A comprehensive new clinical practice guideline for benzodiazepine tapering has been published by a coalition of 10 professional medical societies, providing clinicians with detailed, evidence-based, consensus-derived recommendations for safely discontinuing these medications.

The Joint Clinical Practice Guideline on Benzodiazepine Tapering: Considerations when Benzodiazepine Risks Outweigh Benefits addresses the complex process of tapering patients off benzodiazepines (BZDs) when continued use presents greater risks than benefits.

"BZDs should not be discontinued abruptly in patients who are likely to be physically dependent on the medication and at risk for withdrawal; rather, their medication dosage should be tapered gradually over a period of time under clinical supervision," the guideline authors stated.

An estimated 24 million Americans use BZDs, with approximately 20 million taking them as prescribed. Approximately 50% of patients prescribed oral BZDs receive them for 2 months or longer, with potentially 2 million older adults taking these medications for more than 120 days.

Recommendation Classification System

The guideline uses a clear classification system for its 29 recommendations:

• Strong recommendations use language such as "clinicians should" or "clinicians should not"
• Conditional recommendations use "clinicians can consider"
• Recommendations based on evidence include certainty ratings (low, moderate, high)
• Consensus-based recommendations are explicitly labeled "Clinical Consensus".

Key Strong Recommendations

1. Assessment of risks and benefits (clinical consensus, strong recommendation): "Clinicians should ideally assess the risks and benefits of ongoing BZD prescribing at least every 3 months for each patient taking BZD medications."
2. Avoidance of abrupt discontinuation (low certainty, strong recommendation): "Clinicians should avoid abruptly discontinuing BZD medication in patients who are likely to be physically dependent on BZDs and at risk for BZD withdrawal."
3. Tapering when risks outweigh benefits (low certainty, strong recommendation): "Tapering is indicated for patients who are likely to be physically dependent when the risks of BZD medication outweigh the benefits."
4. Initial tapering pace (clinical consensus, strong recommendation): "Clinicians should generally consider dose reductions of 5% to 10% when determining the initial pace of the BZD taper. The pace of the taper should typically not exceed 25% every 2 weeks."
5. Adjunctive behavioral interventions (low certainty, strong recommendation): "Clinicians should offer patients undergoing BZD tapering behavioral interventions tailored to their underlying conditions (eg, cognitive behavioral therapy (CBT) or CBT for insomnia) or provide them with referrals to access these interventions."

Tapering Strategies

The guideline provides granular details on tapering approaches, noting that different methodologies can achieve the same reduction goal.

For example, a 20% reduction over 4 weeks could be achieved by:

• Reducing the BZD dose by 5% per week
• Reducing the BZD dose by 10% every other week
• Reducing the BZD dose by 20% and maintaining at that lower dose for 4 weeks
• Reducing the number of pills consumed (eg, reducing a 5-mg diazepam twice daily prescription from 60 to 48 pills for 4 weeks).

Recommendations for Special Populations

1. For patients co-prescribed opioids (clinical consensus, strong recommendation): "Clinicians should offer to provide or prescribe opioid overdose reversal medication (eg, naloxone) for all patients co-prescribed BZDs and opioids."
2. For pregnant patients (clinical consensus, strong recommendation): "Clinicians should weigh the risks and benefits for the maternal-fetal dyad when considering continued BZD prescribing or tapering for pregnant patients."
3. For older adults (clinical consensus, strong recommendation): "Clinicians should generally taper BZD medication in older adults unless there are compelling reasons for continuation."
4. For patients with substance use disorders (clinical consensus, strong recommendation): "Clinicians should not use BZD prescribing or tapering considerations as a reason to discontinue or disrupt a patient's medications for substance use disorder treatment, including buprenorphine and methadone."

Evidence Base and Methodology

The guideline development involved a systematic literature review yielding 57 relevant articles, with only 10 studies providing evidence for 3 evidence-based recommendations; the remainder of recommendations relied on clinical consensus using a modified Delphi process. A 15-member Clinical Guideline Committee included representatives from 10 medical societies, with additional input from a panel of individuals with lived experience with BZD discontinuation.

"Many complex factors influence decision-making related to BZD tapering, and there is significant heterogeneity in patient response to tapering. This guideline should be implemented to allow flexibility in response to diverse clinical circumstances," the document's authors state in its guiding principles for implementation.