What are the withdrawal symptoms of clonazepam (Klonopin)?

Clonazepam Withdrawal Symptoms

Clonazepam withdrawal can cause potentially life-threatening symptoms including anxiety, insomnia, tremors, sweating, nausea, vomiting, diarrhea, muscle aches, increased heart rate, and seizures, requiring careful tapering to minimize these risks. 1, 2

Common Withdrawal Symptoms

Withdrawal from clonazepam typically manifests with both physical and psychological symptoms:

Physical Symptoms

• Increased heart rate/palpitations
• Sweating (ranging from mild moistness to streaming sweat)
• Tremors (mild to severe)
• Nausea and vomiting
• Diarrhea
• Muscle aches and joint pain
• Headaches
• Weakness
• Piloerection (goosebumps)
• Runny nose or tearing
• Seizures (in severe cases) 3, 1, 4

Psychological Symptoms

• Anxiety and agitation
• Insomnia and nightmares
• Irritability
• Difficulty concentrating
• Confusion
• Dysphoria and feelings of hopelessness
• Depersonalization
• Hypersensitivity to stimuli (light, sound)
• Panic attacks 1, 4

Severity and Timeline

The severity of withdrawal symptoms depends on several factors:

• Dosage: Higher doses lead to more severe withdrawal
• Duration of use: Longer use (especially >1 year) increases withdrawal severity
• Rate of discontinuation: Abrupt discontinuation causes more severe symptoms
• Individual factors: Age, comorbidities, and concurrent medications 1, 2

Withdrawal symptoms typically begin within 24-72 hours after the last dose and may persist for weeks to months. In some cases, patients develop a protracted withdrawal syndrome with symptoms lasting more than 12 months 2.

Risk Factors for Severe Withdrawal

• Long-term use (>1 year)
• High doses (>1 mg/day)
• History of substance use disorders
• Concurrent use of other CNS depressants
• History of seizures
• Advanced age
• Hepatic impairment 1, 2

Clinical Assessment

The Clinical Opiate Withdrawal Scale (COWS) can be adapted to assess benzodiazepine withdrawal severity, monitoring:

• Vital signs (especially heart rate)
• GI symptoms
• Sweating
• Restlessness
• Pupil size
• Anxiety levels
• Bone/joint aches
• Runny nose/tearing 3

Management Recommendations

To minimize withdrawal symptoms:

1. Gradual tapering is essential:

   • For standard cases: Reduce by 0.25 mg per week 4
   • For long-term users (≥1 year): Slower tapers of 10% per month 1
   • For higher doses (>1 mg/day): Initial taper of 0.5 mg every 2 weeks until reaching 1 mg/day 1

2. After reaching the smallest available dose (0.125 mg):

   • Extend the interval between doses before complete discontinuation 1

3. For severe withdrawal symptoms:

   • Consider temporary pause in tapering
   • For severe agitation: Short-term use of antipsychotics may be considered (olanzapine 2.5-5 mg, quetiapine 25 mg, or risperidone 0.5 mg) 1

Important Cautions

• Never discontinue clonazepam abruptly as this can precipitate life-threatening withdrawal reactions including seizures 2
• Monitor closely for suicidal thoughts or behavior as these may emerge during withdrawal 2
• Be aware of protracted withdrawal syndrome where symptoms persist for months after discontinuation 2
• Special populations (elderly, those with respiratory conditions, hepatic impairment) require even more cautious tapering 1

Clinical Pearls

• Withdrawal symptoms are often mistaken for recurrence of the original condition (anxiety, insomnia)
• Patients may need reassurance that withdrawal symptoms are temporary
• Non-pharmacological approaches for anxiety and insomnia should be maximized during tapering
• Concurrent use of opioids significantly increases the risk of severe outcomes during withdrawal 1, 2