Previous changes

April 2024 — minor update. A typographical error in the prescribing information section has been corrected.

February 2024 — minor update. Added information about prescribing diazepam to people who are breastfeeding with caution. 

April 2023 — reviewed. A literature search was conducted in April 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. There have been no changes to the recommendations.

April 2022 — minor update. Information added to incorporate recommendations from NICE [NG215] 2022 Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults. 

June 2020 — minor update. A typographical error was corrected.

January 2019 — minor update. The drug manufacturer advises that treatment should not exceed 4 weeks including the period of tapering off.

September 2018 — reviewed. A literature search was conducted in September 2018 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone restructuring. No major changes to the recommendations have been made.

April 2015 — minor update. Update to the text to reflect a new law on drugs and impaired driving Department for Transport, 2014.

July 2013 — reviewed. A literature search was conducted in May 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. No major changes to recommendations have been made.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

September 2011 — minor update. Updates the information on the frequency of prescribing of benzodiazepines and z-drugs, based on an MHRA update, and a publication commissioned by the Department of Health. Also a new Definition node has been added to background information. 

April 2009 — minor amendment to wording in the section on Driving. 

November 2008 to March 2009 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. There are no major changes to the recommendations.

January to March 2006 — reviewed. Validated in June 2006 and issued in July 2006. This guidance has been reviewed and updated following a full literature review. The scope of the guidance has changed. It now covers the assessment of a person who is being prescribed long-term benzodiazepines or z-drugs and offers advice on how to withdraw them from these treatments, and no longer covers withdrawal from illicit benzodiazepine use. Several new management sections have now been included, such as how to support the person during and after withdrawal, and how to manage someone who does not want to stop benzodiazepines or z-drugs. A more detailed evidence section to support the recommendations has been included. The guidance title has changed from Hypnotic or anxiolytic dependence to Benzodiazepine and z-drug withdrawal.

November 2005 — minor technical update. 

September 2002 — reviewed. Validated in December 2002 and issued in February 2003.

May 1999 — written. Validated in July 1999 and issued in August 1999.

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 April 2023.

HTAs (Health Technology Assessments)

No new HTAs since 1 April 2023.

Economic appraisals

No new economic appraisals relevant to England since 1 April 2023.

Systematic reviews and meta-analyses

No systematic reviews since 1 April 2023.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 April 2023.

New policies

No new national policies or guidelines since 1 April 2023.

New safety alerts

No new safety alerts since 1 April 2023.

Changes in product availability

No changes in product availability since 1 April 2023.

How do I assess someone on long-term benzodiazepines or z-drugs?

Discuss with the person the benefits and risks of continuing the current dose, adjusting the dose or stopping the medicine and enquire about their willingness to withdraw from the drug.

If the person is willing:

• Assess whether this is a suitable time to stop taking the drugs — the chances of success are improved when a person's physical and psychological health and personal circumstances are stable. In some circumstances, it may be more appropriate to wait until other problems are resolved or improved before starting drug withdrawal. 
  • Enquire about:
    • Symptoms of depression — withdrawing these drugs can worsen symptoms of clinical depression. The priority is to manage depression first, before attempting drug withdrawal. For more information, see the CKS topic on Depression.
    • Symptoms of anxiety — withdrawing treatment when significant symptoms of anxiety are present is likely to make symptoms worse and is therefore unlikely to succeed. The underlying problem should be addressed prior to starting reduction. For more information, see the CKS topic on Generalized anxiety disorder.
    • Symptoms of long-term insomnia — if insomnia is severe, consider addressing this with non-drug treatments prior to starting withdrawal of a benzodiazepine or z-drug. For more information, see the CKS topic on Insomnia.
    • Any medical problems and whether these are well controlled and stable — if problems are causing significant distress, consider managing these first, prior to starting withdrawal of benzodiazepines or z-drugs. 
• Consider whether the withdrawal of the benzodiazepine or z-drug can be appropriately managed in primary care.
  • People are considered suitable if they:
    • Are willing, committed, and compliant, and have adequate social support. 
    • Have no previous history of complicated drug withdrawal. 
    • Can be reviewed regularly. 
    • No longer have a benefit from the medicine. 
    • Have developed problems associated with dependence. 
    • Find that the condition for which the medicine was prescribed has resolved. 
    • Find that the harms of the medicine outweigh the benefits. 
• Consider seeking specialist advice, or referral to an appropriate specialist for people with:
  • • A history of alcohol or other drug use or dependence  — be aware that some people may use alcohol as a substitute for the drug being withdrawn. 
    • Concurrent, severe medical or psychiatric disorder or personality disorder. 
    • A history of drug withdrawal seizures — these generally occur in people who suddenly stop high doses of the drugs. Slow tapering is recommended for these individuals. 
    • Complex needs. 
    • Long-term therapeutic dependency who aren't able to manage withdrawal. 

