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Benzodiazepine Addiction:
Dangers | Withdrawal | Treatment

What are Benzodiazepines, What do they do?

Benzodiazepines (sometimes called “benzos”) are a class of drugs that produce sedative, muscle relaxant, anxiolytic (anti-anxiety), and hypnotic (sleep-inducing) effects. Benzodiazepines are central nervous system (CNS) depressants, which means that they slow down brain activity. Specifically, benzodiazepines enhance the effect of a neurotransmitter called gamma-aminobutyric acid (GABA), which results in calming, sedating, and muscle relaxing effects.

Benzodiazepines are widely prescribed. Worldwide, they are the most frequently used class of drugs, and rates of benzodiazepine use are steadily increasing. According to data analyzed from the 2015-2016 National Surveys on Drug Use and Health, about 30.6 million American adults (12.6%) used benzodiazepines in the past year 1. Of the 30.6 million adults, 25.3 million used benzodiazepines as prescribed while 5.3 million misused them. Overall, adults between the ages of 18-25 had the highest rates of benzodiazepine misuse (5.2%) while adults ages 65+ had the lowest (.6%).

Benzodiazepines are typically prescribed for short-term use, in minimal dosage. Long-term benzodiazepine use is not recommended, as it puts one at risk for developing tolerance and/or dependence. Yet, despite this recommendation, long-term benzodiazepine use still frequently occurs.

Yearly prevalence of benzodiazepine use and misuse in the U.S. | Statistics by NSDUH

Why Do People Get Prescribed Benzodiazepines?

Benzodiazepines are prescribed to treat a wide range of conditions, most commonly including:

Generalized anxiety disorder
Panic disorder
Seizure disorders
Insomnia
Muscle spasms
Alcohol withdrawal syndrome

Benzodiazepines may also be given to patients before medical procedures or surgery, in order to relax or sedate them.

Common Benzodiazepines

There are several different types of benzodiazepines. Benzodiazepines can be categorized as short, intermediate, or long-acting. Short-acting benzodiazepines begin working quickly and wear off quickly, whereas long-acting benzodiazepines take longer to work and wear off.

Common benzodiazepines in the United States include:

Short- to intermediate-acting benzodiazepines:

  • Alprazolam (Xanax)
  • Clobazam (Onfi)
  • Lorazepam (Ativan)
  • Temazepam (Restoril)
  • Triazolam (Halcion)

Long-acting benzodiazepines:

  • Clonazepam (Klonopin)
  • Clorazepate (Tranxene)
  • Diazepam (Valium)

Side Effects of Benzodiazepines

Since benzodiazepines are a central nervous system depressant, taking them together with other depressants, such as alcohol, can be extremely dangerous and even deadly. However, when benzodiazepines are not mixed with other drugs, taken for short amounts of time, and used as prescribed by a doctor, they are relatively safe.

Short-term side effects of benzodiazepines are generally mild, and may include:

Blurred vision
Dizziness
Drowsiness
Dry mouth
Impaired muscle coordination
Memory loss
Mental confusion
Muscle weakness
Slowed breathing
Slowed reaction time
Slurred speech

Long-Term Side Effects of Benzodiazepines

Tolerance

Tolerance occurs when someone repeatedly uses a drug, causing the drug to begin to lose its effectiveness. After someone recurrently takes the same dosage of a drug, the body begins to adapt to constantly being exposed to the drug, and, thus, the drug’s effect on the body begins to decrease. This results in the individual needing to take an increased amount of the drug to achieve the desired effect.

Benzodiazepine tolerance develops at different rates depending on the benzodiazepine used. For instance, tolerance will develop more quickly for benzodiazepines that have a shorter half-life, in comparison to those with a longer half-life. One study found that tolerance for some benzodiazepines (ketazolam, lorazepam, and triazolam) developed after 15 days 4. However, other studies have shown that tolerance can develop within just 24 hours of benzodiazepine use 5.

Dependence

Long-term use of benzodiazepines can also lead to physical dependence, which is characterized by the development of both tolerance and withdrawal symptoms. Dependence occurs when someone’s body has adapted to a drug they have continuously been using, and once they stop using the drug, they experience physical and/or psychological withdrawal symptoms, as their body now relies on the drug to function normally.

