Goodbye Benzos, My Old Friend: Benzodiazepine Tapering Done Right

A benzodiazepine taper can feel like trying to land a plane in bad weather: the stakes are high, the instruments are imperfect, and speed is rarely your friend. We sit down with Dr. Rizzo to translate the ASAM benzodiazepine tapering guideline into real-world addiction medicine decisions, including what to do when a patient shows up on a very high dose of clonazepam and a sudden 50% cut has already happened.

We dig into the practical details clinicians and patients search for: how fast to reduce dose, why “5% to 10% every 2–4 weeks” is often a safer starting point, and when switching to a longer-acting benzodiazepine like diazepam helps or hurts. We also separate physical dependence from benzodiazepine use disorder so withdrawal is treated with seriousness rather than stigma, and we talk candidly about the access-to-care problem when long-term benzo patients can no longer find a prescriber.

We also cover special risks and settings: why older adults (65+) often need extra-slow tapers, why pregnancy requires careful coordination to avoid abrupt cessation, and when polysubstance use with opioids or alcohol should push care toward inpatient or residential support. Dr. Rizzo shares why phenobarbital can be useful in controlled detox settings, plus what actually improves success long term: CBT, treating underlying anxiety and insomnia with non-addictive medications, and building a plan patients can stick with.

If this helps, subscribe, share it with a colleague or family member, and leave a review so more people can find evidence-based guidance on benzodiazepine tapering and withdrawal.

ASAM Benzo Tapering Guideline: https://link.springer.com/article/10.1007/s11606-025-09499-2

To contact Dr. Grover: ammadeeasy@fastmail.com

Transcript

Why Benzodiazepine Tapering Matters

SPEAKER_01 0:08

Hi, I'm Dr. Casey Grove. I spent years practicing emergency medicine before shifting my focus to addiction medicine. This podcast grew out of caring for patients, hearing their stories, and wanting to do better. Here we talk about recovery, medicine, and compassion. This is Addiction Medicine Made Easy. Today's episode is on tapering off of benzodiazepines. This is a follow-up episode to the episode on benzodiazepine-induced neurological dysfunction that I did at the beginning of April with Dr. Rizzo. And just to remind you, Dr. Rizzo is an addiction medicine and emergency medicine doctor on the East Coast. And this is now his third episode with us on this podcast. Apparently, he's been listening to my podcast for quite a while because he referenced one of the very first episodes on my podcast, which is entitled How to Handle Benzodiazepine Dependence. If you would like to listen to poor quality audio and me as a clueless podcaster, you can go back and listen to that episode. The content is actually pretty good. Anyways, Dr. Rizzo and I tackle, as promised, how to taper off of benzodiazepines. And for this episode, we review the ASAM guidelines on benzodiazepine tapering. And if you're wondering, what are the ASAM guidelines, well, ASAM is the American Society of Addiction Medicine, and they review the existing research on benzodiazepines and work with multiple physicians from different specialties and different groups to summarize the best evidence that we have on how to taper off of benzodiazepines. And I will put a link to that article in the show notes. Now, a few clarifications before we start regarding some terms used in the podcast. First, what is PRN? Now you probably know this, but in the medical setting, PRN means as needed. Now, Dr. Rizzo also mentions CWA A and CWA B, CIWA-A and CIWA-B. These are scoring tools to assess withdrawal. CWA refers to the Clinical Institute Withdrawal Assessment for Alcohol. We use it all the time at hospitals to assess the severity of alcohol withdrawal. CWA B is an assessment tool for benzodazipine withdrawal that is only used in research settings. Now, Dr. Rizzo also mentions the medication phenobarbital, also known as phenobarb, for the treatment of benzodiazepine dependents. And I've heard another one of my colleagues speak about this, so I'm hoping there will be more research on this in the future. Now I also wanted to add a little commentary about the last take-home point that Dr. Rizzo brings up, which is that non-addictive medications can be added to the taper. This is so important. Benzodazipines are prescribed for all sorts of reasons: insomnia, anxiety, PTSD, and more. We need to prescribe non-addictive medications to address those symptoms and underlying conditions. Remember, benzos don't actually fix anything. They're a downer and just suppress uncomfortable symptoms. So when we taper off of them, those symptoms come roaring back. And non-addictive medications like trazodone for sleep, propranolol, gebapentin, clonidine, or selective serotonin reuptake inhibitors for anxiety can be so helpful. There are other options as well, which we get into a little bit during the podcast. And with that, let's get going on this podcast episode with Dr. Rizzo on how to taper patients off of benzodiazepines. All right. Everyone listening knows this is going to be a good episode because Dr. Rizzo is here to share his wisdom. Dr. Rizzo, how are you today?

SPEAKER_00 4:03

I'm great, Casey. Thanks for bringing me back. This, I think, is our third episode together, which is amazing. It went from a random late-night email discussing my frustrations in the world of addiction medicine to being able to be on your podcast a couple times to hopefully educate a lot of medical providers, patients, and their families about the complexity of addiction. And so I'm happy to be back.

