Benzodiazepine Withdrawal: What to Expect - How to Taper – How to Cope
Benzos – amazingly effective until they aren’t, until you need more and more and you still don’t feel OK - until the only reason you still use them is because you just can’t stop.
Sound familiar? It doesn’t have to go on like this.
People who break free from benzodiazepine addictions tend to feel a lot better: Studies show that quitting leads to improvements in cognitive performance, mood and sleeping, and since the prolonged use of a benzodiazepine often causes as many anxiety problems as it’s supposed to solve, quitting generally makes very good sense.
But though quitting is sensible, it’s certainly not easy, especially if you don’t start with a reasonable understanding of the process and a solid plan for success.
So read on to learn more about...
- The nature of benzodiazepine withdrawal symptoms (when they arise, why you get them, what they feel like, how long they last, etc.)
- Why a dangerous cold turkey detox makes no sense at all
- Different tapering methods and schedules (including how and why you might want to switch to long-acting diazepam)
- How to cope with withdrawal symptoms (self-help, medications, counseling etc.)
Benzodiazepine Withdrawal Symptoms
Not everyone quitting benzos will experience withdrawal symptoms and most people experience only a few, not the complete list of possible symptoms.
Typical withdrawal symptoms include:1
- Sleeping problems
- Feeling anxious or tense
- Paranoia – thinking other people want to do you harm
- Feelings of disassociation
- Abnormal sensory perception (noises sound loud, colors seem odd, etc.)
- Shaking, or more rarely, convulsions
- Muscle aches, pains and spasms
- Symptoms that mimic flu
See the end of this article for a comprehensive list of less commonly experienced withdrawal symptoms.
Why Do You Get Withdrawal Symptoms?
All benzodiazepines work by increasing the activity of the neurotransmitter GABA. Since GABA is an inhibitory transmitter, which slows or stops the firing of other neurotransmitters, by increasing GABA activity you quiet the brain’s overall activity level. GABA is the brain’s natural sedative, and benzodiazepines simply enhance its functioning.
GABA suppresses excitatory neurotransmitters like dopamine, serotonin, epinephrine (noradrenaline) and acetylcholine. These excitatory transmitters play important roles in memory, muscle movement, alertness, emotional regulation, heart rate and blood pressure and hormonal secretions. When taking benzodiazepines you quiet your whole brain’s activity level. This reduces anxiety and insomnia, but also causes changes to many of the body’s essential systems. This is why taking chronic high doses of benzos can cause such a variety of health problems and why people experience such a wide array of withdrawal symptoms after stopping.
Benzodizepine users quickly develop a tolerance and start needing increasingly larger doses to achieve any desired effects. Because of this, most prescribing guidelines advise against the use of benzos for more than 3 or 4 consecutive weeks.
- The GABA and benzodiazepine receptors compensate for the
medication’s continual presence by becoming less responsive to the medication (so less GABA)
- The excitatory systems that are naturally controlled by GABA
also adapt by becoming
less responsive to GABA inhibition (So less GABA and the GABA that's left doesn't do as much)
So once you’ve developed a tolerance you need large doses of benzos to just get the GABA system functioning at a ‘normal’ level. If a person with a benzo tolerance suddenly stops taking their medication, GABA activity drops substantially and this causes equally substantial increases in the activity of the brain's excitatory dopamine, serotonin, noradrenalin etc. systems.2
In some cases, as your tolerance rises, you can start to experience withdrawal symptoms on a steady dose, and you need to up your daily dosage to keep these withdrawal symptoms at bay.
Do All Benzo Users Get Withdrawal Symptoms?
According to the benzodiazepine dependency advocacy group Reconnexion, between 50% and 80% of people who use benzos for 6 months or longer will experience at least some withdrawal symptoms after stoppage.
The duration of withdrawal symptoms can also vary a great deal, but people who have longer histories of use are more likely to experience longer withdrawal periods than people with shorter use histories.3
You are more likely to have difficult withdrawal symptoms when quitting:4
- After a very long period of use
- When trying to come off a very high daily dosage
- When you have been using potent, fast acting benzodiazepines
When Do Withdrawal Symptoms Start to Occur?
You will start to feel withdrawal symptoms sooner if using a shorter acting benzo, like Xanax, and later, if using a long acting benzo, like valium.
- Users of short acting benzos may start to experience withdrawal symptoms within 2 days of the last dose
- Users of longer acting benzos may start to experience withdrawal symptoms between 2 and 10 days of the last dose5
Withdrawal symptoms may persist for a few days or weeks. Some people experience withdrawal symptoms that persist for months or even years after cessation of use.
How to Quit? Taper Down or Cold Turkey?
Taper. Without a doubt.
If you have been using benzodiazepines on a daily basis for more than three weeks, you should not stop using suddenly – you need to taper down instead.
- A cold turkey detox can be dangerous, or even deadly, and it increases the odds of an agonizing and lengthy withdrawal.
