Benzodiazepines, commonly referred to as benzos, are a class of medications known as sedative-hypnotics that have been around since the 1950s. While benzodiazepines are effective prescription medications for certain medical purposes, their abuse potential is very high and many benzodiazepine prescriptions are misused.
The first task for anyone who has decided to stop using benzodiazepines is to undergo benzodiazepine detox, which involves the process of benzo withdrawal. Benzo detox can be a complicated and dangerous undertaking, so people who are planning to do so should be aware of the facts about benzodiazepine withdrawal and detox.
What Causes Benzodiazepines Withdrawal?
Benzodiazepines work by activating gamma-Aminobutyric acid (GABA) in the brain, which is responsible for slowing down brain function and reducing the brain’s excitability. By doing so, benzodiazepines produce a calming, sedative effect. That effect is why benzodiazepines are useful for treating problems related to hyperexcitability of the brain, such as anxiety or seizures.
When people take benzodiazepines for even short periods, the brain tries to compensate for the slowing effect of the drug by becoming more active and excitable. As a result, when people suddenly stop taking benzodiazepines or reduce the dose too quickly, the brain rebounds and becomes hyper-excitable.
This sudden hyper-excitability produces benzo withdrawal symptoms, including anxiety. For people who have pre-existing anxiety problems, the rebound anxiety from benzodiazepine withdrawal can worsen the existing anxiety. The rebound hyper-excitability of the brain can cause jitteriness (psychomotor agitation), muscle tension, stiffness and seizures.
Diagnosing Benzodiazepines Withdrawal
People who abuse benzodiazepines or other substances are often secretive and even deny their substance use, so if they are having a seizure and are brought to the hospital, the cause of the seizure may not be readily apparent. However, the cause is usually found after some simple investigations. Once benzodiazepine abuse is identified, people will likely consider detox, which then leads to withdrawal.
Withdrawal is anticipated in people who are stopping their benzodiazepine use. One of the telltale signs of benzodiazepine misuse is the appearance of withdrawal symptoms when a person stops consuming benzos.
Benzodiazepine Withdrawal Symptoms
Acute benzodiazepine withdrawal symptoms are grouped together into what is known as benzodiazepine withdrawal syndrome, which includes a number of physical and psychological symptoms. Benzo withdrawal symptoms are somewhat unpredictable and can occur in people after short-term or low-dose use.
The greatest concern with benzodiazepine withdrawal is the possibility of seizures. These seizures are of the generalized tonic-clonic (GTC) type, also known as grand-mal seizures, and can be fatal.
The best way to figure out how to handle withdrawal symptoms from benzodiazepines is to learn what they are, why they occur and when to anticipate them.
Protracted withdrawal symptoms from benzodiazepines are common and characteristic enough to be given their own name: protracted withdrawal syndrome.
Protracted benzodiazepine withdrawal syndrome is similar to but not the same as the post-acute withdrawal syndrome (PAWS) that is seen in withdrawal from alcohol and other drugs. Although it is possible to experience post-acute withdrawal syndrome with benzodiazepines, protracted withdrawal syndrome is more common.
Protracted withdrawal syndrome can occur in up to one-third of people who experience withdrawal symptoms following long-term use of benzodiazepines. Symptoms are somewhat different than those seen in PAWS, in that the main symptoms are anxiety and insomnia. However, other symptoms may occur:
- High blood pressure and rapid heart rate
- Muscle spasms and tightness
- Numbness and tingling
Protracted withdrawal syndrome differs from PAWS in that it usually starts during the acute withdrawal phase and can seem to resolve and then come back in full force throughout the duration of the syndrome.
The acute benzodiazepine withdrawal phase is the period when the brain and body are in shock from the sudden reduction of the drug. This causes physical and psychological symptoms to occur.
Acute withdrawal from benzodiazepines starts one to four days after the last dose, peaks at five to seven days and then tapers off until it resolves completely about two weeks after the last dose.
Acute benzo withdrawal is an unpredictable, uncomfortable and potentially dangerous experience and should not be taken lightly.
