Benzodiazepine Tapering and Patient Autonomy: What Does an Informed Decision Require?

Key Takeaways

• The patient decides when a benzodiazepine taper starts, how fast it goes, and when to hold, while the physician prescribes the medication and watches for danger.
• Informed consent means hearing the risks of physical dependence, tolerance, and withdrawal first, then the expected benefits and the alternatives, including no medication at all. It also means an exit plan from day one and the right to decline.
• A person who takes a benzodiazepine exactly as directed can become physically dependent on it, and dependence is not addiction.
• There is no standard tapering number. The Ashton Manual and the Maudsley Deprescribing Guidelines describe a shape, with reductions that get smaller as the dose gets lower, and the actual steps are worked out with the prescriber.
• Holding a dose for a few weeks, or taking a small step back up after a reduction that proved too large, is a legitimate part of a taper when it is decided with the prescriber.
• Bring the relevant pages of the Ashton Manual or the Maudsley Deprescribing Guidelines, a list of every medication and supplement, and a symptom diary to the conversation with the prescriber. Ask for the plan in writing, with the right to hold or slow it written in.
• If a prescriber refuses to taper or insists on finishing in a few weeks, do not stop the medication abruptly, and consider a second opinion from a physician who has experience with slow tapers.

Who decides how a benzodiazepine taper goes?

The patient does. A physician brings knowledge of the medication, writes the prescription, and watches for danger. The person whose nervous system is doing the adjusting decides when to start, how fast to go, and when to hold.

Professor C. Heather Ashton said so in Chapter II of the Ashton Manual. She wrote that it is important for the person tapering to be in control of the schedule and to proceed at whatever pace is comfortable. Her instruction to patients was blunt: “Do not let your doctor impose a deadline.”

Dr. Mark Leeds, an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida, holds the same position. Yet, a decision only belongs to the patient when the patient has been told the truth first. So, what does an informed decision about a benzodiazepine require?

What does informed consent for a benzodiazepine include?

Risks come first. Before the first prescription, a patient should hear that a benzodiazepine can cause physical dependence, tolerance, and withdrawal, and that this can happen at ordinary prescribed doses. Then come the expected benefits and the alternatives, including the alternative of no medication at all.

Consent also includes an exit plan from day one: how long the medication is expected to be used, and how the patient will eventually come off it. No pilot takes off without knowing where the plane will land. A prescription with no exit plan is a takeoff with no destination. The landing has to be planned before the plane leaves the ground.

Then there is the right to decline. A patient may refuse a medication, refuse a taper plan, pause, or slow down, without penalty to the relationship with the doctor. That includes deciding whether to taper at all, and when.

The same standard applies to the taper itself. Before the first reduction, a patient should hear what withdrawal can feel like, how long a taper may take, and what the alternatives are, including staying at the current dose for now.

Unfortunately, many people who have taken a benzodiazepine for years never had that conversation. It is not too late, because consent is a continuing conversation and not a signature.

Consent is also never a technique for getting a patient to go along with a plan. It protects the right to say no.

Why are people who took a benzodiazepine as prescribed treated as if they were addicted?

A person who takes a benzodiazepine exactly as directed can become physically dependent on it. The nervous system adapts to the medication, and symptoms appear when the dose falls. Doctors call that physical dependence, and dependence is not addiction.

In fact, when the United States Food and Drug Administration (FDA) updated the boxed warning on benzodiazepines in 2020, it listed physical dependence as a risk in its own right. The agency stated that physical dependence can occur when these medications are taken steadily for several days to weeks, even as prescribed.

Still, patients are mislabeled by family members, by emergency room staff, and sometimes by the doctor who wrote the prescription. The label matters because it changes how a person is heard. A request for a slower taper gets read as drug seeking, and a report of symptoms gets read as exaggeration.

Withdrawal symptoms are not weakness, and they are not a failure of will. A patient has the right to be believed about them.

What should a patient understand before the first dose reduction?

First, how the medication works. Benzodiazepines boost the effect of gamma-aminobutyric acid (GABA), the brain’s own calming messenger. With regular use the brain adjusts to that boost, and the same dose does progressively less, which is called tolerance.

Tolerance explains two things patients are rarely told. Symptoms can appear while a person is still taking the full dose, and with a short-acting drug they can appear between doses, which is called interdose withdrawal. Neither one is proof that the original condition has returned.

