Title: Recommendations

Context:
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT.  This is especially true for patients who are already accustomed to receiving both medications (see Patient  Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for  unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering  versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91]  Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse  effects including seizures and death. Tapering benzodiazepines should be performed with caution and  within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the  difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD  CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in  treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a  higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small  clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although  anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in  tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper  may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a  contraindication to initiation of OT.

Question: Why can benzodiazepines be challenging to discontinue once initiated?

Answer: due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety