136 - Benzodiazepines, z drugs and gabapentinoids d

Benzodiazepines, z-drugs and gabapentinoids: dependence, withdrawal effects and discontinuation

466 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 3 Stopping benzodiazepines If the patient is in agreement, benzodiazepines should be withdrawn. Tapering can be difficult and should not be imposed on a patient against their will. A cluster randomised trial supports the effectiveness of a face-­to-­face educational intervention.31 Continuing support can be required to prepare a patient for withdrawal and to support them through the process (e.g. psychological therapies or self-­help groups).32 Dosage reduction (tapering) Gradual reduction of benzodiazepine dose reduces the intensity of withdrawal symptoms by giving time for neural adaptations to the drug to resolve.24 Meta-­analysis has confirmed that gradual dose reduction (‘tapering’) improves drug cessation rates compared with routine clinical care.33 Most studies find that a gradual withdrawal over at least 10 weeks is most successful in achieving cessation,34 although many patients will require considerably longer (sometimes several years). Sudden benzodiazepine withdrawal has potentially fatal consequences, so tapering is always advisable. Direct taper or switching to diazepam? Patients who take short-­ or intermediate-­acting benzodiazepines can be tapered off these drugs directly but more than once-­a-­day dosing might be required. An alternative approach is to switch to an equivalent dose of diazepam, which has a long half-­life and therefore might provoke less severe withdrawal.22,29 Some patients report withdrawal symptoms from abrupt switches to diazepam and so a stepwise switch is probably prudent. Cochrane is lukewarm about switching to diazepam.34 Approximate ‘diazepam equivalent’35 doses are shown in Table 3.24. Owing to individual differences some patients may require more or less diazepam to control withdrawal symptoms. The list in Table 3.24 is an approximate guide only and adjustments should be made to manage withdrawal symptoms for the individual.11 Extra precautions apply in Table 3.24  Approximate ‘diazepam equivalent’ doses.35 Drug Dose Chlordiazepoxide 25mg Clonazepam 0.5mg Diazepam 10mg Lorazepam 1mg Lormetazepam 1–2mg Nitrazepam 10mg Oxazepam 20mg Temazepam 20mg