Benzodiazepine drugs, also known as benzos, are some of the most commonly prescribed psychiatric medications in the country, as they have sedative, hypnotic, and/or anxiolytic effects. Xanax, and alprazolam in its generic form, is the most prescribed drug in the United States in recent years, with close to 50 million prescriptions written in 2013 alone, Psych Central publishes. The Journal of the American Medical Association (JAMA) Psychiatry reports that in 2008, over 5 percent of the American population between the ages of 18 and 80 were using benzodiazepines.
Benzos include sedatives, muscle relaxants, anticonvulsants, and anti-anxiety medications. Popular benzos include not only Xanax (alprazolam), but also:
- Valium (diazepam)
- Klonopin (clonazepam)
- Ativan (lorazepam)
- Serax (oxazepam)
- Restoril (temazepam)
- Librium (chlordiazepoxide)
- Dalmane (flurazepam)
- Versed (midazolam)
- Halcion (triazolam)
How Benzos Work
Benzos are central nervous system depressants that work by increasing the levels of gamma-aminobutyric acid (GABA) in the brain. GABA is one of the brain’s neurotransmitters, which are chemical messengers, and it serves to act as a kind of natural tranquilizer, calming down the “fight-or-flight” reaction, quelling anxiety, and promoting calm. Benzos enhance this reaction by damping some of the functions of the central nervous system that are involved in the stress response, such as respiration levels, body temperature, blood pressure, and heart rate.
Benzodiazepines are also heavily abused. The Drug Enforcement Administration (DEA) publishes that according to the National Survey on Drug Use and Health (NSDUH) of 2011, over 20 million people in the United States who were at least 12 years old at the time of the survey had used a benzodiazepine for nonmedical purposes at least once in their lives.
On the street, benzos are also called nerve pills, downers, and tranks. When abused at high doses, they may have similar effects to alcohol intoxication.
Even when taken as intended and with a legitimate prescription, benzos can cause dependence. These drugs are generally meant to be used for temporary relief of symptoms. As the US Food and Drug Administration (FDA) publishes in the information for Xanax, they are not meant to be taken as a long-term solution to anxiety. Higher doses (i.e., more than 4 mg/day) taken for longer periods of time (such as longer than three months) may cause dependence on Xanax even when taken within the parameters of its prescription, the FDA reports.
Drug dependence occurs when a person takes a drug, like a benzo, regularly. In the case of benzos, the brain becomes accustomed to the drug increasing levels of GABA in the brain, and therefore stops producing and moving it around the brain as it would have before the drug’s interaction. Thus, when the drug is then removed or wears off, a dip in levels of GABA and other natural brain chemicals can occur, causing some of the opposite effects of the drug and creating a withdrawal syndrome.
The journal BMC Psychiatry estimates that between a quarter and half of all individuals who take benzodiazepines will experience some sort of withdrawal symptoms. Benzodiazepine withdrawal syndrome is considered to be significant, and individuals should not attempt to stop taking these drugs “cold turkey” or suddenly. Medical assistance is required for benzo withdrawal.
Benzo Withdrawal Symptoms
In general, when the tranquilizing effects of a benzo are removed, several rebound symptoms may occur. Anxiety, muscle tremors, restlessness, and insomnia may be common side effects of low levels of GABA in the brain caused by benzodiazepine withdrawal. Headaches, nausea, vomiting, muscle pain, irritability, sweating, loss of appetite and weight loss, tension, confusion, trouble concentrating, and dysphoria (a general state of extreme unhappiness that may include feelings of depression and agitation) are additional benzo withdrawal symptoms.
More severe benzo withdrawal symptoms include seizures; sensitivity to light, sound, and touch; numbness in the extremities; derealization; suicidal ideations or actions; depersonalization; and psychosis that may include hallucinations and altered perceptions. These symptoms may be most common in individuals who are significantly dependent on a benzodiazepine drug.
Benzo withdrawal may start as soon as the drug stops being active in the system and will depend on the half-life of the particular drug. Benzos are often divided into either long-acting or short-acting categories, which are directly related to how long the drug stays in a person’s system. Long-acting benzos may stay in the body for 24 hours or more, meaning that withdrawal will likely start between one and four days of the last dose, while short-acting benzos leave the system in less than 24 hours, which means that withdrawal can start sooner. The United States Department of Veterans Affairs (VA) publishes that Klonopin, Librium, and Valium are considered to be long-acting, while Ativan, Xanax, and Serax are considered short-acting benzos.
The withdrawal duration and severity are not the same for every person. They depend on several factors, such as:
- Type of drug abused and presence of polydrug abuse
- Method of abuse (e.g., ingestion, snorting, smoking, injection)
- Length of time using or abusing the drug
- Biological and genetic factors, including family or personal history of addiction
- Amount of the drug taken at each dose
- Environmental factors, such as high levels of stress, etc.
- Any co-occurring medical or mental health disorders
Each of these factors can influence the withdrawal timeline and may stretch out or shorten its duration. In general, physical symptoms are thought to start within the first few days of stopping a benzo and last about a week to 10 days. Psychological symptoms may start in the first few days of stopping the drug as well; however, anxiety, drug cravings, and other emotional symptoms may continue a bit longer and benefit from professional assistance to manage them.
Medical Detox Is Optimal for Benzo Dependence
Benzodiazepine withdrawal syndrome can be intense and even dangerous without proper care; it is therefore best managed with medical detox. Detox is the removal of toxins from the body, and medical detox is a comprehensive method that provides medical and mental health supervision and monitoring 24 hours a day, seven days a week. Generally, medical detox lasts 5-10 days in a specialized, safe, and secure facility.
Often, medications are helpful during benzo detox to control the severity of withdrawal and manage the uncomfortable and sometimes dangerous withdrawal symptoms. Benzodiazepines themselves are commonly used during detox to wean a person off the drugs. A tapering schedule can be established by a medical professional to gradually lower the dosage of the drug, over a controlled period of time, until it is fully removed from the body. Short-acting benzos may be replaced with longer-acting ones during a tapering schedule.
In addition, phenobarbital medications, which are barbiturate sedative drugs, may be commonly used during medical detox from benzodiazepines in place of benzos during a tapering schedule, the Journal of Substance Abuse Treatment publishes. Flumazenil, an antagonist of the GABA receptors in the brain and also a partial agonist drug, has shown promise in treating benzodiazepine withdrawal and minimizing side effects as reported by the British Journal of Clinical Pharmacology.
Adjunct medications that reduce specific symptoms can be helpful as well, the Substance Abuse and Mental Health Administration’s Treatment Improvement Protocol (TIP) reports, such as anticonvulsant medications like valproate and carbamazepine, sedative antidepressants like trazadone, and medications that work on the autonomic central nervous system response, such as propranolol and clonidine. The main goal of detox is to help an individual to reach a safe and stable physical level. Medical detox in a specialized detox facility, staffed by substance abuse treatment providers as well as mental health and medical professionals, provides the safest and smoothest route for managing withdrawal from benzodiazepines.