Implementing Benzodiazepine Deprescribing in the Primary Care Clinic

Clinical importance:

Benzodiazepines are associated with adverse events including injuries, cognitive changes, overdose, and death particularly when combined with other sedating medications or substances.¹ While deprescribing benzodiazepines using gradual tapers is safe and feasible in primary care,^2–4 challenges arise from clinician discomfort, time constraints, and potential disagreement between clinicians and patients about risks and benefits of deprescribing.⁵ Although recommended for short-term use (≤4 weeks), most patients prescribed benzodiazepines beyond this period develop physical dependence, complicating deprescribing.¹ In 2025, the American Society of Addiction Medicine (ASAM) published FDA-supported tapering guidelines,⁶ developed with patient input and based primarily on expert consensus given limited high-quality evidence. This Clinical Insight aims to contextualize these deprescribing guidelines for the primary care physician, with particular attention to high-risk populations.

Approach:

Deprescribing should be individualized and guided by shared decision-making with three goals: address the underlying condition, minimize withdrawal symptoms, and reduce the risk of adverse events. While complete discontinuation following taper is ideal in preventing adverse events from occurring, dose reductions and even continued monitoring may be safe, realistic alternatives for some patient populations. Avoid deprescribing against patient objections unless there is an immediate patient or public safety risk (e.g., benzodiazepine-related overdose, acute somnolence, delirium, or signs of drug diversion such as early refills and multiple providers). We outline a five-step approach to enhance discussions of primary care clinicians with their patients prescribed benzodiazepines for >4 weeks.

Step 1: Preparation for successful deprescribing.

Deprescribing requires patient empowerment, trust in the clinical team, and time, sometimes months to years. Sharing patient education materials (e.g., EMPOWER trial, deprescribing.org) before or after visits can be a starting point to introduce the concept, provide self-directed education, and prime the patient for deeper deprescribing conversations at the next visit.^2,7 If available, engage clinical pharmacists to assist with tapering, nurses for follow-up monitoring, and behavioral health clinicians for psychotherapy to collectively support patient deprescribing (Figure).

Figure.

Approach to benzodiazepine evaluation and deprescribing.

Abbreviations: BZs: benzodiazepines; CBT-I: cognitive behavioral therapy for insomnia.

a. Severe complicated withdrawal events such as seizures, delirium, and suicidality.

Step 2: Evaluate indication, treatment goals, and risks.

Review the original indication of benzodiazepines, current symptom severity, and other treatments being used concurrently or previously tried. Defer deprescribing for compelling indications such as seizures, treatment-resistant mood disorder, psychosis-related complications, spasticity, and catatonia. Clarify usage history, treatment goals, perceived benefits (which often diminish over time), and benzodiazepine-related side effects. Evaluate risks for adverse events, physical dependence, and withdrawal risk associated with potential deprescribing.

Prioritize high-risk populations with greater short- and long-term risk for serious benzodiazepine-related adverse events:

• Older adults (aged 65 and older) or those with frailty are high risk for falls and cognitive changes, and delirium during tapering. Consider including family and caregivers to support deprescribing.

• Patients with advanced chronic disease (e.g., congestive heart failure, chronic respiratory failure, end stage renal disease, cirrhosis) prescribed benzodiazepines are high risk for hospitalization, respiratory depression, and death.

• Concurrent sedating medications—especially opioids—increase the risk of falls, overdose, and death. For patients with concomitant opioid analgesics, engage patients in prioritizing which medication to deprescribe first. Consider deprescribing other sedating agents (e.g., gabapentinoids) if possible.

• Patients with risky substance use and especially substance use disorders (SUDs) are at high risk for injuries, respiratory depression, and severe complicated withdrawal (e.g., seizures, autonomic instability) with abrupt discontinuation. Patients with opioid use disorder (OUD) should be engaged with medications for OUD (MOUD) with optimized dosing before deprescribing. Benzodiazepines increase overdose risk yet may improve MOUD retention,⁸ requiring individualized risk-benefit consideration of prescribing versus deprescribing. Refer patients with stimulant, alcohol, or benzodiazepine use disorders to SUD treatment. Consider inpatient withdrawal management for patients with complicated alcohol or benzodiazepine withdrawal histories. Prescribe naloxone for patients at risk of opioid overdose.

Step 3: Recommend deprescribing and suggest an alternative treatment plan.

When recommending deprescribing, use patient-centered approaches.^5,9 These include clearly communicating risks of ongoing benefits of discontinuation, providing educational materials (See Step 1), setting goals that address patient concerns (e.g., insomnia, anxiety), and offering alternatives for managing the underlying condition and potential withdrawal symptoms (Figure).

Some patients may resist deprescribing. Explore and validate concerns and reassure patients that tapering is flexible and symptom-guided. Although some patients may tolerate shorter 8–10 week tapers,⁴ others may require slower tapers (months-years) to minimize withdrawal symptoms. Adjunctive psychotherapy (e.g., cognitive behavioral therapy) may improve tapering success.⁶ For patients with co-occurring psychiatric conditions, consider delaying tapering until psychiatric treatment is optimized. Although likely confounded by inclusion of non-voluntary tapering, one observational study suggested higher mortality after benzodiazepine discontinuation,¹⁰ underscoring the need to optimize psychiatric and SUD care to minimize unintended harms.

Some patients may need multiple discussions before considering a taper. Follow-up should be tailored to patient risk and benzodiazepine duration. Reevaluate high-risk populations or recent initiators more frequently (e.g., 1–3 months) to minimize adverse events and physical dependence, respectively. Reassess lower-risk patients at least yearly.

Step 4: Initiate a benzodiazepine taper.

Tapering should be attempted for most patients prescribed benzodiazepines for more than 4 weeks due to the risk of physical dependence.¹ ASAM guidelines recommend initially reducing by 5–10% (no more than 25%) in the first two weeks to avoid withdrawal. Liquid formulations (e.g., alprazolam, lorazepam, and diazepam) may provide dosage flexibility. Some clinicians transition patients to diazepam for its long half-life and multiple dose options; evidence of benefit is limited and caution is advised given non-equivalent dosing and variable effects. While deprescribing trials utilize structured tapers, ASAM guidelines support flexible tapering approaches (example tapers in Figure).

Step 5: Monitor progress and potential adverse withdrawal events.

Reassess patients within 1–2 weeks of dose reductions to identify emerging withdrawal symptoms. Consider incorporating nurses and clinical pharmacists for symptom evaluation and dose adjustments, respectively. Counsel patients that mild, time-limited withdrawal or rebound symptoms (e.g., anxiety, insomnia, irritability) are common, while severe adverse events (e.g., seizures, delirium, suicidality) are rare. In two deprescribing trials of 870 participants, only one experienced significant harm possibly associated with deprescribing, while up to 45% experienced rebound symptoms.^3,4 Patients should notify the clinic if symptoms persist beyond 2 weeks, in which case tapering may be delayed. For some, holding at a lower dose with repeat risk-benefit discussions may be an appropriate short-term goal.

Conclusions:

Benzodiazepines are often prescribed beyond their duration of potential benefit and carry significant risks. New ASAM guidelines suggest benzodiazepine tapers are safe and feasible in primary care settings. Clinicians should use structured approaches, regularly reassess risk and benefits, and engage patients in shared decision-making.