- A slow taper maximizes safety and minimizes discomfort.
You may have an impulse to try to power through quickly and tough it out. Although this is understandable – it's a very bad idea.
Tapering should be slow and gradual (months, not weeks) - it doesn’t really matter how long it takes (it probably took you a long time to build up your tolerance) and what’s most important is making steady progress towards your goal while minimizing your discomfort along the way (see below for example tapering schedules).
By tapering you can
- Minimize your withdrawal symptoms - by reducing at a rate that’s comfortable to you
- Stay in control – you decide how fast you want to go forward and you don’t have to endure strong withdrawal symptoms if you don’t want to
You can do:
- A direct taper – where you make steady reductions off whatever benzo you’ve been using
- A substitution taper – where, if you’ve been using a short-acting benzo like Xanax, you first switch off to a longer acting benzo like diazepam, and then once stable on the diazepam, start to taper down
The Benefits of a Substitution Taper (to Diazepam)
Many clinicians recommend switching to diazepam prior to initiating a tapering program.
- Diazepam has a very long half-life (between 20 and 100 hours). Because of this, benzo levels in the bloodstream remain very constant and you avoid the peak and valley levels seen with shorter acting benzos like alprazolam. These more constant benzo levels facilitate neural recovery (the brain ‘heals’ faster) and minimize withdrawal symptoms.
- Diazepam has very low tablet strengths, and this low potency allows you to easily make very small dose reductions. For example, It’s quite easy to take one fewer 2mg diazepam per day – it’s much harder to shave 0.1 mgs of Xanax off a 0.5 mg tablet.6
Because of diazepam’s long half-life, and difficulties in finding exact equivalent dosages between benzos, it is generally recommended that you switch over to diazepam gradually, in a step-wise fashion over a period of weeks, and then once stable on diazepam, start your tapering from there.7
Roughly Equivalent Diazepam Dosages
Because of the wide variations in half-life and thus variations in how people respond to different benzodiazepines (influenced by factors such as age and hepatic impairment) it’s quite difficult to provide an exactly equivalent diazepam to other benzodiazepine dosage.
According to the Victorian (Australia) Gov. drug withdrawal practice guidelines, as of 2009, 5 mgs of diazepam was approximately equivalent to:8
- Alprazolam (Xanax, Kalma) 0.5 mg
- Oxazepam (Serepax, Murelax) 30 mg
- Clonazepam (Rivotril) 0.5 mg
- Nitrazepam (Mogadon, Aldorm) 5 mg
- Flunitrazepam (Hypnodorm) 1 mg
- Lorazepam (Ativan) 0.5 mg
So, for example, if you wanted to switch from 2mgs of Xanax to an equivalent amount of diazepam you would need to take 20 mgs of diazepam.
- However, this is just a rough guideline and you won’t necessarily feel exactly the same on a theoretically equivalent dosage of a different benzodiazepine.
- So, what you need to do, is transfer gradually off your current benzo to diazepam, and then dial in a minimum dose of diazepam that keeps withdrawal symptoms at bay but doesn’t leave you feeling over sedated. Once stable on this dose, you can start your tapering regimen.
Example Tapering Schedules
- Reduce your dose by 10% every 1 or 2 weeks until you’re at 20% of your original dose, and then taper down by 5% every 2 to 4 weeks9
Or, a more aggressive approach, endorsed by the Oregon State College of Pharmacy10
- Taper by 25% per week for the first 2 weeks and then start a 12.5% reduction per week for the next to 6 weeks (note, tapering usually gets harder as you progress to smaller doses). This aggressive approach may not be suitable for people who have tried and failed in the past with a tapering regimen. For such people a 6 month tapering regimen is recommended.
As a general rule, it doesn’t really matter how slowly you taper and it’s a good idea to stabilize at a dosage before moving further down. Reductions tend to get harder in the second half of the process, so it’s OK to slow down as you need to, as you approach the finish line.
However, you should definitely avoid:
- Taking extra pills in times of great stress
- Going back up to an earlier plateau, if a new dosage seems difficult
- Using other substances that mimic the GABA effects of benzos (this obviously corrupts the tapering process)
Avoiding Alcohol during Benzo Withdrawals
Drinking may worsen your withdrawal symptoms (especially the morning after) but there’s another important reason to avoid alcohol until you feel better.
- You experience withdrawal symptoms because your GABA system is all messed up and it needs to normalize before you’ll feel better
- Alcohol increases GABA activity, just like benzos do
- So if you drink, you slow your brain’s healing and there’s a risk that you’ll just start to drink more and more as you taper further as a way to compensate, without really allowing your brain a chance to heal
And if you do this, at the end of it all not only is your GABA system still out of whack – now you’ve got an alcohol problem too!
