Benzodiazepine Tapering: New Guideline and Clinical Strategies

In this episode of ASAM Practice Pearls, Dr. Peter Selby and Dr. Emily Brunner explore The Joint Clinical Practice Guideline on Benzodiazepine Tapering: Considerations When Benzodiazepine Risks Outweigh Benefits. They discuss key recommendations and best practices for tapering benzodiazepines safely and effectively. Additional topics include the risks and benefits of tapering, common withdrawal symptoms, strategies to support patients while minimizing new dependencies, and navigating patient resistance and fear.

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Host

Peter Selby, MBBS, CCFP(AM), FCFP, FASAM 

Dr. Peter Selby is a Senior Scientist and Senior Medical Consultant at the Centre for Addiction and Mental Health (CAMH) and Vice-Chair, Research, and Giblon Professor in Family Medicine at the University of Toronto. His research focuses on innovative methods to understand and treat addictive behaviors and their comorbidities. He utilizes technology to scale and test health interventions, with his cohort of over 400,000 treated smokers in Ontario serving as an example. Dr. Selby has received over $100 million in grant funding from CIHR, NIH, and the Ministry of Health and has published more than 200 peer-reviewed articles. His most recent research program utilizes a Learning Health Systems approach to investigate how technology-equitable, collaborative care can enhance the delivery of evidence-based interventions to the patient while providing a more satisfying care experience for patients and providers across systems.

Expert

Emily Brunner, MD, DFASAM 

Dr. Emily Brunner is board-certified in family medicine and a distinguished fellow in addiction medicine. She has experience treating addiction in both inpatient and outpatient settings. She specializes in trauma-informed clinical treatment of substance use disorders with a comprehensive and compassionate approach. Dr. Brunner has been involved in leadership of the Minnesota Society of Addiction Medicine and is now on the national board of the American Society of Addiction. She is a passionate advocate for improving the care of patients with substance use disorder across the healthcare system, specifically in advocating for increased utilization of medications for opioid use disorder across all levels of care. Minnesota Magazine recognized her as a Top Doctor for Addiction Medicine in 2020 and 2021. She is the medical director of Gateway Recovery and Recovering Hope and does training on behalf of the Hazelden Betty Ford Foundation. 

📖 Show Segments

• 00:05 - Introduction 
• 00:37 - History and Concerns of Benzodiazepine Use
• 01:59 - Clinical Scenario
• 03:46 - The Joint Clinical Practice Guideline on Benzodiazepine Tapering
• 08:15 - Considerations of Risks and Benefits
• 10:46 - Tapering in Different Settings
• 12:06 - Monitoring and Managing Symptoms: Underlying Issues vs Withdrawal
• 15:08 - Synthetic and Illicit Use
• 17:43 - Managing Side Effects
• 20:42 - Addressing Patient Fears
• 22:53 - Differential Diagnosis
• 24:51 - Final Thoughts and Key Takeaways
• 27:17 - Conclusion and Additional Learning Opportunities

📋 Key Takeaways

• Guideline Implementation with Clinical Judgment: Implement best practices outlined in The Joint Clinical Practice Guideline on Benzodiazepine Tapering but recognize that it is not a one-size-fits-all instruction manual for conducting tapers. 
• Physical Dependence vs Addiction: Most patients on long-term benzodiazepines have physical dependence, not addiction. Clinicians should understand the differences to ensure appropriate treatment. 
• Slow and Flexible Tapering: The tapering process should be slow, and adjustments should be made based on a patient's response to the taper. Temporary dose increases may sometimes be necessary. 
• Individualized, Patient-Centered Care: Engage patients in treatment decisions, prioritize their comfort and safety, and individualize tapering plans based on medical history, unique needs, and responses to treatment for a more patient-centered treatment approach. 
• Compassionate Approach: Treat patients with empathy, acknowledge their experiences, and avoid punitive measures. When your patients tell you something or share their experiences, believe them. 
• Use of Urine Toxicology: Exercise caution when using urine toxicology tests. While they can be a supportive screening tool, many benzodiazepines may not appear, and false negatives are common. These tests should never be used punitively but rather as part of a patient-centered, supportive approach. 
• Multidisciplinary Support: Utilize a team-based approach with frequent follow-ups, including possible nurse visits, to monitor and support patients through the tapering process. 
• Risk-Benefit Considerations: Benzodiazepines should never be abruptly discontinued. Clinicians must assess the risks and benefits with each patient before making changes. 
• Awareness of Withdrawal Risks: Understand the potential dangers of withdrawal, including seizures and increased potential for mortality, and adjust tapering accordingly. 

🔗 Resources

• Benzodiazepine Tapering Webinar Series: A four-part series designed to provide clinicians with the knowledge and tools necessary to implement evidence-based benzodiazepine tapering strategies across diverse patient populations and practice settings. Register HERE  
• The Joint Clinical Practice Guideline on Benzodiazepine Tapering: Considerations When Benzodiazepine Risks Outweigh Benefits and other resources such as quick-reference tables, charts, and handouts: Access HERE  
• Provider Pocket Guide: A free, quick-reference digital tool to provide healthcare providers with access to current guidelines in a clear, concise format. Access HERE 
• How to Help Your Patients Taper from Benzodiazepines: A concise six-page guide that provides evidence-based strategies for safely tapering patients from benzodiazepines. Download HERE  
• Dr. Heather Ashton’s Benzodiazepine Guide (Ashton Manual): Download HERE  
• Benzodiazepine Discontinuation and Mortality Among Patients Receiving Long-Term Benzodiazepine Therapy: Maust DT, Petzold K, Strominger J, Kim HM, Bohnert ASB. JAMA Netw Open. 2023;6(12):e2348557  
• Outpatient Treatment of Chronic Designer Benzodiazepine Use: A Case Report: Hauck, Rochon, Bahra, Selby. J Addict Med. 2022;16(2):e137-e139. 
• Appropriate Use of Drug Testing in Clinical Addiction Medicine Consensus Document: Intended to guide provider decisions about drug testing to improve the quality of care for patients with addiction. Access HERE 

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