SPEAKER_01 4:26

Yeah, it really helps the goal of my podcast, which is to cast a wide net of topics from someone who has lived experience with gambling addiction to share his lived experience. One of my staff who's in recovery just shared her history of being homeless and doing sex work and talking about self-esteem as a woman in recovery. And then we get to be geeky together. So you and I both love addiction medicine because it's such a broad topic. And when you and I speak, we get down to the nitty-gritty molecular details. So this is absolutely perfect.

SPEAKER_00 4:59

For today's episode, we're going to be reviewing benzotapering. And a lot of this does come from a paper that was put out within the last year or so. So a lot more of just going over some of the complexity and some of the main points from this paper. But we hopefully will be able to get a little geeky somewhere within the podcast about some anecdotes and the ways hopefully both of us treat our patients that are suffering from the challenges of benzouse disorder or just the unwanted dependence when they didn't realize that was going to happen to them.

SPEAKER_01 5:33

So everybody who hasn't listened to the episode with Dr. Rizzo on benzodiazepine-induced neurological dysfunction may want to go back and take a listen to that because that was really helpful for understanding exactly how benzos work and why they're so uniquely toxic to the brain. And I have to thank you for the glutamate gas pedal analogy, GABA break analogy, because I used it with one of my patients yesterday. So, as we talked about at the end of that episode, we understand what benzos do to the brain, but when someone is on benzos for years, getting them off of it is a really difficult process. So getting people off of benzodazipines, what we're going to talk about today. Should we start with a case? Or I know you're so organized. I'm assuming you've done your homework and you're all prepped for this episode.

A High Dose Clonazepam Case

SPEAKER_00 6:18

I was going to say also to the listeners that like I use a lot of different podcasts for students that rotate through and residents through my facility. And one of the one of the podcasts I use is one of your first podcasts about benzos. And it was just a really great foundation to understand benzos in general. And actually, throughout your years, you have had a lot of really interesting benzo-related episodes. So for the listeners who want to pause this and even go back to the very beginning, I would recommend going back to those first couple episodes that Dr. Grover recorded about benzos to just get a nice foundation. But yeah, today we're going to really just focus on that ASAM guideline for benzotapering. I don't have a particular vignette, but I'm sure we'll have lots of stories about different patients we've encountered across our years that will help give the listeners a better insight to these challenges. And so the paper I'm going to be talking about is from the Joint Clinical Practice Guideline on Benzotapering considerations when risks outweigh benefits. So this was published, I think, in June 2025. And it was published by Dr. Emily Bruner and many other brilliant individuals from multiple ASAM-related committees. They also considered 10 different professional societies that had expertise in benzodiazepines and consulted a patient panel group with lived benzouse disorder and withdrawal experience to create probably the most comprehensive paper to date on benzota. So I would say if anybody wants to go read the full 46 pages, there'll be a link in the show notes, or you can easily find it just kind of by searching for it on the web. I typically keep the 46-page document on my nightstand for those cold evenings, and it's it's perfectly paired with a nice herbal rose tea, three drops of liquid stebia, and and it it puts me to bed like after about 30 minutes of just reviewing it. So that's not recommended.

SPEAKER_01 8:19

Yeah, so I'll give you a case. I'll I'll give an example of what this looks like when people come to me. Dr. Rizzo, it probably looks very similar for you. So I'm here in Monterey, California. I'm actually in my clinic right now, and I got referred from the local emergency department, a 52-year-old female with a history of breast cancer. And so she had read relocated from out of state, and she was very anxious during her cancer treatment and had had her marriage fall apart because of the consequences financially, personally, physically of her cancer treatment. And her oncologist had put her on escalating doses of clonazepam, that's benzodazpine. She started out on one milligram a night because she couldn't sleep. And then as the cancer got worse and she was potentially facing a terminal diagnosis, her anxiety was worse, so they continued to increase it. And over several years, she was eventually put on six milligrams of clonazepam a day at a dose of two milligrams three times a day. And this is, for the listeners, this is about as high a dose as insurance will cover. She decided to relocate to our area. And as many patients do, they don't necessarily consider their medical care and their move. And she realized, uh oh, I'm gonna run out of my clonazepam. So she went to a local emergency department. And the emergency physician was very uncomfortable giving her that much clonazepam and said, uh uh, I am not gonna give you that much clonazepam. Here's three milligrams a day, so that's a 50% drop, which we will talk about is really not a good idea. And they referred her to me. And ultimately, what we ended up doing is putting her back up at five and a half milligrams a day. So we at least started some tapering, and then we've been working for several months to get her down. And she's plateaued at about three milligrams, where she just feels like her anxiety is too bad if we go lower, her insomnia is too bad. And so we're just taking it really slow. But that's kind of what this looks like. I've been working with her for about nine months, and we've only been able to drop her dose by about 50%. So why are we talking about this today? It's a very difficult clinical problem.

