From the Guidelines
Benzodiazepine withdrawal symptoms can range from mild to severe and potentially life-threatening, and medical supervision is essential during the withdrawal process to minimize symptoms and prevent complications. Common symptoms include anxiety, insomnia, irritability, tremors, muscle tension, headaches, sweating, heart palpitations, nausea, and difficulty concentrating. More severe symptoms may include seizures, psychosis, hallucinations, and delirium. These symptoms occur because the brain has adapted to the presence of benzodiazepines, which enhance the effect of the inhibitory neurotransmitter GABA. When the medication is reduced or stopped, the brain experiences a rebound effect as it adjusts to functioning without the drug. Withdrawal severity depends on factors like dosage, duration of use, and whether cessation was abrupt or gradual.
Some key points to consider when managing benzodiazepine withdrawal include:
- Gradual tapering of the dose over weeks or months to minimize symptoms, with a common approach reducing the dose by 10-25% every 1-2 weeks 1
- Switching patients to longer-acting benzodiazepines like diazepam before tapering to reduce the risk of withdrawal symptoms
- Using adjunctive medications such as anticonvulsants, antidepressants, or beta-blockers to manage specific symptoms during the withdrawal process
- Providing education and support to patients to help them manage their symptoms and stay safe during the withdrawal process, as demonstrated by the EMPOWER trial which showed that education and self-empowerment can be effective in tapering benzodiazepines 1
- Considering the use of nonpharmacological interventions such as cognitive-behavioral therapy (CBT) to help patients manage their symptoms and improve their quality of life 1
It's also important to note that benzodiazepine withdrawal can be more challenging than opioid withdrawal, and tapering opioids first may be a safer and more practical approach when patients are receiving both medications 1. Additionally, clinicians should communicate with mental health professionals managing the patient to discuss the patient's needs, prioritize patient goals, weigh risks of concurrent benzodiazepine and opioid exposure, and coordinate care.
From the FDA Drug Label
Acute withdrawal signs and symptoms associated with benzodiazepines have included abnormal involuntary movements, anxiety, blurred vision, depersonalization, depression, derealization, dizziness, fatigue, gastrointestinal adverse reactions (e.g., nausea, vomiting, diarrhea, weight loss, decreased appetite), headache, hyperacusis, hypertension, irritability, insomnia, memory impairment, muscle pain and stiffness, panic attacks, photophobia, restlessness, tachycardia, and tremor More severe acute withdrawal signs and symptoms, including life-threatening reactions, have included catatonia, convulsions, delirium tremens, depression, hallucinations, mania, psychosis, seizures, and suicidality Protracted withdrawal syndrome associated with benzodiazepines is characterized by anxiety, cognitive impairment, depression, insomnia, formication, motor symptoms (e.g., weakness, tremor, muscle twitches), paresthesia, and tinnitus that persists beyond 4 to 6 weeks after initial benzodiazepine withdrawal.
Benzo withdrawal symptoms include:
- Acute withdrawal symptoms:
- Abnormal involuntary movements
- Anxiety
- Blurred vision
- Depersonalization
- Depression
- Derealization
- Dizziness
- Fatigue
- Gastrointestinal adverse reactions
- Headache
- Hyperacusis
- Hypertension
- Irritability
- Insomnia
- Memory impairment
- Muscle pain and stiffness
- Panic attacks
- Photophobia
- Restlessness
- Tachycardia
- Tremor
- Severe acute withdrawal symptoms:
- Catatonia
- Convulsions
- Delirium tremens
- Hallucinations
- Mania
- Psychosis
- Seizures
- Suicidality
- Protracted withdrawal symptoms:
- Anxiety
- Cognitive impairment
- Depression
- Insomnia
- Formication
- Motor symptoms
- Paresthesia
- Tinnitus 2
From the Research
Benzo Withdrawal Symptoms
- The benzodiazepine withdrawal syndrome is typically characterized by:
- Sleep disturbance
- Irritability
- Increased tension and anxiety
- Panic attacks
- Hand tremor
- Sweating
- Difficulty in concentration
- Dry wretching and nausea
- Some weight loss
- Palpitations
- Headache
- Muscular pain and stiffness
- Perceptual changes 3
- Instances are also reported within the high-dosage category of more serious developments such as seizures and psychotic reactions 3
- Withdrawal from normal dosage benzodiazepine treatment can result in a number of symptomatic patterns, including:
- A short-lived "rebound" anxiety and insomnia
- A full-blown withdrawal syndrome, usually lasting 10-14 days
- The return of anxiety symptoms which then persist until some form of treatment is instituted 3
Factors Influencing Withdrawal Symptoms
- Physiological dependence on benzodiazepines can occur following prolonged treatment with therapeutic doses 3
- The risk of physiological dependence is not clear, but it may be dependent upon a minimum duration of exposure or dosage of these drugs 3
- Withdrawal phenomena appear to be more severe following withdrawal from high doses or short-acting benzodiazepines 3
- Dependence on alcohol or other sedatives may increase the risk of benzodiazepine dependence 3
Treatment of Benzo Withdrawal Symptoms
- Carbamazepine and valproate have been used to treat benzodiazepine withdrawal 4
- Other pharmacological interventions, such as pregabalin, captodiame, paroxetine, tricyclic antidepressants, and flumazenil, have shown potential benefits in reducing benzodiazepine withdrawal symptoms 5
- Clonazepam may have a role in withdrawal from high-dose alprazolam dependence 6