Benzodiazepine Withdrawal

Why withdrawal happens

Benzodiazepines boost the calming effect of GABA, the brain's main inhibitory chemical messenger. With regular use, the brain adapts by reducing its own GABA activity and increasing excitatory activity. When the drug is suddenly removed, the brain is left over-excited. That produces anxiety, insomnia and, in severe cases, seizures.

Dependence can develop after as little as 2 to 4 weeks of daily use, even at prescribed doses. This is physical dependence and is not the same as addiction, although the two can coexist. See benzodiazepine dependence.

Symptoms

Common symptoms

• anxiety, panic and restlessness, often worse than before treatment (rebound)
• insomnia and vivid dreams
• irritability and mood swings
• tremor, muscle aches and stiffness
• sweating, palpitations, nausea and loss of appetite
• poor concentration and memory
• heightened sensitivity to light, sound, touch and smell
• tingling, numbness or a feeling of unreality (depersonalization)

Severe symptoms

• seizures, most often after abruptly stopping high doses or short-acting drugs
• delirium and confusion
• hallucinations and paranoia
• suicidal thoughts

Timeline

A minority of people experience protracted withdrawal or post-acute symptoms, with anxiety, insomnia and sensory changes that come and go for months. These usually fade gradually. See post-acute withdrawal syndrome.

Risk of difficult withdrawal is higher with higher doses, longer use, short-acting drugs, abrupt stopping, alcohol or other drug use, and pre-existing anxiety or depression.

Diagnosis

Diagnosis is based on the history of use and the symptoms that follow reduction. A doctor will ask about the medicine, dose, how long you have taken it, previous attempts to stop, alcohol and other drug use, and mental health. They will rule out other causes of symptoms, such as an overactive thyroid or alcohol withdrawal.

Treatment

Gradual tapering

The safest approach is a slow, flexible reduction agreed between you and your prescriber:

• Reductions of about 5% to 10% of the current dose every 2 to 4 weeks are a common starting point, according to the American Society of Addiction Medicine guideline. Some people need slower steps.
• Total taper length is often several months, longer for people on high doses or long-term use.
• The final steps are often the hardest, so they may be smaller.
• Some prescribers switch to a longer-acting benzodiazepine such as diazepam to smooth out levels.
• Pauses are fine if symptoms become hard to manage. The taper does not have to be reversed.

Medically supervised withdrawal

People with very high doses, a history of seizures or delirium, combined alcohol or opioid use, or serious medical illness may need inpatient withdrawal management.

Support during withdrawal

• CBT improves taper success and helps manage anxiety and insomnia. CBT for insomnia (CBT-I) is especially helpful.
• Regular exercise, a consistent sleep routine and limiting caffeine and alcohol.
• Peer support groups and counseling.
• Some medicines may be used for specific symptoms, but there is no substitute that removes withdrawal.

Complications of abrupt withdrawal

• grand mal seizures
• delirium
• psychosis
• suicide risk
• injuries from falls or seizures
• return to use of the benzodiazepine, alcohol or street drugs

Outlook

Most people taper successfully and feel better off the medicine, with improved memory, alertness and energy. Acute symptoms resolve within weeks, and protracted symptoms gradually lessen over months.

Frequently asked questions

What are the symptoms of benzodiazepine withdrawal?

Common symptoms include rebound anxiety, insomnia, irritability, tremor, sweating, a racing heart, poor concentration and sensitivity to light and sound. Stopping suddenly after regular use can cause seizures, confusion and hallucinations, which are medical emergencies.

How long does benzo withdrawal last?

Acute withdrawal usually lasts 1 to 4 weeks for short-acting drugs and up to 8 weeks for long-acting ones, depending on the taper. Some people have milder lingering symptoms for several months, which gradually ease.

Can benzodiazepine withdrawal kill you?

Yes, in some cases. Abruptly stopping after long-term or high-dose use can cause seizures and delirium, which can be fatal. This risk is why a gradual, medically supervised taper is recommended rather than stopping suddenly.

How fast should you taper off a benzodiazepine?

A common approach is to reduce by 5% to 10% of the current dose every 2 to 4 weeks, adjusted to how you feel. Many tapers take several months. Your prescriber will tailor the plan to your dose, the drug and your health.