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How do I assess someone who wants to stop benzodiazepines or z-drugs?
- Assess whether this is a suitable time for the person to stop taking the drugs.
- The chances of success are improved when a person's physical and psychological health and personal circumstances are stable. In some circumstances it may be more appropriate to wait until other problems are resolved or improved before starting drug withdrawal.
- Enquire about:
- Symptoms of depression. Withdrawing these drugs can worsen symptoms of clinical depression. The priority is to manage depression first, before attempting drug withdrawal — see the CKS topic on Depression.
- Symptoms of anxiety. Withdrawing treatment when significant symptoms of anxiety are present is likely to make symptoms worse and is therefore 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 of a benzodiazepine or z-drug — see the CKS topic on Insomnia.
- Any medical problems and whether these are well controlled and stable. If problems are causing significant distress, consider managing these first, prior to starting withdrawal of benzodiazepines or z-drugs.
- Consider whether the withdrawal of the benzodiazepine or z-drug can be appropriately managed in primary care.
- People are considered suitable if they:
- Are willing, committed, and compliant, and have adequate social support.
- Have no previous history of complicated drug withdrawal.
- Are able to attend regular reviews.
- Consider seeking specialist advice or referral to a specialist centre for people with:
- A history of alcohol or other drug use or dependence.
- Concurrent, severe medical or psychiatric disorder or personality disorder.
- A history of drug withdrawal seizures — these generally occur in people who suddenly stop high doses of the drugs. Slow tapering is recommended for these individuals.
Basis for recommendation
How do I manage someone who wants to stop benzodiazepines or z-drugs?
- Decide if the person can stop their current benzodiazepine or z-drug without changing to diazepam.
- Switching to diazepam is recommended for:
- People using the short-acting potent benzodiazepines (that is, alprazolam and lorazepam).
- People using preparations that do not easily allow for small reductions in dose (that is alprazolam, flurazepam, loprazolam and lormetazepam).
- People taking temazepam or nitrazepam who choose to withdraw from diazepam after discussing the advantages and disadvantages.
- People experiencing difficulty or who are 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 (preferably from a hepatic specialist) before switching to diazepam in people with hepatic dysfunction as diazepam may accumulate to a toxic level in these individuals. An alternative benzodiazepine without active metabolites (such as oxazepam) may be preferred.
- For information on converting to diazepam, see Switching to diazepam.
- 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.
- Drug withdrawal may take 3 months to a year or longer. Some people may be able to withdraw in less time.
- For information on withdrawing and advice to give people, see Withdrawing a benzodiazepine or z-drug and Advice.
- 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 considered, reassess the person first, and treat any underlying problems (such as depression) before trying again.
Basis for recommendation
These recommendations are in line with published reviews and guidelines on managing benzodiazepine dependence and are based on expert opinion and limited evidence [CSM, 1988; Lader and Russell, 1993; Mant and Walsh, 1997; Ashton, 2002b; Australian Government Department of Health and Ageing, 2004; Lingford-Hughes et al, 2004; Taylor et al, 2007; BNF 56, 2008; Lader et al, 2009].
- Although less well-studied, given that they work similarly, the same approach as for withdrawing benzodiazepines has been recommended for withdrawing z-drugs [Ashton, 2002c].
- These recommendations also apply to older people; they can stop benzodiazepines as successfully as younger people [Ashton, 2002b]. Benzodiazepine withdrawal is particularly important for older people as they are more prone to their adverse effects and have more to gain from benzodiazepine cessation, see Reasons for stopping.
Gradual withdrawal of benzodiazepines and z-drugs
- Although good quality evidence for this is lacking, withdrawing benzodiazepines gradually is recommended to allow a smooth, gradual fall in the level of drugs in the blood, thus minimizing withdrawal symptoms [Lingford-Hughes et al, 2004; Ashton, 2005; BNF 56, 2008; Lader et al, 2009].
- Abrupt drug withdrawal can produce confusion, toxic psychosis, convulsions, or a condition resembling delirium tremens [BNF 56, 2008; Lader et al, 2009]. This is more likely in people taking high doses, although seizures or psychosis may occur when other predisposing factors are also present [Schweizer and Rickels, 1998; Ashton, 2005].
- As the optimal speed or duration of dose reduction is unknown [Lingford-Hughes et al, 2004; Lader et al, 2009], drug withdrawal should be guided by individual choice and severity of withdrawal symptoms.