Never Stop Benzos Abruptly

SPEAKER_00 10:27

So the that vignette brought up a lot of points. And within this article that we're gonna review, there's really 10 takeaways. And I think within that vignette, there was at least three or four takeaways that really need to be discussed. So I'd like to start with that first takeaway, and that's really never abruptly discontinue benzodiazepine. So clinicians or any medical provider should never abruptly stop benzos. And even if, you know, there's concerns for abuse potential, just because of how physically dependent people become on benzos, whether they like it or not, right? So abrupt cessation or stopping of this drug can lead to severe life-threatening withdrawal. And this includes seizures, delirium, and and many other complications. Uh, there's a very interesting statistic that I found, which was in in 2018, I think they looked at over 50% of patients who were prescribed a benzo by a licensed medical provider ended up taking that benzo for over two months. So, for the people listening to this podcast who have the ability to prescribe benzodiazepines, remember that every prescription that you give out for two patients, one of them will be coming back months later asking for a refill of that benzo prescription. So you really should be thinking twice about whether that is the a great first choice for a medication in regards to dealing with someone's anxiety or some other mental health issue. So that's kind of one thing. The other thing is like even if you are taking it for a short time period, in my practice, I've seen people as as little as two weeks of daily benzouse present to me it with acute withdrawal. So I I always try to preface, like, and I think we talked about it a little bit in this last episode that we recorded, is that a PRN use of benzos really should be the focus when prescribing benzodiazepines. And I understand the people that are listening to this that are on daily benzos, I don't want anyone to just all of a sudden try to switch to an as-needed use of it. That is not the point I'm trying to come across. But at the same time, if this is a new prescription for a patient, or if your doctor is giving you a new prescription for benzos, really try to reiterate the fact that it's an as-needed medication unless decided by a medical professional for another use.

SPEAKER_01 12:52

Yeah, I've actually got a couple of my patients that have a history with benzos but aren't currently on them. And let's say something horrible happens, they get re-traumatized, they're a victim of sexual assault, and they see their abuser and they get really triggered. I'll give them like three doses of benzo for the week. Meaning that I want them to work on using other strategies, therapy, mutual support groups, non-addictive anxiety meds like clonidine or propranolol, increasing their antidepressant to increase their emotional resilience. But when they're facing a relapse on alcohol because their anxiety is so bad, I do try to give them a pop-off valve. And so my patients have been really mad at me. They're like, you need to give me benzos every day. And I just tell them I can't ethically do it. So I don't think this is in the guideline, and this is just something I've tried and has worked is you'll get three, let's say, Larazipam for a week, and then as things get better, you get two for a week. And then some people just even feel better just having one in their medicine cabinet, and they they might not use it for three weeks. But I agree with you 100% that it seems innocuous to give 10 days of lorezepam and yet it's not.

SPEAKER_00 14:01

This goes really nicely into the second takeaway point, which is when starting taper, we start low and we go slow, right? And the recommendations is try to reduce the dosing of the benzo, which you kind of mentioned at about a five to ten percent drop every two to four weeks. This is not possible for every patient. Some can go a little bit quicker. More likely, sometimes you have to go a little bit slower, but typically a lot of patients do tolerate this five to 10% reduction. Now, there's definitely some that are considered way too quick and put patients into a dangerous range. And that's that's really exceeding that 25% drop every two weeks is considered dangerous. And for a lot of our patients that we're talking about, this means that this process is going to take months, if not years. And so I would say that when this conversation begins, it's either started by the provider who has a concern. And as a provider, it's not the physical dependence that should be as much of a concern as the conversation of if they're starting to meet the criteria for use disorder. But on the other side of it, a patient or their family who might have a concern should really present this to the person prescribing the medication or consider seeing a specialist in addiction medicine like yourself, Dr. Grover, and by then engaging that conversation to say, look, I think I'm ready to start tapering off of it and making a plan that makes sense for both parties involved.

SPEAKER_01 15:29

I totally agree. Going back to the case that I shared, this poor patient, again, who didn't consider the medical ramifications of her move, had a 50% drop from the emergency department. And I do not blame that emergency physician. Six milligrams of clinezepam is an exceptionally high dose, but she was very uncomfortable when she made that 50% drop. And we can talk about some of the withdrawal symptoms, but that was why we basically brought her back up to five and a half milligrams, is that represented that small drop. Now it's interesting in the carceral setting, jail or prison, they often do this very quickly. And I'm not quite sure why they don't have more bad outcomes. But some of my patients who have gone to jail on benzos, they will be tapered off within less than a week. And that just makes me really nervous. But it's jail. I guess the way they're told is like we'll do it based on our protocol, and jail's not meant to be fun and feel good. So yeah, I worry about some of my patients when they get incarcerated.

Switching Agents And Jail Reality

SPEAKER_00 16:31

Although I I I had had a patient who was incarcerated and had a withdrawal seizure while incarcerated. And so I feel like I don't know where the evidence, you know, it's either tucked away somewhere or it's all anecdotal because it's hard to produce that level of evidence. But I I can only imagine the amount of complications and trying to abruptly get someone off of something like that in the prison system in the United States. It must be really challenging. So I don't know. I don't know the right answer to that because I I have never worked in in the prison system, but I could I could only imagine there's a lot, a lot that that plays in in some of those decisions. And then there's just a lot of stigmatization and and I think discomfort in in the medical staff there, often trying to put someone on a long taper while in these systems. But I will mention, this comes up with a really interesting point that kind of years prior, we used to say, let's switch a patient to the longest acting agent. So let's say you come in on Larazipam or Adavan, right, which is maybe considered more of a moderate duration agent than something like diazepam or valiant, which is a longer acting agent. I think you can argue why that's not always the right answer, right? So when you're creating this tapering strategy, you know, by dropping five to 10%, I really don't recommend converting everyone to a long-acting agent. There are some opportunities and people who are on very short-acting agents like Xanax or Alprazzolam, because of the fact that there's all these gaps within the withdrawal process that might lead someone to be vulnerable and have a seizure. But for most cases, if if someone comes in to my office on Larazzipam or to my hospital or to my detox facility, I would want to keep them on that same agent and use that 5 to 10% drop within the same medication because genetically we metabolize medications differently and we tolerate medications differently, even though we think we might understand the conversion rates. I think it's been shown that the conversion rates are so variable that it's really hard to be confident about it. So I would say for most providers, if you can keep that patient on the same agent and taper them together, that's probably would be my first choice. But my second choice would be on a safer, long acting agent.

