Benzodiazepines are a class of commonly prescribed tranquillisers that are sometimes used to treat anxiety, sleeping problems and other disorders. Examples include: Diazepam (trade name Valium), Lorazepam (trade name Ativan), Chlordiazepoxide (trade names Librium and Tropium), Alprazolam (trade name Xanax), Oxazepam, Temazepam, Nitrazepam, Flurazepam, Loprazolam, Lormetazepam, Clobazam and Clonazepam. Benzodiazepines work by affecting the way certain brain chemicals (neurotransmitters) transmit messages to certain brain cells. In effect, they decrease the 'excitability' of many brain cells. This has a calming effect on various functions of the brain.
All benzodiazepines have five primary effects: A. Hypnotic (for the promotion of sleep); B. Anxiolytic (for the relief of anxiety); C. Myorelaxant (muscle relaxant); D. Anticonvulsant (to stops fits and convulsions); E. Amnesia (impairment of short term memory).
Different benzodiazepines exhibit these primary effects to varying degrees. For example, Diazepam (Valium) is a relatively powerful hypnotic (sleep inducer), whereas Lorazepam and Clonazepam are less powerful hypnotics, but are very powerful anxiolytics. Do not assume that because one benzodiazepine makes you sleepier than another that this benzodiazepine is more potent than those which do not produce sleepiness to the same degree. Often, the reverse is true.
Benzodiazepines are most commonly prescribed for anxiety conditions, especially Panic Disorder (PD) and Generalised Anxiety Disorder (GAD). They are also sometimes prescribed for seizure disorders. Clonazepam, for example, is often prescribed for epilepsy. Benzodiazepines are also prescribed for insomnia and other sleep problems, such as Restless Leg Syndrome (RLS). Benzodiazepines are also frequently prescribed as muscle relaxants. See page on Minor tranquillisers and sleeping tablets
2. Are benzodiazepines addictive?
Benzodiazepines are potentially addictive drugs. Psychological and physical dependence can develop within a few weeks or months of regular or repeated use. The British National Formulary (BNF) recommend that these medications should be prescribed for 2-4 weeks only.
Physical dependency to benzodiazepines varies widely. The following variables may play a role: the size of your dose, the regularity with which you consume your dose, and most importantly, your personal body chemistry. See page on Minor tranquillisers and sleeping tablets.
3. How do benzodiazepines work?
Benzodiazepines are general Central Nervous System (CNS) depressants. They are all very similar chemically. All benzodiazepines act by enhancing the actions of a natural brain chemical, GABA (Gamma-Aminobutyric Acid). GABA is a neurotransmitter, an agent which transmits messages from one brain cell (neuron) to another. The message that GABA transmits is an inhibitory one: it tells the neurons that it contacts to slow down or stop firing. Since about 40% of the millions of neurons all over the brain respond to GABA, this means that GABA has a general quietening influence on the brain: it is in some ways the body's natural hypnotic and tranquilliser. This natural action of GABA is augmented by benzodiazepines which thus exert an extra (often excessive) inhibitory influence on neurons.
The way in which GABA sends its inhibitory message is by a clever electronic device. Its reaction with special sites (GABA-receptors) on the outside of the receiving neuron opens a channel, allowing negatively charged particles (chloride ions) to pass to the inside of the neuron. These negative ions "supercharge" the neuron making it less responsive to other neurotransmitters which would normally excite it. Benzodiazepines also react at their own special sites (benzodiazepine receptors), situated actually on the GABA-receptor. Combination of a benzodiazepine at this site acts as a booster to the actions of GABA, allowing more chloride ions to enter the neuron, making it even more resistant to excitation. Various subtypes of benzodiazepine receptors have slightly different actions. One subtype (alpha 1) is responsible for sedative effects, another (alpha 2) for anti-anxiety effects, and both alpha 1 and alpha 2, as well as alpha 5, for anticonvulsant effects. All benzodiazepines combine, to a greater or lesser extent, with all these subtypes and all enhance GABA activity in the brain. As a consequence of the enhancement of GABA's inhibitory activity caused by benzodiazepines, the brain's output of excitatory neurotransmitters, including norepinephrine (noradrenaline), serotonin, acetyl choline and dopamine, is reduced. Such excitatory neurotransmitters are necessary for normal alertness, memory, muscle tone and co-ordination, emotional responses, endocrine gland secretions, heart rate and blood pressure control and a host of other functions, all of which may be impaired by benzodiazepines. Other benzodiazepine receptors, not linked to GABA, are present in the kidney, colon, blood cells and adrenal cortex and these may also be affected by some benzodiazepines. These direct and indirect actions are responsible for the well-known adverse effects of dosage with benzodiazepines.
4. What are Z drugs? Are they the same as benzodiazepines?
Drugs called Zaleplon, Zolpidem, and Zopiclone are commonly called the 'Z' drugs. These are classed as non-benzodiazepines but have similar effects on the brain cells as benzodiazepines. Z drugs also have similar long-term usage problems as benzodiazapines.
A short course of a benzodiazepine or a Z drug may be prescribed if a drug is felt necessary to help with sleeping difficulty (insomnia).
If you are taking one of these sleeping tablets on a regular basis you should consider reducing or stopping them this should be done gradually as there could be issues regarding tolerance or dependence (see next question). For advice on how to withdraw safely see question 15 of the FAQs below.
5. What is tolerance and therapeutic dose dependence?
Tolerance Tolerance develops with regular use of either a benzodiazepine or Z drug. The helpful effect on easing anxiety or in helping sleep usually lasts for a few weeks. However, after a few weeks, the body and brain often become used to the benzodiazepine or Z drug therefore becomes less effective and a higher dose is required to obtain the original effect. In time, the higher dose does not work, and you need an even higher dose, and so on. This effect is called tolerance.
Therapeutic Dose Dependence There is a good chance that you will become dependent on a benzodiazepine or Z drug if you take it for more than four weeks. This means that withdrawal symptoms occur if the tablets are stopped suddenly. People who have become dependent on therapeutic doses of benzodiazepines usually have several of the following characteristics. (Prof Ashton Manual)
Have taken benzodiazepines in prescribed "therapeutic" (usually low) doses for months or years.
Have gradually come to "need" benzodiazepines to carry out normal, day-to-day activities.
Have continued to take benzodiazepines although the original indication for prescription has disappeared.
Have difficulty in stopping the drug, or reducing dosage, because of withdrawal symptoms.
On short-acting benzodiazepines they develop anxiety symptoms between doses, or get craving for the next dose.
They contact their doctor regularly to obtain repeat prescriptions.
They become anxious if the next prescription is not readily available; they may carry their tablets around with them and may take an extra dose before an anticipated stressful event or a night in a strange bed.
May have increased the dosage since the original prescription.
May have anxiety symptoms, panics, agoraphobia, insomnia, depression and increasing physical symptoms despite continuing to take benzodiazepines.
6. What are antidepressants?
Antidepressants are medicines used to help people who have depression and anxiety in some cases. Antidepressants are sometimes described as: first, second, or third generation antidepressants: First generation antidepressants are known as TCAs and MAOIs Tricyclic Antidepressants (TCAs), the most widely used type is called Amitriptyline, and Monoamine Oxidase Inhibitors (MAOIs), the two most widely used types are called Moclobemide and Phenelzine. Both TCAs and MAOIs have caused a wide range of side effects, which were often unpleasant. These include: constipation, sweating, shaking or trembling, and difficulty sleeping. Second generation antidepressants are known as Selective Serotonin Reuptake Inhibitors (SSRIs). Fluoxetine is probably the best known SSRI (sold under the brand name Prozac). Other SSRI’s are Citalopram, Escitalopram, Paroxetine and Sertraline. SSRIs are usually the first kind of antidepressant medicine your doctor will recommend. These medicines tend to have fewer side effects than other antidepressants. Some of the side effects that SSRIs can cause include dry mouth, nausea, anxiety and nervousness, insomnia, sexual problems and headache.
Some SSRI’s such as Paroxetine can be given for Generalised Anxiety Disorder and Social Phobia. Third generation antidepressants are known as Serotonin-Noradrenaline Reuptake Inhibitors (SNRIs). These include Venlafaxine, Reboxetine, Duloxetine and Mirtazapine. SNRIs were the result of an attempt to create an antidepressant that was more clinically effective than SSRIs. However, the evidence that SNRIs are more effective at treating everyone with depression is uncertain. It seems that some people respond better to SSRIs while others respond better to SNRIs. These medicines are sometimes chosen because they don’t interfere with certain other medicines. Some common side effects caused by these medicines include nausea (especially in the first two weeks), loss of appetite, anxiety and nervousness, headache, insomnia and tiredness. Dry mouth, constipation, weight loss, sexual problems, increased heart rate and increased cholesterol levels also can occur. It has been reported that most antidepressants, but particularly the SSRI’s and SNRI’s, can cause severe anxiety for some patients over the first few weeks of taking medication. Antidepressants can have an effect on many other medicines. If you're going to take an antidepressant, tell your doctor about all the other medicines you take, including over-the-counter medicines and herbal health products (such as St. John's Wort). Ask your doctor and pharmacist if any of your regular medicines can cause problems when combined with an antidepressant.
7. Are antidepressants addictive?
Whilst antidepressants are not addictive in the same way as hard drugs, you may experience a cluster of symptoms on stopping antidepressant treatment. This is known as discontinuation syndrome. It is therefore essential to come off your antidepressants slowly if you have been taking them for 2 months or longer. The rate of withdrawal will vary according to which drug you have been taking, for how long and in what quantity. The safest way is to make small reductions in the amount taken at intervals of a few weeks, to ensure that any withdrawal symptoms are kept to a minimum. Too rapid withdrawal can result in severe symptoms such as major anxiety or panic attacks, insomnia, sickness, lack of concentration, depersonalisation and even suicidal feelings. Discuss these immediately with your doctor if you are worried about them. See other page on Antidepressants TCAs, MAOIs, SSRIs and SNRIs.
8. How do antidepressants work?
Chemicals in the brain called neurotransmitters are needed for normal brain function. Antidepressants help people who have depression by making these natural chemicals more available to the brain. Different types of antidepressants work in different ways, but all antidepressants are based on the same principle. Neurotransmitters are ‘messenger chemicals’ that are used to transmit signals between brain cells. Some neurotransmitters such as serotonin, norepinephrine, and dopamine are thought to have an important effect on your mood. Increasing the levels of neurotransmitters is a gradual process, so most people will need to take antidepressants for two to four weeks before noticing any improvement in their symptoms. Although antidepressants can treat the symptoms of depression, they do not necessarily address the causes. This is why antidepressants are usually used in combination with therapy to treat moderate to severe depression or other mental health conditions.
9. What are the symptoms of benzodiazepine and Z drug withdrawal?
The following is a list of symptoms. This list is broken down into psychological and physical symptoms.
Psychological symptoms: Anxiety, Depression, Restlessness, Insomnia, Nightmares, Panic attacks, Agoraphobia, Obsessive negative thoughts, Rapid mood changes (crying one moment and laughing the next), Loss of memory, Irritability, Lack of concentration, Fears (uncharacteristic), Feelings of unreality, Changes in perception (faces distorting and inanimate objects/surfaces moving).
Physical Symptoms: Muscular aches and pains, Extreme Lethargy, Heavy limbs, Flu-like symptoms, Sweating, Shaking, Nausea, Indigestion, Abdominal pains and cramps, Distended abdomen, sensitivity to sensory stimuli (such as loud noise or bright light), Seeing spots, Dizziness, Loss of balance Lack of co-ordination, tinnitus, headaches, Tightness in the head (feeling a band around the head), Blurred vision, Heart palpitations, Tightness in the chest, Breathing difficulties.
Note: This list is not exhaustive there may be other symptoms associated with withdrawal that have not been listed here.
10. Should I switch to another benzodiazepine such as diazepam before reducing?
Possibly, but do it gradually, and cut the dose down a little at a time. A switch to a different benzodiazepine (Diazepam) may be advised. This is because it is easier to gradually reduce the dose of Diazepam than with other benzodiazepines or Z drugs.
Switching is not for everyone, many have come off their drug of dependency and recovered. However, there are very good reasons to make the switch for purposes of withdrawal.
First, Diazepam has a far longer half-life than most other benzodiazepines. This means that it is slowly eliminated allowing for the body to adjust to the reductions. Second, Diazepam is low in potency relative to most other benzodiazepines and comes in tablets of 2mg, 5mg and 10mg. For making reductions these sizes are very practical. It also comes as a liquid so at the end of your reduction you can make accurate reductions of small amounts. Finally, it has been noted by some people, including some experts, that the newer benzodiazepines such as Lorazepam and Clonazepam tend to produce more severe withdrawal symptom, although there are no studies that conclusively correlate severity of withdrawal with benzodiazepine type.
If you do decide to switch to Diazepam, it is important to observe the proper dose equivalencies. The crossover process also needs to be carried out gradually, substituting one dose at a time. Many people have suffered because they have been switched too quickly. Making the changeover one dose (or part of dose) at a time avoids this difficulty. Depending on the size of your dose, the period of dose substitution may be anywhere from 2 weeks to 3 months.
Diazepam is a more potent sleep agent therefore many people may find it initially more sedating. However, most benzodiazepine users rapidly develop a tolerance to the sleep inducing (hypnotic) effects of benzodiazepines, so that it is likely that this over sedation will recede within the first few weeks. During this period of dose substitution, sometimes cuts to your total dose are made, and other times, slight increases are made. If you experience extreme over sedation and no withdrawal symptoms, that is a sign that the equivalency dose is too high for you, and you may wish make a small cut in your total dose as you cross over. If, on the other hand, you begin to experience heightened withdrawal symptoms during crossover, you may wish to make a small increase in your dose during cross-over. Because the proper equivalencies vary from person to person, the crossover process can be a matter of trial and error. However, it is important to understand that the end result of switching to Diazepam should be that you are relatively stable after the switch is complete, meaning that you are experiencing either no withdrawal or very mild withdrawal symptoms.
11. If I am taking antidepressants as well as benzodiazepines and/or Z drugs, which one should I come off first?
It is advisable to come off of benzodiazepines and/or Z drugs before your antidepressants.
12. Are there any other drugs to consider taking during benzodiazepine withdrawal?
Additional drugs are rarely needed with a slow reduction from benzodiazepines. Taking alternative medication must be done with caution so carefully research any new drug you are considering. Your doctor may suggest you take an antidepressant due to some having a sedative effect but again you need to proceed with caution as antidepressants are also documented to be addictive and, in fact, there is evidence that the withdrawal syndrome can be very pronounced and similar to benzodiazepine withdrawal in many cases.
13. What are the symptoms of antidepressant withdrawal?
The symptoms reported on withdrawal of SSRI’s and SNRI’s: Fluoxetine, Citalopram, Escitalopram, Paroxetine, Sertraline, Fluvoxamine, Trazodone, Venlafaxine, Reboxetine, Duloxetine and Mirtazapine.
Note: This list is not exhaustive there may be other symptoms associated with withdrawal that have not been listed here.
14. Should I switch to another antidepressant before reducing?
This is not usually necessary or advisable unless you are getting severe withdrawals. For further advice please ring our helpline.
15. How do I withdraw safely from benzodiazepines, Z drugs and antidepressants?
The slower the time you take to reduce and the smaller the cuts you make, the milder the withdrawal symptoms. Reductions should ideally be every 4-6 weeks starting at 10% of your total dose.
The smaller the cuts you make, the less the shock to your system, and the less pronounced the withdrawal symptoms triggered by the cut. It is not recommended that any individual cut represent more than 10% or 20% of your total dose at a given time. Thus, it is preferable to make smaller and smaller cuts as you go, this can be very difficult as you approach the end of your reduction programme. Don’t reduce at the end by miniscule amounts as this can prolong the withdrawal and sustain dependence.
Never abruptly stop any benzodiazepine, Z drug or antidepressant - cold turkey is the largest cut of all and the shock caused by such an abrupt withdrawal is so severe that even after resumption of your drug at the previous dose, it may take weeks or months to "stabilise", and in some cases, you may never stabilise from a cold turkey withdrawal until after you have completed your reduction.
16. What is the length of the withdrawal process when coming off benzodiazepines, Z drugs and antidepressants?
It varies tremendously. It is dependent on type and dose of medication and the length of time you have been taking it. Other factors will include body chemistry – everyone’s symptoms and severity or symptoms may be slightly different. To generalise it can take from a few months to a few years depending on circumstances.
17. Whilst I am coming off medication, will I still be able to work and continue with normal day-to-day activities?
Going through withdrawal while managing the demands of everyday life is a difficult balancing act. It is known that stress can worsen your withdrawal symptoms. You may have to make lifestyle adjustments, but this will depend on the severity of the withdrawal symptoms and how high you rate your stress in certain areas of your life (e.g. work, home, family etc.) Some people can work through withdrawal; others cannot. While in withdrawal, the best advice is to reduce your stress by the maximum amount that is feasible given the demands of your life.
18. Are alternative therapies and herbs safe to take and will they help with withdrawal symptoms?
Maybe. Everyone's experience is different. Acupuncture, massage therapy, and chiropractic have been commented on, but there is little conclusive data as to their effectiveness in relieving withdrawal symptoms. As for herbal remedies we do not recommend, negatively or positively, the use of herbal remedies for anxiety disorders and depression. This page is primarily about benzodiazepine, Z drug and antidepressant dependency and withdrawal, not about alternative treatments for anxiety disorders and depression. The only opinion intimated herein is that some people may experience some relief from certain herbal remedies during the withdrawal process. Many, if not most, experience no relief at all. Some people have felt that their withdrawal symptoms were heightened by taking alternative remedies.
It is important to understand that herbal medicines are drugs. These plants contain organic, bioactive substances that cross the blood brain barrier and act upon your brain just as synthetic drugs do. In fact, many pharmaceuticals are synthesised versions of bioactive substances naturally occurring in plants and animals. The only difference is, you get a much higher purity of the substance in synthetic form than you would in organic form.
Herbs can also have toxic and deleterious effects. Fortunately, most herbal medicines are low enough in potency that they are well tolerated and non-addictive.
19. Are there any foods or drinks I should consume or should avoid during withdrawal?
Caffeine is a stimulant and can worsen symptoms, however if you are a moderate to heavy user stopping caffeine intake can cause its own withdrawal symptoms in which case you should moderate your caffeine intake to 1-2 cups a day. You can use decaffeinated coffee as well. Be mindful as tea, chocolate and many soft drinks also contain caffeine. All other stimulants should also be avoided. When purchasing over the counter medications for other illnesses e.g. colds, flu, migraine/headaches get advice from the pharmacist on whether the drug contains stimulants.
Many people report that alcohol, a sedative that should cause a reduction in anxiety, actually heightens withdrawal symptoms, particularly those of derealisation and depersonalisation. It is advisable, if you do drink, to limit your consumption to 1-2 glasses occasionally. However, you must not substitute increasing alcohol for decreasing the psychotropic medication.
Even if you find that alcohol has a calming effect on withdrawal symptoms, regular alcohol use creates a toxicity that will almost certainly prolong your recovery process. And even if you are able to withdraw successfully while consuming alcohol on a regular basis, which is unlikely, you will have probably substituted one addiction for another.
Make sure, you drink lots of liquid, perhaps double your ordinary intake. Some people feel that this may hasten the recovery process. The evidence of this is inconclusive. However, drinking large quantities of liquids helps to flush toxins from your system and is generally good for digestion. Even if it provides no specific relief in withdrawal, it is generally a healthy practice.
As for food, there are various theories about what should and should not be consumed. To put it simply, eating a health balanced diet is always best.
20. Should I stop smoking cigarettes during withdrawal?
Nicotine is an addictive drug, although it is vastly different in its chemical structure and mechanism of action. The main symptom of Nicotine withdrawal is a craving for the drug. However, other symptoms, especially agitation and insomnia, have been noted as Nicotine withdrawal symptoms. Therefore, it is inadvisable to withdraw from Nicotine while you are in the process of withdrawing. If you plan to quit smoking (which is always a good idea for health reasons), it is preferable that you accomplish this before you begin your reduction programme. Failing that, you should wait until you have fully recovered from withdrawal before discontinuing cigarettes.
21. Should I exercise?
Yes. Exercise is known to reduce both anxiety and depression. Some people believe that exercise may even shorten the course of withdrawal. However, note that strenuous aerobic exercise can cause an influx of adrenaline that can heighten withdrawal symptoms. If this is the case for you, then low impact exercise is best. Brisk walking is a good form of exercise that some people have reported as having an immediate, calming effect. Relatively non-strenuous swimming is also a good option.
22. Insomnia – can I take something to help me sleep?
It should go without saying that you cannot take a different benzodiazepine for sleep. That might be effective in inducing sleep, but it is the equivalent of increasing your dose and reversing your recovery process. You should also avoid the sedative drugs Zaleplon, Zolpidem, and Zopiclone (see question 4 on Z drugs) which are chemically different from benzodiazepines but have the same effects on the body and act by the same mechanisms.
For those coming off antidepressants taking a benzodiazepine or Z drug may initially help in the short term however they are very addictive and will be another drug you will have to come off with similar withdrawal symptoms.
Some people feel that taking virtually any other drug makes their withdrawal symptoms worse. It is important to note that virtually all tranquillisers, including antihistamines, can produce paradoxical symptoms of agitation and heightened insomnia for some users. If you feel that any substance you are consuming as a sleep aid is making your withdrawal symptoms worse, discontinue that substance immediately.
It is important to be cautious regarding your decision to ingest any psychoactive chemicals, be they organic or synthetic, during withdrawal.
23. Is there anything I can take to help manage pain during withdrawal?
Many people experience muscle and joint pain during withdrawal. This can occur to varying degrees. Only a very small fraction of people have reported adverse reactions to over-the-counter pain relievers. These should be used as a first resort. Do not use prescription pain relievers unless your pain is extremely debilitating. Be careful of products containing codeine as these are addictive.
24. Through the withdrawal process when can I expect my symptoms to improve?
There is no way to tell. Sometimes, people's symptoms begin to diminish before their reduction is complete; sometimes shortly after the reduction is complete; sometimes quite a while after the reduction is complete. The important thing to remember is that in all cases you are moving in the right direction, whether you feel this way or not, and eventually you will begin to feel better.
25. Is there a reason as to why after finishing my reduction I sometimes feel better then feel worse again?
This is a typical experience. Recovery from benzodiazepine, Z drug and antidepressant withdrawal occurs in fits and starts. The fact that you have experienced relief for a time means that you will experience it again. As time goes on, generally these recurring episodes are spaced further apart, and diminish in intensity. Withdrawal can leave you vulnerable to stress for quite a long time. It is often reported that people who have felt withdrawal free for several months have had sudden, intense withdrawal episodes brought on by traumatic or stressful events. It is probably helpful to get counselling if you continue to have ongoing anxiety issues long after you have stopped your medication. This way you can find alternative ways of managing issues.
It is important to note that psychotropic medications do not cure anything, all they do is cover up the symptoms. The root cause for the anxiety and/or depression for which the medication is prescribed is often still there. If anxiety and/or depression is still there after withdrawal, it might be worth having cognitive behavioural therapy (CBT) or some sort of anxiety/stress training.
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