Management of Chronic Benzodiazepine Use

Essential Evaluations Before Each Renewal

• The American Academy of Family Physicians recommends verifying the absence of concomitant opioid prescriptions, as the combination increases the risk of respiratory depression and death 2, 3, 1
• The American Academy of Family Physicians suggests screening for other central nervous system depressants (muscle relaxants, hypnotics, sedating antihistamines) that potentiate central nervous system depression 2
• The American Medical Association advises evaluating severe respiratory failure, severe liver failure, or severe myasthenia gravis, as these conditions contraindicate continued use 1
• The American Academy of Family Physicians recommends identifying a history of withdrawal seizures, as these patients require specialized referral rather than routine renewal 1

Consultation of Controlled Substance Registries

• The Journal of the American Medical Association suggests consulting the Prescription Drug Monitoring Program (PDMP) before each prescription, ideally, or at a minimum every 3 months 3
• The Journal of the American Medical Association recommends calculating the total dose if multiple prescribers to identify dangerous combinations 3
• The Journal of the American Medical Association advises discussing any additional prescriptions discovered with the patient and addressing safety concerns 3

Systematic Clinical Evaluation

• The American Academy of Family Physicians recommends screening for signs of tolerance (need for dose increase, decreased efficacy) and dependence, as tolerance indicates the need for discontinuation rather than renewal 4, 5, 1
• The American Academy of Family Physicians suggests screening for cognitive impairment and depression that develop with chronic use 4, 5, 1
• The American Academy of Family Physicians advises evaluating concomitant substance use disorders (alcohol, illicit drugs) that significantly increase the risk of dependence 1

Laboratory Tests

• The Journal of the American Medical Association recommends performing annual urine drug screening to detect prescribed and non-prescribed substances 3

Situations Requiring Specialized Referral

• The American Academy of Family Physicians recommends referring patients with a history of withdrawal seizures, active substance use disorders, or unstable psychiatric comorbidities to specialized care rather than routine renewal 1, 6

Tapering Protocol When Renewals Must Cease

• The American Academy of Family Physicians suggests reducing the dose by 25% every 1-2 weeks for a standard taper 1
• The American Academy of Family Physicians recommends reducing the dose by 10% per month for use exceeding 1 year, rather than faster schedules 1
• The American Academy of Family Physicians advises prolonging the taper over several months for use exceeding 6 years 1

Surveillance During Tapering

• The American Academy of Family Physicians recommends monthly follow-up during tapering or continued use, with more frequent contact during difficult phases 1
• The American Academy of Family Physicians suggests monitoring for withdrawal symptoms: anxiety, tremors, insomnia, sweating, tachycardia, seizures, confusion 1

Alternative Therapies to Consider

• The American Academy of Sleep Medicine recommends cognitive-behavioral therapy for insomnia (CBT-I) as the first-line treatment and should be offered before or during tapering 7, 8
• The American Academy of Sleep Medicine suggests considering sedating antidepressants (trazodone, mirtazapine, doxepin) as second-line treatment, particularly with comorbid depression 9, 7

Common Pitfalls to Avoid

• The Journal of the American Medical Association advises against rejecting patients from practice based on PDMP information, as this could result in missed opportunities to provide potentially vital interventions 3
• The American Academy of Family Physicians recommends avoiding the use of benztropine or trihexyphénidyl to manage extrapyramidal side effects if antipsychotics are also prescribed 4, 5

Required Documentation

• The American Academy of Family Physicians recommends maintaining a record of doses, frequency of use, and perceived efficacy 1
• The Journal of the American Medical Association suggests documenting discussions about safety risks, particularly with multiple prescriptions or dangerous combinations 3
• The Journal of the American Medical Association advises recording the results of urine drug screening and PDMP data 3