How to taper off benzodiazepines

During med school, I lived by my “First Aid for the USMLE” book series.

Over a decade later, I still use some of the acronyms and mnemonics…10 points to Gryffindor if you remember SIGECAPS.* 🙂

Dr. Harvinder Singh MD, founder of Psychiatry Education Forum, joined me on YouTube this week and reminded me of this one: Out The Liver (OLT).

Do you know that one?

Here’s a refresher: All benzodiazepines are metabolized by the liver, and the metabolites are eliminated by the kidneys.

Some benzos don’t have active metabolites, and take a simpler route through the liver…they skip the usual oxidative metabolism and go straight to glucuronidation. 👇

Those are the “OLT” (Out The Liver) benzos:
‣ Oxazepam
‣ Lorazepam
‣ Temazepam

Why does this matter? Because this pathway doesn’t rely heavily on liver function, making these meds safer choices for older adults or people with liver issues (Peng et al, 2022). Plus, they don’t produce active metabolites, so they’re gentler on the kidneys too.

I don’t recommend long-term use of benzodiazepines because of the side effects including a high potential for misuse and physical dependence.

So how do you safely come off of them? Dr. Singh provided us with a masterclass on benzodiazepine tapering this week, based on the 2025 ASAM (American Society of Addiction Medicine) guidelines.

If you’re a clinician it’s a must watch, I learned so much from it. If you’re not a clinician, but are taking benzodiazepines or know somebody who is, this is must-have information.

This talk is jam-packed with high yield information, including:
‣ How long it takes to become dependent on benzos (it happens much faster than you think!)
‣ How to assess withdrawal risk
‣ The number 1 mistake people make with tapering
‣ Dr. Singh’s first step in tapering – it will change how you think about benzo tapers
‣ A tapering table to help you decide how to taper
‣ When you should switch to a long acting benzo, which 3 long acting benzos to choose, and who should NOT be switched to long acting
‣ Tapering pace and how to start
‣ The 2 adjuncts recommended by the ASAM guidelines to support a taper
‣ Managing sleep disturbances during a taper

And so much more…

Watch it here and bookmark the link, because you’ll want to refer back to it again and again. https://www.youtube.com/watch?v=eCzUoh5Cx_A&t=1s

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References:
1. Peng L, Morford KL, Levander XA. Benzodiazepines and Related Sedatives. Med Clin North Am. 2022 Jan;106(1):113-129. doi: 10.1016/j.mcna.2021.08.012. PMID: 34823725.