SPEAKER_01 18:45

One other reason why they do such quick tapers in the jail and prison system is just the risk of diversion. Funny story, I'm gonna make fun of myself. So I was a resident, and one of the county hospitals that I rotated through as a resident took care of patients from the jail. And they brought in an inmate who was altered, and he was very clearly intoxicated. And I remember looking at my attending as a very green second-year resident being like, alcohol, but he's in jail. And my attending looked at me and was like, Go Google Pruno, which, if anyone doesn't know, Pruno is prison wine, meaning that they ferment foods that they are served to be able to make their own wine. There were just recently cases, I think, in England, of drones dropping drugs into prisons and jails. People throw stuff over the walls. You can get anything you want, drugs and alcohol-wise, in jail or prison if you didn't know. So presumably part of the reason why they're so strict with benzotapers is the risk of diversion and wanting to prevent overdoses. So it's really a difficult situation. One follow-up I do want to make to your point, though, I would be totally fine doing a taper on the medium or long-acting benzodazipines, but I would not do one with a very short-acting benzodazipine like I'll praise a lamb. To your point, is that you're gonna get the risk of withdrawal in between the doses.

Shared Decisions When Patients Push Back

SPEAKER_00 20:04

I I also find it there's something probably from a psychological and emotional standpoint from our the side of our patients, is that when we taper someone like in a detox or hospital setting and we convert them to, let's say, a long-acting agent like diazepam, they don't always feel comfortable when they leave the facility because they don't know where they're at in regards to their dosing of the medication they might still have have at home. So they might have Clinazepam, they might have, you know, the Atavan sitting at home, and when they get home, they're gonna say, Oh, they tapered me off of it with this other medication in the hospital. But it I I find patients are more likely to go back to their their regular dosing of the medication we've been trying to taper them off of when we don't keep them on the same medication. So I find there's a there's this like there's this mental gymnastics and benefit that you get out of keeping someone on the same medication because then I can show them, hey, look, I got you down to this low dose of Lirazepam, and now when you go home, whether you're gonna keep taking it or not, you at least know that you can tolerate being on these lower doses and just being familiar with the name of the drums that they have in in their medicine cabinet, I think really goes a long way in regards to benzo tapering. Totally agree. Anyway, this actually ties into the the third takeaway point from this article, and that's prioritize shared decision making, right? Because tapering is truly a collaborative process. And I think that shared decision making is actually the standard of care and healthcare. I think all decisions should be discussed between medical providers and patients, and it should always be collaborative. And I think really done are the days of one sided conversations, but specifically in the world of addiction medicine, a patient and the family of a patient should find solace in talking openly with their addiction medicine or PCP provider. And I think this is the vital portion of short. In long-term success, because when there's a problem with the tapering or there's a problem with how they're feeling, if they don't feel comfortable in having these collaborative decision-making conversations, they're probably not going to come back to the office or they're going to seek alternative measures to feel better. And I think that often leads us down a different pathway that usually does not lead to the outcomes we were originally looking for.

SPEAKER_01 22:25

Interesting point here because some of my patients come to me because no one's willing to write their benzos anymore. So we all know America went through a really tough relationship with prescription opioids. As healthcare providers, we didn't know how to get them off of them. In many cases, we cut them off. And people were in withdrawal or had unmanaged medical needs, and they went to the black market, heroin, now fentanyl. And I've heard several people express concern, let's not do the same with benzos. But what I'm finding in my community is that healthcare providers do not want to write for benzodazpines anymore. And people will come to me and they're like, well, I don't want to taper off my benzos. And the shared decision making gets really difficult when I tell them my practice is addiction medicine. I offer tapering, and they say, Well, I don't want to get off of them, but I can't find another prescriber, and we get stuck in the middle. And I'm just curious if you've run into that experience in your practice as well.

