The Rules for Treating Benzodiazepine Withdrawal

Patients are dying in correctional facilities from benzodiazepine withdrawal!  This is not just a theoretical observation; this really is happening. This fact bothers me since benzo withdrawal deaths are preventable.  Benzodiazepine withdrawal is easy to treat!  It is certainly easier to treat benzo withdrawal than the other two potentially deadly withdrawal states, alcohol and opioids.   By far, the most common cause of benzodiazepine deaths is, of course, not treating it!    

So, is your facility at risk to have a patient die of benzodiazepine withdrawal?  To find out, compare your policies to the following Rules for the Treatment of Benzodiazepine Withdrawal.             

Treat everybody at risk of going through benzo withdrawal

This includes everybody (everybody!) who has been taking benzodiazepines steadily for more than a month.  It is usually not a problem knowing who these patients are.  You can call pharmacies and prescriber offices for details.  Easier still, in most states, you can check prescriptions of benzodiazepines (and other controlled substances) online using the PMP AWARE database (found here). Be aware, though, that patients can get also benzos illicitly online.  Some patients also buy their benzos on the street. Be thorough in your evaluation of benzo use.

Don’t use urine drug screens to exclude people from treatment.

Urine drug screens will not detect many benzodiazepines.  Just because a patient’s urine drug screen is negative for benzos does not mean that they will not experience benzo withdrawal.

Don’t use symptom scoring to exclude patients from treatment.  And don’t use CIWA at all; it doesn’t work.

It is true that patients going through benzodiazepine withdrawal can manifest many symptoms, including tremors, anxiety, psychosis and seizures.  However, it is possible for some patients to have minimal symptoms before they have their BIG EVENT, like a seizure.  Because of this, you really should treat everyone at risk even if they are not having symptoms.  Some jails use CIWA, which is a system to score the severity of alcohol withdrawal, on the theory that alcohol and benzodiazepine withdrawal syndromes are similar.  But CIWA does not work for benzodiazepine withdrawal. 

Know the big three predictors of a potentially serious withdrawal syndrome.

  1. Sudden cessation of benzodiazepine use
  2. Xanax (alprazolam) use
  3. High Benzodiazepine doses

You must use a benzodiazepine to treat benzodiazepine withdrawal.  Period.

Some practitioners are so paranoid about the possibility of diversion and abuse of controlled substances inside their facility that they use other drugs to treat benzo withdrawal, like Benadryl (diphenhydramine).  Don’t do this.  Benadryl does not work!  There are times to be sparing in the use of controlled substances but this is not one of them.  You simply have to use benzos to appropriately and effectively treat benzo withdrawal.

Don’t use alprazolam (Xanax) to treat benzo withdrawal. Use a long acting benzo instead.

By far, the most prescribed and abused benzodiazepine is Xanax (alprazolam).  Xanax has a short half-life, which tends to enhance its euphoric rush.  This increases the danger of dependence for long-term users, but also makes Xanax a poor choice to use to treat benzo withdrawal.  If a patient needs to be withdrawn from Xanax, a far better and safer alternative is to substitute a long acting benzo and use that instead.  I personally use Valium (diazepam) but Ativan (lorazepam) and Klonopin (clonazepam) are good alternatives. Begin by determining the equivalent doses of the long acting agent and the Xanax using a handy conversion chart:

This one comes from the February 2019 edition of the Oregon State Drug Review (found here).

Taper slowly.

As the Oregon State Drug Review says, “There is little evidence available on the optimal duration or rate of tapering and no evidence which indicates a single tapering strategy may be more successful than another.” OSU recommends a more rapid taper early and then a slower tail thereafter.  In the absence of strong evidence, you can set up your own tapering schedule.  I have seen several online.  Most recommend starting at 50-75% of the initial dose and reducing the dose by 12.5-25% a week with a longer taper the lower the dose gets.  The higher the initial dose, the longer the taper will be (of course).  A taper schedule of two months or more is not unusual depending on the initial dose. It is also important to factor in other sedating medications that your patient may be taking when coming up with an optimal tapering schedule.  It is also important (of course) to monitor and adjust the taper as needed depending on how your patient is doing.

Remember Rule One:  Treat everybody at risk for benzo withdrawal.  Any treatment and any length taper is better than allowing an at-risk patient to go “cold turkey.” 

As usual, what I have written here is only my opinion, based on my training, experience and research.  I could be wrong!  If you think that I am wrong, please say why in Comments . . .

2 thoughts on “The Rules for Treating Benzodiazepine Withdrawal

  1. Michael Horvath

    My institution uses Librium 50mg BID tapering to 25 mg QD by day 5 and that is it. Is this safe? We keep benzo abusers in the Medical housing unit during this taper.

    Reply
    1. Jeffrey Keller MD Post author

      Hi Michael and thanks for your question. In my opinion, you are doing the right thing by using a long acting benzo to treat withdrawal. In my opinion, though, your protocol is a bit short. My tapers typically are quite a bit longer.

      Reply

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