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 . . .

17 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.

      • Hello I have been on Xanax and or Valium or Klonopin for a total of 36 years obviously my brain is physically addicted to them I do not use them in an abusive way I am bipolar and I have very severe anxiety disorder from very severe abuse as well as I get I think the beginnings of schizophrenia into my fifties anyhow I did time 30 years ago I’ve never really been a criminal criminal haven’t done much of anything since then recently got caught up into something that I am not guilty for yet I don’t know that that is going to help our system is very flawed if you do not have money for a good lawyer I am pretty certain that if I go into jail for a prolonged amount of time from my daily 4 mg to 8 mg regimen of Xanax I will absolutely seize until I die I have a long psychiatric history they started me young on them tried to take me off of them and I had terrible Grandma seizures as well as I substituted with alcohol and other things my life turn around and I let her productive life for the last 25 years taking either Xanax or Klonopin there is a Warren county jail in glens falls New York I don’t know what to do I would appreciate any suggestions I am about 50/50 with suicide because I can’t imagine what it’s going to be like after a week in there I have tried to get myself off these things as well as doctors but they determined they were the best thing for me and they work very good in practice I’m very careful about keeping my dosage as low as I can moving around as needed but now I don’t know whether to commit suicide before I go into jail or get some kind of legal recourse what you wrote out is exactly right I had to stay for 3 Days on something I wasn’t guilty of but didn’t have fail for all charges dropped 20 years ago and I had two awful Grandma seizures and they just put me in an observation room and told me I wouldn’t be getting any if you have any suggestions I beg you if I even have to get money somewhere from lending my phone number is 518-307-5314 I live in a independent living facility which is pretty much on the brink of just being able to live alone without any help my email is antroc1313@icloud.com or anthony.rocco 1313 at icloud.com I’m really not sure if I have access to either one of them but if you could call my phone number and just give me some suggestions I would pay I would do anything I am facing inevitably horrible death from withdrawal of 36 years of benzodiazepines if that’s what they’re still doing in jail and just cutting you right off them or the much more compassionate thing and just committing suicide before I have to go in there I hope you understand how serious this is please contact my phone number by text in a 5 minute talk my general mental health is very good when I am just living life but I also have seizure disorder and I just do not like having Grandma seizures and now that I’m in my fifties I have no doubt they will kill me I am very intelligent and articulate and I will not be rude if you just said anything to add I would appreciate it thank you so much 518-307-5314 text or phone call

        • I left a comment for him a while back and he never responded. I think that if he does it’s only to the actual prison psychiatric doctors.
          I am so sorry to hear what you are going through and whether you did what they are accusing you of or not…I don’t think that they should cut you off completely that quick. The best advice I can give you is (because it seems like they are going to withdraw you any way) that you start now and do a slow taper. Read https://www.benzoinfo.com/ashtonmanual/ and get some very good tapering information there from Dr. Heather Ashton and also join benzobuddies.com as they are people that have either already been through their taper and are off their benzodiazepine that they were on or there are people still going through it and they can give you first hand information as to how they are doing it themselves. They have several different ways to taper your benzos and you can decide for yourself what could be the best way for you. Also, you can stay completely anonymous on this site unless you want to meet up one on one with someone or talk to them yourself on the phone but it’s completely your choice. I wish you the best with your taper and I’m sorry that you are going through this. I hope this information helps at least a little.

  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: https://www.orpdl.org/durm/newsletter/osdr_articles/volume9/osdr_v9_i2.pdf Plus I have written about benzo withdrawal here: https://www.jailmedicine.com/the-rules-for-treating-benzodiazepine-withdrawal/. 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

    • I recommend looking up the Ashton manual online and you can read it for free. She gives an outline of the best way to taper and it is not a week taper.
      Good luck!

  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…

    • I am not a doctor, only someone who has suffered from benzo withdrawals from recreational use, which in many cases I would say is more helpful than a doctor’s advice. If she has used around 2.5 to 3 mg of xanax a day, I would ask your doctor to switch her to diazepam (valium) or librium. Both are long-acting benzos and she can probably safely taper down with those in about a week to a week and a half. Better not to rush it. They can be taken once a day and have less addictive properties while still preventing withdrawal. Tapering off xanax is nearly impossible and can cause severe health problems. I doubt seizures or death would happen at the dose she was on, but it can and does happen to people who abuse them. Good luck

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