NHS Fife Guidelines for Benzodiazepine Prescribing in Benzodiazepine Dependence
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 1 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013
Contents
Flowchart for Benzodiazepine Withdrawal ……………………………………………………………3 Establishing type of dependence...... 4 Assessment of Benzodiazepine Dependence...... 5 Management of dependence in therapeutic dose users...... 6 Management of dependence in prescribed high dose users...... 7 Management of dependence in illicit and recreational users...... 8 Psychological support...... 9 Pharmacological support...... 10
Appendices
Appendix 1 Example Patient Letter (regular user)...... 11 Appendix 2 Information leaflets and advice from the internet...... 13 Appendix 3 DRUG DIARY...... 14 Appendix 4 Benzodiazepine conversion table...... 15 Appendix 5 Withdrawal regimes for therapeutic dose users...... 16 Appendix 6 Withdrawal regimes for high dose users ...... 18 Appendix 7 Self-help guides for psychological support...... 20
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 2 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013
Flowchart for Benzodiazepine Withdrawal
Patient taking benzodiazepine
Assess. Establish dependence and pattern of usage
Prescribed therapeutic dose Prescribed high dose Recreational high dose and dependence dependence abuse
Monitor benzodiazepine use for Complete drug diary for at 2 3 months & complete at least least weeks two drug screens. Establish boundaries, set goals
Is patient topping up Is minimum intervention prescription with illicitly obtained appropriate? Patient ready to reduce usage? benzodiazepine?
Yes No No Yes Yes No
Advise self-reduction of illicitly Continue to support reduction obtained benzodiazepine to Letter and FAQs using motivational interviewing. prescribed or therapeutic level. Do not Brief intervention Consider referral to prescribe doses of diazepam to Self-help booklet DAPL/FIRST/Psychology compensate for illicitly obtained drugs
Agree gradual dose reduction converting to diazepam with twice daily Yes Patient reduced use to 30-40mg No dosing if appropriate. equivalent diazepam? Prescribe 2mg or 5mg diazepam only
Reduce daily dose by about 1/8th (range 1/10th to ¼) every 2 or 3 weeks
Withdrawal Symptoms? No Yes Maintain at present dose until symptoms improve-avoid increasing the dosage again
Continue reduction at agreed Address any underlying mental rate health problems offering psychological or pharmacological support
Renegotiate rate of reduction if required STOP COMPLETELY (Time needed can vary from 4 weeks to a year or more)
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 3 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013
Following the introduction of benzodiazepines in the 1960s as the treatment of choice for anxiety and insomniaFife Guidelines and their widespread for Benzodiazepine use from the Prescribing1970s onwards in it Benzodiazepinehas been recognised Dependence that long term use can result in physical and psychological dependence as well as tolerance to their use.
In addition to patients prescribed benzodiazepines the illicit use, particularly by opioid drug users is a major problem for users in and out of drug treatment. High doses of prescribed and illicit benzodiazepines are taken and users become extremely tolerant to the sedative effects.
Benzodiazepine withdrawal syndrome is characterised by insomnia, anxiety, loss of appetite and body- weight, tremor, perspiration, tinnitus, and perceptual disturbances. Abrupt withdrawal may produce confusion, toxic psychosis, convulsions, or a condition resembling delirium tremens. For this reason patients exhibiting dependence should undergo gradual withdrawal of the benzodiazepine.
Establishing type of dependence. Patients may exhibit dependency on a therapeutic dose or non-therapeutic dose – the latter group being subdivided into “prescribed high dose dependence” and “recreational high dose abuse and dependence” groups.
Therapeutic Dose Prescribed High Dose Illicit and Recreational Use Dependence Dependence (eg ≥30mg diazepam) Dependence
Characteristics of Therapeutic Dose Dependence – Patient may have:
• taken benzodiazepines in prescribed low doses for months or years. • gradually come to “need” benzodiazepines in order to carry out normal activities of daily living. • continued to take their medication even though original indication has disappeared. • experienced withdrawal symptoms when they try to reduce or stop the drugs. • contacted the prescriber frequently to request repeat prescriptions. • experienced anxiety if there is a delay to the next prescription. • increased the dosage since the original prescription
• experienced anxiety symptoms, panics, agoraphobia, insomnia, depression and increasing physical symptoms despite continuing to take benzodiazepines.
