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Helping patients through a benzodiazepine taper.

Benzodiazepines are one of the most commonly prescribed medication classes worldwide. (1) Patients prescribed benzodiazepines who have no history of abuse or misuse may want to reduce or discontinue using these agents for various reasons, including adverse effects or wanting to reduce the number of medications they take. In this article, we offer strategies for creating an individualized taper plan, and describe additional non-pharmacologic interventions to help ensure that the taper is successful.

Formulating a taper plan

There is no gold-standard algorithm for tapering benzodiazepines. (1,2) Even with a carefully designed plan, tapering can be challenging because approximately one-third of patients will experience difficulties such as withdrawal symptoms. (1) Prior to creating a plan, carefully assess the patient's history, including the type of benzodiazepine prescribed (short- or long-acting); the dose, dosing frequency, and duration of use; comorbid medical and psychiatric conditions; any previous experience with withdrawal symptoms; and psychosocial factors (eg, lifestyle and personality). Consider whether the patient can be safely tapered in an outpatient setting or will require hospitalization. Tapering designed to take place over several weeks or months tends to be more successful; however, patient-specific circumstances play a role in determining the duration of the taper. (1,2)

For the greatest chance of success, a benzodiazepine should not be reduced faster than 25% of the total daily dose per week. (1) Consider which of the following pharmacologic approaches to benzodiazepine tapering might work best for your patient:

* Reduce the daily dose by one-eighth to one-tenth every 1 to 2 weeks over a 2- to 12-month period for patients with a physiological dependence. (1)

* Reduce the benzodiazepine dose by 10% to 25% every 2 weeks over a 4- to 8-week period. (2)

* Some guidelines have suggested converting the prescribed benzodiazepine to an equivalent dose of diazepam because of its long half-life, and then reducing the diazepam dose by one-eighth every 2 weeks. (3)

There is uncertainty in the medical literature about using a long-acting benzodiazepine to taper off a short-acting benzodiazepine, although this practice is generally clinically accepted. (1,2) Similarly, there is no definitive evidence that supports using adjuvant medications to facilitate tapering. (1,2)

Nonpharmacologic interventions

Patients are more likely to have a successful taper if nonpharmacologic interventions are part of a comprehensive treatment plan. (1) To help your patients through the challenges of a benzodiazepine taper:

* Validate their concerns, reassure them that you will support them throughout the taper, and provide information on additional resources for support.

* Provide education about the process of tapering and symptoms of withdrawal.

* Recommend therapies, such as cognitive-behavioral therapy or motivational interventions, that develop or enhance coping skills.

* Enlist the help of the patient's family and friends for support and encouragement.

Despite some clinicians, trepidation, 70% to 90% of patients can be successfully tapered off benzodiazepines by using an individualized approach that includes tailored tapering and nonpharmacologic interventions that provide benefits that persist after the patient completes the taper. (1)

Dr. Payne is a Forensic Psychiatry Fellow, Palmetto Health, Columbia, South Carolina; and is board-certified in addiction psychiatry. Dr. Joshi is Associate Professor of Clinical Psychiatry and Associate Director, Forensic Psychiatry Fellowship, Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, Columbia, South Carolina.

Disclosures

The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

References

(1.) Guina J, Merrill B. Benzodiazepines H: waking up on sedatives: providing optimal care when inheriting benzodiazepine prescriptions in transfer patients. J Clin Med. 2018;7(2):pii: E20. doi: 10.3390/jcm7020020.

(2.) Soyka M. Treatment of benzodiazepine dependence. N Engl J Med. 2017;376(12):1147-1157.

(3.) Diaper AM, Law FD, Melichar JK. Pharmacological strategies for detoxification. Br J Clin Pharmacol. 2014;77(2):302-314.
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Title Annotation:Pearls
Author:Payne, Rebecca A.; Joshi, Kaustubh G.
Publication:Current Psychiatry
Date:Mar 1, 2019
Words:629
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