F13.2
DESCRIPTION
Benzodiazepine addiction may occur after only a few weeks of use. Withdrawal symptoms on abrupt dose reduction or cessation includes anxiety, nervousness, irritability, depersonalisation, delirium and seizures, increased sweating, sound sensitivity, nausea, difficulty concentrating, myoclonus, tremor, weakness and fatigue.
Gradual tapering of the benzodiazepine is recommended to facilitate discontinuation.
GENERAL MEASURES
- The therapeutic relationship between client and doctor is extremely important in initiating dose reduction.
- Confirm benzodiazepine dependence – ascertain usage, history of previous withdrawal symptoms; a urine screen may be necessary
- Establish full dosage of all benzodiazepines being taken, including those prescribed by other medical practitioners
- Take time to explain negative impact of ongoing benzodiazepine use, benefits of stopping, and concepts like tolerance and withdrawal
- Encourage the patient not to seek medication from other doctors.
- Evaluate and optimise management of comorbid substance use disorders, mental illness, and general health conditions.
- Avoid abrupt withdrawal of benzodiazepines; be prepared to take time. Negotiate each reduction with the patient. Individualise regular monitoring and motivation.
- Long-term follow-up with repeated motivation may be necessary to prevent relapse .
MEDICINE TREATMENT
Replace short-acting benzodiazepine with an equivalent diazepam (long acting benzodiazepine) dose.
Patients may present with medicines that are unavailable in the public sector. Approximate equivalent doses to diazepam 5 mg are:
- chlordiazepoxide 12.5 mg
- clobazam 10 mg
- clonazepam 0.25–1 mg
- lorazepam 0.5 mg
- alprazolam 0.25 mg
- bromazepam 1.5 mg
- flunitrazepam 0.5 mg
- nitrazepam 5 mg
- oxazepam 15 mg
- temazepam 10 mg
- zopiclone 7.5 mg
- zolpidem 10 mg
Note: Medicines have only been included for comparison of estimated equivalent doses.
Higher doses may be required for patients who are dependent on both alcohol and benzodiazepines. Inpatient assessment and initiation of benzodiazepine tapering may be warranted in these patients.
Reduction is done according to clinical response.
- Diazepam, oral.
- Reduce daily dose every 1–2 weeks by 10 mg/day until a daily dose of 50 mg.
- Then reduce every 1–2 weeks by 5 mg/day until a daily dose of 30 mg.
- Then reduce every 1–2 weeks by 2.5 mg/day until a daily dose of 20 mg.
- Then reduce every 1–2 weeks by 1.25 mg/day until stopped.
- If symptoms reappear, increase the dose a little and reduce dose over longer intervals.
- No more than one week’s duration of therapy is generally issued at one time.