ABSTRACT
About 1 in 10 adults in the United States report having used benzodiazepines in the past year. These medications carry substantial risks, including falls, cognitive impairment, overdose, and death, particularly when combined with alcohol or opioids. The American Society of Addiction Medicine, in collaboration with 9 other professional societies, has issued recommendations on when and how to taper and discontinue benzodiazepines. The authors of this article summarize important points from the guideline, aimed at all who provide long-term benzodiazepine prescriptions.
Evaluate the risks vs benefits of ongoing benzodiazepine use at least every 3 months and at each prescription renewal.
Engage in shared decision-making with patients regarding whether to continue or discontinue benzodiazepines.
Do not discontinue benzodiazepines abruptly in patients who are likely to be physically dependent and at risk of withdrawal, eg, those taking shorter-acting benzodiazepines or higher doses or who have been taking them longer.
Tailor tapering strategies to each patient and adjust tapering based on patient response.
Offer patients adjunctive psychosocial interventions to support successful tapering.
To help clinicians determine whether patients need to get off benzodiazepines—and if so, how to do it—the American Society of Addiction Medicine, partnering with 9 professional societies, has developed the first national, evidence-informed guideline for benzodiazepine tapering.1 The guideline provides a systematic framework for deciding when tapering is appropriate and for implementing safe, patient-centered discontinuation strategies. It emphasizes shared decision-making, gradual dose reduction, psychosocial support, and ongoing monitoring.
In this article, we summarize the highlights from this 46-page document, aimed at all clinicians who provide long-term benzodiazepine prescriptions.
WIDELY USED BUT RISKY
Benzodiazepines are widely prescribed for anxiety, insomnia, seizures, and other conditions. In the 2023 National Survey on Drug Use and Health, 9.1% of US adults (age 26 or older) reported using benzodiazepines in the past year.2
However, these medications carry substantial risks, including falls, cognitive impairment, overdose, and death, particularly when combined with alcohol or opioids.3 Age, polypharmacy, and comorbid psychiatric or medical illness heighten these risks.4 Physical dependence, an expected outcome distinct from substance use disorder, develops with regular use, and abrupt discontinuation may precipitate withdrawal; symptoms of withdrawal can include anxiety, insomnia, tremors, diaphoresis, palpitations, and, rarely, seizures, which can be life-threatening.5
Despite widespread prescribing, until now, US clinicians have lacked national guidance on safe tapering. Poorly managed discontinuation has led to withdrawal complications, symptom relapse, and resorting to illicit benzodiazepines.6,7
WHO DOES THE GUIDELINE APPLY TO?
These recommendations apply to adults taking benzodiazepines regularly for more than 2 weeks who may be physically dependent, primarily outpatients. They do not apply to patients receiving palliative or end-of-life care, those taking benzodiazepines intermittently or for less than 2 weeks (including patients taking a short-acting benzodiazepine over a prolonged period at infrequent intervals), children and adolescents, or patients tapering from barbiturates or Z-drugs (ie, nonbenzodiazepine hypnotics such as zolpidem, eszopiclone, and zaleplon).
The intended audience is all who provide long-term benzodiazepine prescriptions.
WHO WROTE THE GUIDELINE?
The American Society of Addiction Medicine led the development of the guideline in collaboration with 9 other professional organizations representing primary care, psychiatry, neurology, geriatrics, pharmacy, and obstetrics.
A multidisciplinary committee that included physicians, pharmacists, and experts in addiction medicine, neurology, geriatrics, and primary care oversaw all stages of guideline development. A panel of patients who had actually gone through benzodiazepine tapering also provided input.1
Evidence was evaluated using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework,8 and a modified Delphi process was used to achieve consensus when empirical data were limited.
WHAT ARE THE MAIN RECOMMENDATIONS?
The guideline outlines a structured, patient-centered framework for assessing benzodiazepine treatment, determining when to taper, and implementing safe discontinuation strategies.1 It emphasizes individualized care, shared decision-making, and ongoing monitoring.
Monitor and assess risk
Clinicians should evaluate benzodiazepine therapy at least every 3 months and at each prescription renewal, while concurrently reviewing prescription drug monitoring program data.