- Gradual drug withdrawal is also recommended for people dependent on z-drugs as the manufacturers of these drugs warn that abrupt termination of treatment can lead to withdrawal symptoms, particularly in people taking high doses [ABPI Medicines Compendium, 2008; ABPI Medicines Compendium, 2009a; ABPI Medicines Compendium, 2009b].
Switching to diazepam
- Despite the lack of good quality evidence, switching to diazepam is recommended for some people — particularly if they have difficulty withdrawing or if they are on short-acting, potent benzodiazepines [Ashton, 2002b; Ashton, 2005; BNF 56, 2008].
- Diazepam is preferred because:
- It possesses a long half-life (20–100 hours), thus avoiding sharp fluctuations in plasma level.
- It is available in a variety of strengths and formulations. This facilitates stepwise dose substitution from other benzodiazepines or z-drugs and allows for small incremental reductions in dosage (especially at low doses).
- The National Institute for Health and Clinical Excellence does not recommend the substitution of z-drugs for people who are being withdrawn from benzodiazepines as this is not supported by available evidence of reduced potential for dependency [NICE, 2004].
How do I switch from a benzodiazepine or a z-drug to diazepam?
- Information on the approximate dose equivalents of diazepam for a number of benzodiazepines and z-drugs can be found in Additional information.
- Be aware that this information should only be used as a guide.
- Exact dose substitution is not possible, due to:
- Differences in potency between different benzodiazepines and z-drugs.
- Wide variation in the half-life and response to these drugs (such as the degree of sedation) between different individuals (for example, the elderly and people with hepatic impairment).
- Consequently, a complete dose substitution may not always be required, depending on the individual response (to avoid excessive sedation).
- Switching to diazepam is best carried out gradually, usually in a stepwise fashion.
- Consider making the first switch in the night-time dose to avoid daytime sedation.
- For examples of switching for the three most common hypnotics and an anxiolytic (lorazepam), see Additional information.
- Dose withdrawal may be started when conversion to diazepam is complete.
Additional information
- Dose conversion to diazepam:
- Diazepam 5 mg is approximately equivalent to [Ashton, 2002c; Sweetman, 2005; Taylor et al, 2007; BNF 56, 2008; Lader et al, 2009]:
- Alprazolam 0.25 mg
- Chlordiazepoxide 15 mg
- Clobazam 10 mg
- Clonazepam 0.25 mg
- Flurazepam 15 mg
- Loprazolam 0.5 mg to 1.0 mg
- Lorazepam 0.5 mg
- Lormetazepam 0.5 mg to 1.0 mg
- Nitrazepam 5 mg
- Oxazepam 15 mg
- Temazepam 10 mg
- Zaleplon 10 mg
- Zopiclone 7.5 mg
- Zolpidem 10 mg
- These equivalents are based on clinical experience and may vary between individuals [Ashton, 2002a; Lader et al, 2009].
- Diazepam is available in a variety of strengths (2 mg, 5 mg, and 10 mg) and formulations (scored tablets or liquid) to facilitate switching.
- Examples of switching schedules from the three commonest hypnotics to diazepam [Ashton, 2002c]:
- From temazepam 10 mg to diazepam 5 mg:
- Week 1: convert temazepam 10 mg straight to diazepam 5 mg.
- From temazepam 20 mg to diazepam 10 mg:
- Week 1: convert temazepam 20 mg to temazepam 10 mg and diazepam 5 mg.
- Week 2: convert remaining temazepam 10 mg to diazepam 5 mg, giving a total diazepam dose of 10 mg daily.
- From nitrazepam 5 mg to diazepam 5 mg:
- Week 1: convert nitrazepam 5 mg straight to diazepam 5 mg.
- From nitrazepam 10 mg to diazepam 10 mg:
- Week 1: convert nitrazepam 10 mg to nitrazepam 5 mg and diazepam 5 mg.
- Week 2: convert remaining nitrazepam 5 mg to diazepam 5 mg, giving a total diazepam dose of 10 mg daily.
- From zopiclone 7.5 mg to diazepam 5 mg:
- Week 1: convert zopiclone 7.5 mg straight to diazepam 5 mg.
- From zopiclone 15 mg to diazepam 10 mg:
- Week 1: convert zopiclone 15 mg to zopiclone 7.5 mg and diazepam 5 mg.
