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Benzodiazepine withdrawal management

Withdrawal syndrome

The onset and duration of symptoms varies depending on the particular benzodiazepine/s taken as there is a wide variation in half-life and some benzodiazepines have active metabolites.

Symptoms can be considered under three main headings:

Anxiety and related symptoms

  • anxiety, panic attacks, hyperventilation, tremor
  • sleep disturbance, muscle spasms, anorexia, weight loss
  • visual disturbance, sweating
  • altered mood.

Perceptual distortions

  • hypersensitivity to very loud noises
  • abnormal body sensations
  • depersonalisation/derealisation.

Major events

  • generalised seizures
  • precipitation of delirium or psychotic symptoms.

Predictors of benzodiazepine withdrawal

Withdrawal is unlikely if the patient’s use is intermittent only or follows a binge pattern only. More severe withdrawal is associated with:

  • abrupt cessation
  • short-acting agent (especially alprazolam)
  • high dose.

Benzodiazepine withdrawal can be safely managed as an outpatient unless:

  • other major medical or psychiatric problems co-exist
  • there is polydrug dependence
  • the patient is being prescribed other CNS depressants such as opioids, gabapentinoids, antipsychotics, or tricyclic antidepressants
  • the patient takes a high dose (>50mg diazepam equivalent per day) or injects
  • the patient requires stabilisation of other medication (for example methadone, buprenorphine)
  • there is a history of seizures.

Medication regimen

Inpatient withdrawal

  • If the patient has been using more than 50mg diazepam equivalent then they should be initially managed in an inpatient setting.

Medications

  • Convert daily intake into  equivalent dose of diazepam - see Conversion Chart (PDF 187KB).
  • Determine dosage for QID regimen

  • Commence initial dose at  ½ determined initial dose, to assess tolerance. [eg if estimated to be 80mg per day = 20mg QID then initial dose would be 10mg]. This could be repeated in 2 hours if no sedation evident, then continue with  previously determined QID regimen. 

  • If the patient becomes sedated to the extent that they can not stay awake [sedation score 2 or more] medication should be  with-held.
  • Reduce the daily dose by 10mg (for example 5mg bd) each day.
  • Once the patient’s daily dose is less than 50mg, they can be discharged and their medications continued on a tapering basis as per outpatient withdrawal as long as restricted dispensng from the community pharmacy is arranged. [see below].
  • If the patient is also taking/being administered other CNS depressants such as opioids,  gabapentinoids, antipsychotics or tricyclic antidepressants then consider halving the doses above, and increasing observations to 2 hourly, at least initially. Seek advice from the Drug and Alcohol Clinical Advisory Service 08 7087 1742

Observations

  • Use the CIWA-B (PDF 75KB) for monitoring benzodiazepine withdrawal
  • Monitor Sedation Score before  dose and 1 hour after each dose.


    Score Descriptor Stimulus Response Duration
    3 Difficult to rouse Pain, shoulder squeeze, jaw thrust 

    Brief eye opening
    OR
    Any movement OR
    No response 

    NA
    2 Easy to rouse,  difficult staying awake Voice, light touch Eye opening and eye contact <10 secs
    1 Easy to rouse Voice, light touch
    Eye opening and eye contact <10 secs
    0 Awake, alert NA NA NA

Outpatient withdrawal

  • If the patient has been using less than 50mg diazepam equivalent then they can be managed in an outpatient setting.
  • If the patient is also taking/being administered other CNS depressants such as opioids,  gabapentinoids, antipsychotics or tricyclic antidepressants then seek advice from the Drug and Alcohol Clinical Advisory Service 08 7087 1742.
  • A patient/doctor agreement needs to be completed in writing - see example patient/doctor agreement (PDF 165KB).
  • Controlled dispensing of medications from the pharmacy is advised. Daily, 2nd daily or weekly depending on circumstances.
  • Convert daily intake into  equivalent dose of diazepam - see Conversion Chart (PDF 187KB)
  • Split the daily dose into QID regimen.
  • Test first dose to determine tolerance. Review patient 1-2 hours after  first dose. Preferably keep patient in surgery. If tolerated then continue with regimen as estimated.


Further information and advice

Alcohol and Drug Information Service (ADIS) 1300 13 1340
ADIS is a telephone information,  counselling, and referral service, operating 0830 to 2200 hours, seven days per week.

Drug and Alcohol Clinical Advisory Service (DACAS)
DACAS provides general practitioners and other health professionals direct telephone access to a specialist drug and alcohol medical officer. It operates 24 hours seven days per week.

Telephone: (08) 7087 1742.


Resources

  • Benzodiazepines: Information for GPs (PDF 163KB): designed to assist doctors in the management of patients ceasing benzodiazepine use and should be read in conjunction with the patient resource  Benzodiazapines: Reasons to stop and stopping use.

  • Benzodiazepines: Reasons to stop and stopping use (PDF 231 KB): designed for people who are considering stopping, or who have decided to stop, using benzodiazepines. It contains two parts:
    • Part 1: Reasons to stop

    • Part 2: Stopping use.

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