For a small number of patients, stable long-term use of benzodiazepines may be justified, on a case-by-case basis, if:1
- a patient’s quality of life improves with stable use. This may require specialist consultation. Document the decision to continue long-term benzodiazepine therapy and regularly review and reassess the risks and benefits of benzodiazepine use.
- a patient struggles to reduce and stop benzodiazepine use. In this group you may consider continuing patients on low-dose benzodiazepines, with ongoing regular reviews as part of a long-term plan for cessation of benzodiazepine use.
For patients with complex, multiple morbidities, consult mental health and addiction specialists and other relevant specialists (eg, neurologists) to develop an appropriate treatment plan for the patient.1
Consider a stepped approach, starting with minimal interventions such as advisory letters before progressing to more intense methods. An advisory letter can be sent following an audit of a patient's benzodiazepine prescription.2 The letter can outline the harms and risks of benzodiazepine use and invite the patient to consult the doctor about alternative therapies.2 For a sample advisory letter, see Appendix E RACGP Prescribing drugs of dependence in general practice, Part A Clinical governance framework.
Maintain a strong therapeutic alliance with the patient, and any other health care providers involved in their treatment, to increase their likelihood of successful benzodiazepine cessation.1,2
Withdrawal symptoms will vary between patients, depending on the type of benzodiazepine dependence (low-dose, prescribed high-dose or recreational high-dose).1 This means a withdrawal management plan should be tailored for each patient.1
Common withdrawal symptoms include anxiety, insomnia, irritability, myoclonic jerks, palpitations, and sensory disturbances, such as photophobia and hyperacusis (oversensitivity to certain frequency and volume ranges).1,3
Encourage all patients with dependence to cease taking the benzodiazepine and offer detoxification programs regularly.1
Management of benzodiazepine withdrawal may include:1
- reviewing and discussing prescription records with patients
- sending advisory letters suggesting cessation or dose reduction and offering advice on ways to gradually reduce benzodiazepine use
- acknowledging that benzodiazepine withdrawal can be stressful
- advising patients to make lifestyle changes such as exercising regularly and avoiding alcohol
- encouraging family and friends to support patients by providing further encouragement or practical help
- advising patients to avoid stimulants (eg, coffee and chocolate) that can cause anxiety, panic and insomnia
- informing patients of non-pharmacological methods (eg, exercise, relaxation techniques) to cope with anxiety and insomnia due either to the primary condition or the withdrawal process
- referring patients to appropriate services (eg, psychological or support groups).b
RACGP guidelines recommend that benzodiazepine prescriptions be obtained from a single prescriber and a single pharmacy during gradual dose reduction.1 It is important to maintain regular communication with other health professionals involved in the patient's care, such as the pharmacist, counsellor, psychiatrist or addiction service.1
In some cases, in addition to gradual dose reduction protocols, psychological therapies, such as cognitive behavioural therapy, may aid discontinuation of benzodiazepines.1,11,12
Additional pharmacotherapy (eg, carbamazepine, antidepressants or melatonin) is generally used to treat withdrawal symptoms, such as anxiety, sleep problems or seizures, rather than as a substitute for benzodiazepines.1 However, the evidence to support the use of these medicines in benzodiazepine withdrawal is limited.1,12
b Refer to drug or alcohol dependence services if the patient has a concurrent drug or alcohol problem or if the service specialises in benzodiazepine dependence.