• Consider:
  • Sedative/ethanol withdrawal.
  • Sympathomimetic intoxication.
  • Psychiatric illness.
  • Metabolic (hyperthyroid) causes.
  • Serotonin syndrome.
• High risk of seizures.

CONSIDER CALLING BC Drug and Poison Information Centre (BC DPIC)

24-Hour Line: 1-800-567-8911 or 604-682-5050

(Telephone interpreting in over 150 languages available).

• Continuous use for more than 3 to 4 months is generally required before a patient is at risk for withdrawal.
• Benzodiazepine withdrawal can be life-threatening.

• Benzodiazepine withdrawal patterns can vary widely but can be divided into physical, psychological, and sensory symptoms which can range from mild to severe.
• Physical
  • Tachycardia
  • Hypertensive
  • Sweating
  • Nausea, vomiting
  • Muscle spasms
  • Tremor
  • Seizures → can occur if agent is discontinued abruptly
• Psychological
  • Anxiety, agitation
  • Insomnia
  • Depersonalization, derealization
  • Visual hallucinations, Paranoia, Psychosis / Delirium
• Sensory
  • Photophobia is characteristic
  • Hyperacusis is characteristic
  • Dysesthesia is characteristic (“Pins and needles”)
  • Influenza-like symptoms (e.g., sweating and shivering)
• With abrupt discontinuation, the most severe withdrawal symptoms occur within days.
  • The symptoms generally subside in 2–4 weeks but can be prolonged.
  • Symptoms generally develop gradually and then slowly decline.
• Withdrawal symptoms develop faster with shorter-acting agents (5-10 days) than with longer-acting agents (23 days).
  • Withdrawal symptoms from short-acting benzodiazepines usually more severe.
• Benzodiazepine assays are of limited utility in the emergency but if done by immunoassay urine drug tests (UDT).
  • Detect diazepam, oxazepam, and temazepam, but not alprazolam, lorazepam, or clonazepam.
  • Most designer benzodiazepines (e.g., bromazolam, flubromazepam, clonazolam, etc.) are not detected by immunoassay UDTs, including common adulterants.

• If benzodiazepine discontinuation is desired it needs to occur over several weeks.
• Restart benzodiazepines in the acute setting then taper to avoid withdrawal: can use CIWA or scheduled taper.
• If refractory, phenobarbital or propofol can be used to treat withdrawal symptoms acutely.
• Limited studies.
  • No medication superior:
    • Carbamazepine (200 mg 3x a day for 7-10 days).
    • Gabapentin, no clear benefit.
    • Propranolol- no clear benefit.
    • Trazodone (25 to 150 mg per day) – studies are mixed.
    • Mirtazapine (7.5 to 30 mg per day.
  • Anxiety symptoms
    • Antidepressants that act primarily through SSRI mechanism.
    • Clonidine – no clear benefit.
• In patients with a coexisting psychiatric disorder, address both the underlying psychiatric condition and the benzodiazepine use.

Consider:

• History of inability to complete outpatient taper.
• Taking high doses.
• Risk of seizures.
• Other substance use disorders.
• Other comorbid psychiatric disorders.
• Unstable social living situation.

• Addiction Medicine consult.
• History of inability to complete outpatient taper.
• Taking high doses.
• Risk of seizures.
• Other substance use disorders.
• Other comorbid psychiatric disorder.
• Unstable social history.

If no admission criteria fulfilled, then discharge is appropriate with referral to Addiction Medicine with assurance of start on outpatient taper.

1. Soyka M. Treatment of benzodiazepine dependence. N Engl J Med. 2017 Mar 23;376(12):1147-1157. DOI: 10.1056/NEJMra1611832.

   
   

2. Peng L, Morford KL, Levander XA. Benzodiazepines and related sedatives. Med Clin North Am. 2022 Jan 1;106(1):113-129.

   
   

3. Ebdrup BH, Rasmussen JØ, Lindschou J, Gluud C, Glenthøj BY; Cochrane Drugs and Alcohol Group. Pharmacological interventions for benzodiazepine discontinuation in chronic benzodiazepine users. Cochrane Database Syst Rev. 2018 Mar 15;2018(3)

   
   

4. Lader M. Benzodiazepine harm: how can it be reduced? Br J Clin Pharmacol. 2014 Feb;77(2):295-301.