal, Benzodiazepine Taper Schedule

  • See Also
  1. Benzodiazepine
  2. Benzodiazepine Abuse
  • Indications
  1. Benzodiazepine Abuse
  2. Benzodiazepine Dependence
    1. Age over 65 years
    2. Benzodiazepine use >4 weeks (dependence may start within days of regular use)
  • Symptoms
  • Acute Withdrawal
  1. Common
    1. Anxiety
    2. Irritability
    3. Insomnia
    4. Myalgias
    5. Tremor
    6. Diaphoresis
    7. Gastrointestinal findings (e.g. Nausea, Diarrhea)
  2. Severe
    1. Seizures
    2. Delirium Tremens
    3. Depression with Suicidality
    4. Psychosis
    5. Catatonia
  • Symptoms
  • Chronic Withdrawal (up to 12 months after stopping)
  1. Depressed Mood
  2. Cognitive Impairment
  3. Insomnia
  4. Anxiety
  5. Motor symptoms
  6. Paresthesias
  7. Tinnitus
  • Evaluation
  • Withdrawal Risk
  1. Very low risk for withdrawal (rare)
    1. Use <=3 days weekly (any daily dose for any duration)
  2. Low risk for withdrawal (but possible)
    1. Use >=4 days weekly for <1 month (any daily dose)
    2. Use >=4 days weekly for 1-3 months at low dose (<10 mg Diazepam equivalent)
  3. Moderate to high risk for withdrawal
    1. Use >=4 days weekly for 1-3 months at moderate to high dose (>=10 mg Diazepam equivalent)
    2. Use >=4 days weekly for 3 months (any daily dose)
  • Management
  • Benzodiazepine Taper Schedules
  1. Monitor every 1 to 2 weeks
  2. Evaluate withdrawal risk (see above)
  3. Calculate Diazepam to Benzodiazepine Equivalents
    1. See Benzodiazepine Equivalents
    2. Convert from short acting (e.g, Alprazolam) to long acting Benzodiazepines (e.g. Diazepam) at start of taper
  4. Protocol: Typical for on longterm prescribed Benzodiazepines
    1. Start at 50% of calculated Valium dose
    2. Reduce dose by 25% each week for the first 2 weeks, until 50%, then decrease dose by 12.5% every 4-7 days
    3. Decrease dose by no more than 5 mg Diazepam equivalents/week until <20 mg/week, then decrease by 1-2 mg/week
    4. Decrease Alprazolam by no more than 0.5 mg increments
      1. Alprazolam >=6 mg/day decrease by 0.5 mg every 2 to 3 weeks
      2. Alprazolam <= 2 mg/day decrease by 0.25 mg every 2 to 3 weeks
  5. Example: Rapid Taper for Detox in Benzodiazepine Abuse
    1. Alprazolam 6 mg is equivalent to 60 mg Diazepam
    2. Alprazolam 10 mg is equivalent to 100 mg Diazepam
    3. Start taper at 50% or 50 mg Diazepam per day
    4. Decrease dosing per Diazepam taper below
      1. Days 1-3: 10 mg orally three times daily (30 mg/day)
      2. Days 4-6: 5 mg orally four times daily (20 mg/day)
      3. Days 7-9: 5 mg orally three times daily (15 mg/day)
      4. Days 10-12: 5 mg orally twice daily (10 mg/day)
      5. Days 13-15: 5 mg orally daily (5 mg/day)
  6. Protocol: Slower Taper of Benzodiazepines
    1. Indications for slower taper (over 6 to 12 weeks)
      1. Alprazolam (esp. high dose >4 mg/day)
      2. Benzodiazepine use >2 to 3 months
      3. Seizure Disorder
      4. Panic Disorder
        1. Decrease dose by no more than 10% of dose weekly (typically over 2 to 7 months)
    2. Technique
      1. Start at taper by 5 to 10% reduction every 2-4 weeks
  7. Other adjunctive medications for Benzodiazepine Withdrawal symptoms
    1. Valproate
    2. Tricyclic Antidepressants
    3. Beandrup (2018) Cochrane Database Syst Rev (3): CD011481 [PubMed]
  • References
  1. (2020) Presc Lett, Resource #361206, Appropriate Use of Benzodiazepines
  2. Butler (2026) Am Fam Physician 113(6): 611-4 [PubMed]