Noon conference

1. Benzodiazepines
Karina K. Uldall, MD, MPH
November 13, 2018

2. © 2015 Virginia Mason Medical Center

3. © 2015 Virginia Mason Medical Center
History
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Introduced in the 1960s
Replacement for Barbiturates
Gamma-aminobutyric acid receptors
37.6 Prescriptions/100 Persons in the
US in 2012
1960-70s “anxiety neurosis”
1980s “panic disorder”

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Benzodiazepine Use in the U.S.
• 1 in 20 adults in 2008
• 8.7% of adults 65-80 years old
• 31.4% of adults 65-80 with long
term use
• 2/3 long term use: non-psychiatrist
Rx
• >65 years = 9/10 non-psychiatrist
Rx
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5. 5

6. Common Uses/Common Problems
• Alcohol withdrawal
• Anxiety/Mania
• Epilepsy
• Insomnia
• Muscle relaxants
• Short term use =
less than 1
month
• Dependence
• Sedation
• Memory
impairment
• Delirium
• Falls
• Synergistic
Respiratory
Depression with
Opioids

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Benzodiazepine Equivalents
Drug Action Onset Peak (Hrs) Half Life (Hrs) Dose
Alprazolam 15-30 min 0.7-1.6 6-20 0.5 mg
Chlordiazepoxide 15-30 min 2-4 5-30/3-100 10 mg
Clonazepam 15-30 min 1-4 18-39 0.5 mg
Diazepam < 15 min 1 20-50/3-100 10 mg
Lorazepam 15-30 min 1-1.5 10-20 1 mg
Temazepam > 30 min 0.75-1.5 10-20 30 mg

8. © 2015 Virginia Mason Medical Center
Setting Expectations
• Time Limited Prescription
• 40% of People Become Addicted after
6 Weeks of Daily Use
• Monitoring
• Number and Source of Rx
• No Use of Opioids
• Pharmacist Support in Care
• Letter Re Continued Use

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Outcomes to Avoid
Falls
Cognitive Impairment
The Need For:
Psychiatric Intervention
Detox/Addiction Treatment
Home Health Services

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The Letter
• Explain the concern: drug, dose,
duration
• Highlight potential adverse effects
• Ask to consider a reduction in use
• Include advice on gradual, safe
taper
• Invite the patient to discuss further

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Psychological Considerations
• Expect Anxiety, Insomnia and
Resistance
• Patient Education and Support
Recommended: Set Expectations,
Foster Empowerment
• The Slower the Taper, the Better
Tolerated: Consider Patient
Preference
Aim for < 6 months

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Likelihood of Withdrawal
• Longer the treatment
• Higher the dosage
• Shorter the half-life
• Faster the taper
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13. Withdrawal Symptoms
• Agitation
• Anxiety
• Confusion
• Depersonalization
• Diaphoresis
• Difficulty
Concentrating
• Dizziness
• Fatigue
• Insomnia
• Increased Acuity to
Stimuli
• Loss of Appetite
• Nausea
• Muscle Cramping
• Parasthesias
• Perceptual
Disturbances
• Poor Coordination
• Restlessness
• Tinnitus
• Tremor
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14. © 2015 Virginia Mason Medical Center
Slow Taper
• Calculate the dose equivalence into clonazepam
or diazepam
• Switch the patient to the longer acting
medication, using a conservative estimate of 50-
75% of the calculated dose
• 10 mg lorazepam → 50-75 mg diazepam
• See the patient in ~3 days after starting the
taper
• Reduce to total dose by 5-10% per week
• Slow the taper to <5% per week when the dose
has been reduced to 25-50% of the starting
dose
• Consider adjunctive meds for symptom control

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Rapid Taper
• Seizure prophylaxis
• Valproic acid 500 mg BID or Carbamazepine
200 mg q AM and 400 mg qHS
• Two weeks before and four weeks after
• Behavioral support
• Diazepam 2 mg BID x 2 days, 2 mg/day x
2 days, stop (may start with 5 mg)
• Consider adjunctive meds for symptom
control
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16. © 2015 Virginia Mason Medical Center
References
Billioti de GS et al. Benzodiazepine use and risk of Alzheimer’s
disease: a case-control study. BMJ 2014; doi: 10.1136/bmj.g5205
Lader M et al. Withdrawing benzodiazepines in primary care. CNS
Drugs 2009; 23:19-34.
Mugunthan K et al. Minimal interventions to decrease long-term use
of benzodiazepines in primary care: a systematic review and meta-
analysis. British J Gen Practice 2011; doi: 10.3399/bjgp11X593857
Olfson M et al. Benzodiazepine use in the United States. JAMA
Psychiatry 2014; doi: 10.1001/jamapsychiatry.2014.1763
www.oregonpainguidance.org, Tapering Flowchart
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