51 - Withdrawal management

Withdrawal management

540 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 4 Benzodiazepine misuse Benzodiazepine prescribing reached its peak during the 1960s and 1970s. Prescriptions that were originally started for disorders such as anxiety, depression and insomnia were often continued long term and led to the development of dependence. Benzodiazepines are still widely used in the USA: 5.2% of adults were prescribed a benzodiazepine in 2008,1 just over 4% in 2018 and just less than 4% in 2021.2 There are a growing number of novel or ‘designer’ illicit benzodiazepines (e.g. diclazepam, etizolam, flualprazolam, flunitrazolam and norfludiazepam). There is limited information available about the health consequences and social harms of these substances, but they are likely to be similar to or worse than the established benzodiazepines.3 As well as being prescribed, benzodiazepines can be acquired via the illicit market, diversion of prescriptions and internet purchasing (thought to be a rising trend).4,5 Benzodiazepine dependence can be thought of as either iatrogenic (low daily doses prescribed over many years) or non-­iatrogenic (high doses, illicitly obtained, often ­consumed intermittently). Withdrawal management The UK NICE guideline on safe prescribing and withdrawal management of medicines associated with dependence recommends a shared decision-­making approach with the individual.6 Detailed information regarding benefits of discontinuation, the withdrawal process and possible symptoms should be discussed over the course of regular scheduled reviews. Withdrawal from benzodiazepines usually involves conversion to an equivalent dose of diazepam because its long duration of action may mitigate withdrawal symptoms. Dose reduction recommendations include: ■ ■Gradual reduction rather than abrupt discontinuation.6 ■ ■‘Slow, step-­wise rate of reduction proportionate to the existing dose, so that decrements become smaller as the dose is lowered’ (unless there is clinical risk and rapid withdrawal is needed).6 ■ ■Individualise according to the drug, dose, duration of treatment, history of ­dependence, withdrawal symptoms and re-­emergence of underlying conditions (such as anxiety or insomnia). ■ ■Withdrawal over a period of less than 6 months is appropriate for some patients.7 ■ ■Some guidelines suggest a reduction of about one-­eighth of the daily dose every 2 weeks.8 ■ ■If reduction is unsuccessful aim to review regularly, stop further escalation in dose and consider reduction again later. Additional interventions are given in Table 4.23.