Deprescribing benzodiazepines and zopiclone

Deprescribing benzodiazepines and zopiclone

Dose tapering guidance

• Individualise the withdrawal schedule based on the indication, dose, duration and type of medicine (e.g. short- versus long-acting). Also consider patient-specific factors such as co-morbidities, age and level of home support. A successful taper is more likely when the patient is involved in the decision-making about the rate of withdrawal.
• Withdrawal from benzodiazepines can be complex and lengthy, sometimes taking years to completely withdraw. Unlike other medicine reductions, the withdrawal symptoms with benzodiazepines can be worse towards the end of the withdrawal process.
• If patients are taking high doses, have a longer duration of use or are taking more than one benzodiazepine (or benzodiazepine plus zopiclone), this can be associated with more prolonged and severe withdrawal and increased risk of seizures, delirium and suicidality
• Some guidance suggests switching patients taking a short-acting benzodiazepine to diazepam as this may lessen withdrawal symptoms (due to its long half-life) and allows for a slower reduction with smaller decrements. There is limited evidence that this results in better outcomes but may be beneficial for some patients. N.B. Use diazepam with caution in older patients as it can accumulate due to its long half-life and be associated with over-sedation, falls and confusion.
  • If a patient is taking a high dose of a short-acting benzodiazepine, e.g. lorazepam, or zopiclone, either reducing the dose initially and then switching to diazepam, or an initial conversion of part of the dose, may be necessary to reduce the risk of over-sedation or a high diazepam dose
  • Switching to diazepam can provide practical solutions as the tablet sizes allow slower reduction with smaller decrements, e.g. a lorazepam dose of 2 mg is approximately equivalent to 10 mg of diazepam. The larger equivalent diazepam dose of 10 mg and availability of 2 mg tablets which can be halved enables reduction in 1 mg steps.
  • The NZF contains dose equivalence data to assist in switching benzodiazepines, as well as guidance for withdrawal
• Slowly reduce the dose to the lowest possible dose formulation followed by planned medicine-free days. An example of a deprescribing algorithm is available here. A suggested four-step protocol is available from the NZF.
• Increase the dispensing frequency as appropriate, e.g. to weekly,^* set days of the week or daily. N.B. This approach will not be appropriate for all patients, e.g. if a pharmacy is not easily accessible.

^*Benzodiazepines and zopiclone are Class C controlled drugs. These are dispensed monthly unless otherwise specified. Specifying “weekly” on the prescription means the pharmacist can more easily identify when patients are collecting their medicines early than with a longer cycle (because the day of the week stays the same).

Follow-up and monitoring

• Monitor progress with regular follow up (in person or via phone, text/email or patient portal), e.g. every one to four weeks, depending on patient response. Adjust dose reduction according to patient tolerability.
• If patients are experiencing difficulty, encourage them to remain on the current dose they have achieved at that point or as a last resort if they are experiencing significant withdrawal symptoms, return to the previous dose. Recommence dose reduction when the patient feels able to resume.
  • For patients who have difficulty withdrawing completely, consider discussing their situation with an addiction medicine specialist or referring to addiction services. In some cases, withdrawal can have a significant impact on mental health, and remaining on a low dose may be a reasonable option after considering the risks of persisting with the withdrawal.
• Concomitant non-pharmacological strategies, e.g. cognitive behavioural therapy, motivational interviewing, sleep hygiene techniques, can be effective during the dose taper and help to manage insomnia or other withdrawal symptoms; melatonin may also be considered. Consider referral for counselling or psychological support services, where available.
• Online therapy courses may be useful while patients await access to secondary care services, e.g. Just a Thought, offers free online CBT courses for anxiety, depression and insomnia
• Some patients may benefit from interacting with others who are in a similar situation, or those who have prior experience with addiction. This may be in the form of face-to-face patient focused support groups (if available locally) or online support (e.g. www.benzobuddies.org). Group CBT may also be considered.
• Adjunctive pharmacological treatments, e.g. antidepressants, are not usually required and there is limited evidence of effectiveness for their use in facilitating benzodiazepine tapering. However, they may be prescribed in some clinical situations, e.g. patients experiencing anxiety or depression (usually following discussion with a specialist).