Do Herbal Supplements Help During Benzodiazepine Tapering and Withdrawal?

Do herbal supplements help during a benzodiazepine taper?

Some patients say that a calming herb takes the edge off anxiety, or off the insomnia that gets worse during a benzodiazepine taper. Yet, no herb has been properly tested in people who are coming off a benzodiazepine, and several of the popular ones are thought to act on the same brain system as the medication. An herb cannot replace a benzodiazepine, and it cannot make a fast taper safe.

Most people who ask this question took a benzodiazepine, or a z-drug such as zolpidem (Ambien), exactly as prescribed, and the nervous system adapted to it. That is physical dependence, and dependence is not addiction. It is a medical condition caused by a prescription, so it is no surprise that a patient would rather reach for a plant than for another pill.

Dr. Mark Leeds, an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida, does not keep a list of banned supplements or a list of approved ones. The decision is made per patient, with a physician who understands the pharmacology. Some supplements help during benzodiazepine withdrawal, some can be a problem, and individual response varies.

So, which herbs deserve the most thought, and why?

The calming herbs are thought to act on the same brain system as the benzodiazepine.

Benzodiazepines work by boosting gamma-aminobutyric acid (GABA), the brain’s main calming chemical. In the opening chapter of the Ashton Manual, Professor C. Heather Ashton explained that with long-term use the receptors involved become less responsive. That is why the dose has to come down slowly, so the receptors have time to readjust.

The herbs sold for calm and sleep are not inert. Valerian, kava, passionflower, skullcap, and lemon balm are all thought to act on or near the GABA system, a likely reason they make people drowsy. How much of that effect a capsule or a cup of tea delivers to a human brain has not been worked out.

While a plant may seem gentler than a pill, an herb that calms the brain is acting like a drug, whatever the label says. In a taper, it is a second substance pressing on the very system that is trying to settle. Alcohol belongs in the same group, for the same reason.

How can a calming herb complicate a taper?

First, the sedation adds up. In that same chapter, Professor Ashton noted that benzodiazepines have additive effects with other sedating drugs, including alcohol, and a sedating herb is likely to behave the same way. More drowsiness, slower reactions, and unsteadiness matter for driving and for anyone at risk of a fall.

Second, the herb can hide what the taper is doing. A taper is steered by how the patient feels after each small reduction. Taking a calming herb on some nights and not on others is like stepping on a bathroom scale with one hand on the counter. The number looks better, and it can no longer be trusted.

So, a reduction that seemed easy may have been covered by the herb, and a bad week may be the reduction, the herb, or the herb being stopped. Nobody can tell which.

In Chapter II, Professor Ashton advised against compensating for a lower benzodiazepine dose with more alcohol or non-prescription drugs. She was writing about drugs, not herbs. Yet, the reasoning applies to anything sedating.

Is kava a safe substitute for a benzodiazepine?

No. Kava is often described as a natural version of a benzodiazepine, with the calm and without the risk. However, that claim is not established. Kava is sedating, it is thought to act on the GABA system, and nothing reliable shows that it prevents benzodiazepine withdrawal.

Swapping a benzodiazepine for kava, or for any other herb, amounts to stopping the medication abruptly. When the United States Food and Drug Administration (FDA) updated the boxed warning for benzodiazepines in 2020, it warned that stopping abruptly, or reducing the dose too quickly, can cause withdrawal reactions, including seizures, that can be life-threatening. Call emergency services for a seizure or any other medical emergency.

Kava also carries a liver concern. Rare cases of severe liver injury, including hepatitis, cirrhosis, and liver failure, have been reported in people taking supplements that contain kava. Such injuries appear to be uncommon. Yet, they can be severe.

The warning signs include yellowing of the skin or eyes, dark urine, nausea, abdominal pain, and unusual tiredness. Unfortunately, nausea and fatigue are also common in withdrawal. A person who develops these signs while taking kava should get medical care promptly and tell the physician about the kava, without assuming that it is the taper.

The patient community is cautious about kava, and those cautions have merit, although they are not universal. This is not a blanket prohibition. It is a reason to decide with a physician who knows the patient’s liver health and medication list.

What about ashwagandha and the other adaptogens?

“Adaptogen” is a loose marketing term for an herb that is said to help the body handle stress. Ashwagandha and rhodiola are two that patients often ask about. Neither has been properly tested in people who are tapering a benzodiazepine, and the long-term safety of both is unsettled.

Ashwagandha can be sedating, and liver injury has been reported with it as well. The article on whether ashwagandha helps with benzodiazepine tapering and withdrawal covers that herb in detail.

Interactions are the other unknown. St. John’s wort, an herb sold for low mood, is known to speed up the liver enzymes that clear many medications, and some benzodiazepines are among them. In a taper, that could act like a dose reduction that nobody planned.

How strong is the evidence for any of these herbs?

It is thin. While many of these herbs have a long history of traditional use, what testing exists in people is small and brief, and most of it involved everyday stress or trouble sleeping. An herb can have centuries of use behind it. Benzodiazepines have been prescribed only since the 1960s.

Herbal products are also supplements, not medications. In the United States, a supplement does not have to be proven safe or effective before it is sold, and many calming products are blends of several herbs.

Other herbs, such as turmeric, milk thistle, and dandelion, are sold to people in withdrawal with claims about inflammation or the liver. Those claims do not come from the Ashton Manual. In Chapter III, Professor Ashton wrote that there is “no general need for dietary supplements or extra vitamins or minerals,” and that all of these can be harmful in excess. The same reasoning applies to vitamins during benzodiazepine tapering and withdrawal.

What is left is clinical experience, and it varies. Some patients say that an herbal tea or capsule helps them settle at night. Others notice nothing, feel groggy the next day, or feel worse, and patients in withdrawal often report reacting to things they once tolerated.

Every herb belongs on the list that the prescriber sees.

The FDA’s 2020 update also advised patients to tell the professionals involved in their care about every prescription medicine, over-the-counter medicine, and other substance they take. A calming herb qualifies. So does a tincture, a sleep blend, or a nightly cup of chamomile tea, though a cup of tea is a far smaller exposure than an extract.

The useful details are the product, how long it has been taken, why, and whether it was started or stopped near a dose reduction. An herb that is already being taken when the taper begins is not automatically stopped. That is also decided per patient, with the prescriber.

The decision should run the way informed consent is supposed to run. The risks come first, then the alternatives, including taking nothing, then a plan for stopping the herb. The patient keeps the right to decline.

No doses appear here, because how much of a sedating herb is reasonable alongside a benzodiazepine is a question for that person’s prescriber. The wider question of which supplements help with benzodiazepine withdrawal and tapering has an article of its own.

Fortunately, the pace of the taper can do what the herb was meant to do.

What relieves withdrawal is time and a gradual taper, directed by the patient and adapted to the person. The Maudsley Deprescribing Guidelines describe hyperbolic tapering, in which each reduction is sized to the current dose, so the steps get smaller as the dose gets lower. In Chapter II of the Manual, Professor Ashton described steps of up to one tenth of the dose, with the patient as the best judge of the pace.

When symptoms rise after a reduction, the answer is in the taper itself. The patient may hold at the current dose, or the next step can be made smaller, and the doctor must never push the pace. A taper like that takes months, and sometimes longer.

Dr. Leeds’ practice in Fort Lauderdale focuses on medically supervised benzodiazepine and z-drug tapering for patients in Florida, with a crossover to diazepam as described in the Ashton Manual where that helps. None of them takes the place of a gradual taper. Contact the office 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.