New guidance recommends tapering benzodiazepine use for most older adults

Clinicians should ideally assess the risks and benefits of ongoing benzodiazepine prescribing at least every three months, according to a recent joint clinical practice guideline.

The American Society of Addiction Medicine joined with nine other medical societies, including the American Geriatrics Society and the American Academy of Neurology, to develop the new recommendations, which apply to patients who have been taking benzodiazepines regularly and are at risk for physical dependence and withdrawal. It was published June 17 by the Journal of General Internal Medicine.

At a minimum, clinicians should assess the risks and benefits with each new or renewed prescription, including reviewing the information in the relevant prescription drug monitoring programs, the guideline said. Risk-benefit assessments should be done more frequently in patients who are also taking opioids, have a substance use disorder, or have additional risk factors for adverse effects (e.g., obstructive sleep apnea or bipolar spectrum disorder), the guideline said.

Clinicians should recognize the limitations of urine drug screen immunoassays for benzodiazepines and consider the maternal-fetal dyad when assessing risks and benefits of the drugs in patients who are pregnant.

The guideline said clinicians should taper benzodiazepines in most older adults (i.e., age ≥65 years) unless there are compelling reasons for continuation. The medications should not be discontinued abruptly in those who are likely to be physically dependent and at risk of withdrawal symptoms, the guideline said. While tapering can usually be completed in the outpatient setting, inpatient or medically managed residential care should be considered in patients whose presentation indicates significant risks that can't be safely managed in outpatient care.

Tapering strategies should be tailored to each individual patient and should be designed to minimize harms from both continued use and the tapering process itself, the guideline said. The initial pace of the taper should generally include dose reductions of 5% to 10% every two to four weeks and should typically not exceed 25% every two weeks. The guideline noted that tapering may be able to be done more quickly in patients who have been taking lower doses for a relatively short period of time.

Adjunctive psychosocial interventions, such as cognitive behavioral therapy, should be offered during tapering, as should concurrent treatment for any physical health conditions and psychiatric disorders that could interfere with the taper, the guideline said. Clinicians should employ harm reduction strategies (e.g., naloxone for those at risk of opioid overdose and patient education) based on each individual patient's risks. The authors noted that it may take months to years for patients to fully taper off benzodiazepines, particularly if they have been taking a high dose for an extended period of time.

The guideline includes additional recommendations for the tapering process and management of withdrawal symptoms, as well as guidance for specific populations, including patients coprescribed benzodiazepines and opioids, patients with substance use disorders, patients with psychiatric disorders, older patients, and patients who are pregnant and lactating.

An accompanying editorial noted that guidelines can have unintended consequences and said that while tapering may be indicated in many patients, clinicians should prioritize those who are at highest risk for harm. “Benzodiazepine medications should not be abruptly discontinued in patients who are physically dependent. Alternative strategies for managing benzodiazepine withdrawal risk (e.g., tapering with very long-acting agents) may be used when there are compelling reasons for more rapid taper or discontinuation,” the editorialists wrote. “This Guideline should not be used as a reason to abandon patients who require a benzodiazepine taper or continued long-term benzodiazepine therapy.”