Benzodiazepines
Jen Hand
How should clinicians safely discontinue benzodiazepine medications when continued use presents greater risks than benefits? A new joint clinical practice guideline from 10 medical and professional societies, published June 17, 2025, in the Journal of General Internal Medicine, relies on a patient-centered approach to tapering.
Despite recommendations for short term use, many patients are prescribed benzodiazepines for the long term, even when lower risk interventions may be appropriate. About 50% of patients dispensed oral benzodiazepines received them for 2 months or longer, according to FDA.
As the guideline authors point out, sudden dose decreases can lead to serious or life-threatening withdrawal symptoms. Even with limited evidence to support it, recommendations of 25% dose reduction every 1 to 2 weeks persist in practice, said Amy VandenBerg, PharmD, a member of the clinical guideline committee.
The guideline strongly recommends much slower tapers with initial dose reductions of 5% to 10%, with at least 2 weeks between dose reduction.
“We learned from the response to the opioid epidemic that rapidly tapering or abruptly stopping medications can pose significant risk,” said VandenBerg, who is a clinical pharmacist from the University of Michigan Health.
Background and takeaways
Long-term benzodiazepine prescribing is common among older adults—for whom the guideline recommends avoiding benzodiazepine use all together. Around 24 million people in the United States have reported use of a benzodiazepine, with approximately 20 million reporting use as prescribed.
VandenBerg noted ways this guideline differs from previous iterations. She said it includes a systematic review of the literature and level of evidence for each specific recommendation. Also, before publication, the committee met with a panel of individuals for input on their lived experiences with benzodiazepine tapers.
The researchers identified 57 relevant articles but acknowledged that few of the studies directly addressed many of the core topics within the guideline. The majority of their 29 recommendations were based on clinical consensus and are clearly labeled as such. Special populations, including patients who are pregnant, older adults, patients who are co-prescribed opioids, and patients with SUDs are recognized. Some key takeaways for clinicians include:
- Assessing the risks and benefits of ongoing benzodiazepine prescribing, ideally at least every 3 months for each patient taking benzodiazepine medications.
- Utilizing shared decision-making strategies when considering tapering approaches.
- Not discontinuing benzodiazepines abruptly in patients who are likely to be physically dependent and at risk of withdrawal symptoms.
- Minimizing harms from both continued benzodiazepine use and the tapering process when designing the tapering strategy.
- Tailoring tapering strategies to each individual patient and adjusting based on patient response.
- Providing concurrent treatment for any co-occurring physical health conditions and psychiatric disorders.
- Employing harm reduction strategies (e.g., providing opioid overdose reversal medication to those concomitantly taking opioids) based on individual patient risks.
- Understanding that it may take months to years to fully taper off benzodiazepines, particularly if patients have been taking a high dose for an extended period.
Challenges
A large population of patients could benefit from tapering. However, the guideline authors recognized that health care systems are overburdened, and significant workforce challenges may limit the capacity to manage benzodiazepine tapering at scale. They said if benzodiazepine tapers are managed poorly, there is a real risk for patient harm.
VandenBerg frequently speaks with patients who only hear about the risks of tapering, which she said limits their trust. She thinks pharmacists can utilize motivational interviewing to encourage patients throughout the process.
“Risks and benefits of benzodiazepine use are different for each patient. It is important for pharmacists to remember there is no one-size-fits-all approach to benzodiazepine tapering,” she said.
The researchers “found no trials comparing [benzodiazepine] tapering strategies or other important aspects of managing patients who are taking prescribed [benzodiazepines] and likely to have developed physical dependence.”
More research on best practices for [benzodiazepine] tapering, including strategies that support patient safety and optimal outcomes, is urgently needed, the guideline authors concluded. ■