- Week 2: convert remaining zopiclone 7.5 mg to diazepam 5 mg, giving a total diazepam dose of 10 mg daily.
- Example of a conversion of an anxiolytic (lorazepam 1 mg three times daily) to diazepam [Ashton, 2002c]:
- Week 1:
- Morning: lorazepam 1 mg.
- Midday: lorazepam 1 mg.
- Evening: lorazepam 1 mg.
- Week 2:
- Morning: lorazepam 1 mg.
- Midday: lorazepam 1 mg.
- Evening: lorazepam 0.5 mg plus diazepam 5 mg.
- Week 3:
- Morning: lorazepam 0.5 mg plus diazepam 5 mg.
- Midday: lorazepam 1 mg.
- Evening: lorazepam 0.5 mg plus diazepam 5 mg.
- Week 4:
- Morning: lorazepam 0.5 mg plus diazepam 5 mg.
- Midday: lorazepam 1 mg.
- Evening: diazepam 10 mg.
- Week 5:
- Morning: diazepam 10 mg.
- Midday: lorazepam 1 mg.
- Evening: diazepam 10 mg.
- Week 6:
- Morning: diazepam 10 mg.
- Midday: lorazepam 0.5 mg plus diazepam 5 mg.
- Evening: diazepam 10 mg.
- Week 7:
- Morning: diazepam 10 mg.
- Midday: diazepam 10 mg.
- Evening: diazepam 10 mg.
- Week 8:
- Start diazepam withdrawal.
Basis for recommendation
These recommendations are in line with published reviews and guidelines on switching different benzodiazepines to diazepam and are based on expert opinion [Mant and Walsh, 1997; Ashton, 2002b; Australian Government Department of Health and Ageing, 2004; Taylor et al, 2007; BNF 56, 2008; Lader et al, 2009].
Switching to diazepam
- Despite the lack of good quality evidence, switching to diazepam is recommended for some people. It possesses a long half-life (20–100 hours), thus avoiding sharp fluctuations in plasma level. For further information, see Managing someone who wants to stop.
Examples of benzodiazepine and z-drug substitution schedules
- These are adapted from the Ashton Manual [Ashton, 2002c]. This widely published manual was developed on the basis of clinical experience of managing people withdrawing from benzodiazepines and z-drugs in an English specialist clinic over a 12-year period.
How should I withdraw a benzodiazepine or a z-drug?
- Withdrawal should be gradual (dose tapering, such as 5–10% reduction every 1–2 weeks, or an eighth of the dose fortnightly, with a slower reduction at lower doses), and titrated according to the severity of withdrawal symptoms.
- This may take 3–4 months to a year or longer. Some people may be able to withdraw in less time.
- For advice on withdrawal, see Advice.
- Withdrawal may be undertaken with or without switching to diazepam.
- See Additional information for examples of withdrawal schedules. These should be tailored to meet individual needs.
- For more information on withdrawal schedules for other benzodiazepines and z-drugs, see the Ashton Manual (available online at www.benzo.org.uk).
Additional information
These schedules are adapted from the Ashton Manual [Ashton, 2002c].
- Diazepam is available in a variety of strengths (2 mg, 5 mg, and 10 mg) and formulations (scored tablets or liquid) to facilitate dose reduction, particularly at lower doses.
Suggested withdrawal schedule for diazepam
- From diazepam 40 mg per day or less:
- Reduce dose by 2–4 mg every 1–2 weeks until reaching 20 mg per day, then
- Reduce dose by 1–2 mg every 1–2 weeks until reaching 10 mg per day, then
- Reduce dose by 1 mg every 1–2 weeks until reaching 5 mg per day, then
- Reduce dose by 0.5–1 mg every 1–2 weeks until completely stopped.
- Estimated total withdrawal time:
- From diazepam 40 mg per day: 30–60 weeks.
- From diazepam 20 mg per day: 20–40 weeks.
Suggested withdrawal schedules for temazepam, nitrazepam, and zopiclone without diazepam conversion
- From temazepam 20 mg daily or less:
- Reduce daily dose by a quarter of a 10 mg tablet (2.5 mg) every 2 weeks.
- The target dose for when to stop is when the person is taking only a quarter of a 10 mg tablet as a daily dose.
- If stopping is not possible at the target dose, offer temazepam liquid (10 mg/5 mL) and an oral syringe to achieve further reductions.
