Have you been taking benzodiazepines, such as diazepam (Valium), alprazolam (Xanax), etc. for years? Are you suffering from the adverse effects of these drugs, such as memory impairment, oversedation, and depression, among others? Do you feel that it is high time you weaned yourself off of this dubious chemical diet? Read on then, as we cover everything you need to know about coming off benzodiazepines in this article. More specifically, we discuss:
- Why you should withdraw from benzodiazepines.
- The preparatory stages of withdrawal.
- Withdrawal. Dosage tapering and substituting your short-acting benzodiazepine with a long-acting version of the compound.
- Sample slow withdrawal schedules.
- The pharmacology of benzodiazepines and the withdrawal symptoms you may experience.
Why You Should Eliminate Benzodiazepine from Your System
If you are a long-term benzodiazepine user, you are almost certainly addicted to the drug. Also, it no longer works for you and it does you much more harm than good. The reasons why you should ditch this addiction are numerous.
Benzodiazepines affect your body in scores of intricate ways. Thus, they trigger adverse symptoms you would never attribute to them.
Clinical studies show that long-term benzodiazepine users feel better after coming off the drug. Almost all of the adverse effects disappear.
You may already suffer from withdrawal symptoms, despite being an active user. According to science and the UK Royal College of Psychiatrists, this class of drugs stops producing the desired effects after about two-to-four weeks of use. When its efficacy drops, withdrawal symptoms appear.
Chronic benzodiazepine use increases your risk of traffic accidents, dying from an overdose, attempting suicide, becoming aggressive and antisocial, etc. In addition to these problems, as a long-term user, you likely spend a lot of money on unnecessary medication and run an increased risk of losing your job.
Regardless of whether you take benzodiazepines as hypnotics (sleeping aids), anti-anxiety medication, or anticonvulsants, you will likely not escape the perverted mixture of adverse effects and withdrawal symptoms they create.
Should you be afraid of withdrawal?
You may have heard horror stories from those who have been through such an experience. The answer is a resounding NO.
Proper benzodiazepine withdrawal, involving the gradual tapering of dosage, is highly tolerable. It may surprise you how easy it is to kick the habit when you approach the issue gradually and patiently.
Please note that it is NOT a good idea to abruptly stop taking benzodiazepines. Those who told you the withdrawal-related horror stories probably took this approach.
Some may be able to shake the addiction this way, without significant withdrawal effects, but it is statistically unlikely that you will fall into this category.
The Preparatory Stages of Benzodiazepine Withdrawal
Before you embark on benzodiazepine withdrawal, make sure you want to do it.
Most benzodiazepine addicts who attempt to kick the habit succeed on the first try. Even if you do not succeed, you can always try again.
Unless you are very sure of what you want, however, you should probably not attempt it.
Talk to your doctor about your withdrawal plans. Try to involve him/her too.
Furthermore, it is important to let your doctor know that you plan to quit this drug. In some cases, he/she may advise against withdrawal. In a small number of cases, continued use of a benzodiazepine may be a medical necessity.
Since it is your doctor who prescribes your medication, you will need his/her full cooperation for the gradual tapering approach. Be aware that some doctors are uncomfortable with benzodiazepine withdrawal management. Ideally, you should be in control of your withdrawal process. That said, your doctor’s cooperation is necessary and welcome.
Securing your doctor’s support is important from a psychological perspective as well.
You will need a mentor for your withdrawal journey. This mentor should be someone who understands the trials and tribulations of benzodiazepine addiction.
It would not hurt to get a mentor who has been through withdrawal him/herself. Be careful, however. If this person had a rough withdrawal, he/she may have a negative influence on you.
You will need long-term psychological support from this mentor, so choose carefully.
Whip your mind into shape. In this instance, that means that you should:
Know that you can pull this off.
Be confident. As mentioned, most benzodiazepine addicts succeed with withdrawal the first time they try. Since you will do it right, your odds of success will be even greater.
Go for a small, almost insignificant dose reduction at first. You will want to keep going once you are on this path.
Give yourself time.
There is no need to be impatient. As long as you stick to the path of dose reduction, you are on the right path indeed.