Second, half-life, the time it takes for the level of a drug in the blood to fall by half. Table 1 of the Ashton Manual lists 6 to 12 hours for alprazolam (Xanax), 10 to 20 hours for lorazepam (Ativan), 18 to 50 hours for clonazepam (Klonopin), and 20 to 100 hours for diazepam (Valium), whose active breakdown product lasts longer still.

A short-acting drug wears off between doses, which is why Professor Ashton advised people on the potent, short-acting drugs to switch to diazepam before reducing. That switch is called a crossover taper. It is an option to discuss, and it is not a requirement.

Third, the risks on both sides. The Manual’s first chapter records the recommendation that benzodiazepines be reserved, in general, for short-term use of two to four weeks. It also notes that older people are more sensitive to these medications, and that oversedation in older adults may contribute to falls and fractures.

On the other side, the FDA warns that stopping abruptly or reducing the dose too quickly can cause withdrawal reactions, including seizures, which can be life-threatening. For a seizure or any other medical emergency, call 911, and anyone in crisis can call or text 988, the Suicide and Crisis Lifeline.

How fast should the dose come down?

There is no standard number. The same FDA update tells prescribers that no standard tapering schedule is suitable for all patients, and that the plan should be specific to the patient.

The published guides describe a shape instead. Chapter II of the Ashton Manual says a person could aim at reducing by up to one tenth of the dose at each step, and it notes that many people have taken a year or more. The Maudsley Deprescribing Guidelines size each reduction as a proportion of the most recent dose, so the reductions get smaller as the dose gets lower.

These are illustrations, not a schedule to copy. The actual numbers are worked out with the prescriber, and the time between steps depends on how the patient feels. If a patient wants to go faster than is safe, the prescriber must say so and advise a smaller step.

Holding a dose for a few weeks when life gets hard is a normal part of a taper. A small step back up after a reduction that proved too large is also a legitimate choice, made with the prescriber. A separate article takes up who should set the pace of a benzodiazepine taper at more length.

How do you raise tapering with your prescriber?

Of course, a taper still needs a prescriber, so the conversation has to happen. Many patients find it hard, because the habit of deferring to a doctor runs deep.

Preparation helps, so bring paper. The relevant pages of the Ashton Manual or the Maudsley Deprescribing Guidelines give the prescriber something to read that is more than one patient’s opinion. A list of every medication and supplement, and a symptom diary with dates and doses, gives both people the same facts to work from.

Then ask direct questions. How large will each reduction be, and how long between them? Can a dose be held when symptoms flare? Is there a formulation, such as a liquid or a smaller tablet, that allows small reductions? Is a crossover taper to a longer-acting benzodiazepine worth considering?

Ask for the plan in writing, with the right to hold or slow it written in. Bring a family member or a friend, who can take notes and remember what was said. A prescriber who respects the patient will not be offended by any of this.

What if the prescriber refuses to taper, or insists on a few weeks?

Unfortunately, it happens. Some prescribers decline to supervise a taper at all, some want it finished in a few weeks, and some threaten to stop the prescription.

Whatever the pressure, do not stop the medication abruptly. A schedule of a few weeks for a medication taken for years is not a taper. It is a deadline.

However, a patient is not obliged to accept it. A second opinion is not disloyalty, and a patient may decline a plan that feels unsafe and look for a physician who has experience with slow tapers. The article on how to find care when a doctor does not recognize benzodiazepine dependence explains where to start.

In Dr. Leeds’ practice, the patient directs the taper.

Dr. Leeds works directly with every patient. The first conversation covers the risks of the medication, the risks of coming off it, the alternatives, and what the patient wants, including the choice to wait.

From there, the plan is built with the patient. Where it helps, he uses the Ashton Manual’s crossover taper to diazepam, and the reductions follow the hyperbolic pattern described in the Maudsley Deprescribing Guidelines, each one smaller than the last. The patient may hold at any step, and no one imposes a deadline.

A taper done this way takes months, and sometimes longer. Fortunately, a person who understands the medication, knows the plan, and controls the pace has far less to fear from it.

Dr. Leeds’ practice offers medically supervised tapering of benzodiazepines and z-drugs, the sleep medications such as zolpidem (Ambien), to patients in Florida. Contact the office to talk about a taper that starts with informed consent and moves at the patient’s pace.

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.