Slides and Transcript
Slide 1 of 29
In this section, I will discuss further the principles of benzodiazepine tapering.
Slide 2 of 29
Before you begin a taper or deprescribing with a patient, you want to ensure that you both understand that the goals for a successful taper are to decrease withdrawal effects and manage rebound symptoms as well as recurrence of any underlying symptoms that were being managed by the benzodiazepine.
References:
- Linsky, A., Simon, S. R., & Bokhour, B. (2015). Patient perceptions of proactive medication discontinuation. Patient Education and Counseling, 98(2), 220–225.
- Tannenbaum, C., Martin, P., Tamblyn, R., Benedetti, A., & Ahmed, S. (2014). Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: The EMPOWER cluster randomized trial. JAMA Internal Medicine, 174(6), 890–898.
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Slide 3 of 29
Before you begin a taper, you want to engage in an ongoing shared decision making about the deprescribing plan and establish a flexible gradual taper plan. I tend to try to stick to laying out maybe two steps at a time and waiting to see after initial one or two reductions how a patient does before we kind of come up with the next few steps.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 2024. http://www.benzo.org.uk/manual/.
Slide 4 of 29
It's also extremely important to discuss other lifestyle modifications that patients should engage in to help manage their overall mental health and their withdrawal symptoms, so reviewing with them what their current diet is, how many fruit and vegetable servings are they getting per day, do they get regular meals throughout the day, what their physical activity routine is and how to improve that even if, you know, it's just increasing, taking some short walks between breaks at work and getting out and getting some sunshine, reviewing their sleep hygiene and potential cognitive behavioral therapy for insomnia interventions to help with their sleep and providing other skills for coping with distress such as meditation, mindfulness, and stress reduction.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 2024. http://www.benzo.org.uk/manual/.
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Slide 5 of 29
Also, really important that patients establish a support system around them with a multidisciplinary approach, so engaging their mental health providers, their primary care providers, family members, friends so that they have a wide range of individuals that are aware of what they're embarking on and are there to offer different types of support. I would encourage you to look at the peer support guidance document also on the Benzodiazepine Action Work Group page, benzoaction.org, under Projects, to provide some other examples of ways that our patients can seek support during this process.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 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
Slide 6 of 29
Overall, the goal in deprescribing should be to maintain the patient's function as much as possible so that they're able to continue to do the things they need and want to do and minimize their distress so they don't feel too out of control or bothered by the withdrawal.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 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 29
Additionally, before engaging in a taper, we want to stabilize any interdose withdrawal by either dosing a shorter half-life benzodiazepine more frequently and/or cross-tapering to an equivalent dose of a longer half-life benzodiazepine.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 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
Slide 8 of 29
So I ask them to keep a diary of when and how you're taking your benzodiazepine. This helps me get an idea whether they are able to still take it very consistently or whether there's great fluctuation and they're taking it here and there because they're responding to experiencing interdose withdrawal symptoms or increased anxiety.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 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
- Kaiser Permanente. (2022). Benzodiazepine and Z-Drug Safety Guideline. Kaiser Permanente. https://wa.kaiserpermanente.org/static/pdf/public/guidelines/benzo-zdrug.pdf
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Slide 9 of 29
If it seems that they're taking it more erratically because of existing withdrawal symptoms, I will first try to stabilize their withdrawal symptoms by having them dose the medication more frequently to try to avoid them having those peaks and troughs in their blood levels. This can mean for a super short-acting benzodiazepine like alprazolam, having them take it up to four, maybe even five times a day.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 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
- Kaiser Permanente. (2022). Benzodiazepine and Z-Drug Safety Guideline. Kaiser Permanente. https://wa.kaiserpermanente.org/static/pdf/public/guidelines/benzo-zdrug.pdf
Slide 10 of 29
For lorazepam, also maybe anywhere from three to five times a day. Clonazepam, usually more like two or three but I have seen it four. And diazepam is interesting because while it could be once daily to help with some withdrawal effects, the anxiolytic effect is much shorter lived. So I do find that individuals often benefit from taking it at least three times a day, sometimes even four.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 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
- Kaiser Permanente. (2022). Benzodiazepine and Z-Drug Safety Guideline. Kaiser Permanente. https://wa.kaiserpermanente.org/static/pdf/public/guidelines/benzo-zdrug.pdf
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Slide 11 of 29
