Benzodiazepine Tapering and Creatine for Withdrawal Relief

Does creatine help with benzodiazepine withdrawal?

Patients in the middle of a benzodiazepine taper ask about creatine more often than doctors expect. The question is nearly always the same: the fatigue and the brain fog are wearing them down, creatine is sold as energy for the cells, so would a scoop a day help? The honest answer has four parts, and none of them is a sales pitch.

There is no evidence about creatine in benzodiazepine withdrawal, one way or the other. Creatine is well tolerated by most healthy adults at ordinary doses, and whatever it does for tiredness and concentration comes from its general use, so the evidence is limited and clinical experience varies. And, nothing in a tub of powder replaces a slow, medically supervised taper.

Dr. Mark Leeds, an osteopathic physician and deprescribing specialist, hears this question at his practice in Fort Lauderdale, Florida, where the one service is medically supervised tapering of benzodiazepines and z-drugs. The people asking took a prescribed medication as directed, their brains adapted to it, and now they cannot stop without symptoms. Physical dependence is not addiction. It is a medical condition caused by the medication, and the treatment is a gradual taper.

The fatigue and brain fog are what send people to the supplement aisle.

Chapter III of the Ashton Manual, written by Professor C. Heather Ashton, lists fatigue, flu-like symptoms, weakness, and poor memory and concentration among the withdrawal symptoms in its Table 1. Patients describe the tiredness as heavier than anything a night’s sleep fixes. Brain fog is their word for the slowed thinking, the lost words, and the paragraph that has to be read three times.

Why does coming off a calming drug make a person exhausted? Benzodiazepines enhance gamma-aminobutyric acid (GABA), the brain’s main calming signal, and with steady use the brain turns down its own GABA response to compensate, as the Manual’s opening chapter explains. During a taper the nervous system is rebuilding that response, and the work is slow and costs energy. Read more: the long-term effects of benzodiazepines on the brain.

So, the tiredness is repair work in progress, not a shortage of fuel. Yet, creatine is marketed as fuel, first for muscles and lately for the brain, and a person who cannot think clearly is a natural customer.

Creatine is the cell’s short-term energy reserve.

Creatine is a compound the body makes in the liver and kidneys from amino acids, and it also arrives in the diet through meat and fish. Most of it sits in muscle as phosphocreatine, which hands a phosphate back to spent adenosine triphosphate (ATP), the immediate energy currency of every cell. The brain runs the same system on a smaller scale.

Taking creatine as a supplement raises muscle stores clearly and brain stores modestly, and that is as far as a physician can go with confidence.

Think of phosphocreatine as the small reserve battery in a phone case. It tops up the main battery for a few moments at a time, and it does nothing about the app that is draining it. In withdrawal the drain is a nervous system relearning how to calm itself without the drug, and no reserve battery changes that.

There is no evidence about creatine in benzodiazepine withdrawal.

Websites sometimes claim that creatine relieves benzodiazepine withdrawal, and nothing backs that claim. Neither the Ashton Manual, nor the Maudsley Deprescribing Guidelines, nor the benzodiazepine labels that the United States Food and Drug Administration (FDA) updated in 2020 mentions creatine.

What is known about creatine and mental energy comes from its general use. Some patients in withdrawal say it lifts the fog a little, and others notice nothing. A patient who feels better on it is not imagining it, but no physician can tell in advance who that will be.

Professor Ashton was blunter still. In Chapter III of the Manual she wrote that there is no general need for dietary supplements or extra vitamins or minerals during withdrawal, and that all of these can be harmful in excess. Her point was that a slow taper is the treatment, and the rest is optional.

Patients also ask whether creatine calms anxiety or helps sleep. It is not a sedative, and it does not do what the benzodiazepine did at the GABA receptor, so it cannot stand in for it. A few patients say it leaves them wired, and the answer to that is to stop it and tell the physician.

Creatine is well tolerated by most people at ordinary doses, with two caveats.

At ordinary doses creatine is well tolerated. The common effects are a small gain in water weight in the first weeks, because muscle holds more water when its creatine stores rise, and stomach upset when a large amount is taken at once.

The first caveat is the kidney. Creatine raises the level of creatinine in the blood, the number laboratories use to estimate kidney function, so a routine test can look worse than the kidney actually is, and any physician who orders blood work should know about it. Anyone with kidney disease, a single kidney, or a medication that stresses the kidneys should ask their physician before starting, and some of those patients should not take it at all.

The second caveat is water. A person taking creatine needs to drink normally, and a Fort Lauderdale summer asks more than most people expect.

This article gives no dose on purpose. The amount, if any, is a conversation between the patient and the physician managing the taper, and creatine belongs on the medication list that physician sees. Read more: the role of nutrition in easing benzodiazepine withdrawal symptoms.

Is there such a thing as creatine withdrawal?

No. Creatine is a supplement, not a drug of dependence, and stopping it causes no withdrawal. The body keeps making its own, muscle stores drift back to their usual level over a few weeks, and the extra water weight leaves. No receptor has adapted to it, so there is nothing to rebound.

Searches for “creatine withdrawal” turn up pages that describe a syndrome of fatigue, irritability, and low mood after stopping it. There is no such syndrome.

A benzodiazepine is different because the GABA receptors have adapted to it. The FDA’s 2020 boxed-warning update states that stopping a benzodiazepine abruptly or reducing the dose too quickly can cause withdrawal reactions, including seizures, that can be life-threatening, and that physical dependence can develop within days to weeks of steady use even as prescribed. Chapter II of the Ashton Manual gives the same warning about abrupt or over-rapid withdrawal.

A seizure is a medical emergency, and anyone who has one, or who develops severe symptoms after a missed or reduced dose, should call emergency services.

A supplement never replaces a slow, supervised taper.

Unfortunately, the supplement shelf sells the idea that the process can be hurried. The pace of a taper is set by the nervous system, not by anything in a bottle. Fortunately, the taper itself is the treatment, and a slow enough taper is one the nervous system can follow.

The shape of that taper is described in Chapter II of the Manual: a crossover taper to diazepam where it helps, because its long half-life, up to 200 hours, gives a smooth fall in blood level, then reductions of up to one tenth of the dose at each step, with the patient as the best judge of when the next step comes. The Maudsley Deprescribing Guidelines refine the same idea with hyperbolic reductions, where each step is a proportion of the current dose, so the steps shrink as the dose falls. Months is the usual scale, and sometimes longer.

That is not a schedule anyone can print from a website. It is a plan built with a physician who adjusts it as the patient reports how each step felt, slower when the symptoms say so, a little faster when patient and doctor agree it is tolerated. Read more: a step-by-step approach to benzodiazepine tapering for patients, and the site’s page on the Ashton Manual.

For the patient whose symptoms outlast the taper, the fatigue has a name, and it does get better with time. Read more: protracted withdrawal syndrome after benzodiazepines.

How does Dr. Leeds answer the creatine question?

He answers it the way informed consent requires for anything a patient might take: what is known, what is not, what could go wrong, and the alternative of taking nothing. A patient with normal kidneys who wants to try it, with a physician who knows about it, is taking a small risk for an uncertain benefit, and that is the patient’s decision to make. A patient who hopes it will let the taper go faster is asking it to do something it cannot do.

The energy comes back as the brain finishes its repair. Creatine may or may not make the wait feel shorter, and only the taper makes the wait end.

Dr. Leeds’ practice in Fort Lauderdale, Florida offers medically supervised benzodiazepine and z-drug tapering for patients in Florida, on a concierge basis, one physician and one patient at a time. Questions about creatine belong in that work. Contact Dr. Leeds to ask about a supervised taper.

This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.