Benzodiazepines and z-drugs

To consider the management of insomnia and anxiety in adults, the use of non-pharmacological treatments and appropriate use of benzodiazepines and z-drugs (B-Z) including timely review and deprescribing.

Essential medicines:

• benzodiazepines for alcohol or drug withdrawal, multiple sclerosis, intractable epilepsy, palliative care, or premedication for anaesthesia.

Non-essential medicines in most cases:

• z-drugs: long-term use (more than four weeks) in insomnia
• benzodiazepines: long-term use (more than four weeks) in insomnia, anxiety and back pain

Prior to starting, discuss with the individual, using a person-centred approach the:

• potential underlying causes of insomnia (e.g. pain, dyspnoea, anxiety)²¹⁵
• use of non-pharmacological options, (see NHS Inform, National Wellbeing Hub):
  • insomnia: consider sleep hygiene (e.g. caffeine reduction), use of a sleep improvement programme (e.g. “Sleepio®”)
  • anxiety: use of an anxiety improvement programme (e.g. “Daylight®”)

If B-Z are to be used, the benefits and risks of treatment must be balanced and therapeutic objectives agreed:

• may be effective for the short-term treatment of insomnia, and/or anxiety disorders but use should be limited to less than two weeks on an ‘as required’ basis. They are licensed for a maximum of four weeks only³⁰
• are associated with risks and avoidable harms:³⁰
  • falls, cognitive dysfunction, and increased mortality in some populations
  • dependence. Assess risk factors such as history of drug/alcohol misuse
  • tolerance and a loss of effect within two to four weeks of treatment
  • discontinuation/withdrawal symptoms and potential difficulties in stopping these medicines

The use of B-Z can lead to increased risk of avoidable adverse effects, dependence and tolerance. The lowest effective dose for the shortest period should be used. Review effectiveness and tolerability on a regular basis.

Effectiveness of B-Z in insomnia

• should only be used to treat insomnia when it is severe, disabling, or causing the individual extreme distress, when underlying causes have been ruled out and when non-pharmacological measures have been ineffective
• may be effective when used short-term (maximum four weeks) for insomnia
• should be used on an ‘as needed’ basis²¹⁵

Studies assessing the effectiveness of B-Z, mainly assessment of seven days or less of treatment of insomnia, showed the effects were small, with an increased risk of adverse effects. The number needed to treat (NNT) for improved sleep quality was 13 and the number needed to harm (NNH) for any adverse effect was six.³⁰

Effectiveness of benzodiazepines in anxiety

• Evidence based psychological interventions are recommended as first line treatment
• Benzodiazepines are indicated for the short-term (two weeks) relief in severe anxiety, which is disabling, or causing the person unacceptable distress either alone or when associated with insomnia²¹⁵
• They should not be used routinely and only when specifically indicated

Effectiveness of benzodiazepines in anxiety disorders

Include generalised anxiety disorder (GAD), panic disorder, social anxiety and post-traumatic stress disorder (PTSD).

Effectiveness of benzodiazepines in anxiety disorders

Please note that the table below may need to be scrolled horizontally or vertically in order to view all information, depending on your device.

Benzodiazepines should not be stopped abruptly without specialist advice in individuals taking them for indications such as multiple sclerosis, intractable epilepsy, alcohol or drug withdrawal or palliative care.

B-Z use (list is not exhaustive):^30,232

• can cause respiratory depression
• is associated with a higher mortality risk for people with schizophrenia
• should be avoided in the older person as they are at greater risk of becoming ataxic and confused, leading to falls and injury
• is associated with an increased incidence of depressive symptoms
• can have negative effects on cognition (e.g. amnesia) and may limit the efficacy of psychological therapies such as cognitive behavioural therapy (CBT)
• two or more benzodiazepines or combined with a z-drug can increase the ‘benzo-burden’ creating a synrgistic effect leading to more avoidable medication-related harm
• can cause paradoxical effects (e.g. increased anxiety, hostility and aggression)
• drivers need to be cautioned when taking these medicines. See:
  • Drugs and driving: the law for information on hypnotics whilst driving
  • Zolpidem: risk of drowsiness and reduced driving ability

Practitioners should proactively review benzodiazepine use and need when individuals are stable and well. The following groups of people may be appropriate for proactive reviews:

• recently discharged from hospital on new B-Z
• receiving long-term treatment (≥eight weeks)high dose combination use: >30mg per day diazepam equivalent
• people receiving diazepam 10mg tablets – known as ‘blues’
• reporting/presenting with street/ non-prescribed benzodiazepine use
• receiving other psychotropic medicines e.g. antidepressants, antipsychotics, gabapentinoids
• older (≥65 years) and/or frail adults:
  • care home residents
  • people with dementia and/or receiving other medicines that may cause cognitive dysfunction
  • polypharmacy
  • higher risk of falls

Deprescribe benzodiazepine or z-drugs, if:

• no longer benefiting the person
• the person is experiencing adverse effects
• the person wants to stop taking the medicine

Follow deprescribing guidance see the benzodiazepine tapering tool from Quality prescribing for Benzodiazepines and z-drugs: guide for improvement 2024 to 2027.

