Prescription Guidelines

Summary: Most people will become dependent after 6 weeks continuous use. Only 30% of benzodiazepine dependent people ever get off them completely. While many exist, no benzodiazepine or Z-drug prescription guideline is generally accepted in the United States. However, several prescription guidelines for benzodiazepines, and sometimes Z-drugs, have been written by a variety of organizations. We were able to identify 21 different guidelines on benzodiazepines and/or Z-drugs and an additional 80 guidelines that include at least some reference to at least one aspect of benzodiazepine use.  These source prescription guidelines are listed below, along with a summary of each guideline.

Here are the common themes of these prescription guidelines:

1. Benzodiazepines are not first-line medications for most conditions, including anxiety and insomnia.
2. If used, prescribe the lowest effective dose for the shortest duration.
3. Limit prescribing to no more than 4 weeks (mean, with a range of 2 to 6 weeks).*
4. Benzodiazepine efficacy diminishes after 4-6 weeks of use.
5. Physiological dependence is common after 2-4 weeks’ use.*
6. A guided withdrawal process is usually needed after physiological dependence is established.An FDA review of available data determined that all benzodiazepines carry risks of withdrawal syndrome in newborns and excessive sleepiness or sedation can negatively affect newborns’ breathing.

* The evidence shows that some patients become physiologically dependent in as little as 2 weeks, and may go through a subsequent withdrawal and recovery process that extends many months. For details see the pages about Dependence and Withdrawal. The Alliance supports efforts to establish a widely-recognized evidence-based prescription guideline.


AUGUST 2022: An FDA review of available data determined that all benzodiazepines carry risks of withdrawal syndrome in newborns and excessive sleepiness or sedation can negatively affect newborns’ breathing. The FDA announced that it will require benzo manufacturers to update prescribing information to reflect several risks that may affect newborns exposed to benzos during pregnancy or while breastfeeding.

Consolidated Prescription Guidance Document

This prescription guidance document was developed by our former Medical Director, Dr. Steven Wright, in collaboration with University of Colorado School of Medicine, the Colorado Consortium for Prescription Drug Abuse Prevention, and several other patient advocacy groups.

Prescription Guideline Sources

The source material for the summary benzodiazepine and Z-drug prescription guideline is listed here, along with a brief summary of each guideline.

Deprescribing benzodiazepine receptor agonists: evidence-based clinical practice guideline. Pottie K, Thompson W, Davies S, et al. Canadian Fam Phys. 2018;64(5):339-51.  Article
Summary:   Systematic review of BZRA deprescribing trials for insomnia, review of reviews of harms of continued BZRA use, narrative syntheses of patient preferences, resource implications, using GRADE methodology.  Recommend deprescribing (tapering slowly) of BZRAs be offered to all senior adults (>64 yo) and adults 18-64yo who have used BZRAs >4w. These recommendations apply to patients who use BZRAs to Rx insomnia on its own (1º insomnia) / comorbid insomnia where potential underlying comorbidities effectively managed. This guideline does not apply to those with other sleep disorders or untreated anxiety, depression, other physical or MH conditions that might be causing / aggravating insomnia.  The researchers concluded that BZ receptor agonists are associated with harms, and therapeutic effects might be short-term. Tapering BZRAs improves cessation rates v usual care without serious harms. Patients might be more amenable to deprescribing if they understand rationale (potential for harm), involved in developing tapering plan, offered behavioral advice.

Judicious Prescribing of Benzodiazepines, City Health Information, Volume 35 (2016), The New York City Department of Health and Mental Hygiene No. 2; 13-2013-20 Guideline
Summary: If benzodiazepines are indicated, prescribe the lowest effective dose for the shortest duration—no more than 2 to 4 weeks.

Royal Australian College of General Practitioners. Prescribing drugs of dependence in general practice, Part B: benzodiazepines. 2015. Guideline
Summary: If hypnotics are to be used for treating insomnia, it is recommended that treatment is short term (not more than 4 weeks) and at the lowest possible dose.

Maine Benzodiazepine Study Group. Guidelines for the use of benzodiazepines in office practice in the state of Maine.  2008. Guideline
Summary: The principal indication for BZDs is for short-term treatment (2 to 6 weeks) of anxiety disorders. These conditions include generalized anxiety disorder, phobias, PTSD, panic disorder, and severe anxiety associated with depression, while waiting for the full effect of the antidepressant. While BZDs have been studied and utilized to treat these conditions they are not first-line therapy for any of them. Continuing BZDs beyond 4 to 6 weeks will result in loss of effectiveness, the development of tolerance, dependence and potential for withdrawal syndromes, persistent adverse side effects, and interference with the effectiveness of definitive medication and counseling. BZDs taken for more than 2 weeks continuously should be tapered rather than discontinued abruptly.