Taper gradually in patients at risk
Benzodiazepines should not be discontinued abruptly in patients likely to be physically dependent on them, as doing so can precipitate severe withdrawal. Patients are more likely to be physically dependent if they have taken shorter-acting benzodiazepines or higher doses, or have been on them longer. High benzodiazepine doses can be thought of in terms of diazepam equivalents, eg, higher than diazepam 15 mg per day, clonazepam 1.5 mg per day, lorazepam 3 mg per day, or alprazolam 2 mg per day.1 Moderate doses are typically 10 to 15 mg diazepam equivalents per day.
Gradual tapering, defined as 5% to 10% dose reductions every 2 to 4 weeks or longer, is recommended when risks of continued use outweigh benefits. In patients unlikely to be dependent, clinicians may consider discontinuation or a brief taper.
All patients should be counseled about withdrawal or rebound symptoms such as anxiety, insomnia, tremors, diaphoresis, and gastrointestinal upset, and, if significant symptoms arise, the taper can be slowed or briefly reversed.
Use shared decision-making
Tapering strategies should be developed collaboratively with patients and, when appropriate, their care partners. If patients will not consider tapering, clinicians can inform them that benzodiazepines lose their benefits over time, while their adverse effects persist or increase. Clinicians can additionally emphasize that cognition and psychomotor function should improve after stopping the drug. Clinicians can use motivational interviewing to build patient buy-in.
Motivational interviewing is a therapeutic technique that focuses on helping people navigate ambivalent feelings and build motivation for behavioral change. The Motivational Interviewing Network of Trainers (motivationalinterviewing.org/motivational-interviewing-training) offers excellent resources for developing skills in motivational interviewing.
Go slowly and individualize
Initial dose reductions should range from 5% to 10% of the total daily dose, with reductions not exceeding 25% every 2 weeks. Transitioning to a longer-acting benzodiazepine may help. Although such small changes can be beneficial to patients who have struggled with larger dose changes in tapers before, they can pose practical difficulties for clinicians.
Tapering should be individualized and adjusted based on tolerance, functioning, and emerging symptoms. Tapers should remain adaptable, with clinicians prepared to slow, pause, or temporarily reverse the process as needed.
These principles of benzodiazepine tapering are illustrated in 2 case vignettes (see sidebar).
Level-of-care considerations
Most tapers can be managed safely on an outpatient basis. Inpatient or residential care should be considered when continued use poses imminent risk not mitigated by dose reduction, co-occurring medical or psychiatric conditions make outpatient care unsafe, or the patient experiences or is at high risk for severe or complicated withdrawal.
Adjunctive and supportive interventions
Behavioral interventions are strongly encouraged. Clinicians should offer patients evidence-based therapies, such as cognitive behavioral therapy or cognitive behavioral therapy for insomnia, to address underlying anxiety or sleep disturbance. Cognitive behavioral therapy is a therapy modality that teaches people to identify, challenge, and modify unhelpful thought patterns and behaviors. It was developed by Dr. Aaron Beck, and training is available through the Beck Institute (beckinstitute.org/training), among other places.
If withdrawal symptoms interfere significantly, first pause or slow the taper; adjunctive medications may be used if symptoms persist.
Management of complicated withdrawal
Severe or complicated withdrawal symptoms such as seizures or delirium require inpatient or residential medically supervised care with continuous monitoring, vital sign checks, and seizure risk assessment. Clinicians experienced with using long-acting agents such as phenobarbital can use this agent. Rapid-reversal agents (eg, flumazenil) and anesthetics (eg, propofol, ketamine) should not be used to manage benzodiazepine discontinuation, as they carry significant risks of seizure and cardiac arrhythmia.
Special populations
Patients coprescribed benzodiazepines and opioids. Reassess at least every 3 months, in view of the risk of respiratory depression. Prescribe naloxone and minimize doses of both the benzodiazepine and the opioid while maximizing nonopioid and nonpharmacologic interventions. When appropriate, clinicians should engage in shared decision-making with patients to determine which medication to taper first.
