Benzodiazepine Tapering and Neuropathy: Klonopin Withdrawal Risks

Key Takeaways

• Klonopin (clonazepam) is not known to damage the nerves. Yet, during withdrawal it can make them feel damaged, with tingling, numbness, and burning in the hands, feet, and legs.
• These sensations come from a nervous system that has become oversensitive, and nerve tests in withdrawal usually come back normal.
• They usually fade with time, sometimes over weeks and sometimes much longer, and in the great majority of cases they are not permanent.
• Tingling and burning tend to surge when dose cuts are too large or too close together, and the response is a hold or a smaller step, never a sudden stop.
• In Dr. Leeds’ experience, when clonazepam itself seems to be causing toxic symptoms, the direction is either a transition to diazepam or a continued taper, planned with the prescriber, rather than a higher dose.
• Tingling that began before any dose change, stays on one side, follows one nerve, or keeps worsening through a long hold should be checked by a doctor for other causes.
• Call 911 for sudden weakness or numbness on one side of the body, new loss of bladder or bowel control, or a seizure.

Can Klonopin cause neuropathy?

The short answer is no, not in the sense the word usually carries. Klonopin is not known to damage the peripheral nerves, and nothing in the Ashton Manual or in the drug’s own label describes it doing so. What Klonopin can do, during tolerance and especially during withdrawal, is make the nerves feel damaged: tingling, pins and needles, numbness, and a burning in the hands, feet, and legs are among the most common complaints when the dose comes down.

Doctors call these sensations paresthesia, the medical word for abnormal skin sensations, and Chapter III of the Ashton Manual, written by Professor C. Heather Ashton, lists tinglings, pins and needles, and patches of numbness among the bodily sensations of benzodiazepine withdrawal. In the same chapter she wrote that nerve conduction studies in her clinic revealed nothing abnormal, with no evidence of peripheral neuritis. In her section on protracted symptoms she added that the oversensitive state withdrawal leaves behind usually settles in a few weeks, though disturbing sensations occasionally persist. The nerves, in other words, test fine. The nervous system that reads them does not, yet.

Dr. Leeds is an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida. Patients who took Klonopin exactly as prescribed, often for years, sometimes fear that it has left them with a permanent nerve disease. They have physical dependence, the predictable result of a medication acting on the brain for a long time, and dependence is not addiction. The answer to their symptoms is never to stop abruptly, and the pace of the taper is adjusted with the patient, slower for some and steady for others.

Klonopin is a potent, long-acting benzodiazepine with a difficult reputation.

Klonopin is the brand name of clonazepam. Its United States Food and Drug Administration (FDA) label approves it for seizure disorders, including the Lennox-Gastaut syndrome and akinetic, myoclonic, and some absence seizures, and for panic disorder with or without agoraphobia. Any other use, including insomnia or everyday anxiety, is off-label.

Table 1 in Chapter I of the Ashton Manual lists clonazepam with a half-life of 18 to 50 hours and rates 0.5 mg of it, the label’s smallest tablet, as roughly equivalent to 10 mg of diazepam, so even half a tablet is a large step; the label gives a typical half-life of 30 to 40 hours. Unfortunately, Chapter II of the Manual adds that withdrawal from the high-potency benzodiazepines, Klonopin among them, tends to be particularly difficult.

The FDA’s 2020 boxed-warning update, printed at the top of Klonopin’s label, states that continued use can lead to clinically significant physical dependence, and that abrupt discontinuation or rapid dose reduction can bring on withdrawal reactions that can be life-threatening, and the label names seizures among them. The label’s own instruction is a gradual taper. A seizure, or any other medical emergency, is a reason to call 911 rather than wait it out.

Why does withdrawal feel like nerve damage?

Benzodiazepines strengthen the effect of gamma-aminobutyric acid (GABA), the brain’s main calming chemical, as Chapter I of the Ashton Manual explains. When the drug is present every day for months, the brain compensates by making its GABA receptors less responsive, and that compensation is tolerance. Reduce the dose and the calming signal drops before the receptors have adjusted back, leaving what Chapter III of the Manual calls a nervous system exquisitely sensitive to all sensory and motor stimuli.

Every sense is affected, and the skin’s senses are no exception. Light touch registers as tingling, ordinary warmth as burning, and the quiet resting signal from a foot as numbness. Overbreathing adds to it: an anxious person breathes fast and shallow, which blows off carbon dioxide and makes the fingers, lips, and feet tingle on its own, and Chapter III of the Manual, noting that many anxious people hyperventilate, recommends slow diaphragmatic breathing.

Think of a smoke detector with its sensitivity turned all the way up. It shrieks at toast, then at steam, then at nothing, and a person who did not know better would start tearing into the walls looking for a fire. The wiring in the house is fine. What needs to change is the setting, and the only thing that resets it is time at a dose the nervous system can tolerate.

How long do the tingling, numbness, and burning last?

