ASAM launches Joint Clinical Practice Guideline on Benzodiazepine Tapering

Headline change

The guideline strongly recommends against abrupt BZD discontinuation for physically dependent patients, emphasizing gradual tapering tailored to individual response.

Bedside action

For patients on long-term BZDs, initiate a risk-benefit assessment at least every 3 months, and prepare to discuss a collaborative tapering strategy if risks outweigh benefits.

The American Society of Addiction Medicine (ASAM) has released a comprehensive new guideline on benzodiazepine (BZD) tapering, addressing a critical area of patient safety and long-term care. This document provides much-needed, evidence-informed strategies for clinicians navigating the complex process of BZD discontinuation, particularly for patients at risk of physical dependence. The core message is clear: prioritize gradual, patient-centered tapering to mitigate severe withdrawal risks.

How It Compares Across Societies

While both the ASAM guideline and the 2018 Canadian Family Physician (CFP) guideline on deprescribing benzodiazepine receptor agonists (BZRAs) advocate for tapering, they present some notable differences in scope and specific recommendations.

Tapering de benzodiazepínicos 2018 (CFP)

The CFP guideline states that switching to long-acting BZRAs (e.g., diazepam) has not been shown to reduce withdrawal symptoms or improve cessation rates more than tapering shorter-acting BZRAs.

This guideline

This guideline recommends considering a transition to a comparable dose of a longer-acting BZD for tapering, especially for short-acting agents like alprazolam, with caveats for contraindications.

Why they differThe ASAM guideline, while acknowledging the inexact nature of conversions, offers this as a potential strategy based on clinical consensus, whereas the CFP guideline found no evidence of superior efficacy for this approach in its systematic review.

For the clinicianClinicians following ASAM may consider switching to a longer-acting BZD for taper if appropriate, while those following CFP might prioritize direct tapering of the current BZD.

Tapering de benzodiazepínicos 2018 (CFP)

The CFP guideline notes that severe withdrawal symptoms (e.g., seizures) do not appear to occur with tapering but have been reported rarely with abrupt stopping of very high doses or in patients with underlying seizure disorders.

This guideline

This guideline explicitly warns against abrupt discontinuation for physically dependent patients due to risks of severe withdrawal, including seizures and delirium, and considers inpatient care for severe withdrawal management.

Why they differThe ASAM guideline places a stronger emphasis on the potential for severe, life-threatening withdrawal symptoms even with tapering, advocating for careful monitoring and, in some cases, inpatient management, reflecting a broader risk assessment.

For the clinicianClinicians following ASAM will maintain a higher vigilance for severe withdrawal symptoms during tapering and may consider more intensive settings for high-risk patients.

Tapering de benzodiazepínicos 2018 (CFP)

The CFP guideline found that adding CBT to tapering improved cessation rates post-intervention, but this improvement was not maintained long-term, and CBT did not improve clinical outcomes or ameliorate withdrawal symptoms more than tapering alone.

This guideline

This guideline recommends offering behavioral interventions like CBT/CBT-I, noting 'Low Certainty' evidence but a 'Strong Recommendation' based on clinical consensus.

Why they differWhile both acknowledge CBT's role, ASAM's 'Strong Recommendation' for offering behavioral interventions, despite low certainty evidence, suggests a greater emphasis on their supportive role in the overall tapering process, potentially reflecting broader clinical experience beyond cessation rates.

For the clinicianClinicians following ASAM are strongly encouraged to integrate behavioral interventions, viewing them as crucial support, whereas CFP might suggest a more cautious expectation of their long-term impact on cessation.

Where they agree

Both guidelines strongly recommend gradual BZD tapering over abrupt discontinuation for physically dependent patients.
Both emphasize the importance of shared decision-making and patient education regarding risks, benefits, and withdrawal symptoms during tapering.
Both highlight the increased risks of BZD use in older adults and recommend tapering in this population unless compelling reasons for continuation exist.

Practice Notes

Key considerations for your daily practice, distilled from the guideline's recommendations and implementation insights.

Do not miss

Do not abruptly discontinue benzodiazepine medication in physically dependent patients.

Abrupt cessation can lead to severe, potentially life-threatening withdrawal symptoms such as seizures and delirium. Tapering is indicated when risks outweigh benefits.

Implementation

Develop tapering strategies collaboratively with patients using shared decision-making.

Patient engagement, clear communication about expectations, and addressing concerns are critical for successful tapering outcomes and adherence.

Caution

Initial dose reductions should generally be 5% to 10%, and the taper pace should not exceed 25% every 2 weeks.

Tailor the pace to individual patient response; slower tapers are often necessary, especially for long-term or high-dose users, or those with strong physical dependence.

Red flag

Offer or prescribe opioid overdose reversal medication (naloxone) to all patients co-prescribed benzodiazepines and opioids.

Concomitant use significantly increases the risk of respiratory depression, overdose, and death due to synergistic CNS depressant effects.

Special population

Generally taper benzodiazepine medication in older adults unless there are compelling reasons for continuation.

