How to Safely and Effectively Taper Benzodiazepines

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SPECIAL REPORT: ADVANCES IN PSYCHIATRY

Benzodiazepines, a controversial treatment widely prescribed for patients with anxiety and insomnia, carry a considerable risk of abuse. The poster “Mood Over Matter: Literature Review on Benzodiazepine Tapering, Current Practices and Updates on Adjunct Mood Stabilizers,” which was presented at the 2024 APA Annual Meeting, summarized a literature review of current benzodiazepine tapering practices, outpatient detoxification challenges, and potential barriers to discontinuation. The poster presenters also prioritized reviewing literature that highlighted mood stabilizer adjunct use.¹

Research demonstrates why clinicians should use caution when prescribing benzodiazepines. Results of a recent study revealed that between 2014 and 2016 an estimated 25.3 million (10.4%) adults in the Unted States reported using benzodiazepines, and approximately 17.2% of these individuals admitted to misuse.²

Similarly, the National Institute on Drug Abuse documented that benzodiazepines were implicated in more than 14% of opioid overdose deaths in 2021.³ Furthermore, a report from the Centers for Disease Control and Prevention pinpointed benzodiazepines as a factor in nearly 7000 overdose deaths across 23 states from January 2019 to June 2020, constituting 17% of all drug overdose deaths. This time frame saw a staggering 520% surge in deaths related to illicit benzodiazepines, and fatalities from prescribed benzodiazepines rose by 22%.⁴

The poster presenters stated that psychiatric and addiction- focused clinicians play an integral role in preventing benzodiazepine misuse and addiction.

To help patients taper benzodiazepines to discontinuation, clinicians must be up-to-date on practices; if clinicians mismanage tapering, sudden withdrawal can prove fatal. Challenges to tapering patients with chronic benzodiazepine use can be found in the Table.¹

Table. Challenges to Tapering Chronic Benzodiazepine Use¹

As for tapering strategies, the presenters suggested adjunct mood stabilizers such as carbamazepine and oxcarbazepine. Carbamazepine, when used as an adjunct or prophylactically, can help reduce intense withdrawal symptoms and thus keep patients on track for discontinuation. However, carbamazepine has received criticism regarding its efficacy, and it is well documented to have a series of concerning adverse effects such as skin reactions, agranulocytosis, leukopenia, and significant drug-drug interactions by nature of its metabolism.¹ This makes some clinicians wonder: Are the risks worth the benefit?

Oxcarbazepine has also been proposed as an alternative. Results of some small-scale clinical trials noted moderate efficacy for oxcarbazepine in helping patients with detoxification, and it has fewer adverse effect concerns. The presenters suggested that other mood stabilizers, particularly those with antiepileptic effects, require further research for their potential help with benzodiazepine addiction.¹

“Through a more current literature review, we hope to increase the tools available to psychiatrists for more success in discontinuation and maintaining sobriety for patients,” the presenters wrote.¹

In a previous Psychiatric Times article, Steve Adelman, MD, of the University of Massachusetts Medical School in Boston, suggested 8 universal precautions adapted from Gourlay et al for use by psychiatrists who must decide whether to initiate or continue pharmacotherapy with benzodiazepines.^5,6 They include making a diagnosis with an appropriate differential and creating and ratifying a treatment agreement.⁵ However, other clinicians, such as Daniel Morehead, MD, a Psychiatric Times columnist and featured cover author in this issue, suggest that although benzodiazepines carry risks, those risks are exaggerated by government officials, critics, and the public at large.

What are your thoughts on the use of benzodiazepines? Email us at PTEditor@MMHGroup.com.

References

1. Vo PB, Qazi Z, Rashid K, Rafano CM. Mood over matter: literature review on benzodiazepine tapering, current practices and updates on adjunct mood stabilizers. Poster presented at: 2024 American Psychiatric Association Annual Meeting; May 4-8, 2024; New York, NY. Accessed April 25, 2024. https://s7.goeshow.com/apa/annual/2024/poster_search.cfm?session_key=8E8BB444-90B1-1C06-DFD2-2FB028E89C7E&session_date=Saturday,%20May%2004,%202024

2. Maust DT, Lin LA, Blow FC. Benzodiazepine use and misuse among adults in the United States. Psychiatr Serv. 2019;70(2):97-106.

3. Drug overdose death rates. National Institute on Drug Abuse. May 14, 2024. Accessed May 16, 2024. https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates

4. DeSando CF. Time to remember. Time to act: International Overdose Awareness Day. Prevention Technology Transfer Center Network. August 2021. Accessed May 1, 2024. https://pttcnetwork.org/time-to-remember-time-to-act-international-overdose-awareness-day/

5. Adelman S. Benzodiazepines: it’s time to prescribe caution. Psychiatric Times. November 10, 2021. https://www.psychiatrictimes.com/view/benzodiazepines-it-s-time-to-prescribe-caution

6. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107-112.