Never stop abruptly from high or long-term use: withdrawal can cause seizures, delirium and a severe protracted syndrome. A history of withdrawal seizures or very high doses needs close (sometimes inpatient) monitoring.
Symptoms
- Anxiety, insomnia, irritability, tremor, sweating
- Perceptual disturbance, depersonalisation
- Seizures and delirium if stopped abruptly from a high dose
- Symptoms can be protracted over months
Taper principles
- Switch to an equivalent dose of a long half-life benzodiazepine (usually diazepam) to smooth the taper
- Reduce slowly, for example by about 5 to 10% every 1 to 2 weeks, guided by symptoms
- Slower near the end; let the patient set a tolerable pace
- Flexible, not rigid: pause if withdrawal is severe
Mild
- Anxiety, insomnia, tremor
- Gradual dose reduction
- Switch to long-acting diazepam
Moderate
- Marked autonomic symptoms
- Slow the taper
- Support and monitor
Severe (seizures, delirium)
- Seizures, psychosis, confusion
- Benzodiazepine, admit
- Treat as a medical emergency
Management
1
1. Plan
Agree a written, individualised reducing schedule with the patient; set realistic expectations.
Agree a written, individualised reducing schedule with the patient; set realistic expectations.
↓
2
2. Support
CBT, sleep hygiene, and treat any underlying anxiety or depression. Regular review and encouragement.
CBT, sleep hygiene, and treat any underlying anxiety or depression. Regular review and encouragement.
↓
3
3. Avoid abrupt cessation
Do not stop suddenly except for specific acute toxicity, and then with specialist input.
Do not stop suddenly except for specific acute toxicity, and then with specialist input.
↓
4
4. Review co-use
Address Z-drugs, alcohol and opioids concurrently; combined sedative use raises overdose risk.
Address Z-drugs, alcohol and opioids concurrently; combined sedative use raises overdose risk.
Higher-risk situations
- Very high dose or long duration
- Previous withdrawal seizures or delirium
- Older people (falls, confusion), significant comorbidity
Pitfalls
- Abrupt discontinuation
- Tapering too fast and triggering relapse
- Ignoring concurrent alcohol or opioid use
- Not treating the underlying anxiety
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026