Management of unplanned withdrawal from benzodiazepines, zolpidem and zopiclone

Limited evidence guides the management of patients with unplanned withdrawal from benzodiazepines, zolpidem or zopiclone; advice in these guidelines is based on the consensus view of the Addiction Guideline group.

Patients who develop unplanned withdrawal from benzodiazepines, zolpidem or zopiclone while in hospital for other reasons should have their use quantified if possible; determine their oral daily diazepam equivalent as described in Screening and assessment of disorders of benzodiazepine, zolpidem and zopiclone use.

To treat inpatients with unplanned benzodiazepine, zolpidem or zopiclone withdrawal:

• confirm the calculated oral daily diazepam equivalent with community prescribers, pharmacists and real-time prescription monitoring
• if a patient has higher-dose dependence (an oral daily diazepam equivalent more than 15 mg), consider dose stabilisation on diazepam
• consider the need to reduce the oral daily diazepam equivalent based on the clinical scenario (eg frailty, liver failure, hypercapnic [type 2] respiratory failure, impaired cognitive function)
• consider whether long-term use can be modified after acute management.

These considerations can guide the management plan while in hospital. For indications to seek specialist advice, see Features requiring specialist advice in weaning benzodiazepines, zolpidem or zopiclone.

Regular clinical assessment of withdrawal, intoxication, substance use and general health is required. The Clinical Institute Withdrawal Assessment Scale-Benzodiazepines (available at the Insight website) can be used in conjunction with clinical reviews to monitor the progress of withdrawal and the response to treatment.

If stabilisation is undertaken using a calculated oral daily diazepam equivalent (and there are no indications for specialist advice), divide the calculated diazepam dose into 4 daily doses. Supplemental as-required (prn) diazepam may be required to titrate the dose to control withdrawal symptoms, but care must be taken to avoid sedation. The total daily dose of diazepam (regular plus as-required doses) should not exceed 60 mg without specialist advice.

If the oral daily diazepam equivalent cannot be clarified after consultation with community prescribers, pharmacists and real-time prescription monitoring (and there are no indications for specialist advice), to manage unplanned withdrawal from benzodiazepines, zolpidem or zopiclone, use:

The cumulative diazepam dose given in the first 24 hours of titration can be continued on subsequent days of stabilisation, given in divided daily doses. Seek specialist advice if the diazepam dosing requirement in the first 24 hours exceeds 60 mg.

For all patients who have undergone 1 to 2 days of stabilisation, consider whether the diazepam dose can be reduced, depending on the clinical scenario and treatment goals.