PHARMACIST STEVE

There are studies on long‑term benzodiazepine discontinuation (including many patients also on opioids), and they do show increased anxiety/insomnia and small but real increases in suicidal ideation and related harms after stopping, even in previously “stable” patients. The evidence supports being very cautious about deprescribing in someone who has done well for decades.

Key data on long‑term benzo discontinuation

A large target‑trial–emulation study of over 350,000 adults on stable long‑term benzodiazepines found that discontinuation was associated with small absolute but consistent increases in several harms over 1 year compared with continuation: all‑cause mortality, nonfatal overdose, suicide attempts, suicidal ideation, and emergency department visits. The absolute risk increases for suicidal ideation and nonfatal overdose were on the order of a few tenths of a percent, but the direction of effect was worse, not better, after discontinuation.jamanetwork+1​

A Cleveland Clinic review summarizing this work highlighted that deprescribing in stable long‑term benzo users led to higher mortality and more nonfatal overdoses and suicidal ideation than continuing therapy, challenging the assumption that stopping always improves net risk in this population. This pattern held both in patients with and without recent opioid exposure, though absolute risks were higher in those with opioid co‑prescribing.pmc.ncbi.nlm.nih+1​

Anxiety, insomnia, and mood after stopping

Clinical and observational reports describe benzodiazepine withdrawal and post‑withdrawal symptoms that commonly include marked anxiety, insomnia, irritability, and mood disturbance, and in some cases emergence or worsening of depression and suicidal thoughts. A large patient survey on benzodiazepine use, tapering, and discontinuation found that many long‑term users reported severe and prolonged withdrawal symptoms, with over half endorsing suicidal thoughts or attempts at some point in the course of use or discontinuation; while this is a self‑selected sample, it underscores how significant anxiety, insomnia, and emotional dysregulation can be.vumc+2​

A recent systematic review on benzodiazepines and suicidality concluded that benzo use is linked to increased suicide risk in vulnerable groups, and that changes in benzodiazepine regimens (including abrupt stops) can be a period of elevated risk for suicidal behavior and ideation. Case reports also document serious self‑harm temporally associated with withdrawal or rapid regimen changes, even in previously “stable” older adults.pmc.ncbi.nlm.nih+2​

Interaction with long‑term opioid therapy

For opioids, a separate VA cohort showed that stopping long‑term opioid therapy was associated with a higher risk of death from overdose or suicide, and that this risk increased the longer the patient had been on opioids before stopping (hazard ratios for overdose/suicide rose markedly once prior exposure exceeded about a year). When considering patients on both opioids and benzos for many years, this suggests that major changes to either drug, and especially to both, can unmask or precipitate distress, destabilization of sleep and pain control, and higher risk of overdose or suicide in at least a subset of patients.bmj+2​

What is reasonable to infer for your scenario

There are not many granular studies limited specifically to patients with “couple of decades” of uneventful concurrent opioid–benzo use who are then taken off only the benzo, but the best available evidence supports these points:

• Long‑term “stable” benzodiazepine users, including many with concurrent opioids, who are discontinued have a higher short‑term risk of mortality, nonfatal overdose, suicidal ideation, and ED use compared with similar patients who continue.ccjm+2​

• Anxiety, insomnia, and mood symptoms are common during and after discontinuation, and can be severe and prolonged in some patients, even when the drug history is years to decades of “benign” use.benzoinfo+2​

• Opioid and benzodiazepine regimen changes in long‑term users are periods of elevated vulnerability, so abrupt or forced discontinuation—particularly without strong psychosocial and sleep support—can plausibly increase anxiety, worsen sleep and mood, and raise suicidal ideation risk for at least a subset of such patients.ncbi.nlm.nih+2​

So, for a patient on an opioid–benzo combination for decades without prior adverse psychiatric events, it is very plausible—and supported by current data—that taking away the benzodiazepine (especially rapidly or involuntarily) can lead to high anxiety, sleep disruption with secondary depressive symptoms, and a measurable, though still numerically small, increase in suicidal ideation and related harms over the following year.jamanetwork+2​