Tapering Off Dalmane (Flurazepam): A Long-Acting Benzodiazepine Is Still a Benzodiazepine

Dalmane is a benzodiazepine sleeping medication, and it produces the same physical dependence as any other.

Dalmane is the brand name for flurazepam, a hypnotic benzodiazepine, meaning one prescribed for sleep. Its United States Food and Drug Administration (FDA) label indicates it for insomnia, and it comes only as a capsule of 15 mg or 30 mg. It is an older, less common drug, yet people who have taken it nightly for years still arrive looking for a way off.

Dr. Mark Leeds, an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida, tapers patients off benzodiazepines and z-drugs, and Dalmane belongs on the same list as Xanax, Klonopin, and Ativan. It acts on the same receptors, it produces the same physical dependence, and it is tapered on the same slow, individualized principles. A person who took it as prescribed and now cannot stop without symptoms has a medical condition caused by the medication, and dependence is not addiction.

Why does Dalmane stay in the body so long?

Flurazepam itself is cleared quickly. The body converts it into an active metabolite, N-desalkylflurazepam, and the label gives that metabolite an elimination half-life of 47 to 100 hours. Table 1 in Chapter I of the Ashton Manual lists flurazepam with a half-life of 40 to 250 hours including the active metabolite, the longest figure in the table.

The label reports that the metabolite reaches a plateau after 7 to 10 days of nightly dosing, at roughly five to six times the level measured a day after the first dose. So, a person taking Dalmane every night is topping up a reservoir that drains slowly, and the body’s adaptation to the drug runs around the clock.

A long half-life makes the taper smoother. It does not make dependence optional.

Benzodiazepines work by enhancing gamma-aminobutyric acid (GABA), the brain’s main calming neurotransmitter. With nightly use, the nervous system adjusts to the drug’s presence and comes to rely on it to hold its own balance. That adjustment is physical dependence, and the label says that continued use may lead to clinically significant physical dependence, the risk rising with the length of treatment and the daily dose.

The long half-life does buy something. Short-acting benzodiazepines wear off between doses, and that interdose withdrawal is one reason a taper from them can be rough. Dalmane’s blood level falls slowly and evenly, which is the same reason the Ashton Manual recommends diazepam as its tapering drug.

Yet, smoother is not the same as safe to stop. A long-acting drug taken nightly for years still leaves the nervous system adapted to it. Withdrawal tends to start later, several days after a cut rather than a day or two, and it can still be hard and long-lasting. The half-life changes when the problem shows up. It does not remove it.

What did the 2020 FDA label update change for Dalmane?

In September 2020, the FDA required a new boxed warning on the label of every benzodiazepine, Dalmane included. It says that stopping abruptly or cutting the dose quickly after continued use can precipitate acute withdrawal reactions, which can be life-threatening.

The flurazepam label now instructs prescribers to use a gradual taper to discontinue the drug or to reduce the dosage. It also acknowledges that some people develop a protracted withdrawal syndrome, with symptoms lasting weeks to more than 12 months. Those two sentences, on a government-approved label, say what Professor C. Heather Ashton wrote in the Ashton Manual years earlier.

Chapter II of the Ashton Manual lists convulsions among the results of abrupt or over-rapid withdrawal, especially from high doses. A seizure is a medical emergency: call 911. Anyone in emotional crisis can call or text 988, the Suicide and Crisis Lifeline.

How is a Dalmane taper shaped?

The Ashton Manual’s principle is simple: reduce the dose in small steps, give each step time to settle before the next, and let the person taking the drug set the pace. Chapter II suggests a reduction of up to one tenth of the dose at each step, and it says the best judge of the pace is the patient, who must be in control and proceed at a comfortable speed.

The Maudsley Deprescribing Guidelines refine the shape. Because the drug’s effect at the GABA receptor is not proportional to the dose, the last few milligrams do far more work than the first few, so the reductions should shrink as the dose falls. This is hyperbolic tapering: the steps at the end of a taper are tiny compared with those at the beginning.

