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04. Techniques for Successful Benzodiazepine Tapering

Published on June 1, 2024 Certification expiration date: June 1, 2027

Alexis Ritvo, M.D., M.P.H.

Addiction Psychiatry Fellowship Program director and assistant professor - University of Colorado School of Medicine

Key Points

There are 2 different taper techniques that patients can engage in.
In the cut and hold method, you perform a percentage reduction of the current dose and hold until symptoms subside.
In the microreduction method, you make small microreductions on a daily basis.
The cut and hold method can be utilized with the available commercial tablet, capsule, or oral liquid.
The microreductions require off-label approaches, such as compounded prescription, liquid titration, or a precision scale.
Adjust the taper rate and amount based on the patient's tolerability.

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Slides and Transcript

Slide 1 of 26

In this section, I will talk about overall techniques for successful benzodiazepine tapering or deprescribing.

Techniques for Successful Benzodiazepine Tapering Slide 1 of 26

Slide 2 of 26

There are several different techniques that you can utilize with your patient or educate your patient about when approaching benzodiazepine tapering. Some individuals will find it useful to utilize a mix of techniques or might start with one and then transition to another.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

Techniques for Successful Benzodiazepine Tapering Slide 2 of 26

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Slide 3 of 26

So the first technique is the cut and hold technique and this is the most common one utilized throughout Medicine because it's the most easily explained to most patients and can use the tablets or dosage forms that a medication comes in.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

Techniques for Successful Benzodiazepine Tapering Slide 3 of 26

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So you advise the patient to make a percentage dose reduction of their current dose usually by telling them the equivalent in milligrams or fractions of milligrams and then you have them hold that reduction until any withdrawal symptoms subside.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

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Slide 5 of 26

The benefits of this are accomplished utilizing the existing forms of the medication that a patient can receive from the pharmacy. Patients can fairly easily usually half and potentially even quarter tablets that they have. Some patients can do this just with a tablet cutter. I've had other patients recommend purchasing special medication scissors online that they found are really useful. The cons of this approach are that you become limited as you make subsequent reductions in how small of a reduction you can make or percentage reduction you can make because of the tablet forms that the medications come in.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

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Slide 6 of 26

So an example of a cut and hold would be a patient on 20 mg of diazepam does an initial dose reduction of 5% to kind of test out how they respond to it. This would be 1 mg. So you would prescribe the patient 10 mg tablets. They could take one and a half for 15. And then you could also prescribe them 2 mg tablets to make up the additional 5. So they would be taking two 2 mg tablets.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

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Slide 7 of 26

I will say I often have to write these things out. I write them out multiple times, sending them a message to the patient, put it on the script or say on the script, please follow taper instructions. Have to, you know, calculate and double check when patients are able or their family members, ask them to also do a double check just because that you can start to get yourself a little mixed up as you do these reductions.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

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Slide 8 of 26

It's also helpful if you have a pharmacist that can assist you. And I will often call the pharmacy and speak to the pharmacist about I'm engaging in this patient with a benzodiazepine taper. You will see that I'm sending two scripts for different amounts. And I'll put in the note that there are two scripts or that I'm cross-tapering from one to the other and that's why they're on two benzodiazepines. In that way, they're in communication with me and aware of why they're getting all these prescriptions.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

Techniques for Successful Benzodiazepine Tapering Slide 8 of 26

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Slide 9 of 26

The cut and hold method is what the Ashton protocol utilizes. In her case, she cross-tapered folks to diazepam in order to be able to make smaller percentage dose reductions more easily because diazepam comes as low as 2 mg tablets which can easily be cut in half or quartered. Diazepam also comes in a liquid so some patients also find that it makes them able to make even smaller reductions near the end.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

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However, a limitation to the Ashton protocol is that some patients really do not tolerate diazepam due to increased sedation especially in the elderly where their hepatic metabolism has decreased. I've found that we often hit a threshold of what they can tolerate cross-tapering them to.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

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Slide 11 of 26

And again, it always bears repeating that the Ashton manual while it provides some example protocols is really intended to be a flexible approach where you're working with the patient to adjust the taper rate.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

Techniques for Successful Benzodiazepine Tapering Slide 11 of 26

Slide 12 of 26

Another tapering technique is known as a microtaper and this is also sometimes referred as a hyperbolic taper. In a microtaper, folks are going to make microreductions on a daily basis with the goal to have an overall certain percent reduction across a month. So this is to really capitalize on the, you know, thinking of that diagram of the homeostatic setpoint and changing the dose where you're just really trying to make small reductions allowing the brain and body to adjust more easily.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

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Slide 13 of 26

And folks will often reduce every one to three days using either a precision scale, liquid, or a compounding pharmacy because the commercial formulations are not available in small enough doses for them to reduce comfortably.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

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A benefit is that it can really allow for finer adjustment and symptom control because of the dose limitations with the commercially available doses and many report that they feel like their symptoms are better controlled with this approach. The con is this really is an off-label method, right? You're no longer getting the manufactured tablet. You're starting to have patients, you know, modifying how they're taking it whether that's using a scale and shaving off pieces. And of course, some of our patients probably do it with more precision than others and so there's a risk that it's actually imprecise. We don't know exactly what our patients are taking or how.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

