Benzodiazepine Tapering & Deprescribing
in Sarasota, FL

A sleeping pill meant for a few weeks and refilled for years is one of the most common reasons a person on the Gulf Coast first writes to Dr. Leeds. Dr. Leeds is an osteopathic physician who specializes in deprescribing; his office is in Fort Lauderdale, and patients in Sarasota, Bradenton, Venice, Lakewood Ranch and North Port see him by secure video. Benzodiazepine and z-drug tapering is his lead service and psychiatric medication deprescribing the second; buprenorphine treatment and the Sinclair Method are covered lower down.

In short:

• Sleeping pills such as Ambien (zolpidem) and Lunesta (eszopiclone), like the benzodiazepines prescribed at bedtime, act on the same receptors as Xanax or Klonopin and are tapered by the same principles.
• Dr. Leeds tapers them for Gulf Coast patients by a weekly video visit that often runs close to an hour, with text access for urgent questions at any hour in between. He prescribes for patients in Florida.
• Reductions get smaller as the dose falls, liquid doses make the small steps possible, and the bedtime dose is usually the last to come down. A taper often takes a year to 18 months or longer.
• Physical dependence is not addiction. The taper happens at home, at the patient’s pace, and stopping suddenly is never part of the plan.

Why do sleeping pills belong on a page about benzodiazepine tapering?

Because inside the brain they are the same kind of drug. Zolpidem, eszopiclone, zaleplon (Sonata) and zopiclone are called z-drugs. They are not benzodiazepines chemically, but they act at the benzodiazepine site on the GABA-A receptor, the gamma-aminobutyric acid type A receptor through which a benzodiazepine calms and sedates. The Ashton Manual puts it plainly: zopiclone and zolpidem, although not benzodiazepines, act in the same way and have the same adverse effects, including dependence and withdrawal reactions. The benzodiazepines prescribed for sleep, temazepam (Restoril), triazolam (Halcion) and bedtime prescriptions of clonazepam (Klonopin) or lorazepam (Ativan), belong in the same picture. Taken nightly for months or years, any of them leaves a nervous system that has adapted to the drug and needs it to feel normal.

Physical dependence is not addiction. Addiction is a behavior, compulsive use that continues despite harm, and most people who need help getting off a sleeping pill have never shown it. The U.S. Food and Drug Administration (FDA) said as much in September 2020, when it revised the boxed warning that every benzodiazepine label carries: the drugs produce physical dependence, withdrawal reactions can continue for months, and abrupt discontinuation or too rapid a reduction can bring on serious reactions, seizures among them. The treatment for a receptor change is a gradual, medically supervised reduction, not a meeting and not a refused refill.

When does a sleeping pill taken for years deserve a planned taper rather than another refill?

The labels were written with short-term use in mind; the zolpidem label says that insomnia which has not improved after seven to ten days of treatment may point to another condition that should be evaluated. A few signs suggest that another refill is not the answer:

• The pill no longer does much. The Ashton Manual notes that tolerance to the sleep-inducing effect develops quickly, with sleep patterns drifting back toward their pre-treatment state after a few weeks of regular use. Poor sleep with the pill and far worse sleep without it is dependence, not insomnia.
• Mornings are foggy. In 2013 the FDA recommended lower bedtime doses of zolpidem, especially for women, because of impaired alertness the next morning.
• Something has happened at night that the person does not remember. In 2019 the FDA added a boxed warning to zolpidem, eszopiclone and zaleplon for complex sleep behaviors such as sleepwalking and sleep driving.
• Age. Sarasota and Venice have many residents in their seventies and eighties, and a sedative at bedtime raises the risk of a night-time fall and of confusion.

None of these is a reason to stop. Stopping suddenly after long-term use can trigger seizures and a severe withdrawal reaction, and is never safe. They are reasons to plan a taper.

What is rebound insomnia, and what does a taper do to sleep week to week?

Rebound insomnia is sleep that is worse than it was before the drug was ever started, appearing when the drug is reduced or stopped; the Maudsley Deprescribing Guidelines describe it for the sleeping-pill benzodiazepine triazolam, and the Ashton Manual notes that the z-drugs produce the same withdrawal reactions. It is why people who try to quit a sleeping pill on their own give up after three bad nights: they have met not their original insomnia but withdrawal, the predictable result of too large a step.

