A benzodiazepine is a psychoactive drug (sometimes colloquially “benzo”; often abbreviated “BZD”) whose core chemical structure is the fusion of a benzene ring and a diazepine ring. The first benzodiazepine, chlordiazepoxide (Librium), was discovered accidentally by Leo Sternbach in 1955, and made available in 1960 by Hoffmann–La Roche, which has also marketed diazepam (Valium) since 1963.
Benzodiazepines enhance the effect of the neurotransmitter gamma-amino butyric acid (GABA) at the GABAA receptor, resulting in sedative, hypnotic (sleep-inducing), anxiolytic (anti-anxiety), anticonvulsant, and muscle relaxant properties; also seen in the applied pharmacology of high doses of many shorter-acting benzodiazepines are amnesic-dissociative actions.
These properties make benzodiazepines “useful” in treating anxiety, insomnia, agitation, seizures, muscle spasms, alcohol withdrawal and as a premedication for medical or dental procedures. Benzodiazepines are categorized as either short-, intermediate- or long-acting. Short- and intermediate-acting benzodiazepines are preferred for the treatment of insomnia; longer-acting benzodiazepines are recommended for the treatment of anxiety. In general, benzodiazepines are safe and effective in the short term (less than four weeks), although cognitive impairments and paradoxical effects such as aggression or behavioral disinhibition occasionally occur.
Long-term use is controversial due to concerns about adverse psychological and physical effects, increased questioning of effectiveness and because benzodiazepines are prone to cause tolerance, physical dependence and upon cessation after long term use, a withdrawal syndrome.
Due to adverse effects associated with the long-term use of benzodiazepines, withdrawal from benzodiazepines, in general, leads to improved physical and mental health. The elderly are at an increased risk of suffering from both short- and long-term adverse effects. Withdrawal from a long term benzodiazepine addiction may cause tinnitus as a side effect.
There is controversy concerning the safety of benzodiazepines in pregnancy. While they are not major teratogens, uncertainty remains as to whether they cause cleft palate in a small number of babies and whether neurobehavioral effects occur as a result of prenatal exposure; they are known to cause withdrawal symptoms in the newborn. Benzodiazepines can be taken in overdoses and can cause dangerous deep unconsciousness. However, they are much less toxic than their predecessors, the barbiturates, and death rarely results when a benzodiazepine is the only drug taken; however, when combined with other central nervous system depressants such as alcohol and opiates, the potential for toxicity and fatal overdose increases.
Benzodiazepines are commonly misused and taken in combination with other drugs of abuse. In addition, all benzodiazepines are listed in Beers List which is significant in clinical practice. These medications are often used to help patients during a detoxification process, but these substances themselves can be abused and addictive.
Patients who have taken a prescribed benzodiazepine for two weeks, even in a therapeutic dose, need to be safely detoxified with a slow taper. The amount of drug the person takes is dropped by 10-25% every week if the patient has minimal withdrawal symptoms. If the patient has taken very high doses for long periods of time, he or she is at increased risk for addiction.
I was prescribed benzodiazepines when I was 38 for anxiety and panic attacks. The diagnosis was Generalized Anxiety Disorder (GAD), Panic Disorder with a dual diagnosis of Post-Traumatic Stress Disorder (PTSD) related to childhood trauma.
During the 15 years of ingesting prescribed Benzodiazepines, I have had exposure to Xanax (Alprazolam) Klonopin (Clonazepam), Ativan (Lorazepam), and Valium (Diazepam). Typical daily dosages averaged a total equivalence of 7-10+ milligrams, primarily Klonopin.
I was able to wean down at the end of my addiction to 2 mgs of Klonopin a day but could not reduce any further. On those days when I was taking 2 mgs of Klonopin, I exercised the option of taking additional doses (PRN) if I had what I interpreted as a panic attack.
I cannot say with certainty when I developed a tolerance and dependency to the benzo’s or when the addiction began but I believe it occurred sometime near the later part of my 15 year journey.
Several attempts to wean off the benzo’s were unsuccessful. Contributing factors included my denial of an addiction and my refusal to accept the help of others in the “know” including family, friends, psychiatrists, doctors, and psychologists.
When I thought I was having panic attacks, I was actually having withdrawal symptoms (inter-dose). These symptoms were far more pronounced than the original anxiety and panic attacks I had which led to the first prescription back when I was 38.
