Benzodiazepine Tapering Strategies and Support for Clinicians

Main points

• When to consider a benzodiazepine taper

• Review of benzodiazepine withdrawal symptoms

• Tapering strategies

• Risk reduction strategies

Rural considerations

This resource was developed to help rural primary care clinicians who are managing their patients’ complex chronic pain, which may include benzodiazep

ines. It was developed in response to a direct request from a primary care practice we are partnering with in rural New York State. The practice expressed interest in information about the potential to taper a patient off benzodiazepine medications.

Please also consider:

• If feasible, partner with a larger medical center/hospital system to assist with complicated cases and/or a pain management specialist such as a palliative care provider who will be available to answer specific questions

• Develop consistent protocols for all controlled substance medications, especially for ordering, monitoring, clinical documentation, and intervention parameters. This will help prevent boundary shifts and establish clear expectations for all patients and clinicians.

• Utilize telehealth communication platforms to assist patients with transportation barriers.

• Co-prescribe naloxone routinely.

• Avoid benzodiazepine-opioid combinations whenever possible.

• Join a Project ECHO hub for pain management and behavioral health support.

• Develop informal case review groups with nearby clinicians.

• Resources:

  • Substance Abuse and Mental Health Services Administration (SAMHSA) for rural grants and medications for opioid use disorder (MOUD) resources

  • Health Resources and Services Administration (HRSA) Rural Communities Opioid Response Program (RCORP) for grants and opportunities to collaborate with outside health centers

  • American Society of Addiction Medicine (ASAM) for clinical guidance

  • Providers Clinical Support System (PCSS) for free addiction training

Introduction

Benzodiazepines can cause physical dependence and withdrawal symptoms within as little as 4 to 6 weeks of continued use.¹ Benzodiazepines agonize gamma-aminobutyric acid-A (GABA) receptors in the brain. GABA is the primary inhibitory neurotransmitter in the central nervous system. As long as the benzodiazepine is present, the GABA-A receptors can provide inhibitory signaling. Upon discontinuation of benzodiazepines, inhibitory signaling decreases, causing excitatory clinical manifestations.²

The best way to minimize withdrawal symptoms when discontinuing a benzodiazepine is a slow taper. There are many different tapering strategies and techniques that are utilized, but none have been shown to be superior. Developing a patient-centered taper schedule will help the patient achieve their goal. It may require many conversations before the patient is ready to attempt a taper. Resistance can be mitigated by providing education, reassurance, and clear written instructions. The goals of a successful taper are to decrease withdrawal effects and manage the recurrence of underlying symptoms. It is important to keep in mind that a rapid taper or cessation without tapering results in high morbidity and mortality. A consistent message by the patient’s treatment team and coordination of care will provide the best opportunity for success.    

When to taper³

Any patient taking benzodiazepines daily for longer than 2 to 4 weeks, especially persons:

• Older than 65 years (because of the risk of injury from falls and other cognitive adverse effects), unless there are compelling reasons for continuation

• Taking multiple benzodiazepines, benzodiazepines combined with prescribed opioids or amphetamines, or supratherapeutic dosages of benzodiazepine

• A cognitive disorder, history of traumatic brain injury, or current or history of substance use disorder, especially sedative-hypnotic or alcohol use disorder

High dose and long-term use are associated with a greater chance of developing benzodiazepine withdrawal.

Common acute benzodiazepine withdrawal symptoms⁴

Benzodiazepine withdrawal syndrome includes symptoms specific to benzodiazepine withdrawal as well as symptoms common to most anxiety disorders.

Timeline of benzodiazepine withdrawal syndrome

Acute benzodiazepine withdrawal may persist from 5 to 28 days, though generally peaks after 14 days.

Time course varies based on individual agent, half-life, and presence or lack of active metabolites.

The acute withdrawal phase may develop into a protracted phase.

Possible protracted benzodiazepine withdrawal symptoms⁴ 

Before you begin³

Build a stable relationship with your patient.

Establish a team-based approach (for example, with a primary care clinician, care manager, therapist, group facilitator, and/or pharmacist) as this will be most effective in efforts to taper a patient from benzodiazepines. In rural settings where subspecialty providers are not readily available, it is recommended to expand roles within the current care team and build internal expertise through specialized training in substance use and mental health disorders. Primary care clinicians can establish clear protocols to help manage a broader scope and utilize electronic consultations (e-consults) as available. Nurses can lead care coordination, chronic disease management, and patient education. Medical assistants can assist with screenings, follow-ups, outreach, and care navigation.

Evaluate and treat any concomitant conditions.

Obtain complete drug and alcohol history.

Review recent medical notes and coordinate care with other providers.

Review prescription drug monitoring database.