Characteristics of Prescribed High Dose Dependence – patient requiring ever larger doses may: • try to persuade doctor to escalate doses and/or number of tablets on the prescription. • present at hospital or register at further practices to obtain more tablets • combine benzodiazepine misuse with excessive alcohol consumption or other sedative drugs • be highly anxious, depressed or have personality disorder • tend not to use illicit drugs, but may obtain benzodiazepines from relatives or acquaintances.
Characteristics of Recreational High Dose Abuse & Dependence – • Often develops as polydrug abusers attempt to enhance the effect of opioids or to “come down” from stimulants. • A very high tolerance develops making it difficult to detect the actual scale of drug consumption. • Users may be taking well in excess of 100mg daily in a single dose to maximise the effect. • There may be a concurrent alcohol problem and the user may have been introduced to benzodiazepines during previous alcohol detoxification
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 4 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013
Assessment of Benzodiazepine Dependence
1. Establish PATTERN of benzodiazepine usage 2. Establish DEPENDENCE if 3 or more or the following are present in the
same 12-month period: Date of onset of usage ……………………………… 3 to 5 indicators – mild to moderate dependence
Benzodiazepines used ………………………………. 5 to 7 indicators – moderate to severe dependence
i) Tolerance – a need for increased amounts to achieve desired effect OR Average daily dose and dose intervals …………….. - diminished effect with continued use of same amount
Previous successful withdrawal from use? ………… ii) Withdrawal – previous attempts to cut down result in withdrawal symptoms OR
- substance is taken to prevent withdrawal symptoms If yes, longest period of abstinence? ……………… iii) Substance taken in larger amounts or over longer period than originally intended Any other drug or alcohol used?...... iv) Persistent desire or unsuccessful effort to cut down or control use
v) Great deal of time spent obtaining substance or recovering from its effects
vi) Important activities (social, work related or recreational) given up or reduced
vii) Continued use of drug despite clear evidence of harmful effects 4. Establish CATEGORY of dependence: DSM-IV Diagnostic Criteria for Substance Dependence Therapeutic Dose Dependence Started for a reason and continued 3. Additional considerations (to inform but not prevent detox):
High Dose Dependence Concomitant severe medical or psychiatric illness Started as a prescription and then escalated
No other drug or alcohol problems History of severe withdrawal (including PROVEN history of seizures)
Recreational High Dose Abuse & Dependence Completion of drug diary (for at least 2 weeks, up to 3 months may be appropriate) Used and abused by people who use drugs: illicit, POM or OTC and/or alcohol Confirmation of dependence by drug screening (urine but consider oral fluid)
See page 4 for more detail Level of motivation to change
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 5 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013
Management of dependence in therapeutic dose users
Management can include minimal interventions, gradual dose reduction and gradual dose reduction with additional psychological support.
Minimal interventions (1 and 2 below) are suitable in early/mild dependence.
1. Write to the patient: explain problems associated with long-term benzodiazepine use and the need to reduce their prescription encouraging a gradual reduction or cessation if possible. (appx 1)
2. Brief Intervention: Simple advice and provision of information leaflets and other materials. (appx 2)
3. Gradual Dose Reduction Gradual dose reduction is preferable to abrupt discontinuation of benzodiazepine. There are two methods of achieving a reduction
3A. Dosage reduction of currently 3B. Switching to a long-acting benzodiazepine. prescribed benzodiazepine Switching to diazepam to aid withdrawal may be Dose reduction schedules frequently last useful if: several weeks and may last for over a year. • reduction of short half-life benzodiazepines For a selection of different schedules refer to (loprazolam, lorazepam, lormetazepam, “Benzodiazepines: How They Work & How temazepam) causes problematic withdrawal to Withdraw”. Prof CH Ashton available at symptoms. www.benzo.org.uk • On potent benzodiazepines that do not easily allow for small reductions in dose (as above plus alprazolam)
• Long duration of treatment, high doses and Be Aware history of anxiety problems indicate likely
If withdrawal symptoms occur maintain difficulty in withdrawing.
present dose until symptoms improve – but Approximate equivalent doses are available in the avoid increasing the dosage again. BNF section 4.1 Hypnotics and Anxiolytics:
Consider adding psychological therapies. dependence and withdrawal. (appx 4)
Plan reduction schedule with patient but For switching and dose reduction schedules see review and be prepared to adjust appx 5. according to circumstances – the end goal, however, is completely stopping. Only prescribe 2mg or 5 mg diazepam tablets 10mg tablets have a higher street value and may be diverted.
