Withdrawal from benzodiazepines

The improved safety profile of benzodiazepines compared to barbiturates has contributed to a high rate of prescription since the seventies.

Although benzodiazepines are highly effective for some disorders, people may develop tolerance leading to chronic consumption and dependence on the drug.

• both psychological and physical dependence may occur after few weeks or months of regular or repeated use (2)
• the following factors are associated with an increased risk of developing dependency:
  • long-term use
  • short duration of action
  • high dose
  • high potency
  • alcohol or other drug dependency
  • personality disorders
  • use without medical supervision (1)

The key feature in benzodiazepine dependence is emergence of withdrawal symptoms with dosage reduction or discontinuation (3).

• with withdrawal from benzodiazepines one sees recrudescence of anxiety, perceptual disturbances, panic attacks, cognitive impairment, seizures.
• withdrawal of benzodiazepine should be
  • carried out gradually - the length of the period of withdrawal is dependent on the dose of the benzodiazepine that is being withdrawn and the patient response to the withdrawal process.
    • dose tapering should be flexible and should be according to the patient's individual needs which are different in every case (1)
    • but regimens beyond 6 months should be avoided although a 6 month schedule may be necessary for patients who have tried but failed to withdraw previously (4)
  • achieved after changing the prescription from a short-acting to a long-acting preparation if appropriate e.g. diazepam.
  • the patient's decision and should not be forced by the doctor (2)
  • a collaborative treatment between patient and health professional. Withdrawal symptoms may start within about 2 to 3 days of stopping a short-acting benzodiazepine, and within about 7 days of stopping a long-acting preparation.
• adjunctive therapies such as structured psychosocial interventions, counselling, relaxation techniques could be used for symptomatic treatment (5)
• there may be hyperacusis when withdrawing.

More details regarding the withdrawal of benzodiazepines is provided in the links below. The withdrawal of benzodiazepines is considered in terms of:

• withdrawal from benzodiazepine hypnotics e.g. temazepam, nitrazepam
• withdrawal from benzodiazepine anxiolytics e.g. lorazepam

Notes:

• a systematic review (6) reported that "Carbamazepine might have promise as an adjunctive medication for benzodiazepine withdrawal, particularly in patients receiving benzodiazepines in daily dosages of 20 mg/d or more of diazepam (or equivalents)..... The results of this systematic review point to the potential value of carbamazepine as an effective intervention for benzodiazepine gradual taper discontinuation. Carbamazepine has shown rather modest benefit in reducing withdrawal severity, although it did significantly improve drug-free outcome."

Reference:

• (1) National Prescribing Centre (NPC). Benzodiazepines and newer hypnoticsMeReC Bulletin 2005;15(5)
• (2) Ashton, C.H.  2002. Benzodiazepines: how they work and how to withdraw. The Ashton Manual
• (3) Ashton H. The diagnosis and management of benzodiazepine dependence. Curr Opin Psychiatry. 2005;18(3):249-55
• (4) National Addiction Centre, King's College London and School of Social and Community Medicine 2011. The changing use of prescribed benzodiazepines and z-drugs and of over-the-counter codeine-containing products in England: a structured review of published English and international evidence and available data to inform consideration of the extent of dependence and harm.
• (5) Department of Health (DH) 2007. Drug Misuse and Dependence: UK Guidelines on Clinical Management
• (6) Dennis C et al. Pharmacological interventions for benzodiazepine mono-dependence management in outpatient settings. Cochrane Database Syst Rev. 2006 Jul 19;3:CD005194. Review