McMaster University

Michael G. DeGroote
National Pain Centre

Scope of Search

Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

Appendix B-6: Benzodiazepine Tapering

  1. Benefits of Benzodiazepine Tapering
    • Lower the risk of future adverse drug-related risks such as falls.
    • Increased alertness and energy.
  2. Approach to Tapering
    • Taper slowly: slow tapers are more likely to be successful than fast tapers.
    • Use scheduled rather than p.r.n. doses.
    • Halt or reverse taper if severe anxiety or depression occurs.
    • Schedule follow-up visits q. 1–4 weeks depending on the patient’s response to taper.
    • At each visit, ask patient about the benefits of tapering (e.g., increased energy, increased alertness).
  3. Protocol for Outpatient Benzodiazepine Tapering
    1. Initiation
      • May taper with a longer-acting agent such as diazepam or clonazepam, or taper with the agent that the patient is taking. (Diazepam can cause prolonged sedation in the elderly and those with liver impairment.)
      • There is insufficient evidence to strongly support the use of one particular benzodiazepine for tapering.
      • Convert to equivalent dose in divided doses. (See Table B Appendix 6.1 Benzodiazepine Equivalent Table.)
      • Adjust initial dose according to symptoms (equivalence table is approximate).
    2. Decreasing the Dose
      • Taper by no more than 5 mg diazepam equivalent per week.
      • Adjust rate of taper according to symptoms.
      • Slow the pace of the taper once dose is below 20 mg of diazepam equivalent (e.g., 1–2 mg/week).
      • Instruct the pharmacist to dispense daily, twice weekly, or weekly depending on dose and patient reliability.
    3. Another Approach
      • Taper according to the proportional dose remaining: Taper by 10% of the dose every 1–2 weeks until the dose is at 20% of the original dose; then taper by 5% every 2–4 weeks.

    — Source: Adapted from Kahan 2002.

    Table B Appendix 6.1 Benzodiazepine Equivalent Table

    Benzodiazepine Equivalent to 5 mg diazepam (mg) *
    Alprazolam (Xanax®)** 0.5
    Bromazepam (Lectopam®) 3–6
    Chlordiazepoxide (Librium®) 10–25
    Clonazepam (Rivotril®) 0.5–1
    Clorazepate (Tranxene®) 7.5
    Flurazepam (Dalmane®) 15
    Lorazepam (Ativan®) 0.5–1
    Nitrazepam (Mogadon®) 5–10
    Oxazepam (Serax®) 15
    Temazepam (Restoril®) 10–15
    Triazolam (Halcion®)** 0.25

    * Equivalences are approximate. Careful monitoring is required to avoid oversedation, particularly in older adults and those with impaired hepatic metabolism.

    **Equivalency uncertain.

    — Source: Adapted from Kalvik 1995, Canadian Pharmacists Association 1999.