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How Dangerous is Benzo Withdrawal?

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Benzodiazepines are some of the most commonly used pharmaceuticals in the United States and worldwide.1,2 Some of the most frequently prescribed benzodiazepines include diazepam (Valium), clonazepam (Klonopin), alprazolam (Xanax), and lorazepam (Ativan). All have sedative and anxiolytic effects. Consequently, they are used to treat different manifestations of anxiety (e.g., generalized anxiety disorder or panic attacks). Some, like Ativan, are indicated for use in managing insomnia, though this role has largely been supplanted by newer hypnotic (sleep-inducing) medications, such as Ambien. As benzodiazepines also have some anticonvulsant and muscle relaxant properties, they are sometimes prescribed to treat muscle spasms and seizures. Select benzodiazepines may also be used to manage acute alcohol withdrawal.

Benzodiazepines have known abuse potential. The misuse of these medications may entail taking higher or more frequent doses than prescribed, using in ways other than directed (e.g., dissolving in liquid and injecting), or mixing them with other substances. Benzodiazepines are regularly abused in conjunction with other drugs or alcohol, often to boost their desired effects or mitigate unpleasant active effects of the concurrently used substance or to ease the comedown of stimulants. Whatever the path, it can lead to the same outcome: an inability to stop using despite negative consequences. This is known as benzodiazepine addiction, a chronic condition that can be extremely debilitating.3 The cycle of benzodiazepine abuse can be particularly difficult to break due to unpleasant and sometimes even fatal withdrawal symptoms that result when someone attempts to quit on their own.3

Benzodiazepine Dependence and Addiction

Benzodiazepines are typically prescribed on a short-term basis, as physical dependence develops rapidly and there is weak evidence for the effectiveness of long-term use.2 When someone uses benzodiazepines repeatedly and over a prolonged period of time, they may develop significant physiological dependence, which means that they are likely to experience withdrawal symptoms following reduction or cessation of use.3 Even when used therapeutically, physical dependence can occur. In addition to physical dependence, with chronic use you can develop a benzodiazepine use disorder, or addiction, which is a problematic pattern of use including:3

  • Taking a benzodiazepine in larger amounts or for longer than intended.
  • Experiencing cravings to use benzodiazepines.
  • Spending an inordinate amount of time getting the drug, using it, or recovering from its effects.
  • Failing to fulfill work, home, or school obligations due to use.
  • Continuing to use benzodiazepines despite experiencing interpersonal issues related to use.
  • Neglecting important recreational or social activities in favor of benzodiazepine use.
  • Using benzodiazepines in dangerous situations, such as while driving.
  • Continuing to use benzodiazepines despite knowledge of psychological or physical problems caused or worsened by use.
  • Developing a tolerance to the drug, meaning that higher doses are required to experience desired effects.
  • Experiencing withdrawal symptoms with the cessation of or reduction in use.

In addition to their addictive potential, benzodiazepines have many noteworthy side effects that increase with greater doses. These include mood swings, impaired judgment, sedation, slurred speech, stupor, and disturbances of concentration, attention, and memory.3 Benzodiazepines can impair driving and are also associated with falls and fractures, especially in the elderly.1

Dangers of Benzo Withdrawal

Given the addiction risk, the harms of continued benzodiazepine use, and the potential for a markedly unpleasant or complicated withdrawal, many people need professional treatment to stop using. When you use benzodiazepines for as little as a few weeks, withdrawal symptoms are a real possibility. Longer periods of use and higher doses lead to a higher likelihood of withdrawal and greater severity of withdrawal symptoms.

The most severe withdrawal symptom is the risk of grand mal seizures. They have been reported in as many as 30% of people withdrawing from sedatives, such as benzodiazepines, without treatment.3 Seizures can be particularly dangerous, especially if they occur in an uncontrolled setting, such as when you’re driving a car. Regardless of the setting, though, seizures have the potential to be fatal, which is why formal detox treatment is so pertinent. Delirium and paranoia are also dangerous benzodiazepine withdrawal symptoms, as they can lead to erratic, violent behavior, hallucinations, or delusions with potentially life-threatening consequences. A more complete withdrawal symptom list includes:3,6

  • Anxiety and panic attacks.
  • Insomnia.
  • Rapid pulse.
  • Increased blood pressure.
  • Increased respiratory rate.
  • Nausea or vomiting.
  • Excessive sweating.
  • Muscle spasms.
  • Tremors.
  • Convulsions.
  • Psychomotor agitation, or repetitive, purposeless movements.
  • Hallucinations.
  • Depersonalization, or feeling detached from oneself.
  • Grand mal seizures.

Benzodiazepine withdrawal typically has an acute phase that might last several days to a few weeks, depending on the half-life of the benzodiazepine.3 For many, withdrawal symptoms may persist for months or even years after acute withdrawal has resolved; this is referred to as protracted withdrawal or post-acute withdrawal symptoms (PAWS).9

Given the complex and potentially fatal withdrawal syndromes, medical management of benzodiazepine detoxification is recommended.10 If you are struggling with a benzodiazepine problem and want to quit, seeking treatment is the safest option.