In benzodiazepine dependence, people typically continue to use benzodiazepines in order to relieve withdrawal symptoms, rather than for the drug’s pleasurable effects.

Other Long-Term Effects of Benzodiazepines

Other effects of long-term benzodiazepine use include 6, 7, 3:

  • Cognitive impairment including:
    • Attention and concentration problems
    • Confusion
    • Decreased reaction time
    • Decreased visual-spatial abilities
    • Learning problems
    • Memory problems
  • Muscle weakness
  • Increased anxiety
  • Depression
  • Decreased motor coordination
  • Excessive sedation, increasing one’s risk for falls and motor accidents
  • Increased risk of Alzheimer’s disease 8

Withdrawal

Withdrawal occurs when someone who frequently uses a substance begins to experience undesirable physical and/or psychological symptoms after they stop using the drug. Benzodiazepine withdrawal symptoms are believed to occur because prolonged benzodiazepine use causes various changes in the central nervous system, particularly in GABA receptors, as the body begins to adapt to drug use.

However, once the individual stops taking the drug, the changes in the GABA receptors remain, as the body has adapted to the drug use. This results in disequilibrium, which causes distressing withdrawal symptoms. Consequently, individuals typically continue to use the drug in order to relieve their withdrawal symptoms. It is very common for benzodiazepine users to experience withdrawal symptoms.

It is likely that individuals will experience withdrawal symptoms after taking benzodiazepines for more than 3 or 4 weeks 2. However, benzodiazepines have also been shown to produce withdrawal symptoms after just one to ten days. After eight weeks of taking benzodiazepines, almost one third of patients experience withdrawal symptoms 3.

Benzodiazepine Withdrawal Symptoms

Even when people use the therapeutic doses of benzodiazepines, they can still experience withdrawal symptoms once they stop using them. While it is possible for people using benzodiazepines for a short period of time to experience withdrawal symptoms after they stop using the drug, long-term benzodiazepine users are especially at risk for experiencing more severe withdrawal symptoms. Additionally, benzodiazepines with a short half-life produce more severe withdrawal symptoms.

Short-acting benzodiazepines can produce withdrawal symptoms just one to two days after their use is discontinued, and long-acting benzodiazepines can produce withdrawal symptoms within five to ten days after they are discontinued 3.

Withdrawal symptoms can be both physical and psychological. The severity of withdrawal symptoms also depends on one’s dosage and how long one was taking benzodiazepines for.

Common withdrawal symptoms include 3, 9, 6:
Genetic vulnerability
Anxiety
Concentration problems
Depersonalization or derealization
Depression
Dizziness
Gastrointestinal problems
Headaches
Hypersensitive sensory perceptions
Increased heart rate and blood pressure
Insomnia
Irritability
Loss of appetite
Muscle aches and twitches
Perceptual distortions
Restlessness
Sweating
Tingling or numbness
Tinnitus
Tremors
Twitches
Weakness in legs
More severe withdrawal symptoms include:
Delirium
Psychotic symptoms (auditory, tactile, or visual hallucinations)
Seizures

In order to avoid these serious and possibly life-threatening withdrawal symptoms, it is vital that you do not abruptly stop taking benzodiazepines, especially if you are taking a high dosage. Instead, it is crucial to talk to your doctor about tapering down from your dosage. This involves gradually taking smaller doses over a few weeks or months, until the benzodiazepine is eventually discontinued completely.

Benzodiazepine Withdrawal Timeline

One’s withdrawal timeline can differ significantly due to various factors, such as the type of benzodiazepine used, how long it was used for, and the dosage.

While some people experience acute withdrawal, which typically lasts for 5 to 28 days, others may experience withdrawal symptoms for up to one year or even longer 10.

The latter is known as protracted withdrawal, which is a long-term withdrawal syndrome experienced by about 10 to 25 percent of long-term benzodiazepine users. During protracted withdrawal, one’s symptoms may go away for a few weeks, but then return.

Generally, withdrawal symptoms are the most severe and dangerous during the first three days. It is strongly recommended that people going through withdrawal during this period be under medical supervision, especially as this is when seizures have the highest likelihood of occurring. Although the worst has passed after this period, people typically continue to experience strong physical withdrawal symptoms and cravings for days 4-7 of withdrawal.