How long does it take? Months at least, and the Manual notes that many people have taken a year or more to complete a withdrawal. Dr. Leeds does not set a calendar in advance. If a reduction brings on symptoms that do not settle, the taper pauses or the last step is partly reversed, and if the person feels ready sooner, the next step comes sooner.

The capsule is the problem, and the Ashton Manual’s answer is diazepam.

Dalmane comes only as a 15 mg or 30 mg capsule, and a capsule cannot be halved or quartered the way a scored tablet can. A person taking 15 mg nightly has, in capsule form, exactly one step available, and that step is the whole dose.

Chapter II of the Manual says it may be necessary to switch to diazepam even for someone on a fairly long-acting benzodiazepine of relatively low potency, and it names flurazepam (Dalmane) as its example. Diazepam comes in 2 mg scored tablets and in a liquid, so the dose can be cut into very small pieces. Table 1 puts 15 to 30 mg of flurazepam at roughly the strength of 10 mg of diazepam, which is the starting point for the exchange.

In a crossover taper, part of the nightly Dalmane dose is replaced with the equivalent amount of diazepam, the person stabilizes for a few days to a week or two, and the exchange continues stepwise until the taper proceeds on diazepam alone. Where the Manual’s schedules switch drugs, they switch to diazepam, never to flurazepam. Dr. Leeds uses this route when the steps cannot be made small enough in capsule form, and he describes it further on his Ashton Manual page.

Where a person would rather stay on flurazepam, a compounding pharmacy can prepare it as a liquid or in smaller capsule strengths. It is the same drug in a different form, and it allows smaller cuts. The Maudsley Deprescribing Guidelines describe both routes, a switch to diazepam or a direct taper on flurazepam itself, and either one is a slow taper.

The Manual allows a faster taper after short-term use. It is still a taper.

Chapter II of the Manual says that people who have been on low doses for a relatively short time, less than a year, can usually withdraw fairly rapidly. Fairly rapidly means a quicker taper, not a sudden stop, and the same chapter says, above all, not to try to stop suddenly.

The label agrees: it tells prescribers to use a gradual taper to discontinue the drug or reduce the dose. A carefully prescribed course of up to about a week can usually be stopped without trouble. After about four weeks of nightly use, Dalmane should never be stopped abruptly, and a few weeks of use usually needs only a short taper, slowed for anyone who reacts.

The cost of stopping abruptly in a person whose nervous system has adapted can be a seizure or a withdrawal that lasts for months.

Protracted withdrawal is real, and a slow taper is the best protection against it.

Most people who taper carefully come off Dalmane with symptoms they can live with, and those symptoms fade with time. A minority develop protracted withdrawal, in which anxiety, insomnia, sensory disturbances, muscle pain, and difficulty concentrating come and go for months after the last dose, in what patients call windows and waves. Chapter III of the Ashton Manual describes this syndrome, and the label now names it.

Is it permanent? In most cases it is not, though after months of symptoms coming and going it can feel that way. Unfortunately, there is no medication that reliably speeds the healing. Fortunately, Chapter III of the Manual notes that protracted symptoms are far less common after a slow taper the patient controls, and that taper is within reach of anyone with a willing physician and enough patience.

What a Dalmane taper with Dr. Leeds looks like.

Dr. Leeds’ practice is one physician working directly with each patient, by telemedicine throughout Florida and in his Fort Lauderdale office. There is no facility, no group meeting, and no fixed program length, only a plan built around the person’s dose, history, other medications, and the pace they can tolerate, changed whenever the body says so.

Consent in this practice means the risks first, then the alternatives, including staying on the medication for now, then an exit plan, and always the right to decline or to change course. The patient directs the pace, and the physician’s job is to make each step as small as it needs to be and to know when to hold. His page on medically supervised benzodiazepine tapering has more detail.

A long-acting benzodiazepine is still a benzodiazepine, and a person who wants to come off Dalmane deserves a taper designed for the drug, the capsule, and the person taking it, not a calendar. Dr. Leeds’ practice offers medically supervised tapering to patients in Florida. Contact the office to ask about a Dalmane taper.

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.