Professional Detox Programs

While there are a number of treatment options available for quitting benzodiazepine use, the major components of successful detox are gradual dose reduction, psychological support, and pharmaceutical management of symptoms, as necessary.5,11,12 Detoxification treatment can vary in intensity, duration, and setting depending on your needs, but in all cases, unless a physician has confirmed that there is little to no risk of experiencing a complicated withdrawal, benzodiazepine detox and discontinuation should be medically supervised.

Treatment typically begins with an evaluation by a qualified medical professional who considers the level of dependence, the severity of benzodiazepine addiction, symptoms of co-occurring substance abuse or mental health disorders, and motivation and life circumstances that can encourage or hinder personal treatment goals. Based on this assessment and your choices, a treatment plan will be formulated, which can be individually tailored and adjusted over time.

The most common settings for benzodiazepine detox include:

  • Medical hospital: Depending on patient needs, detox treatment in a hospital setting may take place in an intensive care, general medical, psychiatric, or specialized chemical dependency unit. All are equipped to provide intensive inpatient detox services in an organized, medically monitored setting.
  • Inpatient substance use disorder treatment center: Medically managed inpatient centers provide 24-hour care and support. There are different levels of care in inpatient and residential settings, with some offering social detoxification and others providing a more medically monitored detox. For people in danger of seizures or delirium, facilities equipped to medically manage the acute withdrawal period will be needed.
  • Outpatient substance use disorder clinic: Outpatient detox treatment involves properly credentialed and licensed care providers, such as registered nurses or licensed practical nurses. They monitor your care during sessions that take place at predetermined times.
  • Physician’s office: Treatment can take place in a physician’s office by trained clinicians. Treatment typically takes place at predetermined intervals, similar to outpatient detox. This setting is often used for those who have developed a dependence after taking benzodiazepines therapeutically.

In cases of heavy, long-term use it can take a few months to taper a benzodiazepine dose down to zero. As 24-hour care could be needed, especially in cases of heavy benzodiazepine use, it’s best to verify with a treatment professional if you are considering treatment in an outpatient or doctor’s office setting. If you begin treatment in an inpatient setting, once sufficient progress has been made, outpatient care can follow up the process started in the hospital or inpatient center. For those on therapeutic doses of benzodiazepines, withdrawal often can be initiated and completed on an outpatient basis.

Withdrawal symptoms can be minimized and may be avoidable if dose tapering is carried out at a gradual enough pace. How gradual is “gradual enough” is rather subjective and based on many of the factors previously mentioned, such as type and severity of benzodiazepine use and co-occurring problems. Accordingly, the duration of successful dose reduction can range from a few weeks to many months; there is no precise duration.5,12 While the more immediate goals are successful benzo discontinuation and detoxification, comprehensive substance abuse treatment and follow-up care can further minimize relapse risks and will allow caregivers to assess for and address any protracted withdrawal symptoms.

Sources

  1. Olfson, M., King, M., Schoenbaum, M. (2015). Benzodiazepine Use in the United States. JAMA Psychiatry, 72(2), 136­–142.
  2. Kurko, T.A.T., Saastamoinen, L.K., Tahkapa, S., Tuulio-Henriksson, A., Taiminen, T., Tiihonen, J., Airaksine, M.S., Hietala, J. (2015). Long-Term Use of Benzodiazepines: Definitions, Prevalence and Usage Patterns–A Systematic Review of Register-Based Studies. European Psychiatry, 30, 1037–1047.
  3. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Washington, D.C: American Psychiatric Association.
  4. Tamburin, S, Faccini, M., Casari R., Federico, A. Morbioli, L, Franchini, E. Bongiovanni, L.G., & Lugoboni, F. (2017). Low risk of seizures with slow flumazenil infusion and routine anticonvulsant prophylaxis for high-dose benzodiazepine dependence. Journal of Psychopharmacology, 1–5.
  5. Soyka, M. (2017). Treatment of Benzodiazepine Dependence. New England Journal of Medicine, 3761147–57.
  6. Liebrenz, M.,Gehring, M.T., Buadze, A.,Caflisch, C. (2015). High-Dose Benzodiazepine Dependence: A Qualitative Study of Patients’ Perception on Cessation and Withdrawal. BMC Psychiatry, 15(116).
  7. National Institute on Drug Abuse. (2016). Misuse of Prescription Drugs.
  8. Hood, S.D., Norman, A., Hince, D.A., Melichar, J. K., Hulse, G.K. (2014) Benzodiazepine Dependence and Its Treatment with Low Dose Flumazenil. British Journal of Clinical Pharmacology, 77(2), 285–294.
  9. Center for Substance Abuse Treatment. (2010). Protracted Withdrawal. Substance Abuse Treatment Advisory, 9(1).
  10. Substance Abuse and Mental Health Services Administration. (2006). Detoxification and Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series, No. 45.
  11. Ashton, H. (2005). The Diagnosis and Management of Benzodiazepine Dependence. Current Opinion in Psychiatry, 18(3):249–55.
  12. Lader M., Tylee A. Donoghue J. (2009). Withdrawing Benzodiazepines in Primary Care. CNS Drugs, 23(1), 19–34.

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