National Practice Guidelines for Safe Tapering of Benzodiazepines

Abstract Benzodiazepine medications are commonly prescribed to treat a wide range of conditions including anxiety and mood disorders, insomnia, and seizure disorders. These medications represent important therapeutic tools; however, they are associated with significant adverse events including potentially life- threatening withdrawal, substance use disorder, and overdose (particularly when combined with alcohol, opioids, or other central nervous system depressants). Over the past two decades, fatal overdoses involving benzodiazepines have increased more than 10-fold, often involving the combination of opioids and benzodiazepines.1 Benzodiazepine prescribing rates are highest2 for older adults, among whom these medications pose additional risk for falls, hip fractures, and cognitive impairment.3 While there is little research on the efficacy of benzodiazepine use for longer than three months and the risk for adverse events increases with duration of use, long-term use is common.3 Despite the prevalence of prescribing and the significance of the risks, there are currently no national clinical guidelines to inform clinicians in determining when and how to taper benzodiazepine medications. Safe tapering of benzodiazepines can be clinically complex since rapid dosage reductions may precipitate acute withdrawal, which can be life- threatening. Patients are also at risk for recurrence and exacerbation of the symptoms for which the benzodiazepine was prescribed (e.g., anxiety, seizures, insomnia). In addition, inadequate tapering strategies may push patients to the illicit drug market where counterfeit pills laced with fentanyl and other opioids are common, presenting a risk for overdose and overdose death.4 To support the FDA’s goal of “safely reducing inappropriate prescribing of medications with potential for misuse and dependence”, the American Society for Addiction Medicine (ASAM) will develop a clinical practice guideline (CPG) to guide clinicians in determining when and how to taper benzodiazepine medications. ASAM has significant expertise developing CPGs and established partnerships with other medical societies with expertise relevant to this topic including the American Psychiatric Association, the American Academy of Neurology, the American Society for Geriatrics, and the American College of Gynecology and Obstetrics, among others. ASAM will work with these partners to convene an expert panel with multidisciplinary medical expertise to develop a CPG using a modified GRADE methodology. A systematic review of the evidence related to benzodiazepine tapering will be conducted to inform the work of the expert panel. People with lived experience will be engaged throughout the process to ensure that the CPG addresses patient concerns and needs. Once the guideline is complete, ASAM will work with the FDA and our partners to widely disseminate the guidelines as well as training and clinical decision support tools to facilitate improvements in benzodiazepine prescribing practices.