Benzodiazepine withdrawal syndrome is usually characterized by potential physical symptoms, some or all of which can occur during the acute withdrawal phase. Typical physical symptoms of benzodiazepine withdrawal include:
- Muscle spasms and twitching
- Muscle pain and stiffness
- Heart palpitations
- Profuse sweating
- Dizziness, light-headedness
- Numbness and tingling
- Visual disturbances
- Ringing in the ears
- Loss of appetite
Psychological/mental symptoms can be especially noticeable because they can result in odd behaviors. One of the reasons that people should not withdraw from Xanax alone is because they may exhibit behaviors (during a period of psychosis or delirium) that can cause mishap or harm, without being aware of what they are doing. Typical psychological/mental benzodiazepine withdrawal symptoms include:
- Confusion, disorientation
- Delusions, paranoia
- Visual or auditory hallucinations
- Panic attacks
- Memory difficulties
- Agitation, irritability or aggression
- Feelings of separation from reality
- Benzodiazepine (benzo) withdrawal psychosis
The re-emergence of pre-existing mental health disorder symptoms, especially anxiety, usually begins during the acute withdrawal phase and recurs in bursts during the period afterward.
Benzodiazepines Withdrawal Timeline
Benzo withdrawal symptoms timeline begins with acute withdrawal symptoms which usually start one to two days after the last dose for short-acting benzodiazepines, but may be as late as two to four days for long-acting benzodiazepines. Some people begin experiencing acute withdrawal symptoms in the hours between doses while actively using the drug.
The benzo withdrawal timeline continues with the acute withdrawal symptoms peaking at about five to seven days. Symptoms usually begin to taper off after the peak, and most people can expect the symptoms to resolve by 12 to 14 days after the last dose.
Protracted withdrawal syndrome symptoms can begin to arise during the acute withdrawal period and can last for a year or more. The protected withdrawal syndrome symptoms often wax and wane, sometimes seeming to resolve and then re-emerging.
Benzo Seizure Timeline
The benzodiazepine withdrawal seizure timeline mirrors that of other acute withdrawal symptoms, with the risk arising one to two days after the last dose, peaking around five to seven days and lasting until about two weeks after the last dose.
The benzo withdrawal seizure risk is high and unpredictable, with seizures being reported even in people who took a benzodiazepine at properly prescribed doses for less than 15 days.
Of particular concern is the fact that benzodiazepine use can cause a persisting hyper-excitability in the brain, resulting in epilepsy. A large clinical study showed that epilepsy can occur in low-dose users even after as little as one week of use. The risk can last up to six months after discontinuing benzodiazepine use. The dose and duration affect the risk level. The stronger the dose and the longer the use, the higher the risk of developing epilepsy.
Factors Affecting Withdrawal Duration
Although the general timeline of benzo withdrawal duration is a good guide, it is not possible to predict with certainty how long benzo withdrawal symptoms last. Withdrawal from benzodiazepines varies from person to person. However, benzodiazepine withdrawal symptoms duration and severity may be influenced by many factors, including:
- Age and gender
- General health
- Health of the liver and kidneys
- Genetic and biological make-up of the individual
- Concurrent use of other drugs
- Co-occurring mental health disorders
- Whether the withdrawal is medically assisted
Treatment for Benzodiazepine Withdrawal Syndrome
Benzodiazepine withdrawal duration and severity is largely determined by whether the withdrawal is professionally supervised. Many people may not even experience withdrawal symptoms at all with proper medical treatment.
The most important part of benzodiazepine withdrawal treatment is a proper benzodiazepine taper, commensurate with the duration of benzodiazepine use and the amounts used, which should be determined by a trained professional. Other medications are often used to reduce symptoms severity and to mitigate the seizure risk.
- Medical Detox
For many people with addiction, fear of withdrawal symptoms is a major barrier to recovery. By participating in a medical detox program, people can get through their withdrawal symptoms safely and comfortably.
Medical detox for benzodiazepines involves staying at a detox facility during the withdrawal period and having proper medical supervision. Medications can be used to help reduce uncomfortable symptoms and prevent dangerous withdrawal effects.
Medical detox also has other benefits. It allows individuals to be properly assessed for their physical and mental wellbeing and have help putting together a plan of action for treatment and recovery following detox. Partaking in medical detox also lets people make healthy connections with other people in recovery.
- Outpatient Detox
Outpatient benzodiazepine detox involves detoxing with advice and help from a physician or a benzodiazepine detox center and allows the patient more flexibility with their treatment. The major disadvantages to this approach are the lack of medication to reduce the effects of ongoing withdrawal symptoms and the lack of availability of professional help at all hours in case of difficulty or serious complications.
It should be noted that detox from drug use does not constitute treatment for addiction because it does nothing to identify and address the underlying causes of the drug use, the adverse mental and social effects of the drug use and its related behaviors. Benzo detox is only the prelude to treatment for addiction and a plan for treatment should be put together with an addiction professional prior to or during the detox.
