What is a good approach when you inherit an older adult patient from another prescriber on long-term high-dose benzodiazepine prescription that is not a dose with which you are comfortable prescribing?

I would suggest that no clinician must prescribe medication regimens for a patient with which they are not comfortable. Yet, if you have accepted them as a patient you must balance with keeping them safe. It would be essential to consider for what diagnosis/symptoms the benzodiazepine (BZD) is being utilized (e.g., anxiety, insomnia, seizures, SUD) and seizure history (in which case a taper down of the BZD might be more problematic or unsafe than with other disorders). If you are unable to decline taking over this prescription (e.g., unless your agency requires you to follow transferring prescriber’s dictates), discuss gently with the patient your unease with this off-label and non-evidence-based long-term treatment with benzodiazepines as well as the dangers of long-term use of BZDs for older adults… and you could potentially offer a very conservative taper off (or down) of the BZD to which you can mutually agree. First, you must establish good rapport with the patient in order for them to trust your knowledge and treatment plan, especially when it comes to a deprescribing BZD taper.

Many millions of outpatient prescriptions are written annually for BZDs. Many prescribers do not follow published treatment guidelines and regularly inherit patients who have been treated with BZDs for years. Long-term outpatient prescribed BZD use are recognized, especially among older adults, for whom use should be minimized. Manualized approaches to outpatient down-titration of BZDs have been established. Clinicians should establish therapeutic alliance with these patients utilizing therapeutic communication skills. Early conflict that may occur when the patients expect indefinite BZD regimen with unwillingness to risk discontinuing the drug, leading often to nonadherence to a down-titration plan or even patient termination of the relationship. [Journal of Psychosocial Nursing and Mental Health Services, 58(1), 29–32.] This inheritance of patients on non-rational controlled substance regimens is a common dilemma in healthcare.

Dangers of BZDs for older adults should be discussed with patients – excerpts from the Beers List/Criteria from American Geriatrics Society (2019 update), which provides evidence of potentially harmful drugs in the elderly:  “Benzodiazepines (short, intermediate, and long-acting) Avoid; older adults have increased sensitivity to and decreased metabolism with long-acting agents; increased risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes; may be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia.”

There are two FDA black box (strongest) warnings in the prescribing information (package insert) related to benzodiazepines. 2020 – related to use, misuse, dependence, and withdrawal; 2016 – related to increased overdose/risk of death with combination of benzodiazepines and opioid medications by fatal respiratory depression. For more information on this important topic, see this SMI Adviser webinar: How Much Benzodiazepine Prescribing is the Right Amount of Prescribing?



  1. Amberg A. (2020). Making Alliances With Patients Dependent on Benzodiazepines: A Provider’s Experience. Journal of psychosocial nursing and mental health services58(1), 29–32. https://doi.org/10.3928/02793695-20191218-06
  2. By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel (2019). American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society67(4), 674–694. https://doi.org/10.1111/jgs.15767
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