If they don't tolerate or aren't interested in trying to take what they're currently taking more frequently, then the other approach is to cross-taper them to an equivalent dose of a longer half-life benzodiazepine.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 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
- Kaiser Permanente. (2022). Benzodiazepine and Z-Drug Safety Guideline. Kaiser Permanente. https://wa.kaiserpermanente.org/static/pdf/public/guidelines/benzo-zdrug.pdf
Slide 12 of 29
The one most frequently used is diazepam and that's the one that Heather Ashton really supports in her manual. When that's not an option or patient is not willing or able to take that, you can look at some of the other longer-acting like chlordiazepoxide or clorazepate.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 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
- Kaiser Permanente. (2022). Benzodiazepine and Z-Drug Safety Guideline. Kaiser Permanente. https://wa.kaiserpermanente.org/static/pdf/public/guidelines/benzo-zdrug.pdf
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Slide 13 of 29
A reminder that when you're cross-tapering to equivalent dose of a longer half-life benzodiazepine, you should always engage in a stepwise crossover which is what is utilized in the Ashton method. The reason to do this, to not just substitute a complete dose of one shorter-acting benzodiazepine for a longer-acting is that it's going to take longer for the longer-acting to build up to steady state. And if you completely replace it from the short-acting, initially patients could end up with withdrawal symptoms in the days between the longer-acting reaching steady state.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 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
- Kaiser Permanente. (2022). Benzodiazepine and Z-Drug Safety Guideline. Kaiser Permanente. https://wa.kaiserpermanente.org/static/pdf/public/guidelines/benzo-zdrug.pdf
Slide 14 of 29
When engaging in deprescribing including when cross-tapering to a longer-acting, it's important that you have a good understanding of the formulations that the different benzodiazepines come in. And so this table just kind of outlines overall in the United States the tablet sizes that the different medications come in, and the approximate equivalent to 10 mg of diazepam.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 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
- Kaiser Permanente. (2022). Benzodiazepine and Z-Drug Safety Guideline. Kaiser Permanente. https://wa.kaiserpermanente.org/static/pdf/public/guidelines/benzo-zdrug.pdf
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Slide 15 of 29
What you'll know is the more potent benzodiazepines such as alprazolam, lorazepam, clonazepam, you're somewhat limited in the doses that they come in and can see that equivalently it's still a significant amount of diazepam. You will also see there's a dose range for many of them and this is because there's not a perfect cross-tolerance between everyone.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 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
- Kaiser Permanente. (2022). Benzodiazepine and Z-Drug Safety Guideline. Kaiser Permanente. https://wa.kaiserpermanente.org/static/pdf/public/guidelines/benzo-zdrug.pdf
Slide 16 of 29
When thinking about overall approaches to tapering, recommend engaging a patient in an initial test reduction of the smallest possible dose you can do based on the formulation they have. So for most patients if they get a good tablet cutter, they could cut their tablet in quarters. Certainly, getting them the smallest tablet available is useful. For clonazepam, it does have an oral disintegrating tablet that comes in a 0.25 and a 0.125. Some people find these easier to work with than others. Some find them a little too crumbly. Depending on the insurance, it depends on how expensive they are to obtain although you can also look for coupons to help decrease the out-of-pocket cost.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 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
- Kaiser Permanente. (2022). Benzodiazepine and Z-Drug Safety Guideline. Kaiser Permanente. https://wa.kaiserpermanente.org/static/pdf/public/guidelines/benzo-zdrug.pdf
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Slide 17 of 29
We always recommend doing a test reduction because it will really give you a sense and the patient a sense of how sensitive they may be to this tapering process and whether they may benefit from a slower taper or they might tolerate even initially larger dose reductions.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 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
- Kaiser Permanente. (2022). Benzodiazepine and Z-Drug Safety Guideline. Kaiser Permanente. https://wa.kaiserpermanente.org/static/pdf/public/guidelines/benzo-zdrug.pdf
Slide 18 of 29
As I tell the residents I supervise, you know, the risk of going too quickly, say, doing a 25% reduction initially is that if the patient has a bad experience, you potentially lose their buy-in to the process and they become leery of continuing to taper because this initial dose reduction made them feel so awful or out of control and they also lose their confidence that this is something they can do.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 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
- Kaiser Permanente. (2022). Benzodiazepine and Z-Drug Safety Guideline. Kaiser Permanente. https://wa.kaiserpermanente.org/static/pdf/public/guidelines/benzo-zdrug.pdf
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Slide 19 of 29
When possible, it's best to try to avoid skipping doses, also providing like rescue doses and when at all possible, you want to avoid going back up on the dose when you've decreased it.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 2024. http://www.benzo.org.uk/manual/.