Patients with substance use disorders require integrated treatment of both conditions, including harm-reduction measures such as naloxone distribution and access to community-based drug-checking programs. Benzodiazepine use should never preclude continuation of medications for opioid use disorder (eg, buprenorphine or methadone). Continued addiction treatment and recovery support should follow taper completion.
Patients with psychiatric disorders. Optimize management of underlying psychiatric conditions before or during tapering. Sleep and mood should be monitored closely, particularly in those with bipolar disorder, and tapering paused if destabilization occurs. Tapering should be strongly considered in posttraumatic stress disorder, as benzodiazepines do not improve core symptoms of the disorder, may interfere with psychotherapy, and worsen overall outcomes.9,10
Older adults. Tapering is generally warranted in this population, given their elevated risks of falls, delirium, cognitive decline, and drug interactions, unless there are compelling reasons to continue. Older adults are more sensitive to benzodiazepines, and the metabolism of long-acting agents slows with age, both of which increase the risk of cognitive decline and confusion. Short-acting agents carry higher risks of falls and fractures. Additionally, benzodiazepine exposure in older adults is associated with increased all-cause mortality, with exposed patients dying at an annual rate 1.2 to 3.7 times higher than unexposed patients.3,11
Breastfeeding patients. Breastfeeding is generally compatible with benzodiazepine use, as transfer into breast milk is minimal and adverse effects in infants are rare.12 However, infants should be monitored for sedation, feeding difficulties, and inadequate weight gain.
Lorazepam is generally preferred during lactation due to its lack of active metabolites, low relative infant dose (< 10%), and short half-life.13 In a prospective cohort study of 124 breastfeeding mothers, sedation occurred in only 1.6% of infants and was not associated with benzodiazepine dose or duration.14
For short-term management of anxiety and sleep disturbances, benzodiazepines can be used during breastfeeding.12 If a patient is stable on a particular agent, switching is typically unnecessary.
The decision should balance breastfeeding benefits against maternal clinical needs and potential infant effects.
WHAT IS DIFFERENT FROM PREVIOUS GUIDELINES?
The guideline builds on several foundational resources, including the 2020 US Food and Drug Administration warning on benzodiazepines,15 the 2022 Kaiser Permanente benzodiazepine and Z-drug safety guideline,16 the 2023 American Geriatrics Society Beers Criteria,17 and the 2024 Maudsley deprescribing guidelines,18 which incorporate both practice-based evidence and lived experience. Before these guidelines were developed, existing guidance was fragmented and inconsistent, resulting in highly variable clinical practices. Growing evidence that poorly structured tapers—developed without clinical consensus or patient input—can cause significant harm, including symptom recurrence, severe withdrawal, and use of illicit or fentanyl-contaminated benzodiazepines, highlighted the need for a standardized, evidence-based framework.1
The systematic review conducted for the guideline identified 57 relevant articles; however, high-quality empirical evidence addressing many key clinical questions remains limited. As a result, many recommendations are grounded in expert consensus rather than randomized or comparative data. Despite this limitation, the approach aligns closely with international frameworks from Australia, Canada, and the United Kingdom (more on this below).
ALIGNMENT WITH OTHER SOCIETIES
A multisociety collaboration developed the guideline to ensure comprehensive scope and broad dissemination across disciplines. Recommendations align closely with international guidance on benzodiazepine tapering, particularly in emphasizing gradual, patient-centered, flexible discontinuation strategies, supported by behavioral interventions and shared decision-making.
The Royal Australian College of General Practitioners (RACGP) has published guidelines on prescribing and discontinuing drugs of dependence, including benzodiazepines, with the latest revision in November 2019.19 The RACGP guideline emphasizes a patient-centered approach, strong therapeutic alliance, conversion to a long-acting benzodiazepine when appropriate, and gradual, individualized tapering schedules.
Similarly, the National Institute for Health and Care Excellence (NICE), in collaboration with the Royal College of Physicians, released a guideline in April 2022 addressing prescribing and withdrawal management of opioids, benzodiazepines, gabapentinoids, Z-drugs, and antidepressants across primary and secondary care.20 The NICE recommendations stress carefully assessing ongoing need, shared decision-making, flexible tapering schedules tailored to individual responses, conversion to long-acting agents when appropriate, and slow, symptom-guided dose reductions to minimize withdrawal and relapse.
