Benzodiazepine Deprescribing Designed to Avoid Protracted Withdrawal

Can a benzodiazepine taper be designed to avoid protracted withdrawal?

A taper can be designed to lower the risk. No honest doctor can promise more than that. Protracted withdrawal means withdrawal symptoms that persist for months, and sometimes longer, after the last dose, and how the drug is stopped is the risk factor a patient and a doctor can still control.

Professor C. Heather Ashton wrote in Chapter III of the Ashton Manual that a minority of long-term users develop protracted symptoms. She added that the incidence in people who taper slowly, under their own control, is almost certainly very much lower.

Deprescribing, the planned and supervised stopping of a medication, can be built around that observation. Dr. Mark Leeds, an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida, plans every benzodiazepine taper that way. So, what does such a plan look like, and why do so many patients never get one?

Protracted withdrawal is withdrawal that outlasts the drug.

The United States Food and Drug Administration (FDA), in its 2020 boxed-warning update, described a protracted withdrawal syndrome that persists beyond four to six weeks, and it reported patients whose symptoms lasted many months. Many patients and doctors now use a broader name for it, benzodiazepine-induced neurological dysfunction (BIND).

Chapter III lists lingering anxiety, insomnia, tinnitus, tingling, burning pain, muscle pain, and poor memory, some of which may last at least a year and occasionally several years. The symptoms come and go, and Professor Ashton described “windows” of normality that appear after some weeks and gradually last longer. Patients call the bad stretches waves, and a separate article covers how long protracted withdrawal lasts.

None of this is addiction.

Benzodiazepines strengthen gamma-aminobutyric acid (GABA), the brain’s main calming signal, and over time the nervous system adapts to the drug. That adaptation is physical dependence. The FDA’s 2020 update states that it can occur when a benzodiazepine is taken steadily for several days to weeks, even as prescribed.

Physical dependence is not addiction. The nervous system adapted to a prescription, and it needs time to adapt back.

Why does a slow taper lower the risk?

Because the nervous system needs time to readjust, and a fast taper does not allow it. Chapter II of the Manual states that abrupt or over-rapid withdrawal, especially from a high dose, can give rise to severe symptoms and may increase the risk of protracted withdrawal.

The same FDA update warns that stopping abruptly or reducing the dose too quickly can cause seizures, which can be life-threatening. Call 911 for a seizure or any other medical emergency.

A diver coming up from deep water rises in stages and waits at each stop. What harms the diver is the speed of the ascent, and nobody calls the stops a failure to surface. A taper works the same way.

Fortunately, the shape of a slow taper is well described. The Manual suggests aiming for a reduction of up to one tenth of the dose at each step. The Maudsley Deprescribing Guidelines describe hyperbolic tapering, in which each reduction is sized to the current dose, so the steps get smaller as the dose gets lower.

For short-acting drugs such as alprazolam (Xanax), the Manual describes a crossover taper to diazepam (Valium), whose slow elimination allows a smooth, gradual fall in blood level. And, when a reduction brings a wave, the dose is held until it settles, for a few weeks if necessary.

The patient sets the pace. The calendar does not.

Professor Ashton wrote that the person tapering is usually the best judge of the rate, must be in control, and may need to resist clinics and doctors who push a rapid withdrawal. She called the classic six-week withdrawal used by many clinics much too fast for many long-term users.

Whether a taper takes six months or eighteen, she wrote, matters little after years on the drug. The FDA’s 2020 update agrees that no standard tapering schedule suits all patients, and it calls for a patient-specific plan.

Unfortunately, withdrawal is often mistaken for the old anxiety coming back.

This is the mistake that sends patients back to the drug. Chapter III says that nearly all the acute symptoms of withdrawal are those of anxiety. So, when panic and insomnia surge after a reduction, or linger after the last dose, a doctor may decide that the original condition has returned and that the patient needs the medication for life.

The same misreading can happen before a taper starts. Chapter I describes anxiety that increases over the years despite continuous use, probably because tolerance lets withdrawal symptoms emerge while the drug is still being taken. Patients call this tolerance withdrawal, and Professor Ashton wrote that doctors have often answered tolerance by raising the dose.

Can the two be told apart? Not always, and not quickly. The FDA noted, in the cases it reviewed for the 2020 update, how difficult it was to separate withdrawal symptoms from a return of the symptoms the drug was prescribed for.

Yet, there are clues. The Manual calls hypersensitivity to sound, light, and touch and distorted perception particularly characteristic of withdrawal. It adds that a feeling of insects crawling on the skin and muscle twitching are unusual in anxiety states.

Timing is another clue. Symptoms that follow a reduction, or that the person never had before the drug, point toward withdrawal.

The reading decides what happens next. If the symptoms are called the old anxiety, the dose goes back up, or a new diagnosis and a new prescription are added. If they are recognized as withdrawal, the answer is a hold, smaller steps, and more time.

What does this look like in Dr. Leeds’ practice?

The plan is made with the patient before the first reduction. Informed consent comes first: the risks, including protracted withdrawal, the alternatives, including staying on the current dose for now, an exit plan, and the right to decline or pause at any point.

When a taper has been rushed elsewhere, the first step is usually to stabilize, with no reduction at all. After that, Dr. Leeds uses the crossover to diazepam where it helps, shrinks each step as the dose falls, and settles the stopping point with the patient in advance, so that the last step feels like just another step.

A flare of symptoms after a reduction is information about the pace, and the answer is a hold. A small step back up after a cut that proved too large is legitimate.

Some symptoms may still outlast the taper. However, Professor Ashton observed in Chapter III that even protracted sensory and motor symptoms decline in severity over the years. The nervous system is not broken, and with time it recalibrates.

Dr. Leeds’ practice focuses on medically supervised benzodiazepine and z-drug tapering for patients in Florida, at a pace the patient sets, over months and sometimes longer. Contact the office to ask about a taper designed this way.

This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.