4. Additional Psychological Support
See page 9 of guidelines
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 6 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013
Management of dependence in prescribed high dose users This group of patients will have increased their use of benzodiazepines to above a therapeutic dose, e.g. a dose equal to or greater than 30mg diazepam or equivalent. This dose may be entirely prescribed or their prescription topped up with illicitly obtained benzodiazepines or Z-drugs.
1. Assessment Undertake an assessment of dependence (see page 5 of guidance) including the completion of a drug diary by the patient for at least 2 weeks (appx 3).
Nb. Patients taking high doses of benzodiazepines in binges are not necessarily dependent.
2. Planning Education and motivational techniques are important to ensure patient is willing to embark on detoxification.
Set realistic goals – disagreement with the pace of reduction is likely to end in a poor outcome.
Allow for some periods of stabilisation of dose if withdrawal symptoms occur but avoid increasing the dosage again.
Patients topping up their prescription with illicitly obtained medication should reduce their daily dose until taking their prescribed medication only. They may choose to do this by gradual reduction (see schedules at appx 6). However, doses greater than 30mg diazepam are rarely necessary as this is sufficient to prevent benzodiazepine withdrawal symptoms (including withdrawal seizures) in very high-dose benzodiazepine users. It is not helpful to prescribe additional doses of diazepam to compensate for illicitly obtained drugs.
3. Convert to diazepam Benzodiazepines should be converted to diazepam using the approximate equivalent doses available in the BNF section 4.1 Hypnotics and Anxiolytics: dependence and withdrawal. (appx 4)
Substitute one dose of current benzodiazepine to diazepam at a time, usually starting with the evening or night-time dose. Replace the other doses, one by one, at intervals of a few days or a week until the total approximate equivalent dose is reached before starting the reduction.
Once on diazepam the long half-life should enable the patient to take a single dose at night or a twice daily dose at most.
Prescribe 5mg or 2 mg diazepam tablets only. 10mg tablets have a higher street value and may be diverted.
4. Dose Reduction The daily dose can be reduced in steps of about one-eighth (range one-tenth to one-quarter).
Initially the dose can be reduced every 2 to 3 weeks: if withdrawal symptoms occur maintain the current dose until symptoms improve – do not increase the dose again.
At a dose of 20mg diazepam the dose may need to be reduced in smaller steps over a longer period of time – it is better to reduce too slowly than too quickly.
The aim is to stop completely and the period needed will vary from individual to individual: anything from about 4 weeks to a year or more.
For a variety of schedules see appendices 5 & 6
5. Psychological and/or pharmacological support See page 9 & 10 of guidelines
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 7 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013
Management of dependence in illicit and recreational users
Be Aware Maintenance prescribing in illicit drug users cannot be recommended on the basis of existing evidence.
Doses greater than 30mg diazepam are rarely necessary as this is sufficient to prevent withdrawal seizures even in very high-dose benzodiazepine users .
Always prescribe 5mg or 2mg diazepam tablets as there is risk of diversion of 10mg diazepam tablets.
Dispensing should be daily (especially at start) and always in line with collection of any opiate substitute prescription. Consider supervision if diversion is suspected.
1. Before prescribing: Education and motivational techniques are important to ensure patient is willing to embark on detoxification.
Undertake extended assessment of use (up to 3 months), establish firm boundaries, set specific goals and consider written contract.
Patients on methadone or buprenorphine should keep their dose stable during detoxification.
Patients taking high doses of illicit benzodiazepines must evidence self-reduction to near therapeutic level (less than 50mg of street diazepam) by means of drug diary (appx 3). Self -reduction regimes available appendix 6.
At least two drug screens should be completed (consider oral fluid testing). • Any negative to benzodiazepine would indicate non dependence • Illicit opioids would indicate instability if on opioid substitute treatment
• Stimulant (and alcohol) use needs to be addressed before any detoxification
Liaise with other involved professionals to establish history of benzodiazepine prescribing, other prescribed medication, potential use of other illicit drugs and to inform them of proposed plan.
2. Convert to diazepam: Benzodiazepines should be converted to diazepam using the approximate equivalent doses available in the BNF section 4.1 Hypnotics and Anxiolytics: dependence and withdrawal. (appx 4)
Do not prescribe combination benzodiazepines e.g. nitrazepam and diazepam
Starting dose should not exceed 30mg to 40mg.