Deprescribing notes:

• Abrupt cessation may cause confusion, toxic psychosis, convulsions or a condition resembling delirium tremens. Reduction should be gradual and tapered unless individual is experiencing serious adverse effects.²¹⁵
• The rate of reduction should be tolerable to the individual and depends on the dose, duration of use, and the individual’s clinical response.²¹⁵
• Discontinuation/withdrawal symptoms may occur at any time and up to three weeks after stopping a long-acting benzodiazepine. Symptoms include insomnia, anxiety, depression, cognitive impairment and can be similar to the original complaint. Some discontinuation/withdrawal symptoms may continue for weeks or months after stopping.²¹⁵
• Long duration of medicine use, high dose of medicine, history of discontinuation/withdrawal symptoms, history of problems associated with dependence are associated with increased risk of problems with withdrawal.²³³

Supporting people who do not or cannot reduce/stop

• Schedule more frequent reviews to detect and manage problems
• If a person is unsuccessful on their first attempt, they should be encouraged to try again²³⁴
• People who do not wish to stop taking B-Z should^30,234
  • be advised on the benefits of stopping with face-to-face educational interventions and for the advice to be documented
  • be listened to, and concerns about stopping addressed
  • not be pressurised
  • be reviewed later (consider adding a review date to the prescription)

Specific areas/situations where medication may need to be introduced or increased

Most people experience infrequent, mild or no discontinuation/withdrawal symptoms if the withdrawal is slow and tapered to their needs. However, if they do experience withdrawal, consider reverting to the previous dose that caused no withdrawal effects. Stabilise on the higher dose, then reduce more slowly, using smaller dose reduction steps (which may require the use of liquid preparations).³⁰

Supporting people through reduction and ongoing review of medication

• Ensure the individual is ready and supported during the reduction process
• Understand past experiences of withdrawal
• A gradual reduction at a pace that is agreed with the individual improves the chance that the process is tolerable and successful
• Provide information on self-monitoring and what to do if symptoms re-occur
• Offer a non-pharmacological management plan

Does the person understand the outcomes of the review, including risk and benefits?

• Risk associated with B-Z use
• Discuss reducing/stopping treatment in a supportive environment (including fear of relapse)
• Importance of gradual reduction of treatment and informed of the risk of discontinuation/withdrawal symptoms on stopping
• Discuss Drugs and driving: the law for information on hypnotics whilst driving

Is drug therapy tailored to the individual?

• The individual’s preferences, values and needs should be considered
• Provide continual support during and after the withdrawal process, e.g. self-help groups

Agree the plan

• The reducing/stopping plan should be shared and agreed with the individual (as a written and/or verbal plan)
• Offer non-pharmacological approaches for the treatment of insomnia/anxiety

• self-management/support tools
• decision aids

Quality prescribing for Benzodiazepines and z-drugs: guide for improvement 2024 to 2027

Get help with your mental health and wellbeing on NHS inform (includes links to SilverCloud® (mental wellbeing courses), Daylight® (digital CBT), Sleepio® (digital CBT))

EMPOWER brochures are effective at giving information to support individuals who wish to reduce or stop benzodiazepines and z-drugs.

Choice and Medication available via NHS inform

National Therapeutic Indicators (NTIs) use prescription data in specific areas to provide a measure of prescribing activity for comparison across NHS Boards, Health and Social Care Partnerships (HSCPs), GP clusters and GP practices.

NTIs are available to view online.

NTIs benchmark prescribing across set parameters and are presented in a variety of ways. Examining variation over time can indicate where improvements in prescribing can be made. The indicator detail provides further information and suggested actions.

Indicators for this hot topic include:

• Number of people prescribed benzodiazepine or z-drug (for more than eight weeks) with an antidepressant. See the chart below.
• CNS (triple whammy): Number of people prescribed three or more high risk medicines
• Hypnotics and anxiolytics: doses per list size

Number of people prescribed benzodiazepine or z-drug (for more than eight weeks) with an antidepressant

(Click on image to enlarge)