Benzodiazepines, also called benzos, are psychoactive drugs that were first synthesized in 1955 and, by the 1970s, they had already become the most widely prescribed medication in the world, generally prescribed as sleep aids and anti-anxiety medication, although they have found success treating epilepsy as well.
Previously, barbiturates were the drugs of choice for treating insomnia and anxiety, but they were found to have more common adverse effects and higher addiction potential, and have fallen out of fashion in the medical industry. Now, benzodiazepines are the drugs that are by and large used to treat the 40 to 50 million adults in the United States that suffer from anxiety and sleep disorders.
Benzodiazepines are a broad class of drug, including more than 2,000 unique chemical substances. However, there are only a handful of benzodiazepines that dominate not only the market and medical community, but also illicit use, including Klonopin, Librium, Ativan, Valium, and Xanax, which have nearly 50 million prescriptions written for it each year.
In fact, benzodiazepines are one of the most over-prescribed drugs in America, with the National Institute on Drug Abuse reporting more than four times the amount of fatal overdoses due to benzodiazepines in 2015 as compared to 2012.
Despite their usefulness for helping people with both anxiety and insomnia disorders, benzos have a significant risk for abuse and addiction, and the withdrawal symptoms are uniquely dangerous, with benzodiazepine detoxification generally requiring the intervention and supervision of a professional medical detox facility in order to be carried out safely.
How Benzodiazepines Affect the Brain
Benzodiazepines are in a class of drugs called central nervous system depressants that cause several effects related to calming or relaxing the user. The effects are what allow benzos to be effective treatments for anxiety disorders, insomnia, agitation, seizures, and muscle spasms. Their specific effects include:
- Sedation, or reducing irritability, excitement, and stimulation
- Hypnotic, or inducing sleep
- Anxiolytic, or anti-anxiety
- Muscle relaxant
The binding to GABA receptors is the channel through which the activation process occurs. Benzos bind to the GABA receptors, then stimulate a GABA-ergic (inhibitory) response to stress, anxiety, and fear. GABA does this by blocking the nerve impulses responsible for creating and transmitting those feelings to help the brain keep itself calm.
Benzodiazepines bind to these GABA receptors, activate them, and stimulate (increase) the GABA response; hence, bringing those calming effects with it and creating a significantly more powerful block against anxiety and stress.
Most benzodiazepines are intended for short-term therapeutic use only and are not recommended for regular use past four weeks, although some people can build up both a tolerance and dependence in as little as two weeks. Dosage should also be carefully restricted, as in some cases, high doses of certain benzos can cause amnesia and dissociations.
If your brain becomes chemically dependent on benzos, it can actually make sleep problems worse. If someone tries to cut back or quit benzo use after developing an addiction, they may experience a rebounding of insomnia or anxiety, perhaps even worse than before.
This is because the brain will have stopped producing its own GABA and become reliant on the ones created by benzodiazepines. So when benzo use is stopped, and the stream of GABA dries up, there’s no longer anything blocking the anxiety signals from reaching the brain, and it triggers a shock to the system that causes the symptoms of benzodiazepine withdrawal.
What You Can Expect From Benzodiazepine Withdrawal
Benzodiazepine withdrawal also has some of the most dangerous withdrawal symptoms of any detox. As a central nervous system depressant like alcohol, benzodiazepine withdrawal can cause symptoms that can be life-threatening.
Symptoms can range from milder, early withdrawal symptoms such as:
- Irritability and mood swings
- Muscle pain
- Elevated heart rate
- Abdominal cramps
Along with much more intense and potentially deadly symptoms like:
- Uncontrollable muscle spasms
- Rebound insomnia
- Rebound anxiety
- Vivid nightmares and other sleep disturbances
- Constant, uncontrollable crying
As previously mentioned, upon stopping the use of benzodiazepines after long periods of abuse, old symptoms of anxiety and insomnia return much worse than they were prior to benzo use in rebound form. Rebound insomnia can result in total sleeplessness for several days, and rebound anxiety can cause extreme feelings of paranoia and panic attacks.
Those in benzodiazepine withdrawal can experience an even more severe set of symptoms in the event of benzodiazepine withdrawal syndrome, which is likely to occur after extremely heavy use of benzos within a fairly short period of time. Some symptoms associated with benzodiazepine withdrawal symptoms include:
- Memory loss
- Suicidal behavior
Within this set of symptoms, people in benzodiazepine withdrawal may also specifically experience tonic-clonic seizures as well as Delirium tremens (DT).
Tonic-clonic seizures involve two phases. The tonic phase comes with sudden muscle contractions where the limbs are pulled in, close to the body. The clonic phase comes with violent convulsions. Deaths associated with seizures are usually due to them causing fatal accidents. However, other serious medical complications can occur.
DT is a sudden onset of confusion, hallucinations, high blood pressure, and fast heart rate. People experiencing an episode may also experience an overwhelming feeling of impending doom or imminent death. DT is fatal in 25 percent of cases without medical treatment.