The patient should take a single daily dose (or a twice daily dose at most)
3. Reduction: Starting at 30-40mg the dose may be reduced by 5mg every one to two weeks until 20mg daily. At a dose of 20mg reduction may be slowed to 2mg every one to two weeks.
This rate of withdrawal is relatively rapid and should be tailored to suit the individual. In particular patients showing clear signs of withdrawal symptoms on assessment may benefit from slower
reduction rate.
Patients who fail to cope with reduction may have underlying mental health problems that need addressing. Reductions may be halted for 2 to 4 weeks, but the dose should not be increased.
For a variety of schedules see appendix 5
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 8 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013
Psychological support
4.1. PsychologicalWritten support and /or pharmacological support S ee page 6 of guidelines Patients may find the self help guides available at www.moodjuice.scot.nhs.uk and www.moodcafe.co.uk useful sources of support and advice about anxiety management, panic attacks, depression, sleep problems and relaxation training (appx 7). These may be printed from the internet in booklet form.
2. Internet support
There is a wealth of information and support available on the internet. Apart from two websites set up locally - www.moodjuice.scot.nhs.uk and/or www.moodcafe.co.uk there is also information at www.patient.co.uk/health/stopping-benzodiazepines-and-z-drugs
www.benzo.org.uk specialises in support and information on benzodiazepine withdrawal.
3. Counselling and relapse prevention
Fife wide voluntary organisations FIRST and DAPL offer one to one support. Patients may be referred or self-refer. Contact the organisations for further information.
Fife Intensive Rehabilitation Drug and Alcohol Project & Substance Misuse Team Limited 3 Fergus Place, 2 Parkdale, Park Drive Kirkcaldy, KY1 1YA Leven, KY8 5AO 01592 585960 01333 422277 www.firstforfife.co.uk www.dapl.net
FIRST provides a Fife-wide rehabilitation DAPL offers one to one counselling, service to individuals with Substance support, information and advice to Misuse problems via one to one sessions, individuals and families who are affected by group work and volunteer support. substance use and live within Fife.
4. NHS Fife Adult Mental Health Services
NHS Fife Adult Mental Health Services run a six session evening class entitled “Step Forward” dealing with different aspects of stress and the skills required to fight it. Participants will also be given handouts, diaries and a relaxation CD to enable them to continue to combat stress once the course is completed. Contact NHS Fife Psychology Service for more information on 01383 565402.
5. NHS Fife Psychology Services
Fife NHS Addictions Clinical Psychology Service offer training, consultancy and psychological supervision to staff (support workers, nursing staff, counsellors, therapists, rehabilitation workers etc)
delivering interventions for mild and moderate psychological problems. Phone 01383 565402 for information.
Patients with complex psychological problems may be referred to Fife NHS Addictions Clinical Psychology Service for direct therapeutic contact. Please note that the patient must fulfil the following criteria: • Current history of benzodiazepine use.
• Concurrent complex psychological problems caused by a pre-existing mental health problem not directly attributable to the benzodiazepine misuse and hampering the patient’s treatment progress. • Behavioural indicators demonstrating that the benzodiazepine use is stable. • Currently under medical supervision for their benzodiazepine use. Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 9 ApprovedContact by NHSthe FifeClinical ADTC Psychologyon behalf of NHS Addictions Fife Service for more information onDate 01383 June 2013 565402.
Pharmacological support
Evidence does not support the use of adjunct drug therapy to improve the benzodiazepine withdrawal rate or to reduce withdrawal symptoms.
However the BNF states:
“Beta-blockers should only be tried if other measures have failed; antidepressants should be used only where depression or panic disorder co-exist or emerge; avoid antipsychotics (which may aggravate withdrawal symptoms)”
If psychological measures are not effective enough:
• low dose of propranolol may control severe palpitations, muscle tremors or motor jerks. • low dose of sedative tricyclic antidepressant or sedative antihistamine may help severe insomnia In practice additional drugs are seldom needed with very slow benzodiazepine reduction. (Ashton)
For drug users using other sedative drugs (illicit or prescribed) and/or alcohol, sedative antidepressants and antihistamines should be used with caution as their use may contribute to a fatal overdose.
Treatment of emerging or co-existing depression. There is no comparative evidence to assist in the selection of an antidepressant for severe depression. Both tricyclics and SSRIs have been found to be effective for severe depression during benzodiazepine withdrawal. See Fife Joint Formulary: 4.3 Antidepressant Drugs.
