Benzodiazepine use disorder

Background

• A substance use disorder involving benzodiazepines

Management

• In younger patients who have not been on longterm therapy, a fast taper over 6 weeks is reasonable
• In patients who are elderly, have been on longterm benzodiazepine therapy, or have failed faster tapers, consider following the protocol described in The Ashton Manual
  • e.g. for diazepam 40 mg daily, might taper by 2 mg every 1-2 weeks until 20 mg, then but 1 mg every 1-2 weeks (the complete taper taking 30-60 weeks)
  • You may need to switch to diazepam initially, since it is the only widely-available benzodiazepine that allows extremely small dose decrements, since it comes in 2 mg tablets that can easily be halved
  • If switching to diazepam:
    • It may cause more drowsiness than some of the other benzodiazepines
    • It should be switched gradually, replacing an increasing part of their benzodiazepine schedule every 1-2 weeks, and can be done concurrently with an overall taper
  • Many example tapers and substitution schedules are available in The Ashton Manual
• Regardless of the planned speed of taper, it should be largely driven by the patient who should decide when to try the next decrement

Sample diazepam taper

	Morning	Night	Daily Diazepam Dose
	diazepam 20 mg	diazepam 20 mg	40 mg
1-2 weeks	diazepam 18 mg	diazepam 20 mg	38 mg
1-2 weeks	diazepam 18 mg	diazepam 18 mg	36 mg
1-2 weeks	diazepam 16 mg	diazepam 18 mg	34 mg
1-2 weeks	diazepam 16 mg	diazepam 16 mg	32 mg
1-2 weeks	diazepam 14 mg	diazepam 16 mg	30 mg
1-2 weeks	diazepam 14 mg	diazepam 14 mg	28 mg
1-2 weeks	diazepam 12 mg	diazepam 14 mg	26 mg
1-2 weeks	diazepam 12 mg	diazepam 12 mg	24 mg
1-2 weeks	diazepam 10 mg	diazepam 12 mg	22 mg
1-2 weeks	diazepam 10 mg	diazepam 10 mg	20 mg
1-2 weeks	diazepam 8 mg	diazepam 10 mg	18 mg
1-2 weeks	diazepam 8 mg	diazepam 8 mg	16 mg
1-2 weeks	diazepam 6 mg	diazepam 8 mg	14 mg
1-2 weeks	diazepam 5 mg	diazepam 8 mg	13 mg
1-2 weeks	diazepam 4 mg	diazepam 8 mg	12 mg
1-2 weeks	diazepam 3 mg	diazepam 8 mg	11 mg
1-2 weeks	diazepam 2 mg	diazepam 8 mg	10 mg
1-2 weeks	diazepam 1 mg	diazepam 8 mg	9 mg
1-2 weeks		diazepam 8 mg	8 mg
1-2 weeks		diazepam 7 mg	7 mg
1-2 weeks		diazepam 6 mg	6 mg
1-2 weeks		diazepam 5 mg	5 mg
1-2 weeks		diazepam 4 mg	4 mg
1-2 weeks		diazepam 3 mg	3 mg
1-2 weeks		diazepam 2 mg	2 mg
1-2 weeks		diazepam 1 mg	1 mg

Sample substitution and taper

	Morning	Noon	Evening	Daily Diazepam Equivalent
	alprazolam 2 mg	alprazolam 2 mg	alprazolam 2 mg	120 mg
1 week	alprazolam 2 mg	alprazolam 2 mg	alprazolam 1.5 mg diazepam 10 mg	120 mg
1 week	alprazolam 2 mg	alprazolam 2 mg	alprazolam 1 mg diazepam 20 mg	120 mg
1 week	alprazolam 1.5 mg diazepam 10 mg	alprazolam 2 mg	alprazolam 1 mg diazepam 20 mg	120 mg
1 week	alprazolam 1 mg diazepam 20 mg	alprazolam 2 mg	alprazolam 1 mg diazepam 20 mg	120 mg
1-2 weeks	alprazolam 1 mg diazepam 20 mg	alprazolam 1 mg diazepam 10 mg	alprazolam 1 mg diazepam 20 mg	110 mg
1-2 weeks	alprazolam 1 mg diazepam 20 mg	alprazolam 1 mg diazepam 10 mg	alprazolam 0.5 mg diazepam 20 mg	100 mg
1-2 weeks	alprazolam 1 mg diazepam 20 mg	alprazolam 1 mg diazepam 10 mg	diazepam 20 mg	90 mg
1-2 weeks	alprazolam 0.5 mg diazepam 20 mg	alprazolam 1 mg diazepam 10 mg	diazepam 20 mg	80 mg
1-2 weeks	alprazolam 0.5 mg diazepam 20 mg	alprazolam 0.5 mg diazepam 10 mg	diazepam 20 mg	80 mg
1-2 weeks	alprazolam 0.5 mg diazepam 20 mg	diazepam 10 mg	diazepam 20 mg	60 mg
1-2 weeks	diazepam 20 mg	diazepam 10 mg	diazepam 20 mg	50 mg
1-2 weeks	diazepam 25 mg		diazepam 25 mg	50 mg
1-2 weeks	diazepam 20 mg		diazepam 25 mg	45 mg
1-2 weeks	diazepam 20 mg		diazepam 20 mg	40 mg