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Guide to Safely Withdrawing from Benzodiazepines

In this post, we outline how you can withdraw from benzodiazepines in a safe manner that doesn’t involve going ‘cold turkey.’ Abruptly withdrawing from benzodiazepines is dangerous and should never be attempted for those of you who are addicted to benzodiazepines. By the time you’ve finished reading this guide, you will be armed with precious information that will allow you to begin your journey to a benzodiazepine-free future. We also provide a ‘further reading’ section so you can learn more about benzodiazepine withdrawal.

The below guide is intended as mere guidance and this information should never be enacted without professional medical advice or assistance.

The science behind a benzodiazepine addiction

Benzodiazepines are a class of drug known to attached to GABA receptors located throughout the central nervous system. Although many GABA receptors are located in the brain, they are also scattered throughout the body. GABA receptors allow us to experience calm when stressful cues occur in our environment. That’s why benzodiazepines cause you to relax. However, benzodiazepines damage GABA receptors causing them to develop a sensitivity to benzodiazepines and natural GABA molecules. This means benzodiazepine addicts are not able to relax and often suffer from severe anxiety as a result.

GABA molecules cause chloride channels to open in nerve cells. Nerve cells become more negative when chloride is allowed through. This negative charge due to an influx of chloride makes it harder for neurons to fire meaning you get fewer action potentials in neurons. Less action potential means less brain activity. This causes you to feel more relaxed, calm, sleepy and even happier.

Benzodiazepines mimic the effects of GABA meaning brain activity is reduced. However, problems arise when adaptation occurs. This adaptation comes in the form of tolerance and physical adaptations. When benzodiazepines are first taken, chloride channels will open and your brain activity will slow down. When you continue to take benzodiazepines, those chloride channels become less responsive to benzodiazepines and you will become tolerant.

When you continue to take benzodiazepines for an extended period of time, your brain will become accustomed to this down-regulated state causing physical dependence to benzodiazepines. When benzodiazepines are abruptly withdrawn, the brain will experience too much activity. Brain cells will hire to excess causing withdrawal symptoms such as fever, hypertension, tachycardia, seizures, tremors and anxiety. All of these symptoms are associated with too much nerve activity due to a lack of GABA inhibition.

Benzodiazepine addiction is classed as an iatrogenic illness. This means the condition is typically caused due to medical treatment for an underlying physical or mental health condition.

Long-term benzodiazepine addiction causes ‘down-regulation’ of GABA receptors located throughout the central nervous system. This occurs when the GABA receptor is absorbed back into the nerve cell axon. This means benzodiazepine addicts are no longer able to utilise the neurotransmitter GABA. This causes the addict’s central nervous system to be in a heightened state of excitability and thus unable to cope with stress.

GABA is the body’s most important inhibitory neurotransmitter. This is because GABA is used to achieve a sense of calmness and to help us get to sleep. When GABA receptors are not functional due to benzodiazepines abuse, sufferers are thus not able to experience a sense of calm when cues in their environment cause anxiety or fear. This may mean people suffering from a benzodiazepines addiction suffer from anxiety due to dysfunctional GABA receptors. These symptoms cause them to take even more benzodiazepines and the cycle of addiction becomes well established.

Long-term benzodiazepine addiction is also known to cause a permanently decreased density of GABA receptors and a corresponding decrease in the sensitivity to GABA molecules. Again, this is due to the ‘down-regulation’ of GABA receptors. This means past benzodiazepine addicts may suffer from anxiety disorders for the rest of their life as a result of their past addiction to benzodiazepines.

Furthermore, because GABA receptors are located throughout the nervous system, a host of physical symptoms occur when a person is addicted to benzodiazepines. These physical symptoms include severe muscle and joint pain, hair loss, skin disorders, hair loss and weight loss.

What is benzodiazepine withdrawal syndrome?