Start with the lowest dose and increase slowly, maintaining the effective dose during the benzodiazepine withdrawal before starting to withdraw antidepressant.
All SSRIs and tricyclics prolong the QT interval by varying degrees and an ECG should be considered particularly for patients on a high dose of methadone.
References: 1. BAP Guidelines. Journal of Psycopharmacology 26(7) 899-952
2. Benzodiazepines: how they work and how to withdraw. Prof. C Heather Ashton. Available at www.benzo.org.uk
3. Guidance on prescribing Benzodiazepines to drug users in Primary Care. SMMGP. Available at www.smmgp.org.uk
4. BNF 4.1 Hypnotics and anxiolytics. Dependence and withdrawal. Available at http://www.medicinescomplete.com/mc/bnf/current/PHP2093-hypnotics-and-anxiolytics.htm
5. Fife Joint Formulary: Appendix 4B - Guidance for the use of Pharmacological Agents for the Treatment of Depression in Adults (18 years and over). Available at http://www.fifeadtc.scot.nhs.uk
6. Fife Joint Formulary: Section 4.3 Antidepressant Drugs
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 10 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013
Appendix 1 Example Patient Letter (regular user)
Practice address
Date as postmark
Dear Patient,
In the interests of patient care, the doctors in the practice are continually reviewing their prescribing in order to keep up with the latest developments. The practice is currently carrying out reviews of patients who receive medicines for insomnia and management of anxiety. We are writing to you because we notice from our records you have been taking……………………. for some time now.
There is concern about this type of medication when taken for a long time. • The body can become used to the tablets so that they no longer work properly. • Stopping the tablets suddenly can cause unpleasant withdrawal effects • They can become addictive • They may even cause anxiety and sleeplessness.
For these reasons repeated use of the tablets over a long period of time is no longer recommended. However you should not stop taking the tablets suddenly as you may experience some withdrawal effects.
We are writing to offer you the opportunity to try and cut down the dose of your tablets and perhaps stop them in the future. The best way to do this is to reduce the dose of the tablets very gradually, for example, every 2 -4 weeks to reduce the likelihood of having withdrawal symptoms. If you would be prepared to reduce the dose with a view to stopping your tablets in the future please phone / contact the practice and we will advise you of how best to reduce the dose of medication. Together we can work out a planned timetable for slowly stopping these tablets.
We attach a question and answer sheet answering some of the questions you may have and some information about how best to improve your sleep and help relaxation.
Yours sincerely
Practice/GP
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 11 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013
Reducing your Benzodiazepines & or Z Drugs in anxiety and insomnia
Q. What are benzodiazepines/Z Drugs?
A. These are drugs that can help with sleep problems, benzodiazepines are also used to reduce anxiety. Both types of drugs should only be used for very short periods in patients with severe symptoms.
Q. What are their effects?
A. Short-term: • Reduced alertness. • Drowsiness. This may affect your ability to drive or operate machinery. • Reduced tension and anxiety.
Long-term: • Dependence on the drug. • Reduced alertness may lead to accidents and falls. • Poorer memory. • Lack of emotion. • Tasks take longer to complete. • The short-term effects continue.
Q. What may happen when the drug is withdrawn too quickly?
• Your muscles may ache and strange sensations may be felt on the skin. • You may feel restless and anxious. • You may feel sick and weight loss may occur. • You may sweat more than normal. • You may have difficulty sleeping. • You may feel more frightened or panicky. At first you can have a reduced ability to cope with stress. • Eventually your anxiety will disappear and you will become more assertive.
Q. Why does this happen?
These drugs block some of your emotional responses in the brain. When you reduce the drug, your brain becomes over-stimulated; this can magnify your feelings and senses.
This is why your doctor will very slowly reduce your medication to ease the withdrawal process. Hopefully you won’t experience these side effects or they will be kept to a minimum.
