“Can we switch to something safer?”

Sometimes it's the patient asking.

Sometimes it's us.

Either way, it’s the moment when the risks of long-term benzo use start outweighing the relief they once offered.

This is the follow-up to last week's post on starting anxiolytics.

Today: how to switch when something isn’t working—or is no longer the right fit.

The most common challenge?

Not starting a benzo.

Getting off one. 

Here’s an approach I’ve used (and taught):

▸ Convert short-acting to long-acting. Start by switching alprazolam or lorazepam to clonazepam or diazepam. This helps smooth out withdrawal bumps—literally. Between the two, I prefer clonazepam. Diazepam may have a longer half-life, but its fast onset makes it more reinforcing—and more abusable. 

▸ Taper slowly.

Think weeks to months, not days. I aim for no more than a 25% reduction every 1–2 weeks. If withdrawal symptoms emerge, pause—or slow down further.

▸ Add support early.

Don’t wait until the taper is done to introduce a new agent. SSRIs, propranolol, buspirone, or hydroxyzine can make a huge difference when started during the taper.

▸ Address the insomnia.

That’s often what patients fear most. Options like mirtazapine, low-dose doxepin, trazodone, or melatonin can soften the landing.

▸ Frame it clearly.

I’ve found that patients do better when we’re explicit:

“This is a slow, structured process. It’s about finding something that works better for you in the long run.”

What’s your go-to strategy when switching someone off benzos? 

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