SPEAKER_00 23:25

I find my best approach when shared decision making often feels like the conversation is more of a demand or a more of a patient-centric response that feels like they're ordering uh from a menu at a restaurant than actually talking to a professional in the same room. My strategy is usually as I typically verbalize that I understand where they're coming from. I try to relate with them in some way. I then present them with education and evidence in a hopefully a way that they can understand at whatever level that they're coming in at. And then I try to remind them that I'm coming from a place of safety and respect and autonomy. And I will explain to them why maybe what they are asking for might not fall into those same criteria of what I consider safe. So I always try to find a collaboration. I try to meet them halfway, but I agree with you. Sometimes there are patients who are either not ready to come off of their benzos or other drugs of abuse, or they just are being a bit unreasonable. And that's not even considering some that have secondary gain. I'll tell you, working at an in a you know an abstinence-based residential community facility that has tied in with 12-step facilitation, you know, these conversations are very interesting because people typically come here for that level of care, but every once in a while they they backpedal, realize this is not what they want. And then it really is so important to sit down with that patient and really go over all different options and the risk-benefits. So I find share decision making, sure, it's a vague term, but really it's all about collaborating and meeting somewhere in between. And sometimes, like you said, that first office visit, you might not be able to get your point across to a patient. And so you might let them dictate some of their care at first, but you hope are making steps in that right direction to eventually get to a more even playing field where maybe after that second or third visit, you can meet halfway.

SPEAKER_01 25:36

I don't actually think it's a challenging patient dynamic. It's more that they've been on them, and let's say their primary care retires or their psychiatrist has said, I don't think you should be on this anymore. And in the patient's perspective, many of them do not meet criteria for a use disorder. They are dependent and have whether it's anxiety, agoraphobia, whatever it is, and they come to me with this works for me. I don't feel like tapering off is appropriate. And I just kind of have to tell them, like, I'm addiction medicine. This is what I do. I wean people off of them. And if I try to refer them, there's nowhere else for them to land that wants to prescribe benzos. So it's more like an access to care issue.

SPEAKER_00 26:17

So yeah, that that's very interesting that what you're bringing up, also, because I think we can say that benzos compared to other drugs that we deal with in addiction medicine, the damage is often atrogenic, right? And we haven't seen something like this since the prescribing of opioid or full agonists via pill form in the early 2000s and 90s and things like that. So I would say from a lot of this generation of new physicians and PAs and NPs is that this is their first experience of really dealing with a patient who says, but my doctor put me on this medicine, so it must not be bad for me. And I think this is where the conversation and the dialogue and the education becomes so important because you don't want to discredit what the previous provider who might still be active in the care with that patient is saying. But you should really, like you said, I'm I am the specialist in this field. And let me explain to you why I slightly disagree with how you've been previously managed or why you might think this one way about benzos when actually this is what our major concern should be.

SPEAKER_01 27:26

And that's ultimately what I do is we discuss bind benzodasiapine-induced neurological dysfunction and kind of see where the conversation lands. And then sometimes I'll provide a refill and refer them back to say the patient's not ready to taper. Call me when they are, and have the same conversation with the patient. Like if you think this was working for you, you work with the doctor that was prescribing for you. And if you want to taper, come back and see me. I'd be happy to see you.

Ongoing Risk Benefit Reassessment

SPEAKER_00 27:50

All right, let's go to number four. So the number four takeaway from this paper is all about the regular risk-benefit reassessment that needs to be done when you either have someone who's on benzos on a regular basis, and more importantly, tapering a patient on benzos. And this is really important because tapering does come with risks, right? You can have increased falls, cognitive impairment changes, motor vehicle accidents. You can also worry about someone, you know, wall tapering, maybe taking too much when they're either having cravings or they feel like they need more. And so their tolerance might have slightly dropped. So there's an overdose risk that's not zero. But you really need to look at the benefits of the medication, the tapering speed, and really consider a risk-benefit ratio and reassessment at multiple times during the tapering process. I do think you could you can say that there are some groups that are higher risk than others. And this is an important conversation to have. They specifically mention in the article the 65 and older population and the pregnant patients on benzos. So, in regards to 65 and older, I'm gonna bring that up in another takeaway point. But in regards to pregnant patients, there was a 2024 retrospective study out of JAMA psychiatry that looked at over 3 million pregnancies and found that there was an odds ratio of miscarriage at 1.69 for those women who are actively taking benzodiazepines during pregnancy. So for those listening, an odds ratio of 1.69 means that it's a relative risk of about 69% increase in miscarriage. And this is an important conversation to have with patients who are either trying to get pregnant or find out that they're pregnant who are have been on chronic benzos for other reasons. Obviously, we don't want a woman to stop taking her benzos because she finds out she's pregnant abruptly because of the risk of having a seizure. A pregnant woman's seizing is way more complex than a single individual, and it's a dangerous situation for the fetus and mom. So this is something that really needs to be discussed with all medical professionals, including the woman's OBGYN and the addiction medicine docs, et cetera, et cetera.

SPEAKER_01 30:11

Yeah, I've had a couple of my patients that I almost think about benzotaering as a form of harm reduction. Like again, this patient, let's say, so I got her at six milligrams of clonazepam a day. Let's say I got her down to two and she is like, Dr. Grover, I just cannot get below this. I can't sleep. I'd say, well, you know what? We dropped your dose by quite a bit. Let's get you back to primary care and see if they're willing to take it over again. So I don't know if that's in the guidelines, but I feel like in what we do in addiction medicine, I the way I think about it is I have three buckets. The I'm gonna get you sober and you're gonna stay sober, the you're not ready, but at least you're engaging with me, and then the middle is this harm reduction bucket. And I don't know if that's a thing, but I feel like benzo tapering to a lowered level, not to zero, could still be a potential win for the patient.

