Benzodiazepine withdrawal management
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.
- hypersensitivity to very loud noises
- abnormal body sensations
- 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.
Inpatient withdrawal medication regimen
- If the patient has been using more than 50mg diazepam equivalent then they should be initially managed in an inpatient setting.
- Convert daily intake into equivalent dose of diazepam - see Conversion Chart (PDF 187KB).
- 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 dispensing from the community pharmacy is arranged. [see below].
Determine dosage for QID regimen
- 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.
- Use the CIWA-B (PDF 75KB) for monitoring benzodiazepine withdrawal
- Monitor Sedation Score before dose and 1 hour after each dose.
|3||Difficult to rouse||Pain, shoulder squeeze, jaw thrust||Brief eye opening
Any movement OR
|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|
Outpatient withdrawal medication regimen
- 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.
- Prescribe diazepam equivalent with gradual reduction of 5 to 10% of the dose each week.
- The patient is required to sign an Authority to release personal Medicare and Pharmaceutical Benefits Scheme Claims information to a third party form regarding medical visits and scripts dispensed through PBS.
- The patient will require at least a weekly medical review
- Advise the patient that they should not drive while taking benzodiazepines, in particular at high doses. See Prescription drugs and driving (PDF 280B).
- 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.
Further information and advice
Alcohol and Drug Information Services (ADIS) 1300 13 1340
ADIS is a telephone information, counselling and referral service operating 8:30am to 10:00pm, seven days per week.
Drug and Alcohol Clinical Advisory Services (DACAS)
DACAS provides a telephone and email service for South Australian health professionals seeking clinical information and clarification around clinical procedures, guidelines and evidence-based practice.
Telephone: (08) 7087 172 from 8:30am to 10:00pm, seven days/week including public holidays or email your enquiry to HealthDACASEnquiries@sa.gov.au
This services does not provide proxy medical cover and cannot assume responsibility for direct patient care.