Publications

Reminder: Potential for abuse, dependence and withdrawal with benzodiazepines

Published 2 June 2022
Prescriber Update 43(2): 25–26
June 2022

Key messages

Benzodiazepines have the potential to be misused – even when taken at the recommended dosages. Counsel patients about these risks when initiating treatment with benzodiazepines.
Regularly review the ongoing need for treatment.
Following continuous or high-dose use, benzodiazepines must be gradually tapered to reduce the risk of withdrawal reactions.

The New Zealand benzodiazepine data sheets were recently updated with additional information about the potential for abuse, dependence and withdrawal. This article is a reminder of these risks.

Benzodiazepines have the potential to be misused

Benzodiazepine use can lead to misuse, abuse, and dependence, even when taken at recommended dosage.¹ Dependence can occur with continuous use over several days to weeks, even when taken as prescribed.¹ Abuse and misuse can result in overdose or death, especially when benzodiazepines are combined with opioids, alcohol or illicit drugs.¹ Counsel patients about these risks when initiating treatment with benzodiazepines.^2,3

Before prescribing and throughout treatment, assess each patient’s risk for abuse, misuse, and addiction.² Use caution when prescribing benzodiazepines to patients with a history of alcohol or drug abuse, those known to be addiction prone or with a history that suggests they may increase the dosage on their own initiative.²

When prescribing a benzodiazepine for anxiety or insomnia, ensure the patient understands that these medicines are intended for short-term use (2-4 weeks).³ Non-pharmacological approaches are generally preferred for first-line treatment. Long-term use of benzodiazepines for these indications is not recommended.⁴

New Zealand dispensing data shows that diazepam and lorazepam are the most dispensed benzodiazepines. The total amount of dispensing of these medicines for all indications has increased over the period of available dispensing data (2016–2020),⁵ which may suggest frequent and/or long-term use.³

Regularly review the ongoing need for treatment

Ongoing use of benzodiazepines may lead to dependence.² The risk of dependence increases with dose and duration of treatment and in patients with a history of alcohol or drug abuse or a marked personality disorder.²

Regularly review the ongoing need for treatment, particularly if the patient is at high risk of dependence.²

Slowly discontinue treatment to prevent withdrawal reactions

Abrupt discontinuation or rapid dosage reduction of benzodiazepines after continued use may lead to withdrawal reactions.²

The likelihood and degree of severity of withdrawal depends on the duration of treatment, dose and degree of dependency.² Sudden cessation of benzodiazepines that have been used continually and/or at high doses is associated with serious withdrawal reactions, such as convulsions, delirium or psychosis.⁴ Inform patients of these risks and advise them to consult their doctor before decreasing the dose or abruptly stopping the medicine.²

Discontinuing a benzodiazepine following continuous use must be gradual. Advise patients that stopping treatment requires an individualised tapering schedule that is supervised by their doctor.^2,4

New Zealand case reports

Between August 1969 and March 2022, the Centre for Adverse Reactions Monitoring received 23 case reports for benzodiazepines where the reported reactions included withdrawal and/or dependence. Clonazepam (9 cases) was the most frequently reported benzodiazepine, followed by lorazepam (5), diazepam (3) and triazolam (3).

More information

See the following Bpac^nz articles:

Benzodiazepines and zopiclone: is overuse still an issue? - February 2021
Withdrawing patients from long-term use of benzodiazepines or zopiclone – February 2021

References

U.S Food and Drug Administration (FDA). 2020. FDA requiring Boxed Warning to improve safe use of benzodiazepine drug class 10 February 2020. URL: fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class (accessed 7 April 2022).
Pharmacy Retailing (NZ) Limited/Healthcare Logistics. 2022. Ativan New Zealand Data Sheet 14 March 2022. URL: medsafe.govt.nz/profs/Datasheet/a/Ativantab.pdf (accessed 20 April 2022).
bpac^nz. 2021. Benzodiazepines and zopiclone: is overuse still an issue? 5 February 2021. URL: bpac.org.nz/2021/benzo-zopiclone.aspx (accessed 20 April 2022).
New Zealand Formulary (NZF). 2022. NZF v119: Hypnotics and anxiolytics 1 May 2022. URL: nzf.org.nz/nzf_1991 (accessed 2 May 2022).
Ministry of Health. 2022. Pharmaceutical Data web tool verson 13 January 2022 (data extracted from Pharmaceutical Collection on 26 November 2021). URL: minhealthnz.shinyapps.io/pharmaceutical-data web-tool/ (accesed 11 April 2022).