- Allison, C., & Pratt, J. (2003). Neuroadaptive processes in GABAergic and glutamatergic systems in benzodiazepine dependence. Pharmacology & Therapeutics, 98(2), 171-195.
Slide 20 of 29
Certainly, there are circumstances where you'll decide the benefit of increasing the dose back up is greater than the risks because they're having severe side effects but again all this can be minimized by doing initial smaller dose reduction. Some reasons you might re-increase the dose would be if they're experiencing severe akathisia or significant suicidal ideation.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 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 21 of 29
When approaching tapering in general, you want to always be thinking about the percent reduction from the last dose. As a result, it means that as you go down the dose reduction should become smaller in amount in order to try to maintain about the same percentage reduction.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 2024. http://www.benzo.org.uk/manual/.
- Horowitz, M. A., Wright, J. M., & Taylor, D. (2021). Risks and benefits of benzodiazepines. JAMA, 325(21), 2208.
- Taylor, D. M., & Horowitz, M. (2024). The Maudsley Deprescribing guidelines: Antidepressants, benzodiazepines, Gabapentinoids and Z-drugs. John Wiley & Sons.
Slide 22 of 29
So for example, if you have 1 mg and you decrease by 10%, 0.1, you're going to 0.9. While the next time, decreasing from 0.9, the reduction is going to be 0.09 instead of 0.1.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 2024. http://www.benzo.org.uk/manual/.
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Slide 23 of 29
So for many patients, you can engage in a gradual taper over several months, maybe three to six months. For others, if they find that they're having more symptoms, it may need to be a more gradual process of 12 to 18 months. Some folks, it's even two years. So I think really thinking of it as a marathon and not a sprint with your patient and that each dose reduction you're able to do is helping them decrease the long-term risks of continuing on these medications.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 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
Slide 24 of 29
I would encourage everyone to have urine drug testing be part of their taper process when it's available. I always tell patients the point is not to catch them. The point is to make sure we have a complete picture of everything that they are using so that we can minimize their risks and know what else may be contributing to their symptoms.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 2024. http://www.benzo.org.uk/manual/.
- Moeller, K. E., Kissack, J. C., Atayee, R. S., & Lee, K. C. (2017). Clinical interpretation of urine drug tests. Mayo Clinic Proceedings, 92(5), 774-796.
- Heit, H. A., & Gourlayc, D. L. (2015). Using urine drug testing to support healthy boundaries in clinical care. Journal of Opioid Management, 11(1).
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Slide 25 of 29
If urine drug testing is not possible, would still make sure that you're utilizing the prescription drug monitoring program so that you're aware of any other controlled substances that are prescribed including other benzodiazepine prescriptions they may have gotten recently or in the past. Make sure you have a discussion with the patient that this is also an additional tool you are using in your care of them.
References:
- Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual). 2002. Accessed February 15, 2024. http://www.benzo.org.uk/manual/.
- Moeller, K. E., Kissack, J. C., Atayee, R. S., & Lee, K. C. (2017). Clinical interpretation of urine drug tests. Mayo Clinic Proceedings, 92(5), 774-796.
- Heit, H. A., & Gourlayc, D. L. (2015). Using urine drug testing to support healthy boundaries in clinical care. Journal of Opioid Management, 11(1).
Slide 26 of 29
So overall, the key points for this section are that our goal of tapering patients off of benzodiazepine is to control the rate of the taper in order to minimize their withdrawal effects and manage rebound of any symptoms.
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Slide 27 of 29
Before we begin a dose reduction, we want to stabilize any interdose withdrawal by either dosing a shorter half-life benzodiazepine more frequently and/or cross-tapering to an equivalent dose of a longer half-life benzodiazepine.
Slide 28 of 29
And finally, a reminder, when making dose reductions, think in percent reduction from the current dose. Dose reductions should become smaller as the taper progresses.
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Slide 29 of 29
