https://doi.org/10.1176/appi.ajp.20260426
In clinical practice, benzodiazepine prescribing is complex. Decisions about initiation, continuation, or reduction are shaped by the original indication, current symptoms, prior tapering experiences, co-occurring conditions, psychosocial context, and patient preferences. The central tension is familiar: The same patient may derive meaningful relief, remain vulnerable to cumulative adverse effects, and risk destabilization if the medication is reduced at the wrong time (1–4).
This tension exists within an unsettled clinical landscape. Benzodiazepines are widely prescribed, including for long-term use, despite long-standing recommendations to limit duration and reassess need (1, 5–7). The field remains divided about the magnitude of these risks, the appropriateness of long-term treatment in selected patients, and the potential for overcorrection in response to safety concerns (8, 9). This uncertainty should not obscure the fact that benzodiazepines can be clinically appropriate for selected patients when symptoms are severe, benefits are clear, and prescribing is paired with monitoring and reassessment.
Efforts to reduce benzodiazepine use have had uneven results, with discontinuation rates remaining modest even in structured interventions (10–12). Some patients remain on stable regimens for years without reassessment, while others undergo taper attempts that are difficult to sustain, leading to reinstatement or cycles of reduction and escalation (10, 11). These patterns often reflect difficulty tolerating tapering, symptom recurrence, or clinical instability. Much of the literature focuses on tapering, yet existing strategies vary widely and often lack consistent guidance, particularly in the context of co-occurring conditions or concurrent prescribing (3, 6, 13). These strategies are essential, but they do not fully address a more immediate clinical challenge: how to decide, at a given visit, the goal of treatment.
Benzodiazepines are often continued because a patient is stable, revisited only during crises, or tapered reactively rather than intentionally. Over time, it may become unclear whether ongoing prescribing reflects a deliberate decision, a temporary accommodation, or acquiescence. This lack of explicit framing can make it difficult to align care across visits, clinicians, and different settings (14, 15). It also complicates documentation and handoffs, as the rationale for continued use or prior taper attempts may be unclear (11, 16).
The gap, then, is not a lack of clinical nuance or guidance; patient-centered deprescribing principles are widely endorsed but inconsistently operationalized in routine care (17). Rather, it is the absence of a structured way to translate this complexity into an explicit, shared understanding of the current treatment goal. At any given time, including initiation, the treatment goal should be stated clearly.
Explicitly defining the near-term treatment goal at each visit may help address this gap. Such explicit goal-setting is not intended to replace clinical judgment but rather to make the clinician’s current treatment intent easier to communicate, document, and revisit over time. A simple framework with four near-term goals—maintain, reduce, defer, and discontinue—can provide a shared language for these decisions. This framework can be used alongside controlled substance agreements, which may clarify informed consent, expectations, monitoring, and circumstances for modifying prescribing but often do not specify the immediate clinical goal at a given visit (18). These goals are not fixed categories but working positions that can change over time.
“Maintain” involves continuing the current regimen because the patient is deriving meaningful benefit from it, which outweighs risks in context. This may include patients with panic disorder or severe anxiety who experience sustained symptom control without observed or reported adverse effects (9). Continuation is thus an active decision rather than a default, and it carries an expectation of ongoing reassessment as the risk-benefit balance evolves.
“Reduce” involves lowering the dosage in response to increasing risk while recognizing ongoing benefit. This aligns with harm-reduction approaches that recognize partial dosage reduction as a meaningful and realistic outcome for some patients (3). The goal is to decrease cumulative exposure while preserving clinical stability.
“Defer” indicates that discontinuation is appropriate in principle but not advisable at the present time. This may occur during periods of instability, limited psychosocial support, or after prior taper attempts associated with substantial worsening, including complex persistent benzodiazepine dependence (19). Tapering is often prolonged, nonlinear, and dependent on patient readiness and system-level supports (10, 20, 21). Deferral therefore represents an intentional, time-limited strategy focused on stabilization and preparation.
“Discontinue” involves actively moving toward stopping the medication, with tapering when clinically indicated. This aligns with guideline recommendations and deprescribing algorithms when risks outweigh benefits and sufficient supports are in place (3, 6, 21). It also requires careful attention to tapering strategy, including dosage reduction pace, patient readiness, and the need to distinguish withdrawal, rebound symptoms, and recurrence of the underlying condition, since each may require a different clinical response (20–22). While discontinuation is often assumed to reduce harm, emerging evidence suggests that it may be associated with small but measurable increases in mortality and other adverse outcomes in some patients (4). These findings underscore the fact that discontinuation is not uniformly benign. It is best pursued when clearly indicated, collaboratively planned, and supported by adequate follow-up and psychosocial resources (21).
This approach may be particularly useful for stable patients who report ongoing benefit from long-term benzodiazepine use. In this situation, clinicians are often pulled in two directions. The patient may report meaningful benefit without appreciable adverse effects, while guidelines and product labeling emphasize the risks of long-term use and encourage reduction or discontinuation. Risks are often cumulative and not immediately visible, whereas benefits are concrete. Decisions therefore become preference-sensitive and may not have a single correct answer. Rather than treating discontinuation as the presumed endpoint at every visit, clinicians can identify the current treatment goal, explain the rationale, and revisit the decision as risks, symptoms, and patient circumstances change (2, 8).
The framework may also help in fragmented systems of care. Benzodiazepine prescribing often spans multiple clinical settings, with limited coordination and variable documentation of treatment intent. Deprescribing efforts require coordination among clinicians, patients, and systems, and may fail when these elements are not aligned (11). A clearly documented treatment goal can help reduce ambiguity and improve continuity.
A related issue concerns initiation. While clinical and policy attention has appropriately focused on limiting overuse and long-term exposure, benzodiazepines remain clinically important for selected patients with severe anxiety and related conditions. In some cases, concern about dependence, diversion, or regulatory scrutiny may lead physicians to avoid initiation even when symptoms are acute, functionally impairing, and only partially responsive to first-line treatments (23). The challenge is not only to reduce inappropriate continuation but also to support appropriate initiation when benefits outweigh risks, with a clear plan for monitoring and reassessment. In this context, the proposed framework encourages clinicians to treat initiation not as an open‑ended commitment but as the first step in a sequence of planned goal shifts, with an explicit expectation that the near-term goal will be reassessed and may transition from “maintain” to “reduce” or “discontinue” as symptoms stabilize and risks evolve.
Although this framework focuses on decision making, we acknowledge that it does not capture all the nuances of benzodiazepine prescribing. Clinical reality is more complex than any set of categories can fully represent, and in some cases the appropriate goal may be unclear or shift rapidly. However, explicitly specifying and documenting the near-term treatment goal can help clinicians better translate existing guidance into practice, communicate decisions more clearly, and ensure that benzodiazepine prescribing reflects an active clinical decision rather than clinical inertia.
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