Benzodiazepine dependence: risks, withdrawal and safe reduction

NICE Clinical Knowledge Summaries (CKS) describes benzodiazepines as GABA receptor agonists with hypnotic, anxiolytic, anticonvulsant and muscle relaxant properties. Hypnotic benzodiazepines are used for short-term treatment of insomnia and include nitrazepam, loprazolam, lormetazepam and temazepam. Anxiolytics, which relieve anxiety, include diazepam, oxazepam, lorazepam, alprazolam and chlordiazepoxide. The z-drugs available in the UK are zolpidem and zopiclone, which CKS calls non-benzodiazepine hypnotics developed to overcome some of the adverse effects of benzodiazepines, such as next-day sedation, dependence and withdrawal; like benzodiazepines they act on GABA receptors.

CKS says that despite warnings about long-term use, millions of prescriptions for these drugs are still issued in primary care each year. It advises that people on long-term benzodiazepines or z-drugs should be advised to stop because tolerance progressively reduces their effectiveness for insomnia or anxiety, and dependence may develop, so that continued treatment may serve only to prevent withdrawal symptoms.

Other reasons it gives for stopping include avoiding adverse effects such as depression and increased anxiety, reducing the risk of road traffic accidents because benzodiazepines can impair driving, and minimising interactions with alcohol or other sedating drugs. The NHS says similar things about sleeping pills for insomnia: they can have serious side effects, you can become dependent on them, and they are only prescribed for a few days or weeks at most.

CKS says anxiety is the most common acute withdrawal symptom and is likely to be temporary. It also lists insomnia as a possible problem during withdrawal, and notes that depression can emerge or coexist. It says withdrawing treatment when significant symptoms of anxiety are present is likely to make them worse and unlikely to succeed, so the underlying problem should be addressed before reduction starts. It warns that withdrawal drug seizures generally occur in people who suddenly stop high doses, which is why slow tapering is recommended for those at risk.

For most people who withdraw slowly, CKS says symptoms are mild and can usually be managed by other means. If you experience severe symptoms, such as seizure, confusion, or a feeling of being unable to cope or of being in danger, seek urgent medical help through NHS 111, or call 999 in an emergency.

CKS says that when someone wishes to stop, an assessment should check whether it is a suitable time. The chances of success improve when physical and psychological health and personal circumstances are stable. It advises enquiring about symptoms of depression (managing depression first), anxiety, long-term insomnia (considering non-drug treatment first) and other medical problems. Primary care is suitable if the person is willing, committed and compliant, has adequate social support, has no history of complicated drug withdrawal and can be reviewed regularly.

It suggests considering specialist advice or referral for people with a history of alcohol or other drug use or dependence (noting that some people substitute alcohol), severe medical or psychiatric disorder, past withdrawal seizures, complex needs, or long-term dependency who cannot manage withdrawal. People who do not wish to stop should not be pressured, should be listened to, and reviewed later.

CKS describes two approaches: slowly reducing the current benzodiazepine or z-drug, or switching to an approximately equivalent dose of diazepam, which is then tapered. Switching is considered for short-acting potent benzodiazepines, products that do not allow small dose reductions, and people likely to find direct withdrawal difficult. Seek specialist advice before switching to diazepam in people with liver problems. A flexible schedule is negotiated, guided by the person, so that they remain comfortable.

The guidance says tapering is based on a proportion of the last dose, so the steps become smaller as the total dose falls, with monitoring for 1 to 4 weeks after reductions and the option of increasing back to the last tolerable dose and stabilising. It says withdrawal may take 3 months to a year, or longer, and that liquid forms may be needed for the final small doses. Exact schedules depend on the drug, dose and duration and must be set by a prescriber; this page does not give doses.

• Do not take extra tablets in times of stress or replace them with more alcohol or other drugs (CKS).

• CBT may be offered to help ease withdrawal symptoms where available.

• Short-term medicines for specific physical symptoms are not routinely prescribed but may be considered with specialist advice.

• If a first attempt does not succeed, trying again is encouraged, and reducing the dose even without stopping completely may still be beneficial.

The Royal College of Psychiatrists says it worked with NICE to produce a patient decision aid on stopping benzodiazepines or z-drugs, covering what they are, why someone might want to stop, the options, choosing the best time to stop or reduce, what reducing or stopping might involve and what else can help. Its main benzodiazepine information page was being updated at the time of retrieval. Alternatives to medicine for sleep and anxiety, such as CBT for insomnia, can be explored with a GP.

Most reductions are supervised by the GP who prescribes the medicine, with referral to community drug and alcohol or mental health services in more complex cases. Private psychiatrists and detoxification services also exist. Ask who will prescribe and review the taper, how quickly it will be adjusted if symptoms are difficult, what happens if you slip back to a higher dose, and whether psychological support is included. Be wary of anyone who recommends stopping abruptly, or supplying these medicines without prescription.