The Joint Clinical Practice Guideline on Benzodiazepine (BZD) Tapering

Abstract

The Joint Clinical Practice Guideline on Benzodiazepine (BZD) Tapering represents a comprehensive, multi-society effort led by the American Society of Addiction Medicine (ASAM) in collaboration with major medical organizations including the AAFP, AAN, AAPA, AANP, AAPP, ACOG, AGS, and APA. Funded by the U.S. Food and Drug Administration, this guideline aims to provide evidence-informed and consensus-based recommendations for clinicians managing adult patients who are physically dependent on benzodiazepines and may benefit from dose reduction or discontinuation. It is not intended for palliative or end-of-life care settings.

Purpose and Scope

The guideline addresses when and how to taper benzodiazepines in adult patients taking these medications regularly. It offers guidance on assessing risk–benefit ratios, developing individualized tapering plans, and managing withdrawal or comorbid conditions during the tapering process. It also provides population-specific recommendations for patients co-prescribed opioids, those with substance use or psychiatric disorders, older adults, and pregnant or lactating patients.

Background

Benzodiazepines are approved for anxiety, insomnia, seizures, and related conditions but carry significant risks including falls, motor vehicle accidents, cognitive impairment, dependence, and overdose—especially when used with central nervous system depressants like alcohol or opioids. Long-term use is common, despite limited evidence of sustained benefit. The guideline emphasizes that physical dependence is expected with regular use and distinct from substance use disorder (SUD).

Methodology

The development process followed the GRADE framework for evidence evaluation and incorporated a systematic literature review, public comment, and multi-disciplinary consensus (modified Delphi method). Owing to limited high-quality research, most recommendations are based on clinical consensus, with only three supported by low-quality evidence from 10 studies.

Key Findings and Recommendations

• Risk–Benefit Assessment: Clinicians should reassess the ongoing need for benzodiazepines at least every three months, considering patient-specific risks such as age, comorbidities, and concurrent opioid use.
• Avoid Abrupt Discontinuation: Sudden cessation may lead to life-threatening withdrawal symptoms. Gradual tapering under medical supervision is strongly recommended.
• Tapering Strategy: Initial reductions of 5–10% every 2–4 weeks are advised, not exceeding 25% every two weeks. The pace should be individualized and adjusted based on patient tolerance.
• Adjunctive Interventions: Cognitive Behavioral Therapy (CBT) and CBT for Insomnia (CBT-I) are recommended as supportive treatments during tapering.
• Level of Care: Most tapers can occur in outpatient settings; inpatient or residential management is indicated for severe withdrawal, complex comorbidities, or high-risk cases.
• Special Populations:
  • Older adults (≥65 years): should generally taper unless benefits clearly outweigh risks.
  • Pregnant/lactating patients: require maternal–fetal risk assessment.
  • Co-prescribed opioids: Provide naloxone and monitor closely for respiratory depression.
  • SUD or psychiatric comorbidity: Treat underlying conditions concurrently and avoid disrupting SUD medications (e.g., methadone, buprenorphine).
• Duration and Flexibility: Complete tapering may take months to years. Clinicians are encouraged to proceed collaboratively, adjusting plans based on patient response and symptom recurrence.

Implementation and Guiding Principles

The guideline stresses patient-centered care, shared decision-making, and avoidance of misapplication. Lessons learned from the misinterpretation of the CDC’s 2016 opioid guidelines are highlighted—specifically the dangers of forced or rapid tapers. Clinicians are urged to maintain flexibility, provide education, and prevent stigmatization of physical dependence.

Conclusion

This joint guideline establishes the first unified national framework for safe benzodiazepine tapering. It emphasizes gradual, individualized approaches, collaborative care, and harm reduction as key strategies to minimize withdrawal risks and optimize long-term patient outcomes. Its adoption is intended to enhance clinical consistency, improve patient safety, and reduce morbidity and mortality associated with benzodiazepine misuse and withdrawal.