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Benzodiazepine Dependence — MRCPsych Paper B MCQ

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ModerateSubstance MisuseBenzodiazepine DependenceMRCPsych Paper B

A 45-year-old woman has taken diazepam 40 mg daily for 18 months and meets criteria for benzodiazepine dependence. She requests help to stop. She is clinically stable, with no acute intoxication, concurrent alcohol or opioid dependence, or history of withdrawal seizures. What is the most appropriate withdrawal approach?

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Correct answer: B — Agree an individualised slow, stepwise diazepam taper, using smaller decrements as the dose becomes lower

The correct answer is B. NICE recommends a slow, stepwise reduction proportionate to the current benzodiazepine dose, with progressively smaller decrements as the dose falls. The schedule should be agreed with the patient, reviewed regularly and paused or modified if withdrawal symptoms become intolerable. High-dose, long-term diazepam withdrawal may take months or longer rather than following a fixed timetable. Abrupt cessation risks severe withdrawal, including delirium and seizures. Pregabalin is itself associated with dependence and is not a routine substitute for benzodiazepine withdrawal. Phenobarbital-based rapid detoxification and flumazenil infusion are not standard UK approaches for a clinically stable patient. Switching to a longer-acting benzodiazepine may be considered when withdrawing a short-half-life agent, but this patient is already taking long-acting diazepam.

Reference: National Institute for Health and Care Excellence. NG215, Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults, recommendations 1.5.10–1.5.14. 2022. https://www.nice.org.uk/guidance/ng215/chapter/recommendations