Attachment 2: Reducing and stopping benzodiazepines and Z-
drugs1,2
The PrescQIPP dependence forming medicines resources
contain a
deprescribing benzodiazepine and Z-drug algorithm available at
https://www.prescqipp.info/our-resources/bulletins/bulletin-256-dependence-forming-
medications/
Decide if the person can stop their current benzodiazepine or Z-drug without
changing to diazepam.
Switching to diazepam is recommended for:
People using the short-acting potent benzodiazepines (e.g. lorazepam).
People using preparations that do not easily allow for small reductions in dose
(that is alprazolam, flurazepam, loprazolam and lormetazepam).
People taking temazepam or nitrazepam who choose to withdraw from
diazepam after discussing the advantages and disadvantages.
People experiencing difficulty or who are likely to experience difficulty
withdrawing directly from temazepam, nitrazepam, or Z-drugs, due to a high
degree of dependency (associated with long duration of treatment, high doses
and a history of anxiety problems).
Seek specialist advice (preferably from a hepatic specialist) before switching to
diazepam in people with hepatic dysfunction as diazepam may accumulate to
a toxic level in these individuals. An alternative benzodiazepine without active
metabolites (such as oxazepam) may be preferred.
Concomitant renal or hepatic impairment should be taken into consideration
when prescribing all benzodiazepines.3
Diazepam is available as 2mg tablets which could be halved to give 1mg doses
to allow the dose to be reduced in stages of 1mg every 1 – 4 weeks or more. It is
difficult to obtain such low doses of other benzodiazepines. However, the
manufacturer has no safety or efficacy data to support the use of halved
diazepam 2mg tablets, therefore this would be an off-licence use of the product.3
Negotiate a gradual drug withdrawal schedule (dose tapering) that is flexible.
Be guided by the person in making adjustments so that they remain
comfortable with the withdrawal.
Titrate the drug withdrawal according to the severity of withdrawal symptoms,
e.g. withdrawal should be gradual (dose tapering, such as 5–10% reduction
every 1–2 weeks, or an eighth of the dose fortnightly, with a slower reduction at
lower doses), and titrated according to the severity of withdrawal symptoms.
See withdrawal regimes below. Drug withdrawal may take three months to a
year or longer. Some people may be able to withdraw in less time.
Review frequently, to detect and manage problems early and to provide advice
and encouragement during and after the drug withdrawal.
If they did not succeed on their first attempt, encourage the person to try again.
Remind the person that reducing benzodiazepine dosage, even if this falls
short of complete drug withdrawal, can still be beneficial.
If another attempt is considered, reassess the person first, and treat any
underlying problems (such as depression) before trying again. If they did
not succeed on their first attempt, encourage the person to try again.
The Specialist Pharmacy Services provide a table of approximate equivalents
of benzodiazepines. There is however inter-patient variability, differing half-
lives and differing sedative properties and information should be interpreted
using clinical and pharmaceutical knowledge and applied cautiously with
doses titrated against patient response.3
Table 2: Equivalent doses of benzodiazepines3
Psychotropic
Ashton BNF Maudsley UK
Drug Drug
Manual Guidelines Guidelines
Directory
Diazepam 5mg 5mg 5mg 5mg 5mg
500
250 250 micrograms 250
Alprazolam
micrograms micrograms (250 – 500 micrograms
micrograms)
12.5mg
Chlordiazepoxide 12.5mg 12.5mg 12.5mg 12.5 – 15mg
(10 – 25mg)
Clobazam 10mg 10mg 10mg 10mg
Clonazepam 250
250 250 250
(wide reported 0.5 – 1mg micrograms
micrograms micrograms micrograms
equivalence) (0.25 – 4mg)
Flurazepam 7.5 – 15mg 7.5 – 15mg 7.5 – 15mg 7.5 – 15mg
Loprazolam 0.5 – 1mg 0.5 – 1mg 0.5 – 1mg 0.5 – 1mg
500 500 500 500 500
Lorazepam
micrograms micrograms micrograms micrograms micrograms
500
Lormetazepam 0.5 – 1mg 0.5 – 1mg 0.5 – 1mg 0.5 – 1mg
micrograms
5mg
Nitrazepam 5mg 5mg 5mg 5mg
(2.5 – 20mg)
10mg
Oxazepam 10mg 10mg 15mg 10 – 15mg
(10 – 20mg)
Temazepam 10mg 10mg 10mg 10mg 10mg
Withdrawal regimens can be found at:
All Wales Medicines Strategy Group. Education Pack. Material to support
appropriate prescribing of hypnotics and anxiolytics across Wales. April
2011. Available at
http://www.wales.nhs.uk/sites3/Documents/582/Guide_Hypnotics
%20%26%20Anxiolytics%20Practice%20Guide_version02.pdf Accessed
20/06/09.
Ashton CH. Slow withdrawal schedules. The Ashton Manual, University of
Newcastle, 2002. Available at www.benzo.org.uk/manual/bzsched.htm
Accessed 20/06/19
NHS Clinical Knowledge Summary. Benzodiazepine and Z-drug withdrawal.
Available at http://cks.nice.org.uk/benzodiazepine-and-z-drug-withdrawal#!
scenario Accessed 20/06/09.
Further resources for patients
Benzodiazepines -
www.rcpsych.ac.uk/mentalhealthinfo/treatments/benzodiazepines.aspx
Stopping benzodiazepines and Z-drugs -
http://patient.info/health/stopping-benzodiazepines-and-z-drugs
Battle against tranquillisers - http://bataid.org
PrescQIPP. 258. Hypnotics - Attachment 10 - Self-care resources for insomnia and
anxiety - www.prescqipp.info
References
1. Ashton CH. Benzodiazepines: what they do in the body. The Ashton Manual
University of Newcastle, 2002. Available at
https://benzo.org.uk/manual/bzsched.htm Accessed 20/06/19.
2. Clinical Knowledge Summary. Benzodiazepine and Z-drug withdrawal. Last
revised January 2019. Available at https://cks.nice.org.uk/benzodiazepine-and-z-
drug-withdrawal Accessed on 20/6/19
3. Specialist Pharmacy Services. Medicines Q&A. What are the equivalent doses of
oral benzodiazepines? Published July 2014, updated November 2018. Available at
https://www.sps.nhs.uk/articles/what-are-the-equivalent-doses-of-oral-
benzodiazepines/ Accessed 24/11/19.
