Doctors may retire, but an inappropriate prescription can last forever.

Or, until the field changes. At the moment, a sea change in how doctors prescribe benzodiazepines is taking place across America. On June 5, 2025, Arthur Kleinschimdt, Ph.D., a senior leader in the federal Substance Abuse and Mental Health Services Administration, sent a “dear colleague” letter to physicians noting that “it is an important public health goal to reduce the chronic use of [benzodiazepines] by older adults, as clinically appropriate.”

Americans age 65 or older take benzodiazepines at the highest rate of any group in the United States. About 10 percent of older adults have benzodiazepine prescriptions; an estimated 25 percent to 30 percent of those have been taking them for longer than recommended — some 1.4 million to 1.7 million people. Overall, 9.1 percent of American adults, or more than 21 million people, reported benzodiazepine use in 2023; although prescriptions have declined from their 2013 peak, benzodiazepines are still some of the most-prescribed drugs in American life. And they can be deadly. In 2023, nearly 11,000 Americans died from overdoses involving benzodiazepines.

Benzodiazepines are most commonly prescribed for anxiety and panic disorders. They can be remarkably effective — some produce results within a few minutes. But this quick action is matched by their short windows of effectiveness. Keeping the state of relief they bring requires taking another dose. That combination contributes to tolerance. The longer a patient takes benzodiazepines, on average, the higher a dose is needed to have the same effect.

“It’s a shift in the philosophy of how to treat anxiety,” said Aniket Malhotra, M.D., assistant professor in the UAB Department of Psychiatry and Behavioral Neurobiology, who is board certified in addiction psychiatry.Kleinschmidt cited the greater risk of adverse events for those age 65 or older, compared with younger patients. These include “falls and hip fractures, motor vehicle collisions, delirium and cognitive impairment, and drug interactions.” Research shows that older adults taking benzodiazepines have a 50 percent higher risk of falling than those who do not. Benzodiazepines are particularly strongly associated with hip fractures, which often lead to long hospitalizations and eventually death for old and frail patients. The cognitive deficits seen in patients taking benzodiazepines include particular problems with memory, learning, attention and visuospatial ability. Benzodiazepines have also been repeatedly linked with higher rates of dementia. Studies have found anywhere from a 1.2 to 3.7 times higher rate of mortality in patients taking benzodiazepines.

Kleinschmidt noted that the American Geriatrics Society “strongly recommends avoiding prescribing benzodiazepines to older adults, except under certain circumstances.” (Those circumstances include patients with seizure disorders, rapid eye movement sleep disorders or severe generalized anxiety disorder.)

A few weeks after Kleinschmidt’s letter, the American Geriatrics Society and nine other professional societies published a new set of joint clinical practice guidelines on how to wean patients off benzodiazepines through tapering.

Tapering patients off benzodiazepines, as Kleinschmidt notes, is not easy or simple. Benzodiazepines “should not be discontinued abruptly if patients have been taking them for more than a month; they must be tapered gradually with guidance from a provider,” he noted in his letter. “On an individual level, clinicians and patients need to engage in shared decision-making regarding continuation or tapering of benzodiazepines.” That decision should include the risks of tapering, including withdrawal symptoms or return of anxiety/insomnia symptoms; risks of continuation of benzodiazepines; risks and benefits of alternative treatments; and the patient’s goals, values and preferences.

“It’s a shift in the philosophy of how to treat anxiety,” said Aniket Malhotra, M.D., assistant professor in the UAB Department of Psychiatry and Behavioral Neurobiology, who is board certified in addiction psychiatry. “More evidence has come out about the risk of cognitive issues, both short- and long-term, as well as confusion, falls and car accidents.” Although, Malhotra pointed out, “that philosophy was actually already there, because these drugs from the outset were meant to be used in the short term, not long-term.”

Tolerance does not happen with every patient, Malhotra said: “I have some patients who have been on stable doses for years, but tolerance is a real issue.”

Dangers of getting off benzodiazepines too quickly

“Safe tapering of BZDs can be clinically complex because rapid dosage reductions may precipitate acute withdrawal, which can be life-threatening,” the new guidelines state. “This Guideline was motivated, in part, by patients’ reporting harms associated with too rapid tapering/discontinuation of BZD medications. Inadequate tapering strategies may push patients to the illegal drug market, where counterfeit pills laced with fentanyl and other highly potent synthetic opioids (HPSOs) are common, presenting an increased risk of overdose and overdose death.”

In many cases, patients are referred to Malhotra after their provider has retired. “They will say, ‘My PCP doesn’t feel comfortable prescribing these,’” Malhotra said. “They have been on benzodiazepines for years and have a chronic pain condition, and the provider does not feel comfortable with their being on benzodiazepines and opioids.”

Another factor pushing providers to stop prescribing benzodiazepines are prescription drug monitoring programs, or PDMPs. These electronic databases track prescriptions of controlled substances at the state level (Alabama’s database is here). By offering a central source for these prescriptions, the PDMPs allow providers to see which medications a patient is already taking; they have also allowed pharmacies to proactively contact providers and request more information on why they are prescribing these medications to patients at risk. In some cases, this has led providers to become much more hesitant to renew benzodiazepine prescriptions.

This all adds up to a strong likelihood that older patients who have a benzodiazepine prescription will experience changes ahead. So how does Malhotra approach patients with this conversation? He shares several key points to consider:

1. Taking the right approach is crucial.

The goal “is to maintain long-term safety and sustainability and minimize risk,” Malhotra said. The general recommendation for safe tapering from benzodiazepines is to reduce doses by 5 percent to 10 percent every couple of weeks, Malhotra says. The rate can be faster in inpatient settings, where the patient is closely monitored, he notes. “Also, people who are taking short-acting benzodiazepines should be switched to a longer-acting agent at an equivalent dose before the taper is started,” he said. “This is an important strategy as tapering short-acting agents can cause worse rebound anxiety and more severe withdrawal.” (One published example of a benzodiazepine tapering protocol lasts 22 weeks total.)

