Successful symptom-based management of active withdrawal from multiple illicit benzodiazepines

Benzodiazepines are among the most often misused medications. Medication tapering is required to prevent lethal withdrawal symptoms associated with abrupt cessation. The authors report a case of a male in his early 20s who presented following a seizure precipitated by the abrupt cessation of multiple illicit substances. Further history identified bromazolam, flubromazepam, alcohol, kratom, tianeptine and phenibut to be the predominant substances involved in his presentation. The lack of approved long-acting benzodiazepine equivalents for bromazolam and flubromazolam and kratom's inhibition of benzodiazepine metabolism eliminated utilisation of the conventional withdrawal management strategy. Symptom-based management was initiated using diazepam to stabilise the patient during active withdrawal. Tapering of withdrawal medications and initiation of medical management for co-existing psychiatric conditions followed stabilisation. Current recommendations utilise equivalent benzodiazepine conversions and scheduled tapers. In the setting of unknown equivalents, physicians should prioritise symptomatic stabilisation to prevent poor outcomes.