Coping with Withdrawal Symptoms: Self Help
To minimize your symptoms:12
- Strive to eat a healthy diet with lots of fresh fruits and vegetables. Drink lots of water
- Avoid caffeine
- Exercise (as much as you can...you can’t do too much)
- Rest up as well as you can
- Keep a recovery diary and chart the progress you make
- Ask for help and support from friends or family for things like household chores and general responsibilities
- If interested, explore alternative healing, such as acupuncture or Chinese medicine11
- Avoid using alcohol or drugs. They may help in the short term but will exacerbate symptoms over the long run
- Avoid making major decisions or adding unnecessary stress to your life while going through withdrawals
- Relax in a hot bath
- Practice relaxation techniques, like deep breathing exercises
- Meditate and practice mindfulness
- Learn Cognitive Behavioral Therapy (CBT) techniques (with a therapist or in a group, or on your own through a self help program or books) and learn to challenge negative thoughts and harmful inaccurate beliefs
Keeping Things in Perspective
Staying focused on how bad you’re feeling won’t help you feel better, and the more you obsess about your symptoms, the worse you’ll perceive those symptoms to be – in fact, sometimes worrying about how you’ll feel after dose reductions causes more negative symptoms than the dose reduction itself!13
One trick you can use to minimize the worry is to accept that after each dose reduction you might catch a touch of ‘Benzo Flu’
Think objectively about how you feel after a dose reduction and compare these symptoms to how you feel when you catch a cold or flu. Are they comparable? When you get a flu do you worry a lot about how terrible you’re feeling or do you just accept that you’ll feel crummy for a few days and that you’ll feel better in time.
With benzo withdrawal symptoms it’s pretty much the same thing. You may feel crummy for a short time after a dose reduction, but you’ll feel better quickly enough, so why not just think of your symptoms as a case of benzo flu – and since you know that this flu will pass quickly enough, you don’t need to get too stressed about how bad you feel.
Should You Consider Counseling?
You should, ideally, seek a doctor’s medical supervision to help you with the withdrawal process, but on top of this, should you also seek out some form of counseling support?
Anxiety is the most commonly experienced benzo withdrawal symptom. This anxiety is temporary and will go away as your body readjusts, but if you find it very uncomfortable you may find counseling helpful.
- A counselor or psychologist can help you learn behavioral and cognitive behavioral techniques to manage anxiety. These techniques can be learned in a handful of sessions and can be practiced and implemented as needed, on your own.
- You may also find a community or online support group helpful. It can be reassuring to hear from others who are going through or have gone through similar experiences. People in support groups, or even within online support forums, can provide helpful information and support.
Basically, this is a tough process, and if you’re having trouble coping with your withdrawal symptoms, it’s entirely reasonable to seek out extra helpful support and advice.
Medications That Can Ease Withdrawal Symptoms
Your doctor may prescribe you medications that can reduce the severity of some withdrawal symptoms. Medications sometimes prescribed include:14
- Propranolol – to help reduce tremor and sweating (for up to about 3 weeks)
- Non-benzodiazepine sedatives like antihistamines or sedative antidepressants – to help reduce insomnia (short duration, about 2 weeks)
- Carbamezepine (and other anticonvulsants) – to reduce the risk of convulsions
Less Common Withdrawal Symptoms
In addition to the more commonly experienced withdrawal symptoms from the list above, some people may experience one or more of the following:15
- Tiredness and lethargy – heavy limbs
- Breathing problems or tightness in chest
- Blurry vision, sore eyes, sensitivity to light or seeing spots
- Becoming very sensitive to sounds, or hearing a ringing in ears
- Dizziness or feeling like the ground is moving
- A lack or co-ordination or balance
- Feeling like things aren’t real (depersonalization)
- Heart palpitations
- Digestive problems, diarrhea, constipation or nausea
- Headaches or a sense of tightness in the head
- Urinary problems – urgency, incontinence
- Excessive sweating
- Psychotic symptoms (hallucinations)
- Anger or rage
- Changes in libido
- Change in appetite, loss of taste, weight gain or loss
- Menstrual changes
- Difficulty swallowing, soreness in mouth and tongue
- Intrusive thoughts or memories
- Feelings of numbness or pins and needles
- Increased emotional reactivity
- Suicidal thoughts
- Impulsive behaviors
- Many others
- NSW Health: Benzodiazepine Withdrawal
- The Ashton Manual
- DACAS: Benzodiazepine Withdrawal
- Royal College of Psychiatrists: Benzodiazepines
- The Clinicopharmacotherapeutics of Benzodiazepine and Z drug dose Tapering Using Diazepam
- National Institute for Health Care and Excellence: Managing Benzodiazepine Withdrawal
- Turning Point Benzodiazepine Withdrawal Guidelines
- National Pain Center: Tapering Guidelines
- Oregon State College of Pharmacy
- Coping with Withdrawal Symptoms
- Australian Drug info: Dealing with Anxiety without Medication
- Saint Vincent’s Hospital Fairview: Benzodiazepines
- Benzodiazepine Good Practice Guidelines
- Reconnexion: Rare Withdrawal Symptoms
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