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 12 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013
Appendix 2 Information leaflets and advice from the internet
The following list is comprised of a few of the very many resources available on the internet. For patients without access to the internet some of the information is available in pdf format for ease of printing.
www.patient.co.uk/health/stopping-benzodiazepines-and-z-drugs
4 page Information leaflet for download : www.patient.co.uk/pdf/4638.pdf
www.recovery-road.org
Information leaflets for download: http://recovery-road.org/wp-content/uploads/2010/06/Information-for-Family-Carers.pdf http://recovery-road.org/wp-content/uploads/2010/06/Caring-for-Benzo-Users1.pdf
www.benzo.org.uk
The Ashton Manual, “Benzodiazepines: how they work and how to withdraw” available at http://www.benzo.org.uk/manual/index.htm
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 13 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013
Appendix 3 DRUG DIARY
DRUG DIARIES ARE USEFUL FOR THE FOLLOWING REASONS:-
• IT GIVES A CLEAR PICTURE OF YOUR CURRENT BENZODIAZEPINE (AND OTHER DRUGS) USE
• IT GIVES YOU THE OPPORTUNITY TO LOOK MORE CLOSELY AT WHAT YOU ARE TAKING AND WHY
• THE MORE INFORMATION WE CAN GATHER, THE EASIER IT WILL BE TO PLAN “THE WAY FORWARD”
• THIS WILL ONLY TAKE ABOUT TEN MINUTES TO COMPLETE EACH DAY
NAME……………………….………….. STARTING DATE………..
What did I take and how Why did I take? How was I feeling at the Day Time much? time?
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 14 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013
Appendix 4 Benzodiazepine conversion table
This table is based on the equivalent doses published in the BNF Section 4.1 Hypnotics and Anxiolytics.
Equivalent doses do vary from source to source but, more importantly, can vary considerably between individuals.
BENZODIAZEPINE OR DOSE EQUIVALENT TO 5MG HALF-LIFE (hrs) Z- DRUG DIAZEPAM [active metabolite] Alprazolam (Xanax) 0.25mg 6 -12
Chlordiazepoxide (Librium) 15mg 5 - 30 [36 -200]
Diazepam (Valium) 5mg 21-50 [36 – 200]
Flunitrazepam (Rohypnol) 0.5mg 18 – 26 [36 – 200]
Flurazepam (Dalmane) 15mg [40 – 250]
Loprazolam (Dormanoct) 0.5 – 1mg [10 – 20]
Lorazepam (Ativan) 0.5 – 1mg 10 - 20
Lormetazepam (Noctamid) 0.5 – 1mg 10 - 12
Nitrazepam (Mogadon) 5mg 15 - 38
Oxazepam (Serax) 15mg 4 – 15
Temazepam (Normison) 10mg 8 - 22
Triazepam (Halcion) 0.25 2
Zaleplon (Sonata) 10 2
Zolpidem (Stilnoct) 10 2
Zopiclone (Zimovane) 7.5 5 - 6
In the list of drugs above the original brand names are stated in brackets even though many of the branded drugs are no longer available. Service users may refer to a drug by its original brand name.
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 15 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013
Appendix 5 Withdrawal regimes for therapeutic dose users
BNF 4.1 Hypnotics and anxiolytics – Dependence and Withdrawal: A benzodiazepine can be withdrawn in steps of about one-eighth (range one-tenth to one-quarter) of the daily dose every fortnight.
The following examples are variations from those available at www.benzo.org “Benzodiazepines: How they work and how to withdraw”, Chapter II: Slow withdrawal schedules. Professor C Heather Ashton.
Example 1 – Diazepam 10mg three times daily reducing by approx. one-tenth every 2 weeks
Morning Afternoon Night Total daily dose Starting dose 10mg 10mg 10mg 30mg Stage 1 10mg 8mg 10mg 28mg Stage 2 10mg 6mg 10mg 26mg Stage 3 10mg 4mg 10mg 24mg Stage 4 10mg 2mg 10mg 22mg Stage 5 10mg - 10mg 20mg Stage 6 8mg - 10mg 18mg Stage 7 8mg - 8mg 16mg Stage 8 6mg - 8mg 14mg Stage 9 5mg - 8mg 13mg Stage 10 4mg - 8mg 12mg Stage 11 3mg - 8mg 11mg Stage 12 2mg - 8mg 10mg Stage 13 1mg - 8mg 9mg Stage 14 - - 8mg 8mg Stage 15 - - 7mg 7mg Stage 16 - - 6mg 6mg Stage 17 - - 5mg 5mg Stage 18 - - 4mg 4mg Stage 19 - - 3mg 3mg Stage 20 - - 2mg 2mg Stage 21 - - 1mg 1mg
