Benzodiacepine Tapering Plan

I have been taking benzodiazepines on a daily basis for many years. I want to get off alprazolam tapering down. I take 5-6 2 mg pills every day for years and don’t know how to do it. I am afraid of withdrawal.

Originally posted in Evolution Marketplace 4/5/14 . Reviewed 24/3/23

To safely stop using BDZs, it’s important to keep track of how much you’re taking each day. This includes the number of hours you’re taking them and the amount of doses you’re taking in a typical day. Then, you can calculate the daily equivalent dose of diazepam (a long-acting BDZ). Diazepam can be administered two or three times a day. This is a good option for a gradual tapering plan.

These are the equivalences for common prescription BDZ:

  • Diazepam 10 mg
    Clonazepam 0.5 mg
    Alprazolam 1 mg
    Lorazepam 1 mg
    Lormetazepam 1-2 mg
    Midazolam 5 mg
    Bromazepam 6 mg
    Clorazepate 15

So, for example, someone using 6 mg of alprazolam daily would need 60 mg of diazepam, that can be divided in three 20-20-20 dosages

Tapering means taking progressively lower doses of the medication over time. And once you reach low doses (around 5-10 mg of diazepam), you can safely stop taking the medication altogether. This process is more comfortable with a reduction of 5 mg/week

Additionally, diazepam comes in many different dosages and formats: There are tablets of 2 mg, 2.5 mg, 5 mg, 10 mg, 25 mg and syrup with 2.5 mg/ml). So this makes it easier to adjust the dose precisely for each patient.

Most clinical guidelines recommend using diazepam for tapering, but direct reduction of the BDZ being used by the patient is also possible. Probably, in practise it is more difficult to taper down alprazolam or short action BDZ as triazolam.

So, with these guidelines it is possible to diminish abstinence symptoms (anxiety, insomnia, nightmares, tremor, physical symptoms…). But, many times, instead of «abstinence» there is a «rebound». Rebound phenomenon  refers to the return of symptoms that were originally being treated by the drug after the drug is discontinued or reduced.

In cases in which sleep disturbance is a significant problem, the drugs with which there is most experience are SSRIs with a sedative profile (paroxetine, mirtazapine) and trazodone. Long-term treatment of anxiety disorders achieve better results using SSRI than BDZ.

There are another options to achieve BDZ detoxification but are less safer. Carbamazepine (200 mg twice a day), may be useful in patients with a history of seizures (drug withdrawal or epilepsy). Short regimen of 7-14 days can be considered reasonably safe for outpatient administration. Medical advice is particularly suggested in this case.

Other alternatives with a lesser degree of evidence are anxiolytic agents that act on GABA receptors such as pregabalin and gabapentin. The progressive decrease in BZD doses together with gabapentin has shown better results in opioid-dependent patients. in opiate-dependent patients seeking detoxification from BZDs.