If the person is unwilling to stop taking a benzodiazepine or z-drug: 

• Do not pressurize them to stop if they are not motivated to do so. 
• Listen to the person, and address any concerns they have about stopping.
  • Explain that for most people who withdraw from treatment slowly, symptoms are mild and can usually be effectively managed by other means.
  • Reassure the person that they will be in control of the drug withdrawal and that they can proceed at a rate that suits them.
• Reiterate the benefits of stopping the drug.
  • The discussion should include an explanation of tolerance, adverse effects, and the risks of continuing the drug.
• Review at a later date if appropriate, and reassess the person's motivation to stop.

In people who remain concerned about stopping treatment despite explanation and reassurance, persuading them to try a small reduction in dose may help them realize that their concerns are unfounded.

How do I manage someone who wants to stop benzodiazepines or z-drugs?

• For all people undergoing assisted withdrawal, provide appropriate information and advice. 
  
• The two potential approaches for withdrawal are slow dose reduction of the person's current benzodiazepine or z-drug, or switching to an approximately equivalent dose of diazepam, which is then tapered down. 
  • For information on specific withdrawal schedules, see the section on Withdrawing a benzodiazepine or z-drug.
• Switching to diazepam should be considered for people: 
  • Using short-acting potent benzodiazepines (alprazolam and lorazepam). 
  • Using preparations that do not easily allow for small reductions in dose (alprazolam, flurazepam, loprazolam, and lormetazepam).
  • Experiencing difficulty or who are likely to experience difficulty withdrawing directly from temazepam, nitrazepam, or z-drugs, due to a high degree of dependency (associated with long duration of treatment, high doses, and a history of anxiety problems). 
• Seek specialist advice (preferably from a hepatologist) before switching to diazepam in people with hepatic dysfunction as diazepam may accumulate to a toxic level in these individuals. An alternative benzodiazepine without active metabolites (such as oxazepam) may be preferred.
• Aim to reach agreement using a shared decision-making approach when deciding on a withdrawal schedule (dose tapering) of the person's existing drug or diazepam — allow enough time to explore the person's circumstances and preferences.
  • Be guided by the person in making adjustments, so that they remain comfortable with the withdrawal. 
• When planning withdrawal from a benzodiazepine, or z-drug take into account: 
  • The urgency of the withdrawal.
  • Whether the initial goal should be complete withdrawal or, for people who find complete withdrawal too difficult, whether dose reduction with ongoing review is a more realistic initial aim.
  • Which medicine to reduce first, if the person will be withdrawing from more than one medicine. 
  • Any concurrent medicines and how these might affect the person's response to withdrawal.
  • Factors that might influence the timing of the start of the dose reduction, such as the person's circumstances and available support.
• Offer the person reassurance that they will be in control of the drug withdrawal and can proceed at a rate that suits them. Drug withdrawal may take 3 months to a year, or longer if necessary. Some people may be able to withdraw in less time.
  • The rate of reduction should take into account the drug, dose and duration of treatment, as well as personal circumstances. 
  • Titrate the drug withdrawal according to the severity of withdrawal symptoms. If the person experiences difficulties with a dose reduction, encourage them to persevere and suggest delaying the next step down. Make future dose reductions in smaller steps if necessary.
    • If intolerable, increase the dose to the last dose at which symptoms were tolerable and remain there until symptoms resolve. 
  • Where available, and if considered necessary and appropriate, cognitive behavioural therapy (CBT) may be offered to help ameliorate withdrawal symptoms. 
  • Advise the person against taking extra tablets in times of stress and compensating for benzodiazepines or z-drugs by increasing the intake of alcohol or other drugs (prescription, non-prescription, or illicit drugs). 
• Do not stop a benzodiazepine or z-drug abruptly (complete cessation with immediate effect) unless there are exceptional medical circumstances, such as the occurrence of serious adverse effects — in these circumstances, consider:
  • Scheduling more frequent reviews.
  • Short-term use of medicines to treat the physical symptoms of withdrawal.
• During the withdrawal process, review the person frequently (with intervals determined by clinical judgement) to detect and manage problems, and to provide advice and encouragement. 
  • If anxiety is present:
    • Explain that it is the most common acute withdrawal symptom. 
    • Reassure the person that it is likely to be temporary. 
    • Consider slowing or suspending withdrawal until symptoms become manageable. 
    • Consider recommending non-drug treatments including relaxation techniques (such as progressive muscular relaxation and controlled breathing techniques), or CBT if symptoms are severe or protracted. For more information, see the CKS topic on Generalized anxiety disorder.
    • Adjunct drug therapy should not be routinely prescribed, but may be considered. 
    • Beta-blockers (for example, propranolol) for severe, physical symptoms of anxiety (such as palpitations, tremor, and sweating) only if other measures fail. 
    • Antidepressants: only if depression or panic disorder coexist or emerge during drug withdrawal.
    • Seek specialist advice if symptoms are severe and/or difficult to manage. 
  • If depression emerges or coexists with withdrawal symptoms:
    • Consider suspending drug withdrawal until the depression resolves.
    • For more information on management, see the CKS topic on Depression. 
  • If insomnia is present.
    • Provide information on good sleep hygiene and consider prescribing melatonin if appropriate. 
    • For more information on management, see the CKS topic on Insomnia.
• Be aware that stopping the last few milligrams is often seen as being particularly difficult: 
  • Reassure the person that this is usually an unfounded fear derived from long-term psychological dependence. 
  • Warn the person not to be tempted to prolong the drug withdrawal to an extremely slow rate towards the end (such as reducing by 0.25 mg diazepam each month). Advise the person to consider stopping completely when they reach an appropriate low dose (such as diazepam 1 mg daily). 
• If the person did not succeed on their first attempt, encourage them to try again. 
  • Remind the person that reducing benzodiazepine dosage, even if this falls short of complete drug withdrawal, may still be beneficial. 
  • If another attempt is considered, reassess the person, and treat any underlying problems (such as depression) before trying again. 

What information and advice should I give someone who wants to stop benzodiazepines or z-drugs?