SPEAKER_00 30:59

Casey, it's like you're in my head because takeaway number five is all about the individual taper, no one size fits all schedule. So what you just brought up is exactly what we were about to talk about, and that is the pace should be adjusted based on the patient's response. It's acceptable to pause the taper. It's even acceptable to actually go up temporarily if you feel like the patient is suffering some type of adverse effects from tapering, even if you think you're going at an appropriate rate. I will like to mention there is no one size fit all model in any part of addiction medicine. There never will be. And I also like to remind my staff that like CYA, which is used for withdrawal for alcohol, and CYB, which has been used for benzo withdrawal, but more from a research standpoint and not as uh it doesn't correspond as well from a clinical standpoint, cannot be applied to people withdrawing from benzos. There should be no number CWA score that should make a medical provider feel comfortable, that the patient in front of you, who might be saying that they're very uncomfortable, um, is actually doing okay. So please do not use a scoring system to base whether or not your tapering is the right speed, because I do find that this is where we can often get in into problems. And when I say problems, as in either the patient and the provider will have some level of conflict in the disagreement of the tapering schedule, or a patient might have an adverse event. So I I kind of say deal with the patient in front of you as they are the most important aspect of determining if the tapering regimen is appropriate. And then you can use these adjunct scoring systems if you need some additional information that might be slightly more objective when you're struggling to figure out if if there's other issues going on with this patient. How about that?

SPEAKER_01 32:51

I agree. Individualized tapers is the way to go.

SPEAKER_00 32:56

And then so on on to the takeaway number six, which is really focused specifically on older adults, right? That's the guideline really recommends considering tapering benzos in almost all adults age 65 and older. Now, this is a really challenging, and this is really important to discuss because uh it looks like based on some recent studies on prevalence of benzouse in the age range of 65 and up, that about somewhere between the 5 to 10% of adult patients in this age bracket are currently prescribed benzos. And upwards of 30 to 35% of these patients are taking benzos long term, and that is defined as greater than 120 consecutive days. Now, imagine the challenges of a relatively healthy 25 or 35-year-old patient tapering off of benzos. Now add on all the comorbid conditions a 65-year-old might be dealing with, the fact that they might be been on this medication for many years, the fact that there's a lot of mental health that has been untreated or undiagnosed over that time period, and then say, okay, now it's time to try to get you off the medication. So I'm really happy that ASAM made a very specific consideration in older adults. I often feel like one day we're gonna wake up and our waiting room will be full of 65 and older patients trying to wean themselves off of benzos with hopefully the help of a professional like yourself or many others across the country.

SPEAKER_01 34:28

I have some patients that have been on benzos almost as long as I've been alive. I am 42 years old. Yeah, I have a gentleman came to me again, same thing. He'd been on Lorazepan for many years, and he was like, Well, no doctor wants to prescribe this anymore. What's wrong with it? And he and I talked about it, and he wasn't ready to taper for a while, and I believe he's 78, and he pondered it and read up on things, and six months later he's like, Doc, I'm ready. And we are going so slow with him. He will probably be tapering for about 18 months.

SPEAKER_00 35:02

I would say anecdotally, the hardest benzotaper patients I've ever had are always 65 and up and are typically on longer-acting agents, whether that's a diazepam or clonazepam, those are the two I find being some of the biggest challenges in that patient population. But yeah, it's it's not easy. And I I feel personally that even though we're more cognizant of benzouse disorder and the physical dependence of benzos, I don't think the numbers are are really going down. If anything, we need to watch as our population continues to age, you know, how many more patients will come out of the woodwork and actually say that there is a problem that has been brewing for a long time that they've been able to control for a while.

SPEAKER_01 35:48

So Yeah, generationally, adults over 65 come from a time when controlled substances were given out very freely. I did an episode at the end of 2025 on the history of some of the older drugs of abuse. One of my patients was like, Hey, Dr. Grover, what happened to Black Beauties? It was like, Black Beauties, I had to look it up. But all these older drugs were GABA A agonists, barbituates. And yeah, they just I went through some of the old uh pharmaceutical ads, like QuaLude, for example, and they really targeted specifically women in the home with anxiety. And just I think generationally, people would just used to like, my doctor gives me a prescription. What's wrong with it? So I think it's been very tough for them, to your point. Like, my doctor put me on this. Why are you taking me off of it? So, yes, I think culturally and physiologically, adults over 65 are very unique.

SPEAKER_00 36:44

Moving towards the seventh takeaway from the article, and they talk about managing the co-occurring conditions that come with benzouse disorder. So, whether that's polysubstance use like opioids, alcohol, there's been a ton of evidence to support that benzos plus opioids, benzos plus alcohol just makes everything worse, increases the risk of overdose, increases all these other comorbid concerns, makes withdrawals more intense, makes the medications to treat withdrawal less effective. So these are the patients that we need to consider either admitting to the hospital to start the tapering process, get them to uh a facility like mine that's a 3-7 facility that has 24-7 nursing and physician coverage that allows the detox and the residential process to kind of manage and the time and the focus while the patients are in a challenging situation. But I truly believe addiction medicine in the United States has to be treated from the office level and up because of just the sheer volume of patients that require treatment. And we can do addiction treatment for every patient that's really suffering in the United States by putting everyone in a hospital or a facility. It's just not feasible. So I feel like as a provider, if you're listening to this, you know, finding your higher risk patients in regards to those who might you want to try to taper them off of their benzos and maybe considering recommending an admission to a detox facility or to a hospital if if there's lots of co-occurring conditions that might make this more challenging.