The College of Psychiatry of Ireland. A consensus statement on the use of benzodiazepines in specialist mental health services. June 2012.  Guideline
Summary: Unwanted effects can largely be prevented by keeping dosages minimal and courses short (ideally 4 weeks maximum) and by careful patient selection. Benzodiazepines are licensed for use for 4 weeks only; prescribing for longer than 4 weeks is known as off-label prescribing. The principal indication for benzodiazepines is for short-term treatment (2 to 4 weeks) of anxiety disorders.

Ashton H. Guidelines for the rational use of benzodiazepines. When and what to use. Drugs. 1994;48(1):25-40. Abstract
Summary: As hypnotics, benzodiazepines are mainly indicated for transient or short term insomnia, for which prescriptions should if possible be limited to a few days, occasional or intermittent use, or courses not exceeding 2 weeks. Diazepam is usually the drug of choice, given in single doses, very short (1 to 7 days) or short (2 to 4 weeks) courses, and only rarely for longer term treatment. With long term use, tolerance, dependence and withdrawal effects can become major disadvantages. Unwanted effects can largely be prevented by keeping dosages minimal and courses short (ideally 4 weeks maximum), and by careful patient selection.

JPS Health Network. Prescribing and tapering benzodiazepines. Behavioral health virtual resource. 2014. Guideline
Summary: Benzodiazepines are not first line agents. Continuing benzodiazepines beyond 4 to 6 weeks will result in loss of effectiveness, the development of tolerance, dependence and potential for withdrawal syndromes, persistent adverse side effects, and interference with the effectiveness of definitive medication and counseling. Benzodiazepines taken for more than 8 weeks continuously should be tapered rather than discontinued abruptly.   Insomnia—There is evidence for the effectiveness of benzodiazepines and other hypnotics in the relief of short-term (1 to 2 weeks), but not long-term insomnia. Muscle relaxant—Benzodiazepines are indicated for the short-term relief (1 to 2 weeks) of muscular discomfort associated with acute injuries or flare-ups of chronic musculoskeletal pain.

Eagles L. Guidance for prescribing and withdrawal of benzodiazepines & hypnotics in general practice. NHS Grampian. 2008. Guideline
Summary: There are no licensed indications for the prescription of benzodiazepines for more than 2 to 4 weeks. Benzodiazepines are indicated for the short-term relief (2-4 weeks only) for the relief of ANXIETY that is severe, disabling or subjecting the individual to unacceptable distress… The use of benzodiazepines to treat short-term “mild” anxiety is inappropriate and unsuitable. Benzodiazepines should used to treat insomnia only when it is severe, disabling or subjecting the individual to extreme distress. Dependence on even small doses of benzodiazepines can result in anxiety, insomnia and other distressing withdrawal symptoms if the drug is stopped abruptly.

Kaiser Permanente. Benzodiazepine and Z-drug safety guideline. 2014. Guideline
Summary: Benzodiazepines and Z-drugs (i.e., newer GABA receptor agonists, like zolpidem [Ambien]) are overprescribed, and the reasons behind many prescriptions are not based on evidence or on published guidelines. Despite warnings about the long-term use of benzodiazepines, millions of prescriptions are still issued for benzodiazepines and Z-drugs each year. As a result, clinicians may encounter patients who have been prescribed benzodiazepines or Z-drugs on a long-term basis and are resistant to discontinuation. Use of benzodiazepines beyond 6 weeks is not recommended.

Ireland Department of Health and Children. Benzodiazepines: good practice guidelines for clinicians. 2002. Guideline
Summary: Benzodiazepines are only indicated when the disorder is severe, disabling or subjecting the individual to extreme distress. Dependence is now recognized as a significant risk in patients receiving treatment for longer than one month …

Prescribing Guidelines for Pennsylvania Safe Prescribing of Benzodiazepines for Anxiety and Insomnia Guideline
Summary: Though benzodiazepines are effective in the short-term treatment of severe anxiety and panic disorders, evidence shows that continuing them beyond four to six weeks will likely result in loss of efficacy and the development of tolerance and dependence and, consequently, increase the risk of development of a benzodiazepine substance use disorder. The risk of dependence increases with dose and duration of therapy. While anxiety disorders are amenable to short-term treatment with benzodiazepines, they are not first-line treatments for anxiety disorders and are not effective for the long-term treatment of these disorders.

The Center for Integrated Health Solutions (CIHS), jointly funded the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA), Safe & Effective Use of Benzodiazepines in Clinical Practice, May 31, 2017 Presentation
Summary: Most people will become dependent after > 6 weeks continuous use. Only 30% of benzodiazepine dependent people ever get off them completely.