• Before starting withdrawal: 
  • Give the person information about the process of withdrawal that is tailored to their situation and the medicine they are taking.
    • Signpost to resources such as patient information leaflets — for example from the Royal College of Psychiatrists for benzodiazepines, and MIND for z-drugs. 
  • Explain how the withdrawal will be carried out. 
  • Explain the benefits they can expect from reducing their medicine. 
  • Consider providing details of sources of peer support, national and local support groups for people who are withdrawing from a medicine. 
    • A list of can be found in the Ashton Manual.
• Discuss withdrawal symptoms with the person and tell them about the support that is available. When discussing withdrawal symptoms, explain that: 
  • Withdrawal can be difficult and may take several months or more.
  • Support will be available throughout the withdrawal process.
  • Withdrawal symptoms do not affect everyone, and it is not possible to predict who will be affected.
  • Withdrawal symptoms vary widely in type and severity, can affect both physical and mental health, may occur at any time during withdrawal or be delayed in onset and can change over time or persist over a prolonged period. For more information, see the section on Prognosis. 
  • There are options for managing withdrawal symptoms. 
  • Some people may experience withdrawal symptoms that can be difficult to distinguish from a re-emergence of their original symptoms or a new disorder, and it is important to discuss these with a healthcare professional if they occur.
• When agreeing a dose reduction schedule with the person:  
  • Explain the risk of abrupt discontinuation and that the rate of safe withdrawal varies between people and can vary over time for the same person.
  • Explain that although withdrawal symptoms are to be expected, the reduction schedule can be modified to allow intolerable withdrawal symptoms to improve before making the next reduction.
  • Ensure the person knows who to contact if problems occur.
• Remind the person of the DVLA regulations relating to benzodiazepine use and driving. The following advice should be given to people who take benzodiazepines:
  • It is illegal to drive after taking benzodiazepines (or any other drug, including Z-drugs) if it impairs your driving (for example, you feel drowsy, dizzy, unable to concentrate, or make decisions).
  • It is an offence to drive if you have more than a specified amount of benzodiazepine in your body, whether your driving is impaired or not.
    • Roadside saliva screening tests in the UK test for certain drugs that impair driving. If you have a positive roadside drug test for benzodiazepines, the police may ask you to provide a blood sample to measure the amount of benzodiazepine in your body. 
    • If you are found to have more than the specified amount of benzodiazepine in your body, as long as your driving is not impaired, and you are taking your medicine on the advice of a doctor or pharmacist, you will be able to raise a statutory 'medical defence' and the police may not prosecute you. 
    • It may be helpful to keep evidence that you are taking a benzodiazepine in accordance with medical advice with you while you are driving. Suitable evidence may include your medication box with the pharmacy label on, or the other half of your prescription with the list of medicines prescribed by your doctor.
• For more information, see Assessing fitness to drive: a guide for medical professionals available on the DVLA website.

Contraindications and cautions

• Do not prescribe diazepam to people with:
  • Acute porphyria. 
  • Myasthenia gravis — condition may be aggravated. 
  • Sleep apnoea syndrome — condition may be aggravated.  
  • Severe or acute pulmonary insufficiency. 
  • Respiratory depression, acute or chronic severe respiratory insufficiency. 
  • Severe hepatic insufficiency — elimination half-life may be prolonged. 
  • Depression, or anxiety with depression. 
  • Phobic or obsessional states, psychosis or schizophrenia, hyperkinesis — paradoxical reactions may occur. 
• Prescribe diazepam with caution to: 
  • People with a history of alcohol or drug dependence or abuse.
  • People with personality disorders.
  • The elderly, due to the increased risk of falls — the manufacturer advises reducing the initial dose.
  • People who are breastfeeding — the lowest effective doses should be used. Shorter acting agents, such as lorazepam and oxazepam, are preferred, where this is clinically appropriate.

[MHRA, 2022; BNF, 2023; SPS, 2024]