It is important “to make sure you have a good, working, trustful relationship with the patient,” Malhotra said. “If they see this as a threat, that you are taking away something that has been helpful to them, it is difficult to have success. Coming off these medications can be really scary for many patients. They are like an important person in that person’s life. Every time they are anxious, it is like talking to a close friend. I have had patients say, ‘It brings up anxiety just to think about not having these medications.’”

That is why it is important that the patient understands why this shift is happening, Malhotra adds. “Otherwise, it is common for patients to think, ‘I was given something which was the only thing that helped me, and now you are taking it away,’” he said. “That is not going to work out long-term.”

“Most people are not taking these medications to get high or ignoring everything else in their life to use them,” Malhotra said. “Those are the defining criteria for use disorder versus someone who has been on these medications and never takes more than prescribed, but when they try to stop they cannot. Making sure the patient doesn’t feel they are being judged harshly and labeled as an addict is a big part of that working alliance.”

2. The approach will vary by the person.

“All people are different,” Malhotra said. “One recent example comes to mind. A patient was on 2 milligrams of clonazepam every day, and she had been at that dose for 10 years. When I discussed it, she was open to that, and she is already down to 0.5 milligrams a day within a few months. She is very motivated.”

But another patient “who was referred to me is still struggling,” he said. “I have been able to bring her down to 4 milligrams on most days, but she still has days when she takes more. It is very different for different people, and it depends on what else is going on in your life. If you are struggling with health issues, your self-esteem is poor, it is harder. If you are doing well and close to family, it is not as hard.”

3. Treatment strategies vary as well.

Switching patients from benzodiazepines to an antidepressant, particular the class known as SSRIs, is often helpful, Malhotra says. “If they are not on an SSRI, prescribe one — and if they are, maybe go up on the dose,” Malhotra said. But he noted, “you would be surprised how often these patients are not on an SSRI.” Most of those patients “will say, it doesn’t work for me. I’ve tried it.”

What does he do in that case? “You have to know that you are OK to get on with your life while the SSRI kicks in and you get back into a routine,” Malhotra said. One strategy to help patients make a successful transition to SSRIs is to concurrently switch them from a short-acting benzodiazepine, such as alprazolam or Ativan, to a long-acting benzodiazepine that peaks gradually, like clonazepam and diazepam. Then, after the SSRI has had a chance to work, they can make an eventual successful transition from benzodiazepines altogether, Malhotra says.

Another option is to add a prescription for Buspar (the brand name for buspirone), which is not a benzodiazepine and “is commonly added to help patients with anxiety,” Malhotra said. “Most patients like it.” Other non-benzodiazepine medications, including hydroxyzine and propranolol, can help with anxiety and be added as adjunctive therapies during tapering, “along with cognitive behavioral therapy, mindfulness-focused psychotherapies and other types of therapy,” he said.

Depending on “what the patient’s underlying psychological issues are, some kind of nonpharmaceutical options are also warranted,” Malhotra said. For patients who have been prescribed benzodiazepines for insomnia, or who fear that tapering off the drugs will damage their sleep, cognitive behavioral therapy for insomnia, or CBTi, “has the strongest evidence of efficacy, even when compared to medications,” he said.

4. Warning signs for more difficult tapering.

Are there indications that patients will have more trouble weaning off benzodiazepines?

“Duration is the big one,” Malhotra said. “We see patients who have been on these medications for two decades. They will have a very difficult time compared with someone who started taking them only a few months ago.”

Also, patients who struggle with “a poor sense of self, who have more difficulty in regulating emotions and tend to catastrophize, along with a history of trauma — those people can have a more difficult time,” Malhotra said. Other groups who may struggle more include those with past or current substance-use disorders, those on short-acting benzodiazepines, and those with limited support, he adds.

5. Find a doctor with patience and a willingness to help.

“Not everyone feels comfortable with helping patients come off these drugs,” Malhotra said. “It requires patience and willingness to have these long and at times uncomfortable conversations with the patient and taking that general approach that reflects non-judgment.”

One of the psychotherapeutic modalities that Malhotra uses is called motivational interviewing. It is a person-centered, goal-directed counseling approach that helps patients address resistance to change and increase their own personal motivation to change their behavior. That motivation will differ from person to person.

“It is one of the mainstays of how I talk to patients,” Malhotra said. “It reinforces their autonomy — it is them talking about what they want to do, instead of being prescriptive, ‘this is what you have to do.’” The prescriptive approach tends to elicit “a natural response of defending the behavior and sustains the patient in continuing that behavior,” Malhotra said.

Malhotra believes in what he calls the “MI spirit” — an emphasis on acceptance, compassion, partnership and evocation (MI does not focus on deficits but aims to bring out, or evoke, what the patient needs from within themselves). “You imbibe the MI spirit over time by being intentional about it,” Malhotra said. “By getting the patient to talk about what they want to do and reinforcing their autonomy.”

Malhotra decided to pursue a fellowship in addiction psychiatry when he was in his residency. “People have a lot of negative outlook toward this patient population,” he said. “I saw that they were often misunderstood and needed someone with a lot of patience and empathy.”

Click here to book an appointment with Malhotra or with another provider in the UAB Department of Psychiatry and Behavioral Neurobiology. For help with scheduling, call (205) 934-7008.