Example 2 – Diazepam 10mg three times daily reducing by approx. one-tenth every 2 weeks
Morning Afternoon Night Total daily dose
Starting dose 10mg 10mg 10mg 30mg Stage 1 10mg 8mg 10mg 28mg
Stage 2 8mg 8mg 10mg 26mg Stage 3 8mg 8mg 8mg 24mg
Stage 4 8mg 6mg 8mg 22mg Stage 5 6mg 6mg 8mg 20mg Stage 6 6mg 6mg 6mg 18mg
Stage 7 6mg 4mg 6mg 16mg Stage 8 4mg 4mg 6mg 14mg
Stage 9 4mg 4mg 4mg 12mg Stage 10 4mg 2mg 4mg 10mg
Stage 11 3mg 2mg 4mg 9mg Stage 12 3mg 2mg 3mg 8mg Stage 13 2mg 2mg 3mg 7mg Stage 14 2mg 2mg 2mg 6mg Stage 15 2mg 1mg 2mg 5mg StageAppendix 16 7 1mg 1mg Withdrawal regimes2mg for non therapeutic4mg dose users Stage 17 1mg 1mg 1mg 3mg
StageDr. A. Baldacchino, 18 Liz. Hutchings,1mg Addiction Services - Issued: April 20131mg Review Date: April2mg 2016 16 StageApproved 19 by NHS Fife ADTC -on behalf of NHS Fife - 1mg Date June 2013 1mg
Example 3 – Withdrawal from lorazepam 3mg daily with diazepam substitution Daily diazepam Morning Afternoon Night equivalent Starting dose lorazepam 1mg lorazepam 1mg lorazepam 1mg 30mg
lorazepam 0.5mg Stage 1 lorazepam 1mg lorazepam 1mg 30mg diazepam 5mg lorazepam 0.5mg lorazepam 0.5mg Stage 2 lorazepam 1mg 30mg diazepam 5mg diazepam 5mg lorazepam 0.5mg lorazepam 0.5mg lorazepam 0.5mg Stage 3 30mg diazepam 5mg diazepam 5mg diazepam 5mg lorazepam 0.5mg lorazepam 0.5mg Stop lorazepam Stage 4 30mg diazepam 5mg diazepam 5mg diazepam 10mg Stop lorazepam lorazepam 0.5mg Stage 5 diazepam 10mg 30mg diazepam 10mg diazepam 5mg Stop lorazepam Stage 6 diazepam 10mg diazepam 10mg 30mg diazepam 10mg
Continue reducing diazepam using example 1 or 2 above
Example 4 - Withdrawal from zopiclone 15mg with diazepam substitution
Night time Daily diazepam equivalent
Starting dosage zopiclone 15mg 10mg
Stage 1 (1 week) zopliclone 7.5mg 10mg diazepam 5mg Stage 2 (1 week) Stop zopiclone 10mg diazepam 10mg Stage 3 (1-2 weeks) diazepam 9mg 9mg
Stage 4 (1-2 weeks) diazepam 8mg 8mg
Continue reducing by 1mg every 1 – 2 weeks as in example 1 above
Some notes for patients:
• The first stages of a reduction schedule may be manageable with one week between reductions but the later stages are better taken over at least 2 weeks.
• A mixture of 5mg and 2mg tablets will be required. For reductions of 1mg the scored 2mg tablet may be halved.
• This is intended to be a slow process. Do not try to speed it up in any way.
• If you are struggling, take an extra week to complete a stage rather than going backwards by increasing a dose.
• Tell a friend or a partner what you are aiming for so they can encourage and support you.
• Consult your GP regularly. Especially if experiencing any fainting, fits, depression or panic attacks.
• Access self-help information and booklets at www.moodjuice.scot.nhs.uk & www.moodcafe.co.uk
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 17 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013
Appendix 6 Withdrawal regimes for high dose users
Example 1 – recommended reducing regime from 80mg to 30mg
DIAZEPAM REDUCING REGIME: STARTING AT 80MG DAILY
SOME GROUND RULES: • The following reducing plan is to help you reduce your own benzodiazepine use
• It is unlikely that these doses will be prescribed for you
• It is intended to be a slow process. Do not try to speed it up in any way
• If you are struggling, take an extra week to complete a stage rather than going backwards by increasing the dose.
