# 51 - Withdrawal management

# Withdrawal management

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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:
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■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
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■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.