During the second week, people usually experience psychological symptoms, such as anxiety or depression, as well as their remaining physical symptoms.

In the third and fourth week, people may begin to notice some improvement in their symptoms. Physical and psychological symptoms are typically still present, but to a lesser degree.

Although all symptoms greatly lessen after four weeks, it is possible for some symptoms to linger for several months to a year, or even longer.

Alternative Medications for Anxiety Disorders

While benzodiazepines may be effective in treating short-term anxiety, they are not recommended for long-term anxiety treatment. Instead, alternative medications that are frequently used to treat anxiety disorders include:

Buspirone (Buspar)
Selective Serotonin Reuptake Inhibitors (SSRIs, *first-line drug treatments)
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs, *first-line drug treatments)
Tricyclic Antidepressants (TCAs)

Non-Pharmaceutical Treatments for Anxiety Disorders

There are several ways to reduce symptoms of anxiety without using medication. Some of these ways include:
Acupuncture
Biofeedback
Deep breathing exercises
Exercising for 20 to 30 minutes daily
Meditation
Supplements, including Vitamin D, Vitamin B Complex, and Magnesium 11
Progressive muscle relaxation
Psychotherapy, especially cognitive behavioral therapy (CBT) 12

Benzodiazepine Addiction (DSM-5: “Sedative, Hypnotic, or Anxiolytic Use Disorder”)

Whether one is taking prescribed benzodiazepines from a doctor or taking them illicitly, chronic benzodiazepine use can result in addiction. It should be noted that benzodiazepine addiction is not the same as benzodiazepine dependence.

While all long-term users of benzodiazepines will eventually develop physical dependence, not all users will develop addiction. However, physical dependence frequently accompanies addiction.

Addiction is a complex disease, characterized by being unable to stop using a drug, despite the various detrimental consequences the drug causes. Addiction causes changes in the brain related to pleasure, reward, memory, and motivation 13.

This results in people experiencing distorted thinking and intense cravings for drugs to the point where they have a loss of control over their drug use.

Addiction is referred to as “substance use disorder” in the DSM-5, and benzodiazepine addiction is diagnosed as “sedative, hypnotic, or anxiolytic use disorder.”

In order to be diagnosed with a sedative, hypnotic, or anxiolytic use disorder, one must experience at least two of the following symptoms within the past 12 months 14:

  • Taking the drug in larger amounts or for a longer amount of time than attended
  • Desire to control or reduce the drug use, or unsuccessful efforts in doing so
  • Spending very large amounts of time in obtaining, using, or recovering from the drug
    An extremely strong desire (craving) to use the drug
  • Failure to fulfill work, school, or home obligations due to drug use (e.g., poor work performance or frequent absences)
  • Continuing to use the drug despite the social and interpersonal problems that the drug causes
  • Giving up or reducing significant social, occupational, or recreational activities due to drug use
  • Continuing to use the drug even when it is physically hazardous (e.g., driving)
  • Continuing to use the drug despite knowing the psychological and physical problems it causes
  • Tolerance (defined by either needing a larger amount of the drug to produce the desired effect, or when the same amount of the drug produces a significantly reduced effect)
  • Withdrawal (manifested by either displaying withdrawal symptoms, or by taking sedatives, hypnotics, or anxiolytics in order to relieve or avoid symptoms of withdrawal)

Dual Diagnosis: Addiction and Anxiety Disorders

A dual diagnosis (or “co-occurring disorders”) is when someone has a substance use disorder and a mental disorder occurring at the same time. Substance use disorders and anxiety disorders co-occur together at high rates.
According to the National Epidemiologic Survey on Alcohol and Related Conditions, about 15% of people with anxiety disorders also had a substance use disorder in the past year 15.

Similarly, about 18% of people with a substance use disorder had an anxiety disorder in the past year. Generalized anxiety disorder and panic disorder are most highly related to substance use disorders 16. The National Institute on Drug Abuse has also suggested that compared to the general population, people with anxiety disorders are two times as likely to also have a substance use disorder 17.

It has been proposed that the high rates of comorbid anxiety and substance use disorders may be related to people with anxiety self-medicating to relieve their anxiety symptoms. This could lead to or exacerbate a substance use disorder, which could, in turn, further worsen anxiety symptoms.