- Estimated total withdrawal time: 16–20 weeks or longer.
- From nitrazepam 10 mg daily or less:
- Reduce the daily daily dose by a quarter of a 5 mg tablet (1.25 mg) every 2 weeks.
- The target dose for when to stop is when the person is taking only a quarter of a 5 mg tablet as a daily dose.
- If stopping is not possible at the target dose, offer nitrazepam (2.5 mg/5 mL) liquid and an oral syringe to achieve further reductions.
- Estimated total withdrawal time: 16–20 weeks or longer.
- From zopiclone 7.5 mg per day or less:
- Reduce the daily dose by half of a 3.75 mg tablet (1.875 mg) every 2 weeks.
- The target dose for when to stop is when the person is taking only half of a 3.75 mg tablet.
- If stopping is not possible at the target dose, one option is to convert to diazepam to complete the withdrawal, although this is controversial.
- Estimated total withdrawal time: 16–20 weeks or longer.
Basis for recommendation
These recommendations are in line with published reviews and guidelines on withdrawing benzodiazepines and are based on expert opinion [Mant and Walsh, 1997; Ashton, 2002b; Australian Government Department of Health and Ageing, 2004; Taylor et al, 2007; BNF 56, 2008; Lader et al, 2009].
Withdrawing z-drugs
- Although less well studied, given that they work similarly, the same approach for withdrawing benzodiazepines has been recommended as for withdrawing z-drugs [Ashton, 2002c].
Basis for gradual drug withdrawal
- Despite the lack of good quality evidence, gradual withdrawal of benzodiazepines is recommended to allow a smooth, gradual fall in blood-drug level, thus minimizing withdrawal symptoms. For further information, see Managing someone who wants to stop.
Time required for drug withdrawal
- Although some experts have recommended drug withdrawal over 8–12 weeks, or longer (such as 6 months) if the person has tried to stop before but failed [Lader et al, 2009], the time needed for drug withdrawal can vary from 4 weeks to a year or longer [Ashton, 2002b; Ashton, 2005; BNF 56, 2008].
- Consequently, no specified time frame has been recommended as drug withdrawal should be titrated according to the severity of withdrawal symptoms and individual preference. However, it is recommended that the person should not to be tempted to prolong the drug withdrawal to an extremely slow rate towards the end [Ashton, 2002b; Lader et al, 2009].
Examples of drug withdrawal schedules
- These are adapted from the Ashton Manual [Ashton, 2002c]. This widely published manual was developed on the basis of clinical experience of managing people withdrawing from benzodiazepines and z-drugs in an English specialist clinic over a 12-year period.
- The drug withdrawal schedules are comparable to that recommended by the British National Formulary which suggests withdrawing in steps of about one-eighth (range one-tenth to one-quarter) of the daily dose every fortnight [BNF 56, 2008].
How should I manage withdrawal symptoms?
- Review frequently to detect and manage problems early, and to provide encouragement and reassurance during and after drug withdrawal.
- Manage anxiety.
- Explain that anxiety is the most common acute 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 but may be considered:
- Propranolol: for severe, physical symptoms of anxiety (such as palpitations, tremor, and sweating) only if other measures fail.
- Antidepressants: only if depression or panic disorder coexist or emerge during drug withdrawal.
- Do not prescribe antipsychotics which may aggravate withdrawal symptoms.
- Seek specialist advice if symptoms are severe or difficult to manage.
- Manage depression.
- If depression emerges or coexists with withdrawal symptoms:
- Consider suspending drug withdrawal until the depression resolves.
- See the CKS topic on Depression for further information on the management of depression.
- Manage insomnia.
- Adverse effects on sleep are not likely to be a problem if drug withdrawal is slow.
- Non-drug treatments have proved to be beneficial in managing long-term insomnia and should be considered for all people with long-term insomnia problems — see the CKS topic on Insomnia.
Additional information
- Non-drug treatments for managing anxiety include [Ashton, 2002d]:
- Behaviour therapy — this may require referral to a counselling service, psychologist, or local mental health team — for example:
- Relaxation techniques (such as progressive muscular relaxation and controlled breathing techniques).
- More specialized psychological interventions (such as cognitive behavioural therapy) if symptoms are severe or protracted.
- It should be noted that benzodiazepines may impair the learning of new skills, including strategies for coping with stress. During or after drug withdrawal, the person may be in a vulnerable state and less able to deal with stressful situations.