Usually weeks, sometimes much longer, and no one can promise which. Professor Ashton wrote that these sensations usually settle within a few weeks, and Table 3 in Chapter III of the Manual lists tingling, numbness, and deep or burning pain in the limbs as gradually receding, though they may last at least a year and occasionally several years. Klonopin’s own label, in the language added by the 2020 update, describes a protracted withdrawal syndrome that includes paresthesia and can last from weeks to more than 12 months.

Is it permanent? In the great majority of cases, no, but after months of symptoms coming and going it can feel as if it is. In fact, patients and benzo-aware physicians group these lingering symptoms under the term benzodiazepine-induced neurological dysfunction (BIND), which names what it is: a nervous system still recalibrating, not a nerve that has been destroyed. Dr. Leeds covers the wider picture of benzodiazepine withdrawal and nerve pain in a separate article.

Fortunately, a symptom that appears during a taper answers to the taper. What makes it worse is almost always the same thing, and it is fixable.

Sensory symptoms surge when the cuts are too large or too fast.

Each reduction removes a slice of the calming signal, and the nervous system needs the interval that follows to catch up. If the slice is larger than it can absorb in that time, or the next cut arrives before the last one has settled, the over-sensitivity climbs and the tingling and burning climb with it. Yet, the same thing can happen without any cut at all, when tolerance outruns a steady dose.

The response is a hold or a smaller step, never a stop. Chapter II of the Ashton Manual suggests reductions of up to one tenth of the dose at each step, allows a person to stand still at any stage for a few weeks, warns against going too fast, and advises, as far as possible, never going backwards. Klonopin’s label takes a softer line, telling prescribers who see withdrawal reactions to consider pausing the taper or returning to the previous dose before reducing more slowly. Either way, the pace belongs to the patient’s nervous system, and the patient, not a calendar, decides.

The shape of a safe taper is a curve, not a staircase of equal steps. The Maudsley Deprescribing Guidelines describe hyperbolic reductions, in which each cut is a fraction of the current dose rather than of the starting dose, so the steps shrink as the dose falls. Because Klonopin’s tablets make small steps hard to cut, Dr. Leeds uses the Manual’s crossover taper to diazepam where it helps, which Chapter II favors for its slow elimination and its small tablets, and a compounded liquid or a micro-taper where it does not.

The Manual names one exception to slow reduction, triazolam (Halcion), which Professor Ashton thought could be stopped abruptly because it leaves the body within hours. Dr. Leeds tapers triazolam like any other benzodiazepine, and the exception has no bearing on Klonopin, whose label calls for a gradual taper.

Some numbness and tingling deserves its own examination.

While withdrawal explains most of the tingling in people who are tapering, a taper does not make a person immune to everything else. Diabetes, a low vitamin B12 level, thyroid disease, heavy drinking, and pressure on a single nerve all cause tingling and numbness. A physician should look for them when the symptoms began before the medication ever changed, sit on one side of the body, follow the path of one nerve, or keep worsening through a long hold.

Some signs call for an examination soon rather than waiting: a foot that drags, a hand that keeps dropping things, or numbness that keeps spreading. Sudden weakness or numbness on one side of the body, or new loss of bladder or bowel control, is an emergency, and the right call is 911. Withdrawal itself can make the legs feel weak and the balance unsteady, and an examination is how a physician tells the two apart. Anyone in a mental health crisis can also call or text 988, the Suicide and Crisis Lifeline.

So, a normal examination and normal nerve tests, the usual result in withdrawal, are good news rather than a dead end. The wiring is intact, and the taper can go on, more slowly than before.

Slow breathing helps, and the evidence for products sold for nerve pain is thin.

Nothing on a shelf resets the detector, and the evidence behind supplements and over-the-counter products sold for tingling and burning is thin. Slow, unhurried breathing counters the overbreathing that anxiety brings, the diaphragmatic breathing Chapter III of the Manual recommends, and a daily walk, regular sleep, and plain water do more for an over-sensitive nervous system than they seem to.

In general, Dr. Leeds avoids adding a medication that would need its own taper later, so when symptoms climb the first moves are a hold, a slower rate, or a gradual transition to diazepam. In his experience, going back up and then tapering more slowly suits a diazepam taper, but when clonazepam itself seems to be causing toxic or tolerance-withdrawal symptoms, the direction is a transition to diazepam or continuing the taper, not an updose. A symptom that follows a cut is information about the size of the cut, and that information belongs to the patient.

Dr. Leeds starts with the taper when the nerves flare.

Dr. Leeds’ practice offers medically supervised benzodiazepine and z-drug tapering, its primary service, for patients in Florida, following the Ashton Manual and the Maudsley Deprescribing Guidelines. When a patient tapering Klonopin reports new tingling or burning, the first move is to look at the size and spacing of the last reductions and adjust them with the patient, who keeps the right to hold, to slow down, or to decline any step. Informed consent in his practice means the risks come first, the alternatives are on the table, and the exit plan is written before the first cut.

Anyone in Florida who is tapering Klonopin and frightened by what their hands and feet are telling them can use the practice’s contact form to Contact the office today.

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.