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).
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 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 from 8.30 am to 10.00 pm 7 days/week including public holidays or e-mail your enquiry to HealthDACASEnquiries@sa.gov.au.
This service does not provide proxy medical cover and cannot assume responsibility for direct patient care.
- 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.