Be aware that it might take you as much as a year or even more, to completely wean yourself off this drug.
If you feel you are dropping your dose too quickly, stop for a while. It is important, however, never to go back to a higher dose.
Come off the drug your way.
You must complete the withdrawal process on your time and through your means. This way, you will learn to cope with the lack of benzodiazepine in your system as you go.
There are other solutions as well, such as entering a detoxification center and letting the professionals there handle your schedule. This is less than ideal, however, as it will deprive you of the means of developing your coping mechanisms. Once the institution discharges you, you will be clean, but unable to cope with the “new you,” in your day-to-day environment.
Benzodiazepine withdrawal is predicated upon three core concepts:
- Dosage tapering.
- Switching your fast-acting benzodiazepine with a long-acting version of the drug.
- Designing your withdrawal schedule.
Dosage Tapering is the gradual reduction of your benzodiazepine dose.
Do not attempt sudden discontinuation of your benzodiazepine medication. Such an approach will exacerbate your withdrawal symptoms. Such symptoms can be convulsions, uncontrollable panic attacks, psychotic reactions, etc.
Gradual tapering is the only proper way of withdrawal. The goal of this approach is to lower the benzodiazepine concentration in your blood slowly and steadily. This way, you give your brain enough time to adapt to the new chemical realities and to compensate for them. Benzodiazepines support and enhance the action of the neurotransmitter GABA.
GABA occurs naturally in the brain and it is the natural tranquilizer of the body. In an over-stimulated brain, the number of GABA receptors decreases. If you suddenly cut all benzodiazepine intake, you will strand your brain in a perpetual state of alertness and hyper-excitability.
By exactly how much you reduce your dosage and how fast you achieve withdrawal is a matter of personal preference/ability. No two benzodiazepine addicts are exactly alike.
Some specialists will aim to wean you off within 6 weeks. Such goals are unrealistic.
How quickly you achieve complete withdrawal is irrelevant.
As long as you move forward, you are on the right path.
You must set the pace. Do not fall for haphazard assessments stating that slow withdrawal is “prolonging agony.” In this instance, ripping off the plaster should not be an option.
Substituting your short-acting alprazolam, or lorazepam with a long-acting benzodiazepine such as diazepam is another crucial step. Why do you have to do this?
Short-acting benzodiazepines make it impossible to achieve steady levels of active compounds in the blood. They create spikes and troughs and may sometimes bring about mini-withdrawal symptoms.
The half-life of alprazolam is 6-12 hours, while that of diazepam can be as much as 200 hours. Given the fact that you need benzodiazepine levels in your blood to drop gradually, diazepam is the obvious choice for a withdrawal schedule.
Despite similar pharmacology, alprazolam is hardly the equivalent of diazepam. To effectively substitute the former with the latter, you need to consider some realities.
The potency is the most obvious variable here. 10 mg of diazepam is roughly the equivalent of 0.5 mg of alprazolam. Benzo.org.uk features an equivalency table here. You have to convert the dosage to reflect this potency equivalence.
You also have to consider the differing profiles of action of various benzodiazepine-based drugs. For example, if you are switching from the short-acting lorazepam to long-acting diazepam, you need to bear in mind that the latter has a more pronounced hypnotic effect. An equivalent amount of diazepam will thus make you drowsy.
To work around this problem, you should make the switch one dose, or part-dose at a time.
What does that mean?
For example, if you take 2 mg of lorazepam in the evening, you could take 1 mg of lorazepam and 8 mg of diazepam in its stead. This dosage already includes a reduction of 2 mg of diazepam. Without this reduction, the equivalent of 2 mg of lorazepam would be 1 mg of lorazepam and 10 mg of diazepam.
Dosage formulations are yet another factor to consider.
Diazepam is the ideal choice in this regard too. This benzodiazepine variant comes in 2 mg tablets. These tablets are even scored at the middle, meaning that they are very easy to halve or to quarter.
The smallest lorazepam tablet is 0.5 mg – the equivalent of 5 mg of diazepam. Thus, dosage reduction with lorazepam is a much more difficult exercise.
Some doctors may recommend switching from lorazepam/alprazolam to clonazepam (e.g., Klonopin) instead of diazepam. Be aware that clonazepam is not an ideal choice. Its action profile is faster than that of diazepam and its dosage formulations are cumbersome as well.
You should design your withdrawal schedule personally. Here is why that’s the only way to go:
You need to build this schedule around your personal needs. You may be taking benzodiazepines as a sleep aid. In this case, you should take most of your daily dose before bed.
If you are agoraphobic, take most of your dose in the morning, before leaving the house.
Since diazepam has a more pronounced hypnotic effect, first switch your evening dose to diazepam. Only start dose reduction once you have substituted all of your daily doses to diazepam.
Since diazepam is a long-acting benzodiazepine, you only need to take two doses of it per day, at most.
The amount with which you reduce your doses should be proportional to your dose size. The larger your dose-size, the larger your dose reduction should be. Aim for 1/10th reduction for every withdrawal step.
Do not make a big deal of your withdrawal schedule. Just stick to it as a normal fact of daily life. You can also make it open-ended. You do not need to add finality to it from the beginning.
Quitting the last micro-dose of benzodiazepines is easier than you would expect it. Do not make a fuss about it. At that point, the effects you get from the drug should be purely placebo-based, anyway.
Do not draw out that final step forever. Once you are down to just 0.5 mg of diazepam per day, you are ready to let it all go.
Do not revert to upping your dose in times of stress. Do not ever go back to larger doses for any reason.
If you happen to take anti-depressants on top of your benzodiazepine regimen, complete your benzodiazepine withdrawal before you start tapering your anti-depressants. Take care of one problem at a time.
Sample Withdrawal Schedules
These are just rough approximations of how your personalized withdrawal schedule should be.
Let us assume that you are currently taking the equivalent of 40 mg of diazepam per day.
Your first reduction should be 2 mg every week or two weeks until you reach a dose of just 20 mg per day. That feat would take you 10-20 weeks.
From that point onward, only reduce your daily dose by 1 mg every one or two weeks.
After about 20-40 more weeks, you should be able to kick your benzodiazepine addiction for good.
Let us get more specific.
You start with 40 mg diazepam per day. 20 mg in the morning and 20 mg in the evening.
In your first week, you reduce your morning dose to 18 mg. You keep your evening dose at 20 mg, for a total of 38 mg.
On your third week, you reduce your evening dose to 18 mg as well, for a total of 36 mg. At this point, you are taking 18 mg in the morning, and 18 mg in the evening.
On your 5th week, you reduce your morning dose to 16 mg, while keeping your evening dose at 18 mg. Your total is 34 mg at this point.
Rinse and repeat these steps every two weeks, until you are down to 6 mg in the morning and 8 mg in the evening, for a total of 14 mg. From this point on, you only reduce your doses by 1 mg.
Your next step will have you taking 5 mg in the morning and 8 in the evening.
Then, you move to 4 mg in the morning and 8 in the evening.
You repeat these steps until you eliminate your morning dose. At this point, you are only taking 8 mg in the evening.
Reduce that by 1 mg, to 7 mg as your next step.
Rinse and repeat, until you drop your last dose and rid yourself of the addiction.
For more sample schedules, take a look here.
The Pharmacology of Benzodiazepines
As mentioned, benzodiazepines enhance the action of the neurotransmitter gamma-aminobutyric acid (GABA).
GABA is the natural tranquilizer of the brain. It causes neurons to slow down and stop firing.
GABA’s action reduces the effects of other neurotransmitters, such as serotonin, dopamine, acetylcholine, etc. The activity of these neurotransmitters is necessary for the proper functioning of the body.
It is, therefore, safe to say that benzodiazepine use impacts every function of the brain.
Benzodiazepine Withdrawal Symptoms
Benzodiazepine withdrawal symptoms are of two types: psychological and physical.
Psychological symptoms include but are not limited to:
- Panic attacks.
- Insomnia, nightmares, poor sleep.
- Impaired concentration.
Some of the physical symptoms are:
- Fatigue, muscle weakness, tremor.
- Irritable bowel-like symptoms.
- Weight loss.
- Dry mouth.
- Dizziness. Loss of balance.
- Hypersensitivity to all types of stimuli.
- Difficulties urinating.