Cleveland Clinic Journal of Medicine (CCJM)Benzodiazepines: Caught Between Patient Needs and Guidelines

Guidelines push benzodiazepine deprescribing despite mounting evidence that discontinuation increases mortality, overdoses, and emergency visits in stable long-term users. Only 15% of benzodiazepine users continue beyond one year, and just 7% escalate doses, challenging assumptions that prescribing inevitably leads to addiction.

⚖️ PROFESSIONAL IMPACT

• Deprescribing stable patients paradoxically increased deaths, nonfatal overdoses, suicidal ideation, and ED visits compared to continued treatment in 2023 study
• FDA reversed position on buprenorphine co-prescribing, tacitly acknowledging benzodiazepine abstinence goals shouldn’t override opioid use disorder treatment
• Danish 20-year study found dose escalation occurred in only 7% of long-term users, with highest risk in patients with psychiatric comorbidity and substance use
• Primary care clinicians report discomfort refusing prescriptions during acute crises when mental health services unavailable or patients starting SSRIs

🎯 ACTION ITEMS

• Document patient-specific risks vs benefits before initiating deprescription in stable long-term users
• Implement shared decision-making using EMPOWER model—face-to-face discussions plus educational materials on tapering
• Screen for psychiatric comorbidity and substance use before prescribing, as these predict long-term use and dose escalation
• Reserve benzodiazepines for severe disabling symptoms as short-term crisis intervention, not first-line treatment

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