Older adults face higher risks of adverse events like falls, cognitive impairment, and motor vehicle accidents with continued BZD use, often outweighing benefits.

Monitoring

Monitor patients for signs and symptoms of withdrawal and recurrence with each dose reduction.

Adjust the taper pace (pause or slow) if significant interfering symptoms emerge, and educate patients that these symptoms often reflect physical dependence, not a need for continued BZD.

Key Recommendations

The ASAM guideline offers clear, actionable recommendations for managing benzodiazepine tapering, focusing on patient safety and individualized care. These recommendations cover critical aspects from initial assessment to specific population considerations, providing a roadmap for clinicians to navigate this complex process effectively in daily practice.

Key recommendations15 highlighted

In all patients taking BZD medications, ideally assess the risks and benefits of ongoing BZD prescribing at least every 3 months, and at a minimum, with each new prescription or renewal.

Line / StrengthStrong Recommendation

Level of EvidenceClinical Consensus

EvidenceThis recommendation is based on clinical consensus among the guideline committee members, reflecting their collective expertise rather than direct empirical studies, given the complexity and patient-specific nature of risk-benefit assessments.

For practiceIntegrate regular BZD risk-benefit assessments into routine patient encounters.

CaveatMore frequent assessments are needed for patients with co-prescribed opioids or substance use disorders.

In patients receiving BZD prescriptions, review Prescription Drug Monitoring Program (PDMP) information as part of the risk-benefit assessment for BZD prescribing.

Line / StrengthStrong Recommendation

Level of EvidenceClinical Consensus

EvidenceThis is a clinical consensus recommendation, emphasizing the importance of PDMP data to identify potential polypharmacy, concurrent CNS depressant use, and other risks that inform the overall risk-benefit assessment.

For practiceUtilize PDMP data proactively for all BZD prescribing and renewals.

CaveatPDMP mandates vary by state, but review is recommended regardless of local requirements.

In patients likely to be physically dependent on BZDs and at risk for withdrawal, avoid abruptly discontinuing BZD medication; instead, initiate tapering when risks outweigh benefits.

Line / StrengthStrong Recommendation

Level of EvidenceLow Certainty

EvidenceTwo RCTs (70 participants) showed tapering resulted in significantly less severe BZD withdrawal and insomnia symptoms compared to abrupt cessation, though both had unclear bias risk and short taper durations (7-8 days). The committee agreed benefits of tapering outweigh risks of abrupt discontinuation.

For practiceNever abruptly stop BZDs in physically dependent patients; always plan a taper.

CaveatPhysical dependence can develop within weeks and is heterogeneous; careful assessment is needed.

In patients experiencing significant withdrawal or rebound symptoms after BZD discontinuation without taper, consider using medications for symptom management or restarting BZD and initiating a taper.

Line / StrengthConditional Recommendation

Level of EvidenceClinical Consensus

EvidenceThis recommendation is based on clinical consensus, acknowledging the need for flexible management when patients experience adverse outcomes from rapid or abrupt discontinuation, prioritizing patient safety and symptom control.

For practiceBe prepared to intervene if patients experience severe symptoms post-discontinuation.

CaveatThis is a reactive measure; proactive tapering is preferred to prevent such scenarios.

In patients undergoing BZD tapering, develop the BZD tapering strategy collaboratively with patients and their care partners using shared decision-making whenever possible.

Line / StrengthStrong Recommendation

Level of EvidenceClinical Consensus

EvidenceThis recommendation is rooted in clinical consensus and supported by evidence on shared decision-making improving patient satisfaction and adherence across various clinical settings, though not specific to BZD tapering trials.

For practiceInvolve patients and their care partners actively in all tapering decisions.

CaveatSome patients may be ambivalent or resistant; persistent engagement is key.

In patients undergoing BZD tapering with imminent risk of significant harm from continued BZD use, consider inpatient care for BZD tapering if outpatient management cannot rapidly mitigate the risk.

Line / StrengthStrong Recommendation

Level of EvidenceClinical Consensus

EvidenceBased on clinical consensus, this recommendation addresses scenarios where patient safety (e.g., medication interaction, overdose, falls, suicidality) necessitates a higher level of care that cannot be provided in an outpatient setting.

For practiceIdentify high-risk patients who may benefit from inpatient tapering for safety.

CaveatInpatient care can trigger distress or delirium in some patients, especially older adults.

In patients undergoing BZD tapering, implement initial BZD dose reductions of 5% to 10%, with the taper pace typically not exceeding 25% every 2 weeks.

Line / StrengthStrong Recommendation

Level of EvidenceClinical Consensus

EvidenceThis is a clinical consensus recommendation, informed by the committee's experience and consideration of studies where faster tapers led to high patient dropout. It prioritizes minimizing withdrawal symptoms.

For practiceAdhere to conservative tapering rates, adjusting based on patient tolerance.

CaveatPatients taking lower doses for shorter periods may tolerate faster tapers; those with strong physical dependence may require slower tapers (5-10% every 6-8 weeks).

