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Sussex Health Authority
Practical General Practice · 2001
Every practice needs a policy to avoid initiating dependence in patients given benzodiazepines. For example:
Benzodiazepines will only be used for the short-term relief of severe anxiety or insomnia, or for specific medical emergencies such as alcohol detoxification or the management of convulsions.
Short acting compounds (such as lorazepam) will not be used in the daytime.
No repeat prescriptions will be given except to those already established as long-term users.
No patient not already on benzodiazepines will be prescribed a course which lasts more than 4 weeks.
Current benzodiazepine users will be identified and invited to attend to discuss withdrawal. The invitation will be repeated annually until the drug is withdrawn. An exception to this might be the older patient maintained long-term symptom free on the same dose.
An annual audit of the number of benzodiazepine users will be conducted to monitor success and to learn from failures.
Management of withdrawal
Withdrawal symptoms can be distinguished from a return of anxiety and include:
disordered perceptions: feelings of unreality, increased sensory perception, or a sensation of movement.
Serious psychiatric and neurological adverse effects: convulsions or acute psychosis.
Symptoms typically emerge in the first week after stopping or reducing the dose. Occasionally they occur in patients on a stable dose, and are temporarily abolished by an increase in the dose. They usually last for up to 3 months but may last for over a year.
Withdrawal symptoms may be seen in patients who have been on benzodiazepines for as little as 3 weeks and they occur in up to almost half of patients who have taken them for over 3 months (*).
Two-thirds will be able to stop with some disturbance of sleep but without the true withdrawal syndrome. They may, however, need help in finding a different solution to the problem for which they were taking the benzodiazepine.
Offer withdrawal with explanation to all patients on long-term benzodiazepines who have become dependent inadvertently following therapeutic use. Record the discussion in the notes.
Refer patients who are misusing other drugs or alcohol, as well as benzodiazepines to the specialist services. Concurrent withdrawal of more than one drug is not recommended.
Refer patients requiring very high doses or who are injecting the drugs.
A number of withdrawal regimens have been used. There is a spectrum of possibilities with the two proposed below at opposite ends of the spectrum. The two principles behind all regimens are to use a long-acting benzodiazepine and to reduce slowly, or very slowly.
Rapid Withdrawal: for patients who give no indication that a withdrawal syndrome is likely.
Reduce the benzodiazepine dose by a quarter every 2 weeks and see the patient each time. If true withdrawal symptoms develop then change to a slow withdrawal.
Slow Withdrawal: for patients in whom a withdrawal syndrome is likely (because of evidence of tolerance or previous symptoms of withdrawal).
Change patients on short-acting to long-acting benzodiazepines, e.g. diazepam. For equivalent doses see BNF (chapter 4.1); e.g. lorazepam 2 mg is equivalent to diazepam 20 mg. If the changeover proves difficult do it in stages, e.g changing 1 mg lorazepam to 10 mg diazepam at a time.
Start with a plan agreed with the patient, e.g. reducing the daily dose by 1/8th per fortnight, with smaller reductions in the final stages. Expect to take several months or even 1 year. If the patient has been obtaining the drug illegally, start with a dose considerably below the amount claimed.
Be prepared to renegotiate the plan if the patient develops severe withdrawal effects. Keep patients on each dose long enough for them to settle before the next reduction.
If the patient requests a slower rate of reduction because of psychological rather than physical dependence, it is better to keep to the agreed plan and intensify support.
Be prepared for the emergence of anxiety, depression or insomnia, and manage accordingly. Patients on long-term benzodiazepines often have inappropriate reactions to difficulties in their lives. Withdrawal of the drug must be accompanied by re-education by the GP or referral, for instance, to a benzodiazepine-withdrawal support group.
Symptom control: For patients not willing to tolerate the symptoms of withdrawal, consider using other drugs temporarily:
promethazine 25mg at night for insomnia;
propranolol 10 to 40mg t.d.s. for somatic symptoms;
tricyclic antidepressants, e.g. amitriptyline 25 to 75mg daily, for depression and anxiety. This should be started 4 weeks before reducing the benzodiazepine in those in whom its need can be predicted.
Avoid using buspirone or major tranquillizers. They may make withdrawal worse. Do not use zopiclone or chlormethiazole; they have cross-dependency with benzodiazepines.
* Kan CC, Breteler MH, Zitman FG. High prevalence of benzodiazepine dedendence in outpatient users, based on the DSM-III-R and ICD-10 criteria. Acta Psychiatrica Scandinavica 1997; 96: 85-93.
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