Benzodiazepine withdrawal syndrome is a broad term used to describe a series of symptoms that occur when a person addicted to benzodiazepines attempts to withdraw from the drug or reduce his or her dosage of benzodiazepines over time.

Benzodiazepine withdrawal syndrome gives rise to a range of mentally and physically debilitating effects. This includes seizures, hallucinations, breathing problems and cardiac arrest. These symptoms are common when the dosage of benzodiazepines is cut rapidly. However, deadly symptoms may also occur when gradual dose reduction is attempted. To avoid or minimise these deadly symptoms, withdrawal from benzodiazepines should really be attempted in a medically supervised environment where the drugs are tapered down slowly. This is particularly true where addiction to benzodiazepine has arisen.

When benzodiazepines are consumed for an extended period of time, neural adaptations in nerve cells eventually counteract the effects of benzodiazepines. This means sufferers become tolerant and dependent on benzodiazepines. This dependence arises even when a ‘therapeutic dose’ of benzodiazepines is taken. This means an ever greater quantity of benzodiazepines must be consumed in order for the addict to function.

When does benzodiazepine withdrawal syndrome occur?

Unlike other drugs affecting GABA receptors such as alcohol, benzodiazepines are metabolised slowly by the body. The metabolization of benzodiazepines varies between people and depends upon the type of benzodiazepine the sufferer is addicted to.

Below we outline a table that roughly details how long a benzodiazepine withdrawal requires:

Withdrawal symptoms	Short-Acting e.g. lorazepam, alprazolam	Long-acting e.g. Diazepam, chlordiazepoxide
Onset	24 hours	5 days
Peak	1-5 days	1-9 days
Duration	7-21 days	10-28 days

Many people suffer from insomnia and rebound anxiety for many months or even years after benzodiazepines were last taken, so the above table is only intended as a rough estimate. A condition known as Post Acute Withdrawal Syndrome (PAWS) may last for up to two years following initial abstinence from benzodiazepines.

Why give up benzodiazepines?

Many patients ask why they must give up benzodiazepines. They must realise that benzodiazepines are not recommended for long-term use, in the same way, other drugs such as methadone. This is because benzodiazepines cause cognitive impairments. This is particularly due to users’ inability to store long term memories when under the influence of benzodiazepines. Forgetfulness is one of the key reasons why benzodiazepines must not be taken on an ongoing basis.

Treating benzodiazepine addiction correctly

Before treatment for benzodiazepine addiction begins, a thorough psychiatric assessment should take place. This assessment typically results in a tapered benzodiazepine withdrawal schedule being written up. A tapered withdrawal helps minimise the symptoms associated with a benzodiazepine withdrawal syndrome. A rapid taper must be avoided at all costs. For this reason, we do not recommend short-term detoxification programmes for benzodiazepine withdrawal.

Why? Because when an addict consumes benzodiazepines, GABA receptors become ‘down-regulated’. It’s impossible to compel GABA receptors to return to normal functioning. The body may require a significant amount of time to ‘up-regulate’ GABA receptors to normal functioning.

When benzodiazepines are abruptly withdrawn, the central nervous system will react in ways that cause severe withdrawal symptoms. When benzodiazepines are slowly withdrawn, the body is allowed to slowly but surely heal itself whilst minimising the risk of benzodiazepine withdrawal syndrome.

Outpatient tapering programmes

Tapering is known as the ‘weaning’ approach. If patients are receiving treatment on an outpatient basis, we recommend they reduce benzodiazepine consumption by 10% per 1-2 weeks. This approach typically will not succeed for users with a full blow dependence to benzodiazepines due to their inability to control the quantity of benzodiazepine they consume. It’s not unknown for doctors to write out a complicated six-week weaning schedule only for their patient to take all their medication on day 2 of the schedule. Thus, weaning down on an outpatient basis is only advisable for patients who are able to do so. If patients are addicted to benzodiazepines, they are unlikely to be able to reduce on an outpatient basis and it’s unreasonable to ask them to do so.