Benzodiazepine Withdrawal Timeline
When considering the severity of some of the symptoms of benzodiazepine withdrawal, it’s understandable that the main question on someone’s mind when beginning benzodiazepine detox is how long the process will last.
While there is a general established withdrawal timeline for drugs that fall into the benzodiazepine class, the exact length of any given withdrawal period is going to be different from person to person based on factors that are unique to them and their situation, including:
- How long an individual has been abusing benzodiazepines
- In what form they were taking them (as tablets, crushed and snorted, injected, etc.)
- If they have been abusing benzodiazepines at the same time as other drugs or alcohol
- If they also have a mental illness or other co-occurring disorders
- The condition of their general physical health
- If they have a history of addictio
- nIf they experience benzodiazepine withdrawal syndrome during detox
- If they are put on a tapering schedule to slowly lower their benzo use
The specific benzo that the individual has become dependent on is also an important factor, as some, such as Xanax and Ativan, will leave the body faster and have a shorter withdrawal period than benzos with a longer half-life like Klonopin or Valium.
With these different influencing factors in mind, the typical stages of the benzodiazepine withdrawal timeline are as follows:
10 TO 48 HOURS
While those in withdrawal from benzos with a short half-life like Xanax can start feeling withdrawal symptoms as early as six hours, it’s usually between roughly 10 and 12 hours after the last use, with symptoms reaching their peak at around one to four days. Conversely, for benzos like Librium that don’t reach their peak strength for several hours, it can take up to two days after the last use for early symptoms to appear.
4 TO 10 DAYS
Depending on the benzodiazepine in question, withdrawal symptoms may reach their peak as early as four days and begin to diminish after a week. For others, it may take the course of a week or longer for symptoms to be at their peak strength.
2 TO 4 WEEKS
Over the course of roughly the next few weeks, benzodiazepine withdrawal symptoms will either disappear completely or become greatly diminished and much more manageable. Even for benzos with faster withdrawal periods, psychological symptoms can still linger during this stage.
ONE MONTH AND BEYOND
At this point, no matter which specific benzodiazepine detox someone is undergoing, the withdrawal period will have, for the most part, come to an end, although anxiety, depression, and insomnia are likely to remain for some.
As previously stated, the withdrawal process can become significantly lengthened by benzodiazepine withdrawal syndrome or by being placed on a tapering schedule, which can sometimes stretch the withdrawal period to as long as two months. But when dealing with a severe addiction, especially when benzos are involved, it’s always a better idea to play it safe and avoid seizures and other life-threatening symptoms.
Someone undergoing benzodiazepine detox is also more susceptible to experiencing post-acute withdrawal syndrome or PAWS. PAWS is a secondary withdrawal phase that can persist months after someone has completed their benzodiazepine detox, and can include random, intermittent bouts of symptoms like unstable moods, suicidal thoughts, and drug cravings.
What Are the Benzodiazepine Withdrawal Treatment Steps?
As we’ve illustrated, benzodiazepine withdrawal is among the most difficult and dangerous withdrawal processes that someone can experience. While there are some substances that are safe to detox from on a limited outpatient basis, benzodiazepines are almost never one of them.
“It is also understandable and unsurprising that benzodiazepine detox has an extremely high relapse rate, as many people who attempt to detox on their own cannot handle the intensity of the symptoms of benzodiazepine withdrawal and relapse midway through the process to alleviate these symptoms. The danger here is that someone in the midst of a relapse, desperate to find relief from their withdrawal symptoms, is at a much higher risk of accidentally overdosing, potentially fatally. ”
For these reasons and many more, it is critical that the first step in benzodiazepine withdrawal treatment be a medical detox at a professional facility.
This way, an individual’s safety can be guaranteed with around the clock monitoring by medical professionals. They will be there to administer medication to ease the discomfort of many benzodiazepine withdrawal symptoms and set up a tapering schedule to slowly reduce use until it is safe to stop without triggering a seizure.
Some of the common medications administered during benzodiazepine detox include:
While anticonvulsant medication is usually only given in the case of someone experiencing seizures during the benzodiazepine withdrawal process, it has been found to be useful for treating the general symptoms of benzodiazepine withdrawal.
An over-the-counter supplement used to help regulate sleep and wakefulness, melatonin is used to reduce the symptoms of insomnia and anxiety while bypassing the built-up tolerance to benzos.
Specifically, serotonin reuptake inhibitors such as Zoloft and Prozac are used to lessen the intensity of symptoms like depression and the dangers of suicidal thoughts and behavior.
Once past the withdrawal period, the next step in effective benzodiazepine withdrawal treatment is checking into an addiction recovery treatment program. Following through with continuous treatment after detox is crucial for a successful recovery in the short-term and avoiding relapse in the long-term.
- Individual therapy
- Cognitive behavioral therapy
- Group therapy
- Family therapy
- Addiction education
- Relapse prevention planning
After completing an inpatient recovery treatment program, attending an outpatient program is recommended as well, as it gives people more time to readjust to their regular lives without the use of benzodiazepines, giving them a higher chance of managing their addiction long after completing benzodiazepine withdrawal treatment.