Adverse effects

• The most common adverse effects of diazepam relate to its sedative effect and include drowsiness and decreased concentration — people taking benzodiazepines who drive should be given the following advice:
  • It is illegal to drive after taking diazepam if it impairs your driving (for example, you feel drowsy, dizzy, unable to concentrate, or make decisions).
  • It is an offence to drive if you have more than a specified amount of benzodiazepine in your body, whether your driving is impaired or not.
    • Roadside saliva screening tests in the UK test for certain drugs that impair driving. If you have a positive roadside drug test for benzodiazepines, the police may ask you to provide a blood sample to measure the amount of benzodiazepine in your body.
    • If you are found to have more than the specified amount of benzodiazepine in your body, as long as your driving is not impaired, and you are taking your medicine on the advice of a doctor or pharmacist, you will be able to raise a statutory 'medical defence' and the police may not prosecute you.
    • It may be helpful to keep evidence that you are taking a benzodiazepine in accordance with medical advice with you while you are driving. Suitable evidence may include: your medication box with the pharmacy label on, or the other half of your prescription with the list of medicines prescribed by your doctor.
• Other adverse effects include: 
  • Headache, vertigo, tremor, slurred speech, decreased libido, erectile dysfunction, and gynaecomastia.
  • Paradoxical effects such as restlessness, agitation, irritability, aggression, delusion, inappropriate behaviour, and suicidal behaviour. 
  • Tolerance and dependence (these can develop over time).
  • Withdrawal syndrome.

[Department for Transport, 2014; Taylor, 2021; DVLA, 2022; MHRA, 2022; BNF, 2023; HM Government, 2023]

Drug interactions

• Drug interactions with diazepam include:
  • Alcohol — the depressant effects of diazepam are increased. The degree of sedation will depend on the individual. 
    • Warn all people of the potential effects and advise against driving or undertaking other skilled tasks. 
  • Opioids  — concurrent use of opioids and diazepam can cause enhanced sedation and respiratory depression, and can result in death. The degree of impairment will depend on the individual person.
    • Monitor for increased adverse effects such as sedation and respiratory depression and warn all people of the potential effects and counsel against driving or undertaking other skilled tasks. If concurrent use is unavoidable, use the minimum possible dose and duration required to achieve the desired clinical effect. 
  • Drugs that enhance the sedative effects — for example, neuroleptics, antipsychotics, anxiolytics/sedatives, tranquillisers, antidepressants, hypnotics, anticonvulsants, analgesics, narcotic analgesics, anaesthetics, barbiturates and sedative antihistamines. 
    • The degree of sedation will depend on the individual and the drug combination. However, all people should be warned of the potential effects and caution advised when driving or undertaking other skilled tasks. 
  • Drugs that inhibit cytochrome P450 enzyme (for example cimetidine, fluconazole) — exposure to diazepam is increased. Consider reducing the diazepam dose if necessary, advise people of the potential increased sedation and caution advised when driving or undertaking other skilled tasks. 
  • Drugs that induce cytochrome P450 enzyme (for example, St John's Wort, rifampicin, carbamazepine) — levels of diazepam may be reduced. Monitor for diazepam efficacy and increase dose if necessary.  
  • HIV protease inhibitors (ritonavir and indinavir) — concomitant use with diazepam is contraindicated. The interactions between HIV protease inhibitors and benzodiazepines are variable; however, the manufacturers of ritonavir and indinavir advise that concurrent use with diazepam is contraindicated. 
  • Modafinil — exposure to diazepam may be increased. Be alert for diazepam adverse effects and consider reducing the dose if necessary. 
  • Phenytoin — phenytoin concentrations may be increased and diazepam concentrations reduced. Monitor for diazepam efficacy and phenytoin toxicity. 

[MHRA, 2022; Preston, 2019]

