Friday, January 29, 2016

Management of Benzodiazepine Misuse and Dependence

There are well-recognised harms from long-term use of benzodiazepines. These include dependency, cognitive decline and falls. It is important to prevent and recognise benzodiazepine dependence. A thorough risk assessment guides optimal management and the necessity for referral. 

The management of dependence involves either gradual benzodiazepine withdrawal or maintenance treatment. Prescribing interventions, substitution, psychotherapies and pharmacotherapies can all contribute. Unless the patient is elderly, it is helpful to switch to a long-acting benzodiazepine in both withdrawal and maintenance therapy. 

The dose should be gradually reduced over weeks to lower the risk of seizures. Harms from drugs such as zopiclone and zolpidem are less well characterised. Dependence is managed in the same manner as benzodiazepine dependence.

Benzodiazepine and z-drugs half-life and conversion table
DrugApproximate half-life (hours)Dose of oral benzodiazepine approximately equivalent to diazepam 5 mg
Short- to intermediate-acting benzodiazepines
Triazolam1–30.25 mg
Oxazepam4–1515 mg
Temazepam5–1510 mg
Lorazepam12–161 mg
Bromazepam203 mg
Alprazolam6–250.5 mg
Flunitrazepam20–300.5 mg
Nitrazepam16–485 mg
Clobazam17–4910 mg
Long-acting benzodiazepines (includes effects of active metabolites)
Clonazepam22–540.5 mg
Diazepam20–805 mg
Zolpidem2.410 mg
Zopiclone5.27.5 mg

Benzodiazepine withdrawal syndrome – clinical features




Tremor, fasciculations
Muscle pain, stiffness and aches (limbs, back, neck, jaw)


Dizziness, light-headedness
Paraesthesia, shooting pains in neck and spine
Visual disturbances (blurred vision, diplopia, photophobia, vision lags behind eye movements)
Faintness and dizziness, sense of unsteadiness
Confusion, disorientation (may be intermittent) – a common cause of confusion in older patients
Delirium (in the absence of autonomic hyperactivity) – particularly in older patients
Delusions, paranoia
Hallucinations (visual, auditory)
Grand mal seizures 1–12 days after discontinuing benzodiazepines


Diarrhoea (may resemble irritable bowel syndrome)


Rebound insomnia, nightmares
Anxiety, panic attacks
Irritability, restlessness, agitation
Poor memory and concentration
Perceptual distortions – sensory hypersensitivity (light, sound, touch, taste), abnormal sensations (e.g. ‘cotton wool’ sensations)
Metallic taste
Distortions of body image
Feelings of unreality, depersonalisation, derealisation
Depression, dysphoria

Full article at:

By:  Brett J1Murnion B2.
  • 1Clinical Pharmacology and Addiction Medicine, Drug Health Services, Royal Prince Alfred Hospital.
  • 2Clinical Pharmacology and Addiction Medicine, Drug Health Services, Royal Prince Alfred Hospital ; Concord Repatriation General Hospital, Sydney. 
  •  2015 Oct;38(5):152-5. Epub 2015 Oct 1.

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