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Slide 15 of 26

So we've talked about the techniques for tapering and now I want to talk about kind of the methods that you might use to engage in these techniques. So there's kind of five different methods you might use. The first as we discussed is using the commercial tablet or capsule as it's available and either using that whole or splitting it into halves or maybe even quarters. The second approach is using the manufacturer's oral liquid either alone or further diluted. Just make sure that they follow instructions about how they can dilute it or ask the pharmacist about what is appropriate to use to dilute it like distilled water versus other liquids. This does allow for fine taper reductions via finely graduated syringe.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

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The third method is compounded prescriptions. And then the other two taper methods. One is using a liquid titration where individuals will take the tablet or capsule and mix it with a liquid such as water, milk or suspension vehicle and then make their own reductions via finely graduated syringe. And last, using a precision scale. So individuals can weigh drug or powder capsule content and then make dry cuts with a pill cutter, razor or file.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

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Slide 17 of 26

Using a liquid titration. There's a lot of online support to educate patients about doing this. It's important to know that many medications are not water soluble. So if you put them into water, it doesn't become an equally distributed solution and instead has to be constantly stirred liquid suspension to distribute the medication as evenly as possible. Therefore, there's a significant risk of imprecision dose to dose. So I would recommend using a USP grade suspension vehicle if they're going to do a liquid titration just to try to limit that imprecision. Additionally, there is some thought that some of these medications might be able to be diluted like the clonazepam oral disintegrating tablet into milk. This is still considered off-label but is being recommended in the new Maudsley textbook and they felt in their review of the properties of the medication that it was a reasonable way to approach doing a liquid titration with clonazepam.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

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In compounded prescriptions, I would recommend that you help patients identify pharmacies where there's a pharmacist associated with either the International Academy of Compounding Pharmacists or the Professional Association of Compounding Pharmacists just to ensure that they're using as much precision as possible when compounding the prescriptions.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

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Slide 19 of 26

Again, the compounded prescription, liquid titration, precision scale are all off-label methods that have not undergone any systematic review and have limitations because there's, you know, greater room for imprecision depending on the patient and what tools they're using to engage in the method.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

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There was a review done by Horowitz and a group of colleagues looking at how 13 different deprescribing practices approach deprescribing, eight practices in the UK and five from other countries. And in analyzing the interviews from these individuals, they found that overall the approach is a gradual taper of medications often over more than a year.

References:

Cooper, R. E., Ashman, M., Lomani, J., Moncrieff, J., Guy, A., Davies, J., Morant, N., & Horowitz, M. (2023). “Stabilise-reduce, stabilise-reduce”: A survey of the common practices of deprescribing services and recommendations for future services. PLOS ONE, 18(3), e0282988.

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Slide 21 of 26

I think that's an important thing to keep in mind that it is extremely important to provide support and reassurance throughout the process as well as psychosocial support for the management of underlying conditions.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

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I have found it extremely useful to engage in cognitive behavioral therapy for insomnia with my patients that have been taking these medications for sleep or find that they start to have more sleep difficulty when tapering off of them as well as other psychotherapies especially cognitive behavioral therapy or mindfulness-based practices to help with anxiety and overall distress.

References:

Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 28, 2024. http://www.benzo.org.uk/manual/.
Colorado Consortium for Prescription Drug Abuse Prevention, Benzodiazepine Information Coalition, Benzodiazepine Action Work Group, & Easing Anxiety, E. A. (2022, January). Benzodiazepine Deprescribing Guidance. Colorado Consortium for Prescription Drug Abuse Prevention. https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

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Slide 23 of 26

So just to review the key points from this section, there are two different taper techniques that our patients could engage in. One is the more traditional cut and hold method utilized in the Ashton manual where you do a percentage reduction of the current dose and then hold until symptoms subside.

Techniques for Successful Benzodiazepine Tapering Slide 23 of 26

Slide 24 of 26

The other is a microreduction where on a daily basis you might be making a small microreduction with the goal of doing a certain percentage reduction over the course of a month. And the, the first one is the one that can be utilized with the available commercial tablet or capsule or oral liquid.

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Slide 25 of 26

The microreductions require off-label approaches such as compounded prescription, liquid titration or precision scale. And to just reiterate again and again, I mean the importance that the taper rate and amount is really adjusted based on patient's tolerability to the taper.

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Next Section

05. Understanding and Managing Benzodiazepine Withdrawal Symptoms

Learning Objectives:

After completing this activity, the learner will be able to:

Perform motivational interviewing techniques for effective benzodiazepine deprescribing.
Develop individualized benzodiazepine tapering strategies tailored to patient needs.
Recognize and manage benzodiazepine withdrawal symptoms.

Original Release Date: June 1, 2024

Expiration Date: June 1, 2027

Expert: Alexis Ritvo, M.D.

Medical Editor: Paz Badía, M.D.

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None of the faculty, planners, and reviewers for this educational activity have relevant financial relationships to disclose during the last 24 months with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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