Switching to diazepam

• Information on the approximate dose equivalents of diazepam for a number of benzodiazepines and z-drugs, as well as some examples of switching schedules are shown below and based on information in the Ashton Manual. Be aware that this information should only be used as a guide. Exact dose substitution is not possible, due to: 
  • Wide variation in the half-life and response to these drugs (such as the degree of sedation) between different individuals (for example, the elderly and people with hepatic impairment).
  • Differences in potency between different benzodiazepines and z-drugs.
  • Consequently, a complete dose substitution may not always be required, depending on the individual response (to avoid excessive sedation).
• Switching to diazepam is best carried out gradually, usually in a stepwise fashion. Diazepam is available in a variety of strengths (2 mg, 5 mg, and 10 mg) and formulations (scored tablets or liquid) to facilitate switching. Consider making the first switch in the night-time dose to avoid daytime sedation.
• Dose withdrawal may be started when conversion to diazepam is complete.
• Diazepam 5 mg is approximately equivalent to [Ashton, 2002c; BNF, 2023]:
  • Zolpidem 10 mg. 
  • Zopiclone 7.5 mg.
  • Temazepam 10 mg.
  • Oxazepam 10 mg. 
  • Nitrazepam 5 mg.
  • Lormetazepam 0.5 mg to 1.0 mg.
  • Lorazepam 0.5 mg.
  • Loprazolam 0.5 mg to 1.0 mg.
  • Clonazepam 0.25 mg.
  • Clobazam 10 mg.
  • Chlordiazepoxide 12.5 mg.
  • Alprazolam 0.25 mg. 
• Examples of switching schedules from the three commonest hypnotics to diazepam [Ashton, 2002c]:
  • From temazepam 10 mg to diazepam 5 mg: 
    • Week 1: substitute temazepam 10 mg for diazepam 5 mg.
  • From temazepam 20 mg to diazepam 10 mg: 
    • Week 1: substitute temazepam 20 mg for temazepam 10 mg plus diazepam 5 mg.
    • Week 2: substitute remaining temazepam 10 mg for diazepam 5 mg, giving a total diazepam dose of 10 mg daily.
  • From nitrazepam 5 mg to diazepam 5 mg: 
    • Week 1: substitute nitrazepam 5 mg for diazepam 5 mg.
  • From nitrazepam 10 mg to diazepam 10 mg: 
    • Week 1: substitute nitrazepam 10 mg for nitrazepam 5 mg plus diazepam 5 mg.
    • Week 2: substitute remaining nitrazepam 5 mg for diazepam 5 mg, giving a total diazepam dose of 10 mg daily.
  • From zopiclone 7.5 mg to diazepam 5 mg: 
    • Week 1: substitute zopiclone 7.5 mg for diazepam 5 mg.
  • From zopiclone 15 mg to diazepam 10 mg: 
    • Week 1: substitute zopiclone 15 mg for zopiclone 7.5 mg plus diazepam 5 mg.
    • Week 2: substitute remaining zopiclone 7.5 mg for diazepam 5 mg, giving a total diazepam dose of 10 mg daily.
• Example of a conversion of an anxiolytic (lorazepam 1 mg three times daily) to diazepam [Ashton, 2002c]: 
  • Starting dose:
    • Morning: lorazepam 1 mg.
    • Midday: lorazepam 1 mg.
    • Evening: lorazepam 1 mg.
  • Week 1:
    • Morning: lorazepam 1 mg.
    • Midday: lorazepam 1 mg.
    • Evening: lorazepam 0.5 mg plus diazepam 5 mg.
  • Week 2:
    • Morning: lorazepam 0.5 mg plus diazepam 5 mg.
    • Midday: lorazepam 1 mg.
    • Evening: lorazepam 0.5 mg plus diazepam 5 mg.
  • Week 3:
    • Morning: lorazepam 0.5 mg plus diazepam 5 mg.
    • Midday: lorazepam 0.5 mg plus diazepam 5 mg.
    • Evening: lorazepam 0.5 mg plus diazepam 5 mg.
  • Week 4:
    • Morning: lorazepam 0.5 mg plus diazepam 5 mg.
    • Midday: lorazepam 0.5 mg plus diazepam 5 mg.
    • Evening: diazepam 10 mg.
  • Week 5:
    • Morning: diazepam 10 mg.
    • Midday: lorazepam 0.5 mg plus diazepam 5 mg.
    • Evening: diazepam 10 mg.
  • Week 6:
    • Morning: diazepam 10 mg.
    • Midday: diazepam 10 mg.
    • Evening: diazepam 10 mg.
  • Week 7:
    • Start diazepam withdrawal.
• For information on switching for other benzodiazepines or z-drugs, see the Ashton Manual (available online at www.benzo.org.uk).