The relationship between dose and effect at the receptor is hyperbolic, a relationship the Maudsley Deprescribing Guidelines apply to z-drugs as well as benzodiazepines: at a high dose a cut of a milligram removes little of the effect, while near the bottom the same cut removes most of what is left. A taper built on that curve, described on the benzodiazepine tapering page, makes larger reductions early and smaller ones later, so that each step costs the nervous system about the same.

A reduction follows a pattern. For a few nights sleep is lighter or shorter and dreams are vivid; then the brain catches up and the nights settle back to roughly where they were. When they have settled, the next reduction is considered; when they have not, the dose is held for as long as needed. Over a year to 18 months or longer that cycle repeats until the last fraction of a milligram is gone.

Why does the evening dose usually come down last?

The first reason is in the Ashton Manual. When a short-acting drug is being replaced with diazepam (Valium), Professor C. Heather Ashton advised substituting the night-time dose first, and in her withdrawal schedules the daytime doses are removed before the bedtime dose, so the final reductions come off the dose taken at night. The second reason is practical: sleep is often the function most sensitive to the drug’s absence, a bad night spoils the whole next day, and protecting the night protects everything else.

For a patient whose only dose has always been at bedtime, the usual case with a sleeping pill, the taper is a single evening dose shrinking slowly. A common route is to move a very short-acting hypnotic, which leaves the body within hours and gives the brain a small rehearsal of withdrawal every morning, over to diazepam, whose long half-life smooths the night and the following day. Not everyone needs or tolerates that switch, and some patients taper on the medication they already take. The final steps call for a precisely measurable form of the drug: diazepam comes as a manufactured 1 mg/mL oral solution, one milligram per milliliter, with its own FDA label, and a compounding pharmacy can prepare liquid forms of other drugs, so a reduction of a fraction of a milligram is routine.

What can a patient do about sleep during a taper without adding another sedative?

The first rule is what not to do. Alcohol works on the same GABA-A receptor, so a nightcap, used as a sleeping aid, undermines the taper, and the Ashton Manual lists alcohol among the sedatives that must not be used as a substitute sleeping aid during withdrawal. The same goes for a leftover z-drug or an antipsychotic such as quetiapine prescribed off label for sleep. Dr. Leeds does not start an antidepressant, an antipsychotic or a gabapentinoid to treat withdrawal from the first.

What helps is less dramatic and more reliable:

• A fixed wake-up time, seven days a week, even after a bad night; the body clock is set by when a person gets up.
• Morning light. The Gulf Coast has plenty of it, and a little time outdoors soon after waking does more for the following night than most people expect.
• Less time in bed, not more. Lying awake for hours teaches the brain that the bed is a place to worry; getting up, doing something dull in dim light, and returning when sleepy breaks that link.
• Expecting the rough nights. A few poor nights are expected after a reduction and usually settle, and knowing that in advance takes much of the fear out of them.

The Maudsley Deprescribing Guidelines make the point that learning to manage insomnia without a drug can make the withdrawal easier and prepares a person for life without the medication.

How does a telemedicine taper work from Sarasota, Bradenton, Venice or Lakewood Ranch?

Sarasota sits on the Gulf Coast between Tampa Bay and Charlotte Harbor, and the page serves the stretch around it: Bradenton to the north, in Manatee County; Lakewood Ranch, which straddles the county line along University Parkway; the barrier islands; and Venice and North Port down US 41 and I-75 to the south. Fort Lauderdale is roughly 220 miles away, three and a half to four hours by road.

The taper runs by secure video from the patient’s home. Visits with Dr. Leeds are weekly and often up to an hour, with text access for urgent questions between visits, day or night. Each prescription is sent electronically to whichever pharmacy the patient prefers; chain and independent pharmacies in Sarasota, Bradenton and Venice can order the diazepam oral solution as anywhere else in Florida, and compounded liquids come from compounding pharmacies, of which Florida has many. The Fort Lauderdale office is open Monday to Friday, 10 AM to 2 PM, for any patient who would rather be seen face to face, and that trip is a choice, never a requirement. Dr. Leeds prescribes for patients in Florida. For someone outside Florida, a consultation may still be possible.

A common history on this coast is a sleeping pill started after a move, a retirement, a bereavement or a hospital stay, meant for a few weeks and still refilled a decade later, or a clonazepam prescription that began for anxiety and migrated to bedtime.

What about symptoms that linger after the final dose?