- Exercise (tailored to the person's capabilities) and other techniques (such as yoga and mediation).
- Complementary or alternative therapies (such as aromatherapy, massage, and reflexology).
Basis for recommendation
These recommendations are in line with published reviews and guidelines on managing benzodiazepine dependence and are based on expert opinion and limited evidence [Lader and Russell, 1993; Mant and Walsh, 1997; Ashton, 2002b; Australian Government Department of Health and Ageing, 2004; Taylor et al, 2007].
Adjunct drug therapy
- Use of adjunct drug therapy to assist benzodiazepine withdrawal is not routinely recommended because there is no good evidence to support its use.
- Although propranolol is recommended by the British National Formulary for managing withdrawal symptoms when other measures have failed [BNF 56, 2008], the evidence for its effectiveness is poor.
Adjunct psychological intervention
- There is limited evidence to support the use of adjunct psychotherapy to promote benzodiazepine withdrawal.
- It is recognized that the choice of, and response to, these treatments will depend very much on the individual and may be helpful for those having difficulty while withdrawing [Ashton, 2002d; Lingford-Hughes et al, 2004].
What should I advise people undergoing withdrawal?
- Advise that drug withdrawal should be gradual to minimize the risk of withdrawal effects.
- Offer reassurance that the person will be in control of the drug withdrawal and that they can proceed at a rate that suits them. Drug withdrawal may take 3 months to a year or longer if necessary. Some people may be able to withdraw in less time.
- If the person reaches a difficult point in the drug withdrawal schedule, maintain the current dose for a few weeks if necessary. Try to avoid going backwards and increasing the dosage again if possible.
- Avoid taking extra tablets in times of stress.
- Avoid compensating for benzodiazepines or z-drugs by increasing the intake of alcohol or other drugs (prescription, non-prescription, or illicit drugs) or smoking.
- Stopping the last few milligrams is often seen as being particularly difficult.
- Reassure the person that this is usually an unfounded fear derived from long-term psychological dependence on benzodiazepines.
- Warn the person not to be tempted to prolong the drug withdrawal to an extremely slow rate towards the end (such as reducing by 0.25 mg diazepam each month). Advise the person to consider stopping completely when they reach an appropriate low dose (such as diazepam 1 mg daily).
- Give information on withdrawal symptoms.
- With slow tapering, many people experience few or no withdrawal symptoms.
- If withdrawal symptoms are present with slow tapering, some users will have lost all their symptoms by the end of the drug withdrawal schedule. For most people, symptoms will disappear within a few months.
- Only a very small number of people will suffer from protracted withdrawal symptoms which will gradually improve over a year or longer.
- Inform the person that nearly all 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 as these will depend on a number of factors (such as severity of dependence and speed of withdrawal).
- For information on managing withdrawal symptoms, see Managing withdrawal symptoms.
- Reassure the person that they can try again if they did not succeed at their first attempt.
- Remind the person that reducing benzodiazepine dosage, even if this falls short of complete drug withdrawal, can still be beneficial.
Basis for recommendation
How do I manage someone who does 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 a rate that suits them.
- 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 date if 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.
Basis for recommendation
Should a person with benzodiazepine or z-drug dependency drive?
- People who take benzodiazepines at doses recommended by the British National Formulary (BNF) and have no evidence of impairment do not need to inform the Driver and Vehicle Licensing Agency (DVLA).
- The non-prescribed use of benzodiazepines and/or the use of supra-therapeutic dosage, whether in a substance withdrawal/maintenance programme or otherwise, constitutes misuse/dependency for licensing purposes. This will lead to licence refusal or revocation.
- Car drivers or motorcyclists can reapply for a licence when they have not misused benzodiazepines for 1 year.
- Drivers of large goods vehicles (LGVs) or passenger-carrying vehicles (PCVs) can reapply for a licence when they have not misused benzodiazepines for 3 years.
- On reapplication, an independent medical assessment and urine screen arranged by the Driver and Vehicle Licensing Agency (DVLA), as well as a favourable report from a consultant or specialist, may be required (and is normally required for LGV and PCV drivers).
- The DVLA provides no advice for people taking z-drugs.
- For more information, see the 'At a glance guide' available on the DVLA website.
Basis for recommendation
These recommendations are based on the At a glance guide to the current standards of fitness to drive published by the Driver and Vehicle Licensing Agency [DVLA, 2010].