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The Benzo Withdrawal Guide

One of the most commonly asked questions on a benzo withdrawal support site is how fast should benzo withdrawal be done at? We have created this benzo withdrawal guide to answer this and several other questions which are commonly asked regarding benzo withdrawal. It should be noted that in this guide where benzodiazepines is stated that benzodiazepines equally applies to the guidance for withdrawal from the Z Drugs although there are some additional tapering options for zolpidem and zaleplon which can be considered. Please read our page on The Z Drugs for further information.

The most commonly asked question is how fast should I withdraw? There really is no hard and fast answer to this question. Most organisations suggest cutting by approximately 10% but the advice on the gaps between cuts often differs between organisations and experts. Some experts and organisations have suggested a withdrawal rate of 1 - 2 weeks whereas others have suggested cutting every 2-3 weeks or every 3 - 4 weeks.[1],[2],[3],[4] However, the most important advice is that suggested schedules are not taken literally as inflexible rigid dictations but as suggested guides which may not be suitable for everyone as everyone is different. Professor Ashton herself has stated that withdrawal guides should be flexible throughout the taper and determined by the individual who only he or she can know what rate of withdrawal can best suit the individual.[1] Some of the best advice on the subject matter is made by the Committee on Safety of Medicines which is published in the British National Formulary which is a handbook on medications for doctors in the UK. It states that "it is better to reduce too slowly rather than too quickly".[4]
The rate at which people become dependent and to what degree also differs. As a general rule people who have been on benzodiazepines a short while for example less than 8 weeks should usually be able to reduce their dose fairly quickly whereas those who have been on benzodiazepines for years or especially decades may need to reduce their benzodiazepines very slowly perhaps taking up to 4 or even 6 weeks in more severe cases between cuts. However, there are always exceptions to the rule and some people become rapidly and significantly physically dependent on benzodiazepines after only a matter of weeks of use and there are others who have taken benzodiazepines for years who are only moderately dependent and can reduce quicker than those who have been on benzodiazepines for a shorter time. This reinforces the fact that tapering advice given by organisations and representatives of organisations and healthcare professionals can only be taken as an educated guess and that insight by the individual is required to make the final decision as to the rate of withdrawal by the individual who is dependent on benzodiazepines and seeking to withdraw. Readers of this page should also take note that doctors in general are typically not trained to any significant degree in drug dependence including benzodiazepine withdrawal and it is not unusual to receive harmful and even dangerous advice from healthcare practitioners who express medical advice on drug withdrawal which is outside their training as medical doctors.
For best results and to minimise withdrawal symptoms during a benzodiazepine taper it is best advised for a dependent person to cross over their current benzodiazepine to an equivalent dose of diazepam if they are currently not taking diazepam.[5],[6] Similar advice may be required for the Z drugs.[7] The cross over to diazepam should be done in a gradual stepwise fashion usually over a period of 2 - 4 weeks but sometimes the cross over needs to be done more slowly. It should be kept in mind that because diazepam is very long acting it accumulates over a period of several weeks with most of the accumulation occurring within the first week so some discomfort may be felt during the initial transition phase from a benzodiazepine drug to the benzodiazepine drug diazepam.[2] A very small minority of people may get side effects from diazepam such as nausea or depression or other side effects. Such side effects are usually mild to moderate and abate after a few days or weeks after a cross over has been completed as their body adjusts. However, if symptoms are very severe and do not abate by persevering with holding a cross over or slowing down the rate of cross over then trying another long acting benzodiazepine may be required. The next best alternative to diazepam is crossing over to an equivalent dose of chlordiazepoxide. Our estimate is that at least 95% of people can tolerate diazepam just fine and do a lot better tapering diazepam after crossing over and a period of stabalisation has occured usually 2 - 4 weeks.
As the taper proceeds the individual will likely find that the rate and especially the size of the cuts may have to change as the dose gets lower. For example a person reducing from say 30 mg of diazepam may find that 2 mg sized dose cuts are tolerable but as they get below 20 mg of diazepam that they need to reduce the size of the cuts to say 1.5 mg or 1 mg or add an extra week between cuts or sometimes both. Much of benzodiazepine tapering is trial and error. One of the most important things about benzodiazepine addiction or dependency is for a person to take the same dose of their benzodiazepine each day to allow the body to stabalise on a fixed dose whilst making gradual step wise reductions. Upping and downing the dose will just plunge the individual into and out of withdrawal and will defeat the purpose of a benzodiazepine taper. Individuals on a short acting benzodiazepine should space their dose out over the day in 2 - 4 devided doses depending on the individual and the half life of their benzodiazepine. Some mild to moderate discomfort may be felt for a few days or weeks when altering the time of doses with short acting benzodiazepines while the body adjusts.