As benzodiazepines produce calming, anti-anxiety effects in the user, people with anxiety disorders may be particularly inclined to use these drugs to self-medicate. Since people with substance use disorders are more likely than others to have a co-occurring anxiety disorder, properly identifying and treating both disorders is crucial for long-term recovery.

Benzodiazepine Addiction Treatment

As benzodiazepine withdrawal can be dangerous and even deadly, medical detox is almost always recommended as the first step of treatment. Depending on the severity of one’s addiction, inpatient or outpatient rehabilitation is often also suggested, followed by aftercare.

Detoxification

Detoxification, or “detox,” is the process of safely eliminating a drug from one’s body. Detox can either be in an inpatient setting (medical detox) or in an outpatient setting (at-home detox). In a medical detox, patients receive 24-hour care and are closely supervised and monitored by doctors and other health professionals. Additionally, medical professionals prescribe patients medications to help manage their withdrawal symptoms and keep them safe.

Specifically, a doctor will help patients in tapering off of benzodiazepines. Tapering will differ depending on the patient’s specific benzodiazepine usage, although it can either be done by gradually reducing the dosage of the benzodiazepine the patient is currently taking, or by switching the patient to a longer-acting benzodiazepine. For instance, in the first option, a patient’s benzodiazepine dosage may initially be reduced by 10-30%, and then further reduced by 5-25% daily or weekly, until eventually, it is discontinued completely 18.

Common long-acting benzodiazepines used for tapering down from short-acting benzodiazepines include diazepam (Valium) or clonazepam (Klonopin). Patients may also be prescribed additional medications to help ease withdrawal symptoms, such as carbamazepine, imipramine, trazadone, and valproate 19.

Although detox is a vital first step of recovery, it is often not enough to help someone maintain long-term sobriety. Therefore, it is highly advised that after completing detox, patients continue their recovery in inpatient rehabilitation, outpatient rehabilitation, or psychotherapy.

Inpatient Rehabilitation

In inpatient rehabilitation programs, patients reside at the treatment center, where they receive 24-hour care and support from professionals. Individuals with more severe benzodiazepine addictions often benefit from inpatient rehabilitation, as treatment is more intensive and patients are provided with a structured, supportive, distraction-free environment to recover in.

Patients typically stay at inpatient programs for 30 to 90 days, and are treated by a team of professionals, including doctors, therapists, psychiatrists, and addiction counselors. Inpatient rehabilitation programs provide a range of services to patients, including individual therapy, group therapy, education about addiction, and medication, if necessary.

Outpatient Rehabilitation

In outpatient rehabilitation programs, patients live at home and come to the treatment center during the daytime or in the evening for their treatment sessions. Patients will typically receive 6 to 30 hours of treatment each week in outpatient rehabilitation. Outpatient programs are usually three months to a year long in duration, although, if necessary, patients may receive treatment for even longer.

Outpatient programs are ideal for those who want to continue going to school or work, maintain their daily responsibilities, and live with their families while also receiving benzodiazepine addiction treatment. Outpatient programs are also more suitable for people who have mild benzodiazepine addictions and who live in a safe, supportive environment.

While outpatient rehab is less intensive than inpatient rehab, patients will receive similar treatment services, such as individual therapy and group therapy. If necessary, patients can also meet with the facility’s psychiatrist for medication. It is common for patients who complete treatment at inpatient programs to continue their recovery at outpatient programs.

Aftercare

Due to the high relapse rates of addiction, it is important for individuals to continue with their recovery by receiving ongoing treatment once they have completed their initial phase of treatment. This is referred to as “aftercare,” which aims to help individuals maintain their recovery and prevent relapses. Before the initial phase of treatment is completed, patients’ therapists, counselors, or case managers can help them create an aftercare plan.

Aftercare treatment options for benzodiazepine addiction include:

Individual therapy

Group therapy

Support groups and self-help groups, such as 12-step programs (e.g., Narcotics Anonymous)

Educational Video:

Listen to psychiatrist Dr. Tracey Marks discuss the differences between dependence and addiction, followed by tips on how to avoid dependence when using benzodiazepines. Information included is intended for educational purposes and not for specific individual medical advice.

Information found both in this video and web page should only serve as preparation for a discussion with your appointed doctor.