Guide to Tapering Opioids and Benzodiazepines


The benefits of long-term opioid therapy and the evidence to support its use in managing chronic non-cancer pain are limited.1 Benzodiazepines (BZDs), when combined with prescription opioids, significantly increase the risk of overdose, as BZDs can have a synergistic effect on respiratory depression.2 Due to substantial risk of fatal overdose, higher risk of suicide, higher health service utilization, and suboptimal treatment outcomes, it is important to assess the risks and benefits of co-prescribing opioids and BZDs.3 According to a 2017 retrospective analysis, eliminating concurrent opioid and BZD use may result in an estimated 15% reduction in risk for emergency room visits and inpatient admissions related to opioid overdose.2,3 Tapering one or both medications may be an effective strategy to decrease risk and improve patient outcomes.

Tapering Considerations

  • Collaborate with patients to determine the appropriateness of tapering off one or more medications, which agent to taper first, and taper rate.5
  • Address patient perceptions and educate on the risks, benefits, and side effects of tapering.5,6
  • Individualize taper plans based on patient goals and concerns.3,6
  • Taper one agent at a time to improve the safety and success of tapering.4,5
  • Consider individual patient factors, preferences, and risks when determining which agent to taper first.
  • Coordinate tapering decisions and plans with all prescribers involved in the patient’s care.5,6
  • Assess patients throughout the taper process, especially with each dose change.4

Opioid Taper Tips

Opioids may be tapered using a rapid or slow taper method.6 The taper rate may be determined by treatment history, degree of risk, and individual patient factors.6,7 Below are taper recommendations from the United States Department of Health and Human Services.

Rapid Taper6

  • Reduce dose by 10% or less each week.
  • Consider a rapid taper in patients on opioid therapy for weeks to months.

Slow Taper6

  • Reduce dose by 10% or less each month.
  • Consider a slow taper in patients on opioid therapy for more than a year. This may take several months to years to complete.

General Recommendations6

  • Increase intervals between dose reductions and/or pause the taper and restart when the patient is ready. This allows the patient time to adjust to the newly reduced dose and allows for the start of non-opioid pharmacologic and non-pharmacologic therapies.
  • Extend the dosing interval for motivated patients once the lowest effective dose is reached to slow the taper process further.
  • Utilize a taper strategy and timeframe that will minimize opioid withdrawal symptoms.
  • Provide additional reinforcement with psychosocial support and cognitive behavioral therapies throughout the taper process.

For additional information regarding opioid tapering strategies, clinical pearls, and opioid taper examples from the Veterans Affairs, please refer to the Drug Information Group FAQ about guidance on tapering long-term opioid analgesics.


Sample Opioid Slow Taper Schedule6

opioid_and_bzd_taper_img_1.png


Benzodiazepine Taper Tips

Benzodiazepines may be tapered using a rapid or slow taper method.7 Abrupt withdrawal is not recommended, as it may lead to life-threatening events. Specific taper strategies may vary, depending on treatment history, degree of risk, and individual patient factors. Below are taper recommendations from the Oregon Pain Guidance.

Rapid Taper7

  • Premedicate with an anti-epileptic medication (eg, valproate, carbamazepine) for 2 weeks prior to initiating a taper and continue for 4 weeks after completion of the BZD taper.
  • Discontinue the current BZD and switch to a long-acting BZD (eg, diazepam).
  • Rapid taper may take approximately 3 months.8

Slow Taper7

  • Switch from a short-acting BZD to a long-acting BZD (eg, diazepam).
  • Calculate the dose equivalence of the short-acting agent to the long-acting agent.
  • Consider an initial dose reduction of 25-50% of the calculated equivalent dose.
  • Continue dose reductions by 5-10% each week in divided doses, as tolerated.
  • Consider further slowing taper down to 5% or less each week after the patient has reached 25-50% of the starting dose.
  • Slow taper may take approximately 6 months.8

General Recommendations6

  • Recommend adjunctive psychosocial support and cognitive behavioral therapies while tapering to aid in long-term abstinence from BZD.
  • Use additional agents such as trazodone, antidepressants, anxiolytics (eg, buspirone, hydroxyzine), alpha agonists (eg, clonidine), or neuroleptics to help manage rebound anxiety and other withdrawal symptoms.
  • Conduct taper slowly to avoid serious or life-threatening withdrawal symptoms such as rebound anxiety, seizures, tremors, disorientation, death.3,7
  • Use liquid formulations towards the end of the taper for more precise dosing, if needed.
  • Consider inpatient treatment for taper in patients who are at a higher risk of life-threatening withdrawal symptoms such as those with a history of substance abuse, overdose, or seizure disorder.

