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 . . .

13 thoughts on “The Rules for Treating Benzodiazepine Withdrawal

  1. 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.

    • 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.

  2. I think your first few sentences are way off….benzo withdrawal is easy to treat? easier than booze and opiates? Opiates is easy….day 1 2mg subutex 4 times a day, then 3x, then 2x for 2 days, and 1 time for 2 days, then 1 mg last day. One week, simply easy. Alcohol use valium 10mg 3-4x a day, lower 10mg a day until cessation. Benzo withdrawal is by far the longest and hardest detox.

    • Thanks for the comment, Troy. My experience evidently is different from yours. In general, the patients I treat for Benzo withdrawal do very well with minimal symptoms or complaints. It is true that their treatment lasts far longer that that of opioid or alcohol withdrawal, but, in general, with fewer problems.

  3. I came across this page while researching for my own withdrawal symptoms. I was on 6 mg (2mg 3x a day) for 14 years as prescribed by a physician. I tapered off over 6 months with a different physician but it was too quick and after my last dose .25 mg started down a nightmarish rabbit hole of debilitating symptoms. It’s been 5 months with about 50% improvement. But it’s hell and there is little help from the medical establishment, just support from fellow sufferers. It’s not a given a person will be affected by withdrawals but it’s a good possibility. I’m not in jail nor do I have a lot of stress from my daily life so I know I’m lucky because honestly if I was doing this in a difficult environment such as jail, I think I would fail. So kudos to your patients and also just food for thought for you as a practitioner.

  4. I practice in a jail on the East Coast. I totally agree that Benzo’s must be used, but I can’t find anything in the literature concerning length of treatment to avoid life-threatening vs. annoying symptoms. The months-long tapers are not well accepted by either Correctional Healthcare companies or Correctional institutions. Most providers here go with a week of tapering diazepam. I usually go with 10-14 days. I would like to try your general formula of choosing the dose of diazepam, then tapering down every 4-6 days. Do you have any literature or expert panel opinion on how long to taper in order to avoid life-threatening consequences? Do you see any benefit to using other meds after the benzo taper simply to decrease annoying symptoms from withdrawal?

    • Thanks for the question, Dr. Wilbraham! Yes, the psychiatry literature talks about tapering benzodiazepines very gradually over many months or even years. But what they are doing is different than what we are doing. They are treating benzodiazepine addiction and we are doing a withdrawal/detoxification protocol. It is analogous to the difference between treating opiate addiction in a methadone clinic, which can last for months or years, versus what we do when we treat patients for opiate withdrawal.
      The problem is that compared to opiate withdrawal, there is very little literature about the optimum strategy for treating benzodiazepine withdrawal. Here is one good article: Plus I have written about benzo withdrawal here: The basic rules are: 1. Treat everyone at risk. 2. substitute a long acting benzo for short acting benzos, like Xanax. 3. Taper slowly. One addiction specialist told me this rule: Taper no more rapidly than 50% per 5-7 days. It’s OK to go more slowly but be leery of going more rapidly. Tapering some one taking really large doses of Xanax (like, say, 2mg of Xanax four times a day) in one week is probably too fast. Be cautious.

      • Hi, I’m trying to get myself off of clonazepam from what a psychiatrist has prescribed (2 mg per day). I am scared to do this alone but I have no choice as I want to do it as slow as possible as to have as minimal withdrawal symptoms as possible. What do you recommend?

        • i am in same position but my psychiatrist is assisting me in taper. is your psychiatrist not able to do this with you or not on board?

          • I asked my psychiatrist about it and he sounded like he was in disbelief as to why I would come off of such a fantastic medication. I am on a pretty big cocktail of medication and tried to come off clonazepam pretty close to cold turkey on my own because of this. But, had a lot of bad withdrawal effects that showed up pretty quickly before cessation. If you don’t mind me asking how much are you on and what did your psychiatrist recommend and how is it working for you so far? Thank you for reaching out…

  5. Pingback: Reader Questions Benzo Withdrawal and Inhaler Abuse | Jail Medicine

  6. My dr is recommended a 7 day Valium taper for a month of 6 mg of Xanax. It did see in a study it’s effective. What is your opinion

  7. Hello my wife has used alprazolam for about 3weeks. We did not know about the severity of the addiction level of this as the doctors did not inform us. We lost our youngest son on June 2nd of this year in a bad car accident. He would have been 22 this past 12th of July. My wife was so distraught with grief and anxiety she went to the hospital on the 2nd and they gave her some alprazolam then to relieve her anxiety. 3 to 4 days later she started what we thought were more grief/anxiety so she ended up going to the hospital again and they gave her some more alprazolam and then she went to her primary care provider a few days later and he prescribed Lorazepam. She took one dose of that the next day and it seemed to due the opposite. She felt like she needed to crawl out of her skin. So back to the hospital we went and they gave her a diagram which seemed to work and she calmed down. Went back to primary and he prescribed alprazolam qty20 1mg this time and over 2 weeks she finished the pills because we thought her anxiety/grief was causing her to feel the way she felt… so now this last week we have identified the root problem and are trying to kick the benzo issue. What taper would you recommend for her since she has used them less than a total of 30 days…

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