Updosing and reinstating

We have found that reinstating is most successful if it is carried out within 2 weeks after complete discontinuation of benzodiazepines. Generally reinstating is discouraged beyond 2 weeks after discontinuation as reinstating beyond this point in time may not always work and sometimes in rare cases may even make the individual feel worse. However, there may be circumstances where reinstating is required for example a person may have been cold turkeyed and is suffering extreme withdrawal effects such as psychosis or intolerable symptoms of anxiety or insomnia and may be acutely suicidal. However, due to the unpredictability of reinstating which may not always fully alleviate withdrawal symptoms the choice to reinstate beyond 2 weeks completely off of benzodiazepines must be made by the individual.
Updosing is sometimes an option for an individual who has tapered too quickly but has not discontinued benzodiazepines. If the tapering speed has only been a bit too quick, often holding for 4 weeks or so should alleviate withdrawal effects but if they are intolerable a small updose may be required. If the tapering has been much too quick and major drops in dosage have occured then updosing can be done beyond 2 weeks since the last reduction with success unlike reinstating after complete discontinuation of benzodiazepines which is unpredictable. For example a person may have dropped from say 30 mg of diazepam to say 10 mg and been on that dose for say a month or more without relief of symptoms. Such a person would likely benefit from an updose to say at least 25 mg of diazepam.
If a person is going to reinstate after complete discontinuation of benzodiazepines and have been off of benzodiazepines for more than a couple of weeks and have made the decision to reinstate, it is better to introduce benzodiazepines gradually rather than picking a dose out of thin air and going straight on it. One reason for doing it this way is that a person can judge what their tolerance level is. So a person may want to start off taking 1 mg of diazepam and increasing the dose by 1 mg each day until they find relief of intolerable withdrawal symptoms. This approach is recommended by Dr Reg Peart for people when they have decided to reinstate.