Benzodiazepine-induced neurological dysfunction (BIND) is the name for the cluster of symptoms a benzodiazepine or z-drug can cause while it is being taken, during a taper, and after the last dose, among them surges of anxiety, burning skin, brain fog and, for the sleeping-pill patient, insomnia that outlasts the drug. A slow taper is the best available protection against the worst of it, though not a guarantee, and Dr. Leeds treats these symptoms as genuine medical problems and handles them within the taper. Symptoms that continue for months after the final dose are called protracted withdrawal; they improve with time, usually unevenly, in the pattern many patients call windows and waves. The benzodiazepine withdrawal and life after benzos pages go further.

Does the same approach apply to antidepressants, gabapentinoids and antipsychotics?

It does. The selective serotonin reuptake inhibitors (SSRIs) such as Lexapro (escitalopram) and Zoloft (sertraline), the serotonin-norepinephrine reuptake inhibitors (SNRIs), gabapentin (Neurontin) and Lyrica (pregabalin), and the antipsychotics, Seroquel (quetiapine) among them, which is often handed out for sleep, are all tapered with reductions that shrink as the dose falls. The Maudsley Deprescribing Guidelines describe hyperbolic reductions for the antidepressants and the gabapentinoids, antipsychotics come down on the same principle, and compounded liquids provide the small steps. Dr. Leeds tapers patients off these medications and does not start them. The psychiatric medication deprescribing page has more.

What else does Dr. Leeds treat?

Dr. Leeds also treats opioid dependence, prescribing buprenorphine, the active medication in Suboxone, ZubSolv and their generic film and tablet forms, to patients in Florida by telemedicine. Induction happens at home with phone support, and when fentanyl is in the picture the first dose is kept low where that is needed. Buprenorphine visits are monthly, weekly when the situation calls for it. The buprenorphine treatment page explains the process.

Alcohol use disorder is treated with the Sinclair Method: naltrexone taken before drinking so that, over months, the reward fades and drinking fades with it, and abstinence from day one is not a condition. When a patient needs to stop drinking altogether, withdrawal can be supervised in the patient’s own home with a nurse present 24 hours a day, since alcohol withdrawal, like benzodiazepine withdrawal, is never safe to attempt alone. Whether Dr. Leeds can help with another addiction, including stimulant dependence, for which there is no medication, is decided at a consultation.

What is different about concierge care for a Gulf Coast patient?

The physician who wrote the plan is the one on the screen each week. Dr. Leeds works as a concierge practice rather than through insurance, so there is no handoff to a coach, a nurse practitioner or a covering provider, and urgent texts between visits reach him. Care begins with a consultation, which a person may book without going further; it is a conversation, not a medical visit, and creates no physician-patient relationship. Dr. Leeds sits on the medical advisory board of the Benzodiazepine Information Coalition, and deprescribing is a frequent subject on The Rehab Podcast, which he hosts.

Frequently asked questions

I have taken Ambien every night for eight years and it still seems to work. Why would I taper?

Because what it most likely does now is hold off withdrawal rather than treat insomnia. The Ashton Manual notes that tolerance to the sleep effect develops within weeks. If a night without the pill is dreadful and a night with it is merely ordinary, the drug is preventing rebound, and a planned taper is the way to learn what sleep is like without it.

My sleeping pill is temazepam, a benzodiazepine. Is the taper different from an Ambien taper?

The principles are identical: hyperbolic reductions, small steps near the end, liquid doses when tablets are too coarse, and the bedtime dose last. Temazepam stays in the body longer than zolpidem, which changes how the nights feel after a reduction and whether a crossover to diazepam is worthwhile.

Is any part of the taper done in person on the Gulf Coast?

No. Dr. Leeds has no office, staff or clinic in Sarasota, Bradenton or anywhere on the Gulf Coast; the whole taper runs by secure video. His only office is in Fort Lauderdale, about 220 miles away, and an in-person visit there is available to anyone who wants one.

What if I cannot sleep at all for a few nights after a reduction?

Send a text. That is what the 24/7 text access is for: Dr. Leeds can hold the dose or shrink the next step without waiting for the following video visit. A few lighter nights are expected; several nights without sleep deserve a message. If a symptom is a seizure, chest pain, or thoughts of suicide, call 911 or go to the nearest emergency room first and let the taper wait; the 988 Suicide and Crisis Lifeline answers around the clock.

Anyone in Sarasota, Bradenton, Venice, Lakewood Ranch or North Port who has been refilling a sleeping pill, a benzodiazepine or a psychiatric medication for years and wants a planned way off it can ask Dr. Leeds for a consultation by filling in the contact form. Consultations and care are by secure video for patients across Florida.

This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.