Stopping (deprescribing) benzodiazepines and z-drugs

Reproduced from NICE

Hypnotics and anxiolytics are associated with considerable increase in risk of morbidity: addiction, falls and cognitive impairment. These risks are likely to be increased for patients on multiple medicines, which is why they should be prioritised for review

Assessing the persons readiness to stop

Does stopping the drug matter to the patient, and are their physical and psychological health and personal circumstances stable? Enquire about:

  • Symptoms of depression.Withdrawal can worsen symptoms of clinical depression. The priority is to manage depression first, before attempting withdrawal
  • Symptoms of anxietyWithdrawal in the presence of significant anxiety is unlikely to succeed. However, when symptoms are reasonably well controlled and stable it may be possible to attempt careful drug withdrawal
  • Symptoms of long-term insomnia.If insomnia is severe, consider treating this with non-drug treatments prior to starting withdrawal
  • Medical problems are well controlled and stable.If other problems are causing significant distress, consider managing these first, prior to starting withdrawal
  • Withdrawal in primary care. Is there adequate social support with no previous history of complicated drug withdrawal and ability to attend regular reviews?
  • Specialist advice or referral. Consider where there is a history of alcohol or other drug use or dependence. Also where there is severe medical or psychiatric disorder or personality disorder. A history of drug withdrawal seizures where low tapering is recommended
Managing someone who wants to stop

Decide if the person can stop their current benzodiazepine or z-drug without changing to diazepam.

  • Switching to diazepamis recommended for:
    • People using short-acting potent benzodiazepines (alprazolam, lorazepam)
    • Preparations that do not allow small dose reductions (alprazolam, flurazepam, loprazolam, lormetazepam)
    • People likely to experience difficulty withdrawing directly from temazepam, nitrazepam, or z-drugs, due to a high degree of dependency (associated with long duration of treatment, high doses, and a history of anxiety problems)
  • Seek specialist advice before switching to diazepam in people with hepatic dysfunction. Diazepam may accumulate to a toxic level in these individuals. An alternative benzodiazepine without active metabolites (oxazepam) may be preferred
  • Negotiate a gradual drug withdrawal schedule (dose tapering) that is flexible. Be guided by the person in making adjustments so that they remain comfortable with the withdrawal
  • Titrate the drug withdrawal according to the severity of withdrawal symptoms
  • Withdrawal may take 3-12months or longer. Some people take less time
  • Review frequently, to detect and manage problems early and to provide advice and encouragement during and after the drug withdrawal
  • If they did not succeed on their first attempt, encourage the person to try again
  • Remind the person that reducing benzodiazepine dosage, even if this falls short of complete drug withdrawal, can still be beneficial
  • If another attempt is consideredreassess the person first, and treat any underlying problems (such as depression) before trying again
How should benzodiazepines, or z-drugs be withdrawn?
Managing withdrawal symptoms
  • Review frequentlyto detect and manage problems early, and to provide encouragement and reassurance during and after drug withdrawal
  • Manage anxiety and explain that anxiety is the most common withdrawal symptom
  • . Reassure that anxiety is likely to be temporary. Consider slowing or suspending withdrawal until symptoms become manageable. Consider additional use of non-drug treatments
  • Adjunct drug therapy should not be routinely prescribed. May be considered onlyif other measures fail (e.g. propranolol for severe symptoms, such as palpitations, tremor, and sweating) 
  • Manage depression with antidepressants if required. Consider suspending withdrawal until depression resolves or stabilises. See the NICE CKS topic on Depression
  • Donot prescribe antipsychotics which may aggravate withdrawal symptoms
  • Manage insomnia. See NICE CKS topic on Insomnia
Advice to people undergoing withdrawal
  • Gradual withdrawal minimizes the risk of withdrawal effects
  • Reassure that the person will be in control of the rate of drug withdrawal. This can take 3-12 months or longer. Some people take less time
  • Difficult points can be managed with maintaining the current dose for a few weeks. Try to avoid increasing the dosage if possible
  • Avoid compensating for withdrawal by the use of alcohol, other drugs (prescription, non-prescription, or illicit drugs) or smoking
  • Stopping the last few milligrams is often seen as being particularly difficult. Warn against prolonging the drug withdrawal to an extremely slow rate towards the end (g. reducing by 0.25 mg diazepam each month). Advise the person to consider stopping completely when they reach an appropriate low dose (e.g. diazepam 1 mg daily)
  • Withdrawal symptom advice:
    • With slow tapering, many people experience few or no withdrawal symptoms
    • If withdrawal symptoms are present with slow tapering then symptoms will disappear within a few months
    • Rarely some people will suffer from protracted withdrawal symptoms which will gradually improve over a year or longer
    • The acute symptoms of withdrawal are those of anxiety
    • Explain that some of the withdrawal symptoms may be similar to the original complaint and do not indicate a return of this
    • It is not possible to estimate the severity and duration of withdrawal symptoms for the individual
    • For information on managing withdrawal symptoms, see Managing withdrawal symptoms
Advice to people who do not want to stop taking benzodiazepines or z-drugs?
  • Do not pressurize the person to stop if they are not motivated to do so
  • Listen to the person, and address any concerns they have about stopping
  • Explain that for most people who withdraw from treatment slowly, symptoms are mild and can usually be effectively managed by other means
  • Reassure the person that they will be in control of the drug withdrawal and that they can proceed at their rate
  • Discuss the benefits of stopping the drug. The discussion should include an explanation of tolerance, adverse effects, and the risks of continuing the drug. See Reasons for stopping for further information
  • Review at a later dateif appropriate, and reassess the person's motivation to stop
  • In people who remain concerned about stopping treatment despite explanation and reassurance, persuading them to try a small reduction in dose may help them realize that their concerns are unfounded
References

Reproduced from NICE at this link