Detoxing

Cold turkeying off of benzodiazepines is not recommended as it can result in severe withdrawal symptoms including seizures, psychosis and suicide and a wide variety of other severe psychological and physical symptomatology. Cold turkey detoxes are often carried out in detox centers with the aid of a 7 day course of phenobarbitol or in the cases of gross negligence where a doctor has abruptly discontinued chronic benzodiazepines sometimes even without the aid of an anticonvulsant which is very dangerous. Phenobarbitol although cross tolerant with benzodiazepines it is not fully cross tolerant with benzodiazepines and withdrawal symptoms will still occur despite taking phenobarbitol although it does dampen down and mask some of the withdrawal symptoms. The main problem with the 7 day phenobarbitol detoxes is that benzodiazepine withdrawal and especially cold turkey benzodiazepine withdrawal is that the benzodiazepine withdrawal syndrome is often protracted and severe. When the phenobarbitol effects wear off the individual typically experiences a full blown benzodiazepine withdrawal syndrome. Unfortunately typically such people have been discharged from detox centres and are left to their own devices to cope with extreme withdrawal effects. Occasionally such detoxes are forced on people for example in psychiatric facilities or court enforced detoxes and occasionally people who have had complicated withdrawals or have difficulty controlling their drug addiction (severe psychological dependence/psychological addiction) feel that they can't manage a slow taper at any rate of reduction opt for this option. If you fall into this category either by choice or a phenobarbitol detox is forced on you, all that can be advised is that you vigorously resist the 7 day approach and request that you are given phenobarbitol for a longer period of time, usually at least 3 months before tapering your phenobarbitol over a period of a further 3 months. You may need to find an addiction doctor who is familiar with or open minded to the protracted nature of benzodiazepine withdrawal to agree with this approach. As an organisation we advise that a slow benzodiazepine taper is the best approach and urge readers to strongly think twice before opting for any quick fix solution such as a pheno detox as the results are often dire especially the 7 day pheno detox approach. People who opt for the slow benzodiazepine taper using diazepam recover much quicker and have smoother recoveries than those who opt for a detox.
Other approaches include the flumazenil detox. Flumazenil has shown evidence in animal studies of reverting receptor function (reversing tolerance) back to normal and preventing withdrawal symptoms and there is some evidence that this to occurs in humans.[8] However, we would like to advise against using this method as the results are unpredictable. We as an organisation know of people who have had their lives saved by using flumazenil such as cases where people have been acutely suicidal and possibly getting some psychotic phenomenom and getting other intolerable symptoms even on a stable dosage or during very slow tapering (such cases only occur in about 1% of people dependent on benzodiazepines and are not unique to benzodiazepines as chronic users/misusers of cannabis and alcohol can also induce a state of severe mental ill health from chronic stable intake of the addictive substance) and we know of people where the opposite occurred and the flumazenil proceedure backfired and resulted in severe withdrawal and in at least one case suicide. So flumazenil is a big gamble and may backfire with severe consequences. Such extreme detox approaches are unpredictable and potentially dangerous and should only be considered as an absolute last resort and we urge people not to take such proceedures and urge people to stick with a slow diazepam taper which does not have such serious and unpredictable outcomes. Making the wrong decision during benzodiazepine withdrawal may cost you your health or in severe cases even your life. Benzodiazepine dependence and withdrawal is a serious medical condition and decisions on how to withdraw should not be taken lightly.
The benefits however, of coming off of benzodiazepines are decreased depression and anxiety, general improved mental and physical health, improved cognition and a decreased risk of suicide. So staying on benzodiazepines or going on them in the first place is also a decision not to be taken lightly and can have dire consequences for a persons quality of life and health.[9] Not everyone who is on chronic benzodiazepines suffers significant mental or physicial ill health from chronic benzodiazepines just like not every smoker dies from smoking and not every alcoholic gets serious liver damage or serious neuropsychiatric problems. The reasons why some people develop ill health from chronic benzodiazepines and others do not is likely due to many factors but probably the most important factor is genetics and dosage.
Readers should not be alarmed by reading this page. With a slow tapering of dosage withdrawal symptoms are almost always minimal and tolerable and infact many people feel better as the dosage slowly gets lower and eventually with sufficient time off of the drug people regain their physical and mental wellbeing and go on to have a good quality of life. This page is meant to give knowledge on how to have a successful withdrawal and to provide the knowledge to avoid a person from making serious mistakes during withdrawal. Many people will remark that staying on the drug for the rest of their life would have been the true torture, not coming off of it.

References

[1] Benzodiazepines How They Work and How to Withdraw - By Professor Ashton
[2] Valium (Diazepam) vs. Klonopin (Clonazepam) in Benzodiazepine Withdrawal
[3] A Guidance to Rates of Reduction
[4] Hypnotics and anxiolytics
[5] The Clinicopharmacotherapeutics of Benzodiazepine and Z drug dose Tapering Using Diazepam
[6] BENZODIAZEPINE EQUIVALENCY TABLE
[7] The Z Drugs
[8] A pilot study of the effects of flumazenil on symptoms persisting after benzodiazepine withdrawal
[9] Benzodiazepine Withdrawal: Outcome in 50 Patients

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