The night before I went to treatment, I was experiencing extreme anxiety and certain parts of by body were numb to the touch – especially my legs. I was unable to rest the night before treatment. Anxiety and panic were extreme.
I arrived at Pat Moore Foundation on June 28, 2012. They started me on 5 mg of Klonopin and reduced my dose 1 mg each day until I was not taking any. This was called a “fast track titration”.
When I got down to about 1 milligram of Klonopin, I had what I thought was a severe panic attack. This led me to the ER at a local hospital. The ER doctor injected me with 1 mg of Ativan and I recovered almost immediately.
Back at treatment, about 36 hours later, I again had what I thought was a severe panic attack and prior to going to the ER, I was given .25 mgs of Klonopin and again the symptoms subsided.
Again, in another 36 hours, the symptoms of panic came. This time, they took me to the ER and left me there. I was in a serious anxiety state where I was unable to sit or articulate my thoughts. I felt like I was going to lose my mind. I could not wait to be admitted to the ER and when I finally was allowed to speak to an ER doctor, I could not articulate who I was or provide information about me. I was shaking with severe tremors and stuttering.
The ER doctor, Dr. Fernandez, was empathetic and discussed with me that I was going through Benzodiazepine withdrawal and that he would give me two options. I could accept 1mg of Ativan or 50 mgs of Benadryl.
If I chose the 1 mg of Ativan, he explained to me, I would be back in the ER 36 hours later or I could accept the Benadryl and begin the withdrawal process which he explained could be a few days of physical stress followed by weeks or months of psychological stress.
I chose not to accept the Ativan and began the journey of withdrawal. It was at this point that I knew beyond a shadow of doubt, I was an addicted to the Benzodiazepines.
For the next three days, I “kicked” the benzo’s and went through some of the most excruciating pain both physically and psychologically. I thought I was going to die. It was very difficult.
During my withdrawal, I was prescribed Depakote, an anti-convulsant medicine to prevent my brain from seizing.
While I was in treatment, I was invited to attend meetings of Alcoholics Anonymous and to find a sponsor. Every Saturday morning, the treatment center would load the vans and go to a men’s stag meeting and so I decided to join.
On my second time attending, I decided to approach a gentleman and introduced myself. His name was Mike. I asked him to be my sponsor. He agreed. He told me he would take me to the meetings and asked me to do a few things. He asked me to read 164 pages of the Big Book of Alcoholics Anonymous, work on the first three steps, and get the names and phone numbers of three participants in the meetings and make a concerted effort to call them every day.
On one occasion, he took me to a meeting and asked me to stand at the front door of the hall and greet each person as they came through the door. That day I shook hundreds of men’s hands.
When I was ready to leave treatment on the 27th of July, I had completed the first three steps of Alcoholics Anonymous, read 164 pages of the Big Book and the first three chapters of the 12 Principles & 12 Traditions of Alcoholics Anonymous.
The first three days after treatment, I was very sick. I felt good at first but within the first 24 hours, I felt as though I was losing my mind. I had the shakes and felt as though I did not have a good hold of my faculties.
When my wife and I had arrived at the airport to go home three days after treatment, the plane was full of passengers and my wife and I were not able to sit together. She sat in the back and I sat further up on the other side.
The stewardess approached me and asked if I was alright and I told her I was going through withdrawal and asked for a bag of ice. I was sweating, shaking and felt skin numbness in my hands and arms. She told me that she had a son who just finished treatment and that it took a lot of courage to tell her I was withdrawing.
The lady sitting next to me was the director of my home town anxiety center and the woman sitting next to her was an addiction specialist. I felt considerably more comfortable.
Withdrawal Episode – 12/12/12
4:30 pm – Sense of anxiety. Tunnel vision. Increase in self-absorption.
5:00 pm – Higher level of anxiety. Increased self-absorption. Began autogenic exercise (meditation).
5:30 pm – Autogenic exercise not effective. Anxiety almost critical. Self-absorption high. Took 50 mgs of hydroxyzine.
5:45 pm – Realized I missed 3 pm dose of Gabapentin. Took 600 mgs Gabapentin (missed dose).
6:00 pm – Anxiety level critical. Panic episode commenced. Fleeting/racing thoughts. Fear of events. Minor shaking in jaw and right hand. Need to evacuate urine and bowels. Loose bowels. Call neighbor and friend. Friend not reachable. Neighbor reachable – to come over in 15 minutes. Call wife. Minor stutter. Moderate fear and psych imbalance.
