Benzodiazepine withdrawal and safe tapering

If you take a benzodiazepine such as alprazolam every day, stopping suddenly can cause seizures. The FDA’s boxed warning says abrupt stopping or a fast dose cut “may precipitate acute withdrawal reactions, which can be life-threatening.” The safer route is a slow taper, planned with the person who prescribes it.

Being physically dependent is also not the same as having an addiction. The 2025 joint tapering guideline calls dependence an expected result of ongoing prescribed use, distinct from a substance use disorder.

When to call 911

• They have a seizure.
• They’re confused, disoriented or seeing things that aren’t there.
• They’re very sleepy and hard to wake, or breathing slowly, especially if opioids or alcohol are involved too.

Why benzodiazepine withdrawal can be dangerous

SAMHSA’s TIP 45 groups sedative withdrawal with alcohol withdrawal as the kinds that can be life-threatening, unlike uncomplicated opioid withdrawal. The 2025 guideline says symptoms range from anxiety and sleep problems to seizures and delirium. The FDA’s 2020 safety notice describes withdrawal seizures as potentially life-threatening.

Some people are at higher risk. Past seizures raise the risk of withdrawal seizures, and a history of complicated withdrawal with seizures or delirium “is a significant predictor of future complications,” per the guideline.

Dependence can build faster than people expect. The guideline says it can develop within weeks, and that alprazolam tends to cause dependence more quickly. A taper may make sense even after 2 to 4 weeks of daily use.

There’s a second risk, separate from withdrawal. Taken together, benzodiazepines and opioids can cause profound sedation, slowed breathing, coma and death, according to the FDA label. TIP 45 notes that benzodiazepines alone rarely cause a fatal overdose, but combined with alcohol or other drugs the result could be fatal.

The FDA boxed warning (2020)

On September 23, 2020, the FDA required the boxed warning on every benzodiazepine to be updated to cover misuse, addiction, physical dependence and withdrawal reactions. The label now says the risks of dependence and withdrawal rise with longer use and higher daily doses, and that a gradual taper should be used to stop or lower the dose.

The FDA also said there’s no standard tapering schedule that suits every patient. That’s why the plan has to be built around you.

How fast a taper goes

In June 2025, ASAM and a group of other medical societies (psychiatry, neurology, family medicine, geriatrics, obstetrics and others) published the Joint Clinical Practice Guideline on Benzodiazepine Tapering. Its pace, written for clinicians:

• Start with dose cuts of 5 to 10% every 2 to 4 weeks.
• The taper should typically not exceed 25% every 2 weeks.

That is slow on purpose. The guideline says it may take months to years to fully taper off, especially after a high dose taken for a long time. These are the outer limits a clinician works within, and the right pace for you is a decision to make with your prescriber. Please don’t build your own schedule from these numbers.

The guideline also says clinicians should keep monitoring for 2 to 4 weeks after the last dose.

Where tapering happens

Most people can taper as outpatients, the guideline says. It tells clinicians to consider inpatient or medically managed residential care when someone’s risk can’t be safely handled in outpatient care. Past withdrawal seizures or delirium are the kind of history that points that way.

Alcohol makes it riskier. ASAM’s alcohol withdrawal guideline says a person going through alcohol withdrawal who is also physically dependent on benzodiazepines shouldn’t be managed at the lowest outpatient level. See alcohol withdrawal and levels of withdrawal care.

Protracted withdrawal

For some people, symptoms don’t end when the last pill does. The FDA’s 2020 notice says protracted withdrawal symptoms may last weeks to as long as 12 months. The 2025 guideline goes further: some people have symptoms for months or years after stopping.

The guideline lists possible symptoms including anxiety, depression, insomnia, memory and thinking problems, tingling or numbness, ringing in the ears and stomach or bowel trouble. If this is happening to you, tell your clinician rather than pushing through alone.

If you got your pills from someone other than a prescriber

The same rule holds: don’t stop suddenly if you’ve been taking them daily. You can still get medical help to come off safely. A primary care clinician or a withdrawal management program can assess you. Tell them honestly what you take and how often; they need it to plan safely.

Asking for a taper

Don’t stop on your own. If you have a prescriber, call them and say you want to come off, or lower the dose, and ask for a taper plan. If you don’t, or you’re also drinking or using opioids, find a withdrawal management program by ZIP in the finder. SAMHSA’s National Helpline, 1-800-662-4357 (free, 24/7), refers callers to local treatment.

Sources

• FDA Drug Safety Communication: FDA requiring Boxed Warning updated to improve safe use of benzodiazepine drug class, Sep 23, 2020
• FDA-approved alprazolam label, Boxed Warning, label effective Jan 3, 2025
• Brunner E, et al. Joint Clinical Practice Guideline on Benzodiazepine Tapering: Considerations When Risks Outweigh Benefits, J Gen Intern Med, 2025 (epub Jun 17, 2025)
• ASAM, The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management, J Addict Med, 2020
• SAMHSA, Quick Guide for Clinicians Based on TIP 45: Detoxification and Substance Abuse Treatment, based on TIP 45 (2006)
• SAMHSA National Helpline, last updated Jun 9, 2023