Additional Resources for Tapering

Opioid Tapering Flow Sheet from Oregon Pain Guidance

Taper recommendations for opioids and BZDs

https://www.oregonpainguidance.org/app/content/uploads/2016/05/Opioid-and-Benzodiazepine-Tapering-flow-sheets.pdf

The National Center for Posttraumatic Stress Disorder

Prescriber considerations for BZD taper

https://www.va.gov/painmanagement/docs/OSI_6_Toolkit_Taper_Benzodiazepines_Clinicians.pdf

The Veterans Health Administration

BZD dose conversion chart and sample tapering schedule

https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Benzodiazepine_Provider_AD_%20Risk_Discussion_Guide.pdf


Summary

Several risks are associated with the concurrent use of benzodiazepines and opioids. Tapering one or both medications may be necessary to reduce these risks. Set specific goals and follow-up visits before implementing a taper plan. Support patients with pain by offering alternative therapies during an opioid taper (ie, non-pharmacologic and non-opioid medications) for effective pain management during and after the taper. During a BZD taper, consider optimization of first-line agents for any underlying disorder. Use supportive medications to alleviate withdrawal symptoms during the taper process. Effective and successful tapering can improve a patient’s quality of life and often requires collaboration between prescribers and patients.


  1. Lembke A, Humphreys K, Newmark J. Weighing the risks and benefits of chronic opioid therapy. Am Fam Physician. 2016;93(12):982-990. Accessed May 28, 2021. https://www.aafp.org/afp/2016/0615/p982.html
  2. Sun EC, Dixit A, Humphreys K, Darnall BD, Baker LC, Mackey S. Association between concurrent use of prescription opioid and benzodiazepines and overdose: retrospective analysis. BMJ 2017;356:j760 http://dx.doi.org/10.1136/bmj.j760
  3. Centers for Medicare & Medicaid Services. Reduce risk of opioid overdose deaths by avoiding and reducing co-prescribing benzodiazepines. Updated July 1, 2019. Accessed May 28, 2021. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19011.pdf
  4. Opioids & benzodiazepines just don’t mix. South Carolina Department of Health and Human Services. March 2018. Accessed May 13, 2021. https://schealthviz.sc.edu/Data/Sites/1/media/downloads/tipsc_resources/tipsc_mailer_v3_23%20final%204-13-18%20%28003%29.pdf
  5. BRAVO! A collaborative approach to opioid tapering. Oregon Pain Guidance. February 2022. Accessed March 23, 2022. https://www.oregonpainguidance.org/guideline/tapering/
  6. US Dept of Health and Human Services. HHS guide for clinicians on the appropriate dosage reduction or discontinuation of long-term opioid analgesics. US Dept of Health and Human Services; 2019. October 2019. Accessed May 13, 2021. https://www.hhs.gov/opioids/sites/default/files/2019-10/Dosage_Reduction_Discontinuation.pdf
  7. Opioid prescribing guidelines. Oregon Pain Guidance of Southern Oregon. August 2014. Accessed May 28, 2021. https://www.careoregon.org/docs/default-source/providers/manuals-and-formulary/opioid-prescribers-guidelines.pdf
  8. Benzodiazepine risks. Are you aware of the possible risks from taking benzodiazepines? U.S. Department of Veteran Affairs. October 2016. Accessed July 22, 2021. https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Academic_Detailing_Educational_Material_Catalog/24_Benzodiazepines_Provider_AD_Risk_Discussion_Guide_IB10_953.pdf


Prepared by:

Liana Osis, PharmD
Clinical Pharmacist, Academic Detailer
University of Illinois Chicago College of Pharmacy

Tara Gallagly, PharmD
Clinical Pharmacist, Academic Detailer
University of Illinois Chicago College of Pharmacy

Nerissa Caballes, PharmD, MS, CRC
Supervisor, Academic Detailer
University of Illinois Chicago College of Pharmacy

The information presented is current as of March 2022. This information is intended as an educational piece and should not be used as the sole source for clinical decision making.