6:30 pm – Wife prays and consoles. Overwhelming nausea setting in. Neighbor arrives. Wife speaks to neighbor on phone. Wife calls friend to request support. Feeling of impending doom, depression, panic and anxiety in full bloom. Unable to relax or breathe slow and deep consistently. Moderate shakes consistent in right hand and arm, left hand and jaw.
7:00 pm – Friend arrives and joins neighbor to console and reassure. Friend recommends another hydroxyzine dose and delivers it. 50 mgs dose taken. Minor hot and cold spells appearing. Driving thirst. Cold compress applied. Loose stools more frequent. Attempts to stay in rested position unsuccessful. Extreme anxiety. Dry heaves set in.
07:30 pm – Friend leaves. Neighbor stays. Attempts to fall asleep unsuccessful. Cold and hot flashes pronounced. Nausea and loose stools continue. More pronounced stuttering and shaking.
08:00 pm – Feeling of desperation and impending doom are pronounced. Nausea and hot and cold spells becoming consistent. Extreme fear and despair apparent.
08:30 pm – Request dose of Pepto Pismol and ingest. Laying on back, falling asleep. Sleep 30 minutes.
09:00 pm – Sleep ended. Woke and inventoried symptoms. Fear and anxiety diminished. Nausea and loose stools diminished. Shaking and stuttering diminished. Feel exhausted and head ache but overall improvement in symptoms.
Withdrawal episode ended.
Why Some Recover and others do not …
To discover that one has become a casualty of long term exposure to benzodiazepines is very difficult to begin with because it means coming to terms with the fact that the medicine prescribed to help us with a serious medical condition such as generalized anxiety disorder or panic attacks is no longer helping us. It means realizing that the medication we have been taking that was at first giving us relief is now causing us secondarily, even more pain and suffering by multiplying the original symptoms.
What I discovered after I realized I was dependent on the benzodiazepines, was that there are different types and cycles of withdrawal. For example, inter-dose withdrawal which occurs 36 hours after the last dose or acute and post-acute withdrawal which occurs between three and 24 months after the last dose, and finally protracted withdrawal which can last as long as 48 months after the last dose.
Most treatment centers provide inpatient benefits for 30, 60 and 90 days but as I discovered, post-acute withdrawal became apparent 90 days after the initial “kicking” process which was 36 hours after the last dose. At a time I was expecting I’d be getting better, I was surprised to learn that this was the beginning of a long and very difficult period of time when clusters of symptoms began.
Post-acute withdrawal experiences can be broken down into two categories, “windows” and “waves”. Window experiences are of calm and peace as the barrage of symptoms eases. On the other hand, waves come on like a sea flooding the body with an overwhelming number of symptoms from digestive problems to shakes and twitches, partial seizures, heart palpitations, neuropathy, psychobabble, extreme anxiety and a myriad of other frightening experiences.
During the initial phases of withdrawal, usual right after inter-dose withdrawal, one may need a prescription of some kind of anti-seizure medication to prevent possible grand mall seizures which can be debilitating and even cause death. Taking medications such as Tegretol, Depakote and Gabapentin (Neurontin) can lead to a whole set of other complications. Depakote in particular is hard on the liver and can in some patients, lead to liver failure. In addition, as with Gabapentin, one can go through a benzodiazepine-type withdrawal after taking this drug for longer than 4 months.
So why do some recover and some do not? Because even if we are able to come to terms with our dilemma, that we became dependent and tolerant to benzodiazepines, the process of withdrawal and the time it takes for the brain to heal is usually more than one can manage or bare. Not to mention the lack of support and understanding by the medical community or from within our own circle of family and friends.
When we become suspicious that we may have become addicted to benzodiazepines and are undergoing withdrawal, we go to a doctor and ask for help. We seek out a method to titrate off the benzodiazepines. We solicit methods to reduce the number and severity of symptoms as we move forward into recovery.
What we discover is that the medical community encourages us to take other medications like abilify, seroquel, paxil, celexa, etc. which really provide little or no relief and in fact add a new dimension to our recovery making it even harder for us to do the things we need to do like exercise, rest, eat nutritiously, meditate, biofeedback, do yoga, get therapy, etc.
We discover that our friends and family get frustrated with us and alienate us, not understanding the enormous task ahead for one who chooses to go through the withdrawal process. We are told that our symptoms are unreal or imagined. We are questioned about our motives when we are faced with so many symptoms that prevent us from doing regular daily functions.