• Tell a friend or partner what you are aiming for so that they can encourage and support you
• Access self-help information and booklets at www.moodjuice.scot.nhs.uk & www.moodcafe.co.uk
Morning Midday Afternoon Night Total for the day Starting dose 20mg 20mg 20mg 20mg 80mg Stage 2 weeks 20mg 20mg 15mg 20mg 75mg 1 2 2 weeks 20mg 15mg 15mg 20mg 70mg 3 2 weeks 15mg 15mg 15mg 20mg 65mg 4 2 weeks 15mg 15mg 10mg 20mg 60mg 5 2 weeks 15mg 10mg 10mg 20mg 55mg 6 2 weeks 10mg 10mg 10mg 20mg 50mg 7 2 weeks 10mg 10mg 5mg 20mg 45mg 8 2 weeks 10mg 10mg stop 20mg 40mg 9 2 weeks 10mg 10mg - 15mg 35mg 10 2 weeks 10mg 5mg - 15mg 30mg 11 2 weeks 10mg stop - 15mg 25mg 12 2 weeks 10mg - - 10mg 20mg
Total = at least WELL DONE. NOW FOLLOW SLOWER REDUCTION SCHEDULE FROM 20mg 24 weeks BY HALVING 5mg TABLETS OR QUARTERING 10mg TABLETS
13 2-4 weeks 7.5mg - - 10mg 17.5mg 14 2-4 weeks 7.5mg - - 7.5mg 15mg 15 2-4 weeks 5mg - - 7.5mg 12.5mg 16 2-4 weeks 2.5mg - - 7.5mg 10mg 17 2-4 weeks Stop - - 7.5mg 7.5mg 18 2-4 weeks - - - 5mg 5mg 19 2-4 weeks - - - 2.5mg 2.5mg 20 2-4 weeks - - - STOP -
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 18 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013
Example 2 – recommended reducing regime from 200mg to 80mg
DIAZEPAM REDUCING REGIME: STARTING AT 200MG DAILY
SOME GROUND RULES: • The following reducing plan is to help you reduce your own benzodiazepine use
• It is unlikely that these doses will be prescribed for you
• It is intended to be a slow process. Do not try to speed it up in any way
• If you are struggling take an extra week to complete a stage rather than going backwards by increasing the dose.
• Tell a friend or partner what you are aiming for so that they can encourage and support you
• Access self-help information and booklets at www.moodjuice.scot.nhs.uk & www.moodcafe.co.uk
Morning Midday Afternoon Night Total for the day Starting dose 50mg 50mg 50mg 50mg 200mg Stage 2 weeks 50mg 40mg 40mg 50mg 180mg 1 2 2 weeks 40mg 40mg 30mg 50mg 160mg
3 2 weeks 40mg 30mg 30mg 40mg 140mg
4 2 weeks 30mg 30mg 20mg 40mg 120mg
5 2 weeks 30mg 20mg 20mg 40mg 110mg
6 2 weeks 30mg 20mg 20mg 30mg 100mg
7 2 weeks 20mg 20mg 20mg 30mg 90mg
8 2 weeks 20mg 20mg 20mg 20mg 80mg
Total = at least WELL DONE. NOW FOLLOW SLOWER REDUCTION SCHEDULE FROM 80mg 16 weeks
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 19 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013
Appendix 7 Self-help guides for psychological support
SUBJECT WEB ADDRESS
http://www.moodcafe.co.uk/article/uploaded/UnderstandingAnxietyportrait_2.pdf
http://www.moodcafe.co.uk/article/uploaded/dealingwithworry_1.pdf ANXIETY http://www.moodjuice.scot.nhs.uk/anxiety.asp
http://www.moodjuice.scot.nhs.uk/stress.asp
http://www.moodcafe.co.uk/article/uploaded/Panic-Aselfhelpguide.pdf
PANIC http://www.moodcafe.co.uk/article/uploaded/GeneralisedAnxietyandPanicAttacks.pdf
http://www.moodjuice.scot.nhs.uk/panic.asp
http://www.moodcafe.co.uk/article/uploaded/Copingwithdepression-NHSFife.pdf
http://www.moodjuice.scot.nhs.uk/Depression.asp DEPRESSION
http://www.moodcafe.co.uk/article/uploaded/TipsforBetterSleep_2.pdf SLEEP PROBLEMS http://www.moodjuice.scot.nhs.uk/sleepproblems.asp
http://www.moodcafe.co.uk/article/uploaded/guidetorelaxation_1.pdf
RELAXATION http://www.moodjuice.scot.nhs.uk/mildmoderate/Relaxation.asp
http://www.moodjuice.scot.nhs.uk/relaxationsearch.asp
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 20 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013