Inpatient tapering programmes

Patients receiving treatment on an inpatient basis may reduce benzodiazepine use by as much as 10% per day. Why is this figure so high? Because anything below 10% would require the patient to remain in a hospital for an unreasonably long period of time. Whilst a benzodiazepine detox on an inpatient basis typically requires a lengthy inpatient stay, this method may be the only option for people with a full blow addiction to benzodiazepines.

Substituting one benzodiazepine for another

Another approach to benzodiazepine withdrawal is to first substitute one benzodiazepine for another before weaning is initiated. For instance, it’s common to first substitute a short-acting benzodiazepine such as lorazepam for a long-acting benzodiazepine such as chlordiazepoxide or Valium. Long-acting benzodiazepines have a long half-life and a slow onset. Benzodiazepines with a fast onset are harder to wean off because they are reinforcing. This means benzodiazepines with a fast onset cause the addict to want more and more of them before their urges are satisfied. Valium is particularly effective for detoxing because it has a liquid option, meaning it’s possible to reduce to a very low dose before complete abstinence is attempted.

Substituting for barbiturates

Another drug worth substituting benzodiazepines for is a barbiturate known as phenobarbital. Phenobarbital is a barbiturate that affects the same GAGA receptors as benzodiazepines do. Oral phenobarbital has an extremely long half-life and a very slow acting onset making it a very effective drug to reduce on for people suffering from a benzodiazepines addiction.

However, the downside to barbiturates is that they are more dangerous than benzodiazepines when an overdose is taken. This is because barbiturates work even when GABA is not present. This means addicts are more likely to suffer from respiratory failure and die when a barbiturates overdose occurs. Thus, phenobarbital use for benzodiazepine withdrawal is only recommended in a medically supervised environment.

How to taper correctly

When the dosage of benzodiazepines is reduced by 10% each day, we don’t recommend patients reduce by 10% of the initial dose each day. Instead, patients must reduce by 10% of the new dosage that results from the proceeding reduction. So if you start at 100 mg of your dosage on day 1 of your detox, you will reduce to 90 mg, and then to 81 mg (since 90mg minus 10% equals 81 mg). This means reduction steps get smaller and smaller as the weaning programme continues. Implementing small incremental steps in this fashion is vital when a weaning programme is implemented, particularly towards the end of the cycle. However, micro-reductions in dosages requires a commitment in terms of time. For instance, If you are reducing by 10% each week, to get down to a tenth of the original dose, it will take you 20 weeks to achieve this reduction.

This 10% incremental reduction is outlined in the table below.

Day 1	100 mg
Day 2	90 mg
Day 3	81 mg
Day 4	73 mg
Day 5	66 mg
Day 6	60 mg
Day 7	54 mg
Day 8	49 mg
Day 9	44 mg
Day 10	40 mg

Please note, the above dosages are purely hypothetical and for illustratory purposes only.

The time it takes to implement a weaning programme is particularly problematic when treatment takes place in an inpatient setting.

Alternative medications used for a benzodiazepine detox

Below we list a number of non-GABA-ergic medications that are used to treat benzodiazepine withdrawal:

• Anticonvulsants such as Tegretol and Depakote
• Anti-psychotics such as Haldol
• Anti-hypertensives such as beta blockers and clonidine
• Anti-depressants such as Trazodone and Buspirone
• Anti-histamines such as Hydroxyzine and diphenhydramine
• Benzodiazepine ‘blockers’ such as Flumazenil

Further reading

• Ashton manual
• Benzodiazepine Dependence, Toxicity and Abuse by the American Psychiatric Association
• CIWA-B
• Benzodiazepine withdrawal lecture by Jim Walsh
• The Ashton Manual Supplement: How Benzodiazepines Work & How to Withdraw (2002)
• Benzo-Wise: A Recovery Companion by V Baylissa Frederick

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