When one makes the decision to go through benzodiazepine withdrawal, to its bitter end, one is almost assuredly going to be successful. One needs the support of educated and informed medical professionals, treatment centers, family and friends. These resources need to be tolerant, compassionate and patient. The journey is difficult and takes quite a long time before noticeable improvement takes place – but it does!
It can be difficult for family, friends, doctors and other caregivers to fully understand the effects of benzodiazepine withdrawal. No amount of empathy can prepare them for the impact of the physical and psychological symptoms, personality changes and emotional challenges, as well as the practical support which may be required. It is not unusual for them to allude to an overreaction or to the medication causing some form of permanent mental or physical disorder.
Compassion fatigue or burnout occurs when a caregiver becomes emotionally, socially, mentally and sometimes physically exhausted, resulting in apathy or lack of ability, willingness or energy to provide further attention and care. This is a natural response to the upheaval associated with especially chronic or intense situations.
If you care for someone who is withdrawing from a benzodiazepine, the following tips will help you to provide the required support without becoming fatigued.
Learn more about withdrawal and what it entails
The more knowledgeable you are about benzodiazepines and withdrawal, the better prepared you will be to cope with its stages and idiosyncrasies. You will find that you are more understanding and accepting of your loved one’s experience and will be well equipped to give the support needed.
You may have your own ideas regarding how withdrawal should be dealt with and what coping strategies and treatment are appropriate. As much as you may be able to empathize, you will not know what your loved one is going through. Resist suggesting visits to psychiatrists, accelerating or slowing tapers, reinstating the drug, querying other diagnoses or anything other than allowing the time and space to heal.
The true effects of benzodiazepines are understated and there is an ‘unbelievability factor’ which causes many to doubt that taking a legally prescribed drug could result in such adverse reactions. Try to be open and not make judgements based on assumptions or what you perceive to be credible. Even many well-intentioned medics are unaware and uneducated about the true effects of long-term benzodiazepine use, specifically dependency and withdrawal.
Appreciate that you have no control over the recovery process so that you don’t feel responsible or pressured. The benzodiazepine withdrawal experience is unique and unpredictable; you may have to provide support for a much longer period than anticipated.
Give practical support
Your loved one may be in severe discomfort and feeling extremely lethargic and depleted of energy. Mowing the lawn, cooking, cleaning, shopping and attending to the children can seem like insurmountable tasks during withdrawal. Also, for those with intense symptoms, any form of exertion can cause flare-ups. Offering to help with practical matters can make a big difference.
Withdrawal can be overwhelming and your loved one may feel traumatized. Talking is therapeutic and some people feel a need to talk about their experience. Follow your loved one’s cues: if you can, listen actively – without judgement or preconception – as feelings and concerns are shared; at other times space and/or companionable silence may be all that is needed. Remember too, that non-verbal communication can be powerful and your warmth, acceptance, expressions and body language are even more important than your words.
Don’t take things personally
If you’re loved one is agitated or becomes angry and overly-sensitive, try not to take it personally. The effects of withdrawal can cause mood swings, organic fear, paranoia and a host of other psychological symptoms. Understanding that these reactions are ‘normal’ will allow you to accept them for what they are while you continue to give your support.
Look after yourself
Eat healthily, exercise regularly, maintain your hobbies, and get the rest and relaxation you need. Set limits and commit to what is realistic, rather than feel obligated to deliver on promises you are unable to keep as this will drain you even more. If possible, arrange a respite or back-up person who is reliable and trustworthy so that you can take regular breaks.
Get emotional support
Caring for someone in withdrawal can be mentally draining so you need to ensure that you take care of your own emotional needs and receive adequate support at this time. It is also important that you have a trusted friend or relative to discuss your fears, needs and feelings with. If you become emotionally drained and fatigued you will have nothing left to give.
Reassure your loved one
More than anything, someone experiencing withdrawal needs reassurance. Persistent, intense symptoms can cause doubt and increased anxiety. You will need to keep encouraging and reassuring your loved one that recovery is taking place. Hope is one of the most valuable coping tools and your positive attitude can make a big difference.
Keep in touch
Keep in contact with your loved one even when it seems she or he has recovered. Withdrawal symptoms often come in ‘waves’ and you may mistake a ‘window of clarity’ (period during which the symptoms temporarily subside) as full recovery. Most people are devastated when the symptoms resurface and this is when you may be needed the most.
See Recovery-Advocate.Net for more information.