- Detoxing at Home
Given the unpredictability of benzodiazepine withdrawal syndrome, people should carefully consider whether to do their benzo detox at home. When making the decision, individuals should do so in conjunction with their physician and should be forthcoming about the extent of their benzodiazepine and other drug use.
The major risk in detoxing at home is being alone if a seizure, psychosis or delirium occur. Even if not alone, people should ensure that their friends or family members are aware of the withdrawal symptoms and know what to do if serious side effects occur.
People who decide to detox from benzodiazepines at home should be sure to get appropriate medical advice on how to detox from benzos at home. They should find out in advance from a qualified professional how to detox off benzos at home and should make sure that the appropriate support plans are in place. Home detox should only be considered by people who:
Consult their physician first
Lightly used benzodiazepines
Do not live alone and live with responsible people
Have a safe, drug-free home
Have help available if they develop serious complications
Have a plan for treatment of their addiction after detoxing
Dangers of Quitting Cold-Turkey
The dangers of benzodiazepine withdrawal are greatly increased if the drug is abruptly discontinued. Even people who use benzodiazepines without a prescription should consult with a doctor to help them with tapering off the drug rather than putting themselves through a sudden withdrawal or trying to self-taper.
Because of these concerns, weaning off benzodiazepines is appropriate and a benzo tapering plan should be planned out in conjunction with a doctor. The FDA maintains a general recommendation for a benzo taper of decreasing the dose by no more than 0.5 mg every three days, or even less rapidly if the drug has been used for an extended period or at high doses.
For people who have been using benzodiazepines for longer periods or at high doses, the FDA tapering schedule may be too fast, so a tapering regimen should be established for each person by a medical professional.
Can You Die from Benzo Withdrawal?
There is a risk of death from untreated benzodiazepine withdrawal. A case report examined the benzodiazepine withdrawal death of a woman who died from withdrawal seizures. However, she was taking massive doses of Xanax (200 mg in six days; the maximum safe dose in six days is less than 24 mg). She stopped Xanax use abruptly when she ran out.
The danger of benzo withdrawal death lies in the seizures that can occur. The type of seizures seen in benzodiazepine withdrawal poses a small risk of death, especially in individuals who are alone when a seizure happens.
Finding a Detox Center
The most important factor for anyone with benzodiazepine addiction is to get help, starting with a safe and supportive benzo detox. However, finding the right benzodiazepine detox center can be daunting. A few points to consider in the search are:
- Staff to Patient Ratio
How Long Does Detox Take?
The timeline for acute withdrawal symptoms from benzodiazepine use suggests that most people will have fully detoxed from benzodiazepines within 14 days. However, because benzodiazepine withdrawal syndrome can include protracted symptoms, it is not possible to reliably predict ahead of time how long it will take to detox from benzos.
Medications Used in Benzodiazepines Detox
The mainstay of benzo detox medications is the use of benzodiazepines to taper individuals. The benzodiazepine flumazenil is the usual first choice for helping people detox from benzodiazepine abuse because it’s relatively safe to use.
The medication clonidine is sometimes used as a detox aid to reduce withdrawal symptoms. However, small studies have not shown clonidine to be especially useful for benzodiazepine detox, other than by reducing blood pressure.
The muscle relaxant baclofen may be helpful for short-term use in benzodiazepine detox.
The medication trazodone is sometimes used for treating insomnia in Xanax withdrawal because it works differently than benzodiazepines do, so it is not affected by benzodiazepine tolerance.
Various non-benzodiazepine, anti-seizure medications may be useful for preventing withdrawal seizures.
Beta-blocker medications, especially propranolol, are sometimes used to reduce the physical withdrawal symptoms of Xanax withdrawal.
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Key Points: Understanding Benzodiazepines Withdrawal and Detox
Keep the following key points in mind when considering benzodiazepine withdrawal and detox:
- Benzodiazepine use, even with a legitimate prescription, can lead to uncomfortable and dangerous withdrawal symptoms if not tapered properly
- Benzodiazepine withdrawal can be acute or protracted
- Benzodiazepine abuse almost always occurs alongside other drug use, which complicates the withdrawal process
- Benzodiazepine abuse often co-occurs with an underlying mental health disorder, which can also complicate withdrawal
- Medical detox is the safest way to withdraw from benzodiazepine use
If you struggle with benzodiazepine misuse, reach out to The Recovery Village Palm Beach at Baptist Health to speak with a representative about how addiction treatment can help. You deserve a healthier future, call today.
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Medical Disclaimer: The Recovery Village Palm Beach at Baptist Health aims to improve the quality of life for people struggling with a substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare provider.