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.

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.

Medications

  • Convert daily intake into equivalent dose of diazepam - see Conversion Chart (PDF 187KB). Seek specialist input for more complex presentations (e.g. poor hepatic function etc).
  • 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 dispensing 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 equivalency and initial doses discussed 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: 3
Descriptor: Difficult to rouse
Stimulus: Pain, shoulder squeeze, jaw thrust
Response: Brief eye opening OR any movement OR no response
Duration: n/a

Score: 2
Descriptor: Easy to rouse, difficult staying awake
Stimulus: Voice, light touch
Response: Eye opening and eye contact
Duration: <10 secs

Score: 1
Descriptor: Easy to rouse
Stimulus: Voice, light touch
Response: Eye opening and eye contact
Duration: <10 secs

Score: 0
Descriptor: Awake, alert
Stimulus: n/a
Response: n/a
Duration: n/a

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 split dose 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 reductions of approx 10% of the original dose per week, and may be slower as one approaches completion e.g. 5-10% monthly from total dose of approx 15mg/day. 
  • Review the patient’s medication history in my Health Record but be aware that this is sometimes incomplete. In future, ScriptCheckSA will be a reliable source of all S8 and targeted S4 medications prescribed and dispensed
  • Consider weekly medical review
  • Advise the patient that they should not drive while taking benzodiazepines, in particular at high doses. See Austroads - Assessing Fitness to Drive for commercial and private vehicle drivers (2022 edition) - Medical Standard 9. Substance Use.
  • A dose reduction period can be lengthened by one to two weeks (ie reduction by 5-10% at 6 weeks rather than 4) if acute issues warrant this, but avoid increasing to a previous dose
  • Avoid pharmacological treatment of withdrawal symptoms such as sleep difficulties and anxiety, because a common feature of the dependence is the habit of using medication to treat discomfort. In particular, pregabalin should be avoided, as it is associated with overdose and dependence. There are also case reports of patients seeking a psychotropic effect from the combination of benzodiazepines and gabapentinoids
  • Withdrawal symptoms are often related to uncertainty and anxiety. Interventions such as physical activity, social engagement and weekly counselling may therefore be helpful.  

Resources

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 1742 — 24 hours a day 7 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.