In patients undergoing BZD tapering, offer or refer to tailored behavioral interventions (e.g., CBT, CBT-I) for underlying conditions.

Line / StrengthStrong Recommendation

Level of EvidenceLow Certainty

EvidenceA systematic review found gradual tapering supported by adjunctive psychosocial interventions was more effective than tapering alone. A Cochrane review found moderate quality evidence that CBT improved cessation rates at 1 and 3 months post-treatment, though long-term maintenance was not sustained.

For practiceIntegrate behavioral therapies as a supportive measure during BZD tapering.

CaveatAccess to these interventions may be limited by cost and availability.

In patients experiencing significant interfering symptoms during BZD taper, first, consider pausing or slowing the taper; second, consider adjunctive medications.

Line / StrengthConditional Recommendation

Level of EvidenceClinical Consensus

EvidenceThis recommendation is based on clinical consensus, prioritizing non-pharmacological adjustments to the taper schedule to manage symptoms, and only then considering adjunctive medications to minimize polypharmacy.

For practicePrioritize adjusting the taper schedule over adding new medications for withdrawal symptoms.

CaveatIf symptoms do not resolve after pausing, it may be protracted withdrawal or worsening underlying conditions.

In patients requiring BZD withdrawal management in inpatient settings, consider tapering with very long-acting agents (e.g., phenobarbital), but only by or in consultation with experienced clinicians.

Line / StrengthStrong Recommendation

Level of EvidenceLow Certainty

EvidenceTwo retrospective studies (over 650 patients) found phenobarbital-based protocols safe and effective for inpatient tapering, with low rates of falls, seizures, or delirium, though with limitations (no comparison group, no long-term follow-up).

For practiceReserve phenobarbital tapering for inpatient settings with expert consultation for severe cases.

CaveatHigh potential for overdose associated with barbiturates; requires expert supervision.

In patients co-prescribed BZDs and opioids, offer to provide or prescribe opioid overdose reversal medication (e.g., naloxone).

Line / StrengthStrong Recommendation

Level of EvidenceClinical Consensus

EvidenceThis is a clinical consensus recommendation, driven by the well-established increased risk of respiratory depression and overdose when BZDs and opioids are co-prescribed.

For practiceRoutinely provide naloxone to all patients on concomitant BZDs and opioids.

CaveatEnsure patients and caregivers receive education on naloxone use.

In patients receiving Substance Use Disorder (SUD) treatment medications (buprenorphine, methadone) who are also on BZDs, do not use BZD prescribing or tapering considerations as a reason to discontinue or disrupt a patient's medications for SUD treatment.

Line / StrengthStrong Recommendation

Level of EvidenceClinical Consensus

EvidenceThis is a clinical consensus recommendation, aligning with ASAM's broader stance on not disrupting MOUD due to concomitant BZD use, as the harms of untreated OUD often outweigh the risks of combined use.

For practiceMaintain SUD treatment medications during BZD tapering, coordinating care as needed.

CaveatCoordinate care between SUD treatment providers and BZD prescribers.

In patients with Posttraumatic Stress Disorder (PTSD), strongly consider tapering BZD medication.

Line / StrengthStrong Recommendation

Level of EvidenceClinical Consensus

EvidenceThis recommendation is based on clinical consensus, supported by evidence that BZDs are ineffective for PTSD core symptoms and may increase risks like substance use and aggression, while decreasing psychotherapy efficacy.

For practicePrioritize tapering BZDs in patients with PTSD due to lack of efficacy and potential harms.

CaveatWithdrawal can worsen PTSD symptoms; consult psychiatric specialists for tapering strategy.

In patients with mood or psychotic disorders undergoing BZD tapering, monitor sleep closely, especially for bipolar disorder, and pause the taper if significant sleep disturbance occurs.

Line / StrengthStrong Recommendation

Level of EvidenceClinical Consensus

EvidenceThis clinical consensus recommendation addresses the risk of sleep disturbance triggering episodes of mania in bipolar disorder and exacerbating other psychiatric conditions during BZD tapering.

For practiceActively monitor and manage sleep disturbances during BZD tapering in psychiatric patients.

CaveatContinued BZD use may present imminent safety concerns that outweigh the need to pause the taper.

In infants exposed to BZD in utero and at risk for neonatal withdrawal, encourage breastfeeding to reduce symptoms and communicate with the infant's healthcare provider.

Line / StrengthStrong Recommendation

Level of EvidenceClinical Consensus

EvidenceThis clinical consensus recommendation is supported by research suggesting breastfeeding can delay onset, reduce severity, and decrease the need for pharmacologic treatment of neonatal abstinence syndrome.

For practiceAdvise breastfeeding and inter-provider communication for infants with in-utero BZD exposure.

CaveatLong-term effects of BZD exposure via breast milk are unknown.

SOURCE GUIDELINE

Joint Clinical Practice Guideline on Benzodiazepine Tapering: Considerations when Benzodiazepine Risks Outweigh Benefits

ASAM

TypeFull Guideline