SPEAKER_01 38:22

Sounds good. What's our next recommendation?

Phenobarbital For Inpatient Detox

SPEAKER_00 38:26

So the eighth takeaway is to distinguish really about the physical dependence compared to the actual substance use disorder. And the reason this was brought up is because it's really easy for healthcare providers and people who work in healthcare to stigmatize addiction. And I listened to a podcast with Dr. Emily Brunner, who was the main author of this article. And when she was being interviewed on this podcast, she had this story about working in a hospital years prior, how a patient verbalized a history of chronic benzouse. I think she mentions larazipam. And on their urine drug screen, it was negative for benzos, even though we both know, Dr. Grover, that benzos sometimes are very difficult to pick up on the standard UDS screening. And because of that, the hospital did not give this patient the benzos that she might have needed, and that led to some severe withdrawal complications. So it was just this story listening to Dr. Brunner talk about it. It's just an awful reminder of how misinterpreting physical dependence with addiction will never lead to a good outcome. Well said. So number nine, we're almost there for those who are wondering how close to the end is this podcast going to go. So number nine is about the outpatient versus the inpatient care. And so I have the luxury, either working in the hospital setting in Brooklyn or here in Connecticut in my detox facility, to really spend a decent amount of time working with patients who are suffering from addiction. And I what I've noticed is that when we can get someone in an inpatient or a residential care, either 2-7 ASAM designated or 3-7 ASAM designated facility, I find that we can really kind of speed up the tapers a little bit to make sure we keep our patients safe, but also allow them to continue to move forward in the process while keeping a close eye on them. And I understand this is not possible in the outpatient setting for a lot of patients, but I lean on phenobarb. And phenobarb is is my one of my favorite drugs in regards to the fight against addiction. I could go on and on and on why phenobarb is so amazing. And I will, for the listeners, go through some of the little bit of the nitty-gritty understanding of why I love it. I will say that a caveat is there's literally no good evidence on using phenobarb safely in the outpatient setting. And I would not recommend using phenobarb in the outpatient setting unless there's a very specific situation. And I haven't found one yet. So let's just really quickly go over phenobarb. So phenobarb or phenobarbital is uh, like you said in your previous podcast, it was a very old historical drug that was used for the everyday situational anxiety. It was over the counter for many, many years in the United States, to the point where I want to say billions of tablets of phenobarbital were being bought upwards to the early 40s. And benzos was the response to get people off of phenobarb as a safer alternative. Interesting, right? So, how does phenobarb work? Well, it keeps the GABA channel open, that same GABA A channel that's been constantly being triggered and has an upregulation and tolerance to benzodiazepines over the years or months of using benzodiazepines, phenobarb hits a different part of that receptor. And even for someone who is using high doses of benzos, that receptor is quite virgin to that the phenobarb that lands onto it. And because of that, it can keep the GABA channel open even in the absence of GABA floating around in your system. So it does cause respiratory depression. It has some abuse potential, but a lot lower abuse potential than many other drugs. And a lot of that has to do with the fact that it has a very long half-life. And if the long half-life is somewhere between the realm of 80 to 120 hours, that really allows people from abusing those like quick on-off type of drugs that we talk about all the time in addiction medicine, like fentanyl, cocaine, and Xanex or Alprazzolam, all heavily abused drugs because of the quick on and off. And because it has this long half-life, it kind of auto-tapers. So it creates this like nice tapering regimen that we get, similar to how we get with, for example, like Sublicade or other long-acting injectables. And it crosses the blood-brain barrier really quickly. So I tell my patients and my staff that an oral dose of phenobarb after about an hour is what you see, is what you get. So if the patient in front of you is not over-sedated, they will not be over-sedated two, three, four hours into that medication because of how quickly it crosses that blood brain barrier. In the same vein, if you push 15 to 20 minutes, what you see is what you get also, it crosses that blood brain barrier. So in the hospital setting, it's I find it relatively safe when used in a controlled setting. And in my 3-7 facility, I also find it quite safe and really effective. And so what I'll do is I'll bridge people from their benzo taper at the end of their detox process. And then I will then pulse up some phenobarb to a level that gets them really comfortable. And then I'll I'll actually transition them to the residential care facility on a phenobarb taper on a nice low dose that keeps them comfortable. And then I'll continue to add on these adjuncts. And anecdotally, I don't have at least yet, I don't have enough evidence to write up something. I will tell you that over about a four. Four to six week period, I can get people down to a very low dose of phenobarb and nothing else and quite comfortably often. I won't say all the time, but I will say often. And so I do feel there is hope in people who have tried other methods to get themselves off of benzos to consider maybe getting themselves into a a four to s four to eight week residential program where we can kind of work together with other professionals.

SPEAKER_01 44:27

Very nice. Yeah, I don't have a ton of experience with phenobarbital. Our hospital doesn't use it much, but I've used it a couple of times in bad alcohol withdrawal.