Employ risk reduction strategies such as providing naloxone to those concomitantly taking opioids or who are otherwise at risk for opioid overdose, connecting patients to local resources, and providing patient education based on each individual patient’s risks.

Three-step approach to benzodiazepine tapering⁵

Tapering strategies³, ⁶, ⁷

For patients on supratherapeutic benzodiazepine doses, consider hospital admission due to greater medical risks and need for monitoring.

Patients on therapeutic dosing

Dose reductions of 5% to 10% every 2 to 4 weeks.

• The taper should typically not exceed 25% every 2 weeks.

Patients who have been taking lower doses for a relatively short period of time (i.e. < 3 months) may be able to taper more quickly.

Clinicians should tailor tapering strategies to each individual patient and adjust tapering based on patient response.

It may be necessary to slow the rate of reduction towards the end of the taper.

• Doses should be scheduled; avoid as-needed use.

• Provide a 7- to 14-day supply of medication at a time. 

• Holding a dose for longer than expected or slowing the rate of the taper may be necessary, but avoid increasing the dose once a taper has started. 

• Schedule follow-up visits every 1 to 4 weeks depending on the rate of the taper and the patient’s response. 

• Psychotherapy and cognitive behavioral therapy have been found to be beneficial during and following taper, especially for anxiety and insomnia. 

Flexibility, shared decision-making, and clear goals are required for a successful taper.

Withdrawal symptoms are best managed by adjustment of taper rate and nonpharmacologic measures, such as lifestyle modifications, peer support, and psychotherapy.

When patients are unable to taper gradually or are rapidly discontinued, detoxification or inpatient hospital admission is recommended to decrease associated morbidity and mortality from benzodiazepine withdrawal.

Conversion from shorter-acting to longer-acting agent to reduce withdrawal symptoms⁷  

Data regarding this approach increasing the chances of a successful taper is lacking, but it may be helpful for some patients.⁶ Studies by Schweizer, Rickels, Weiss, and Zavodnick of benzodiazepine-treated patients showed no significant effect of half-life on the results of a gradual taper but greater withdrawal severity after abrupt discontinuation with agents having shorter half-lives and with higher daily doses.⁸ 

• If this approach is chosen, use the table below to convert the short-acting benzodiazepine to a longer-acting benzodiazepine.

• Reduce the dose by 50% the first 2 to 4 weeks then maintain on that dose for 1 to 2 months then reduce the dose by 25% every 2 weeks.

Pharmacology of commonly prescribed benzodiazepines for anxiety⁹ 

IR = immediate release

ER = extended release

* Preferred agents for elderly patients and patients with hepatic impairment because they are metabolized by conjugation and do not have active metabolites 

** Important: Data shown are approximate equal potencies relative to lorazepam 1 mg orally and are NOT recommendations for initiation of therapy or for conversion between agents. 

₹ Intermediate acting (12–24 hr) 

^ Long acting (> 24 hr)    

Concurrent benzodiazepine and opioid use¹⁰

Combining opioids and benzodiazepines is of particular concern due to the risk of accidental overdose. In 2016, the Food and Drug Administration added a boxed warning cautioning against the concomitant use of benzodiazepines and opioids. After opioids, benzodiazepines are the drug class most commonly involved in intentional and unintentional overdose deaths. Opioids play a role in approximately 75% of deaths involving benzodiazepines. Risk of opioid overdose increased fivefold during the first 90 days of concurrent prescription with a benzodiazepine.

Risk Reduction⁶

If complete discontinuation is not possible, taper the benzodiazepine to the lowest dose possible and encourage only as needed or intermittent use.

Caution patients to avoid mixing benzodiazepines with other central nervous system (CNS) depressant drugs or alcohol.

Advise patients to avoid driving or other dangerous activities after taking benzodiazepines.

Bottom line³

When prescribed at a low dosage for a short time (fewer than 30 days), benzodiazepines can effectively treat generalized and social anxiety, panic disorder, and sleep disorders. Long-term use for anxiety and sleep disorders is not supported by research because it is associated with the development of physiologic and psychological dependence characterized by tolerance, withdrawal, and reluctance to reduce or discontinue use despite the objective lack of effectiveness.

The best way to prevent benzodiazepine dependence for high-risk patients is to adhere to treatment recommendations and emphasize nonpharmacologic therapies for anxiety and insomnia. If benzodiazepines are used, they should be prescribed for short-term, intermittent use (2 to 4 weeks at no more than 3 times per week), intermittent brief courses (daily use for no more than 2 weeks in cases of extreme stress and anxiety), or occasional doses to limit the potential for new long-term users.