HOW WILL THIS CHANGE DAILY PRACTICE?
Practical implementation in primary care
The guideline shifts clinical practice from a “stop prescribing” mentality to a structured, patient-centered tapering approach. For primary care clinicians managing long-term benzodiazepine use—often inherited from previous clinicians or specialists—the guideline provides a clear, stepwise roadmap for safe management. Recommending quarterly risk-benefit assessments establishes a framework for ongoing evaluation. However, implementation in busy outpatient practices will require workflow adaptations, interdisciplinary coordination, and dedicated time.
Documentation and shared decision-making
The guideline’s emphasis on collaborative decision-making formalizes what should already be routine practice, and it validates slower, flexible tapering processes responsive to patient needs. Thorough shared decision-making documentation is essential for patient safety and medicolegal protection. Clinicians should record the risks and benefits discussed, patient preferences and concerns, agreed tapering plan, and rationale for the chosen approach.
Managing complex patients
Detailed guidance for special populations helps address common clinical dilemmas. For patients prescribed both opioids and benzodiazepines, the guideline provides clear directives for frequent monitoring, universal naloxone provision, and robust risk-mitigation strategies. These measures may necessitate closer care coordination, expanded patient education, and collaboration with behavioral health or addiction specialists.
A particularly important component of the guideline is its explicit recommendation against discontinuing opioid use disorder medications, such as methadone or buprenorphine, in patients concurrently receiving a benzodiazepine. This clarification addresses a previously widespread and harmful practice, underscoring that continuity of addiction treatment must remain a clinical priority.
WHEN THE GUIDELINE WOULD NOT APPLY
The guideline was designed for adults taking benzodiazepines regularly who may be physically dependent. Certain groups fall outside the intended scope, while others warrant individualized consideration.
Explicitly excluded populations
The guideline does not apply to the following groups:
Patients prescribed benzodiazepines but not taking them regularly
Patients prescribed benzodiazepines for short-term use (< 2 weeks)
Patients receiving palliative or end-of-life care
Children and adolescents (< 18 years of age)
Patients taking Z-drugs or barbiturates.
Populations requiring individual consideration
While not designated as a formal section in the guideline, certain populations are noted throughout as requiring individualized consideration and clinical judgment:
Patients with treatment-refractory anxiety disorders
Patients with cognitive impairment or limited decision-making capacity
Patients with limited access to behavioral or medical resources
Patients in acute crisis situations (eg, psychiatric emergencies)
Patients who decline tapering.
AN URGENTLY NEEDED FRAMEWORK
This joint national guideline provides US clinicians with an urgently needed, structured framework for safe, patient-centered benzodiazepine tapering. The guideline emphasizes gradual dose reductions after collaborative risk-benefit discussions between patient and clinician, psychosocial support, and ongoing monitoring, bridging the gap between indefinite continuation and forced discontinuation of benzodiazepines.
Implementation will require enhanced access to behavioral health services, workflow adjustments, increased resources and tools for clinicians such as the American Society of Addiction Medicine provides (elearning.asam.org/benzodiazepine-guidelines-education), and sufficient time for patient engagement. Despite these challenges, the guideline marks a major advance in patient safety and clinical consistency around benzodiazepine prescribing. They equip clinicians across all specialties to approach benzodiazepine use and tapering with greater safety, clarity, and compassion.
DISCLOSURES
Dr. Viguera has disclosed consulting for UpToDate. The other authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.
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- ABSTRACT
- WIDELY USED BUT RISKY
- WHO DOES THE GUIDELINE APPLY TO?
- WHO WROTE THE GUIDELINE?
- WHAT ARE THE MAIN RECOMMENDATIONS?
- WHAT IS DIFFERENT FROM PREVIOUS GUIDELINES?
- ALIGNMENT WITH OTHER SOCIETIES
- HOW WILL THIS CHANGE DAILY PRACTICE?
- WHEN THE GUIDELINE WOULD NOT APPLY
- AN URGENTLY NEEDED FRAMEWORK
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