Adjunct Meds CBT And Treating Root Causes

SPEAKER_00 44:37

Let's go to the final takeaway, and that's the use of adjunct support meds, right? So I think any successful taper often requires more than just a dose reduction. We really need to focus on the psychosocial interventions, CBT, right? So cognitive behavior therapy has been shown to be effective. I think there's a Cochrane review which they which they quote in the paper, basically stating that you're more likely to be successful one month and three months into your tapering if you have CBT going on at the same time. Um you also can use medications like clonidine and propanolol, like you mentioned, that help with that hyperadrenergic dysregulation. There's GABA healthy diets, right? Lots of healthy whole foods, high B vitamins. You know, B vitamins have been shown to be like cofactors in really uh helping balance out glutamate and GABA. So I find that being an important aspect of care. Magnesium also has been shown to help balance out glutamate. So there's these things that we can do that really can help a lot of our patients that are not prescriptions that will help as an adjunct to supporting a successful taper. And then finally, my little push for baclefin. I love baclefin too. So baclefin works on the GABA B receptor, right? It's not a GABA A receptor agonist like benzos, but there have been shown to be a couple things about baclefin that's kind of unique that really makes sense in the world of using it as an adjunct in tapering. So presynaptically, it limits glutamate production. So glutamate is a precursor to GABA, and glutamate is also the nemesis to GABA, right? Like you said, the our previous analogy of the breaks in the gas between GABA and glutamate. If you can limit the production of glutamate, you can technically argue that there might be less of that glutamate surge, which means less of some of those side effects the patient's feeling in that dysregulated state. Postsynaptically, baclefin's been shown to help hyperpolarize a nerve cell. And if you hyperpolarize a cell for the patients that are listening that are not in the medical field, by hyperpolarizing anything, you make it less responsive. So if you can make a nerve cell less responsive, then you can maybe take away some of that nervous energy or the anxiety or that like discomfort that a lot of our patients feel when tapering. It decreases internalized tremors. And I've I'm sure you've seen that with patients as they're tapering, they get this like internal tremor feel. And it really dampers the reward pathway that causes a lot of those cravings. So I really believe that baclefin, although not a benign drug, is a great drug to use as an adjunct while you're tapering someone off of benzos or any actually challenging drug of abuse to taper off of.

SPEAKER_01 47:11

Yeah, I would argue that what this take home is really about is treat the underlying condition for which they got on benzos in the first place, right? So if they were put on benzos for insomnia, use your non-addictive sleep meds, right? If they were put on benzodazipines for anxiety, let's maximize our use of selective serotonin reuptake inhibitors and propranolol and clonidine. So, yes, I 100% agree. I think this is really helpful for patients as the, and you're gonna laugh at me because we talked about our spouses last episode, as the very beautiful and fantastic Dr. Close likes to say, a lot of addiction is feel something, take something. Like that's what they learn over time. And so something like a CBT, they don't have that feel something, take something. So absolutely these adjunct medications give patients the empowering feeling that they can take something when they don't feel good during their taper.

Staying The Course Through Setbacks

SPEAKER_00 48:05

So you, because you brought up your wife, now you're gonna make me do that seriously. I because you always talk about your wife, Dr. Grover, I will have to bring up my wife, which I love to bring up my wife in this podcast. And I will let the audience know that my wife is really passionate about conservation and the environment, and recently was accepted a position as a board member for our land trust in our town. And by talking to her about how much work it takes, stewardship and all this other stuff, in just fighting invasives and how every year you cut back all of these invasives, you try to remove them from properties, and every year they come back. It reminds me of the patient process that we need to focus on in addiction medicine. That just because we're battling something that might be a forever, you know, disease process, that might be a forever challenge in finding a healthy balance of happiness and comfort in the world around us, it doesn't mean that we should give up when we have a little bit of a setback. And just like fighting invasives on your property, don't give up. And we just have to constant pressure and constant forward momentum will eventually get everyone to where they need to be. So I felt inspired about talking about battling invasives and then comparing it to the world of addiction medicines. But anyway, it's great to talk with you. Thanks for inviting me. It really was.

SPEAKER_01 49:31

I just want to just unpack that point that you said, which is that yes, many of my patients feel hopeless. Addiction can be a very frustrating illness, particularly when someone has benzodazine-induced neurological dysfunction, the discomfort they feel during tapering. So I didn't have invasive species and staying persistent in treating addiction as a link in my mind. But it's just, you know, to anyone out there listening or knows someone that's struggling, just keep coming back and keep trying. You hear these stories of people going to rehab 17 times and on the 18th it's stuck. So I totally agree. So as healthcare providers, we are advocates for our patients. And even if they're having a bad day, we're still there for them. So I 100% agree.

SPEAKER_00 50:14

And for the providers who are battling addiction with their patients, don't give up. It's it's a battle worth fighting for.

Final Takeaways And Closing

SPEAKER_01 50:21

We'll end with Winston Churchill. Never give up. Thank you so much for listening to Addiction Medicine Made Easy. If you found this helpful, please leave a review. It really helps others find the show. And a huge thank you to Central Coast Overdose Prevention for supporting this podcast. And always remember treating addiction saves lives.