Benzodiazepine Overdose

What to do right now

1. Call 911 or your local emergency number if the person is hard to wake, breathing slowly or not breathing normally.
2. Check breathing. If they are not breathing or only gasping, start CPR.
3. Give naloxone (such as Narcan nasal spray) if available and opioids could be involved. It will not reverse the benzodiazepine, but it can reverse an opioid, and many street pills contain fentanyl. It does no harm if opioids are not present.
4. Put them in the recovery position: on their side, top knee bent, head tilted back slightly, so vomit cannot block the airway.
5. Stay with them and keep checking breathing until help arrives.
6. Do not give coffee, cold showers, food or drink, or try to make them vomit.
7. Keep the pill bottles or packaging to show paramedics.

Signs and symptoms

Mild to moderate

• drowsiness and slowed reactions
• slurred speech
• confusion and poor memory of events
• unsteadiness, poor coordination and falls
• blurred or double vision
• low mood or unusual behavior, sometimes agitation (paradoxical reaction), especially in older adults and children

Severe

• deep sleep or coma
• slow, shallow breathing and low oxygen
• low blood pressure
• low body temperature
• blue lips and fingertips

Why combinations are so dangerous

Benzodiazepines enhance GABA, the brain's main calming messenger. On their own they have a wide safety margin, and most people who overdose only on a benzodiazepine recover with supportive care. The danger rises steeply with other depressants:

• Opioids: together they suppress breathing far more than either alone. The FDA requires boxed warnings on both drug classes about combined use. Many overdose deaths involve both.
• Alcohol: adds to sedation and breathing suppression and increases vomiting and aspiration risk.
• Other sedatives: sleep medicines such as zolpidem, barbiturates, gabapentinoids, some antihistamines and antipsychotics.
• Counterfeit pills: fake "Xanax" and other tablets may contain fentanyl or potent designer benzodiazepines (such as bromazolam or etizolam) at unpredictable doses.

Who is at higher risk

• Older adults, who are more sensitive and more likely to fall
• People with lung disease such as COPD, or sleep apnea
• People with liver disease, which slows breakdown of many benzodiazepines
• People using benzodiazepines without a prescription or at high doses
• People with depression or suicidal thoughts

Hospital treatment

• Airway and breathing support: oxygen, and a breathing tube with a ventilator if breathing is inadequate.
• Monitoring: heart rhythm, oxygen levels, blood pressure and consciousness.
• Tests: blood tests for acetaminophen (paracetamol), aspirin, alcohol and other drugs that may have been taken; ECG; blood sugar. Standard urine drug screens miss some benzodiazepines.
• Activated charcoal is rarely used, only in specific circumstances where the airway is protected.
• Flumazenil: an antidote that reverses benzodiazepines, but it can trigger seizures in people dependent on benzodiazepines or who also took certain drugs such as tricyclic antidepressants. It is used selectively, for example in accidental overdose in a child or after medical sedation, not routinely.
• Mental health assessment for any intentional overdose before discharge.

Most people recover within 12 to 36 hours, depending on the drug and dose.

Complications

• Aspiration pneumonia from inhaling vomit
• Injuries from falls, including head injuries and fractures
• Pressure injuries and muscle breakdown from lying still for long periods
• Brain injury from low oxygen in severe combined overdoses
• Death, usually when opioids or alcohol are also involved

After an overdose: dependence and withdrawal

Regular use for more than a few weeks can lead to physical dependence. Stopping suddenly can cause dangerous withdrawal, including seizures. Never stop abruptly: a doctor can plan a gradual taper. See benzodiazepine withdrawal and benzodiazepine dependence.

Prevention

• Take benzodiazepines only as prescribed, at the lowest dose for the shortest time.
• Avoid alcohol and do not combine with opioids or other sedatives unless your doctor has specifically planned it.
• Keep medicines locked away from children and visitors; dispose of unused tablets safely.
• Do not use pills bought online or from others; use fentanyl test strips if you use non-prescribed drugs, and never use alone.
• Carry naloxone if you or someone you live with uses opioids.
• Talk to a doctor if you feel you need more to get the same effect.

For related emergencies, see opioid overdose, alcohol poisoning and drug overdose.

Frequently asked questions

What are the signs of a benzodiazepine overdose?

Signs include extreme sleepiness, slurred speech, confusion, poor coordination, slow reflexes and, in severe cases, slow or shallow breathing, blue lips and unresponsiveness. Symptoms are much more dangerous when benzodiazepines are combined with opioids or alcohol.

Can you die from a benzodiazepine overdose?

It is uncommon from a benzodiazepine alone in a healthy adult, but it can happen, especially in older adults or people with lung disease. Most deaths involve combinations with opioids, alcohol or other sedatives, or counterfeit pills containing fentanyl.

Does naloxone work for a benzo overdose?

Naloxone does not reverse benzodiazepines. Still, give it if opioids could be involved, because many overdoses include opioids and street pills are often contaminated with fentanyl. It is safe if no opioid is present. Always call 911 as well.

How long does a benzodiazepine overdose last?

It depends on the drug and amount. Short-acting drugs like alprazolam wear off faster than long-acting ones like diazepam or clonazepam. Most people wake within 12 to 36 hours with supportive care, but monitoring in hospital is needed until breathing and alertness are safe.

What should I do if someone took too much Xanax?

If they are hard to wake or breathing slowly, call 911, place them on their side and give naloxone if available. If they are awake and alert, call Poison Help at 1-800-222-1222 (US) for advice and do not leave them alone.