Benzodiazapine tapering must be done thoughtfully and according to tapering guidelines to prevent morbidity and mortality related to benzodiazepine withdrawal, and at times may require higher level of care including hospital admission. Maintaining a patient on a lower dose may be sufficient to reduce the current risks so that they no longer outweigh the benefits (and even if risks still outweigh benefits, lower dose = lower risks). It may take months to years to fully taper off of benzodiazepines, particularly if patients have been taking high doses for an extended period of time.

Authors

Marin Valentino, PharmD, BCCCP, CPP

Holly Ann Russell, MD, MS

Jade Malcho, MD

Additional resources

U.S. Department of Veterans Affairs, Re-evaluating the use of benzodiazepines (2021)

American Society of Addiction Medicine, The joint clinical practice guideline on benzodiazepine tapering: Considerations when benzodiazepine risks outweigh benefits (2025)

American Association of Psychiatric Pharmacists, AAPP Pharmacist Toolkit: Benzodiazepine Taper (2023)

References 

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2. Kang, A. M. Benzodiazepine withdrawal. (2024). UpToDate. Retrieved November 1, 2024, from https://www.uptodate.com/contents/benzodiazepine-withdrawal?search=benzodiazepine%20withdrawal&source=search_result&selectedTitle=1%7E46&usage_type=default&display_rank=1. 

3. Ogbonna, C. I., & Lembke, A. (2017). Tapering patients off of benzodiazepines. American Family Physician, 96(9), 606–610. https://www.aafp.org/pubs/afp/issues/2017/1101/p606.html

4. Ashton, C. H. (2002, August). Chapter III: Benzodiazepine withdrawal symptoms, acute and protracted. In Benzodiazepines: How they work and how to withdraw (The Ashton manual). https://www.benzo.org.uk/manual/bzcha03.htm

5. Popish, S. J., & Wells, D. L. (2016, August). Re-evaluating the use of benzodiazepines. U.S. Department of Veterans Affairs. https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Benzodiazepine_Provider_AD_Educational_Guide.pdf 

6. Gold, J., & Ward, K. (2023). AAPP pharmacist toolkit: Benzodiazepine taper. American Association of Psychiatric Pharmacists. https://aapp.org/guideline/benzo

7. National Center for PTSD. (2013). Effective treatments for PTSD: Helping patients taper from benzodiazepines. U.S. Department of Veterans Affairs. https://www.va.gov/painmanagement/docs/OSI_6_Toolkit_Taper_Benzodiazepines_Clinicians.pdf

8. American Psychiatric Association. (2004). Practice guidelines for the treatment of psychiatric disorders, Compendium 2004.  

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12. Schweizer, E., Rickels, K., Case, W. G., & Greenblatt, D. J. (1991). Carbamazepine treatment in patients discontinuing long-term benzodiazepine therapy. Effects on withdrawal severity and outcome. Archives of General Psychiatry, 48(5), 448–452. https://doi.org/10.1001/archpsyc.1991.01810290060012  

13. Bobes, J., Rubio, G., Terán, A., Cervera, G., López-Gómez, V., Vilardaga, I., & Pérez, M. (2012). Pregabalin for the discontinuation of long-term benzodiazepines use: An assessment of its effectiveness in daily clinical practice. European Psychiatry, 27(4), 301–307. https://doi.org/10.1016/j.eurpsy.2010.12.004

14. Hadley, S. J., Mandel, F. S., & Schweizer, E. (2012). Switching from long-term benzodiazepine therapy to pregabalin in patients with generalized anxiety disorder: A double-blind, placebo-controlled trial. Journal of Psychopharmacology, 26(4), 461–470. https://doi.org/10.1177/0269881111405360  

15. López-Muñoz, F., Marín-Mayor, M., & Rubio, G. (2014) Anticonvulsant agents for the management of benzodiazepine dependence. Journal of Addiction and Addictive Disorders, 1, 1–10. https://doi.org/10.24966/AAD-7276/100003

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21. U.S. Department of Health and Human Services. (2019, October). HHS guide for clinicians on the appropriate dosage reduction or discontinuation of long-term opioid analgesics. https://www.hhs.gov/system/files/Dosage_Reduction_Discontinuation.pdf 

22. Oregon Pain Guidance. (2016). Pain treatment guidelines: A provider and community resource. https://northwestpainguidance.org/wp-content/uploads/2016/05/OPG_Guidelines_2016.pdf   

23. Fluyau, D., Revadigar, N., & Manobianco, B. E. (2018). Challenges of the pharmacological management of benzodiazepine withdrawal, dependence, and discontinuation. Therapeutic Advances in Psychopharmacology, 8(5), 147–168. https://doi.org/10.1177/2045125317753340

24. American Society of Addiction Medicine. (2025). The joint clinical practice guideline on benzodiazepine tapering: Considerations when benzodiazepine risks outweigh benefits. https://www.asam.org/quality-care/clinical-guidelines/benzodiazepine-tapering