Safe Prescribing for Benzodiazepines

Information on safe prescribing recommendations, interactions to be aware of, such as opioids and alcohol with benzodiazepines.

Benzodiazepines are not first-line medications for most conditions, including anxiety and insomnia.

Start with non-medication options

This includes things like:

Cognitive behavioral therapy
Cognitive behavioral therapy for insomnia (CBT-I)
Mindfulness exercises

Consider non-benzodiazepine options

Anxiety and depression medications include:

SSRIs
SNRIs
TCAs
Mirtazapine
Hydroxzyzine
Buspirone

Medications used for acute situations (e.g. situational anxiety):

Hydroxyzine
Propranolol

Insomnia medications include:

Melatonin receptor agonists (i.e., over the counter melatonin, Ramelteon [Rozerem], Tasimelteon [Hetlioz])
Dual orexin receptor antagonists (i.e., Suvorexant [Belsomra], Lemborexant [Dayvigo], Dairdorexant [Quviviq])
Doxepin, trazodone, mirtazapine

Benzodiazepine prescribing should be for rare circumstances, of less than 4 weeks duration, and at the lowest possible dose

If benzodiazepines need to be prescribed, they should only be prescribed for 2-4 weeks. Start with the lowest possible dose, then adjust as needed.

Special attention should be given to the pharmacokinetics of benzodiazepines if a benzodiazepine is absolutely necessary:

Alprazolam

Alprazolam should be avoided due to its quick onset and short duration, which contribute to high misuse potential and difficulty tapering.

Temazepam

Temazepam may be a better benzodiazepine option for patients with insomnia due to its longer half-life.

Lorazepam/ Diazepam

Lorazepam and diazepam may be better benzodiazepine options for patients with anxiety in certain scenarios due to relatively quicker onset and moderate to longer half-lives, respectively.

Patients should be counseled regarding the dangers of benzodiazepine prescribing

It can be helpful to fill out a patient-provider agreement for providing benzodiazepines. In this agreement, you can go over risks, benefits, and the management plan.

View Agreement

Benzodiazepines are potentially inappropriate for most older adults

The AGS Beers Criteria® recommends avoiding benzodiazepines in many older adults due to increased risk of harm.

Risks increase with age

Benzodiazepine use in older adults is associated with falls, fractures, cognitive impairment, delirium, sedation, and motor vehicle accidents.

Use often exceeds evidence-based recommendations

Research suggests benzodiazepines are prescribed to older adults more often and for longer durations than the evidence supports.

Be aware of other medications that might interact

It’s important to thoroughly review any other medications an older adult might be taking to minimize adverse interactions.

Use caution when prescribing benzodiazepines and opioids together

Patients using benzodiazepines and opioids concurrently have a higher risk of overdose. This risk of overdose is also a concern for patients on Medications for Opioid Use Disorder (MOUD), such as methadone or buprenorphine. Use caution and your best clinical judgment when deciding to prescribe these medications concurrently.

Check the Prescription Drug Monitoring Program to determine current prescriptions

It can be helpful to check the PDMP to see if another medical provider has prescribed opioids or other benzodiazepines or z-drugs to your patient.

Prescribe naloxone

Make sure you prescribe naloxone and educate your patients and their families if you are prescribing opioids and benzodiazepines.

Screening for misuse

Benzodiazepine substance use disorder can be diagnosed using DSM-5 criteria. The Severity Dependence Scale is a simple, 5-question screening tool validated for use in the community. It can be administered by the clinician or self-administered by the patient.

Do you think your use of (substance) is out of control?
Does the prospect of missing a dose make you feel anxious or worried?
Do you worry about your use of (substance)?
Do you wish you could stop?
How difficult do you find it to stop or go without (substance)?

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NIDA: Benzodiazepines and Opioids

This webpage highlights the research behind the increased risk of co-prescribing opioids and benzodiazepines. The risks addressed include being admitted to or visiting the ED, life-threatening overdose, or death due to overdose.