Can Benzodiazepine Withdrawal Cause Chest Pain, and When Is It an Emergency?

Is chest pain during a benzodiazepine taper an emergency?

It has to be treated as one until a clinician has examined the person. Chest pain in someone who is tapering a benzodiazepine is still chest pain. Withdrawal does not protect anyone from a heart or lung problem.

Call 911 if chest pain or pressure comes with any of these:

• shortness of breath
• pain that spreads to an arm, the jaw, the neck, or the back
• dizziness, lightheadedness, or fainting
• sweating or nausea

When in doubt, call 911. Anyone in crisis or with thoughts of suicide can call or text 988, the Suicide and Crisis Lifeline, at any hour.

Chest pain works like a smoke alarm. Many alarms turn out to be burnt toast, yet nobody finds that out by staying in bed. So, the examination comes first, and the explanation comes second.

Can benzodiazepine withdrawal cause chest pain and tightness?

It can, although usually not in the way people fear. Chest pain is not named among the withdrawal symptoms that Professor C. Heather Ashton listed in Table 1 of Chapter III of the Ashton Manual. Palpitations, overbreathing, pain and stiffness, and panic attacks are on that list, and once the heart and lungs have been checked, chest discomfort during a taper usually traces back to one of those four.

Why would lowering a medication do this? Benzodiazepines strengthen the effect of gamma-aminobutyric acid (GABA), the main calming signal of the nervous system. After months or years of steady use, the nervous system adapts to that help, and each dose reduction leaves it overactive for a while.

That adaptation is called physical dependence. The United States Food and Drug Administration (FDA) stated in its 2020 boxed warning update that it can occur when these medications are taken steadily for several days to weeks, even as prescribed. Physical dependence is not addiction, and a person with chest tightness during a taper has done nothing wrong.

Where does the chest discomfort come from?

The first source is muscle. Professor Ashton wrote that benzodiazepines are efficient muscle relaxants, and that stopping them after long-term use brings a rebound increase in muscle tension, with stiffness commonly reported in the limbs, back, neck, and jaw. The chest wall is muscle as well, and constant tension between the ribs can ache or feel tight.

The second source is breathing. Overbreathing, which means fast, shallow breaths taken high in the chest, can tire those same muscles and bring tightness, tingling, and lightheadedness. The Ashton Manual’s advice is slower, deeper breaths that carry air deep into the lungs, which is the idea behind mindful breathing during a slow taper.

The third source is the heartbeat itself. Professor Ashton wrote that palpitations, a pounding heart, a rapid pulse, and breathlessness usually accompany panic attacks but may occur without panic. She described them as the expression of an overactive autonomic nervous system, and she wrote that they do not signify heart or lung disease.

Still, that reassurance is for a symptom that has already been examined. It is never a reason to skip the examination, because none of these sources can be told apart from a heart problem at home.

Unfortunately, many patients leave the emergency room with the words “just anxiety.” A normal electrocardiogram is good news. Yet, it does not mean that the pain was imagined.

What does a slower taper do for chest symptoms?

Fortunately, chest symptoms that come from withdrawal usually respond to pace. Tightness, or palpitations and a racing heart, that rise in the days after a reduction and settle as the nervous system catches up suggest that the last step was too large for that person.

In Chapter II, Professor Ashton described reducing by up to one tenth of the dose at each step. She told patients to be in control of their own schedule and not to let a doctor impose a deadline. When a stage is hard, she wrote that a patient can stay at the same dose for a few weeks, which she preferred to going back up, and patients call that pause a hold.

A hold is not a failure. The next reductions can also be made smaller, and the Maudsley Deprescribing Guidelines describe reductions that get smaller as the dose gets lower, which is the hyperbolic pattern.

Professor Ashton preferred not to go backwards. Still, when one reduction proves too large, a small step back up, agreed with the prescriber, is legitimate.

What a flare of chest symptoms never calls for is stopping the medication. The FDA warns that stopping abruptly, or reducing the dosage too quickly, can result in withdrawal reactions, including seizures, which can be life-threatening. A seizure is a reason to call 911.

In Chapter III, Professor Ashton also noted that in a few cases severe palpitations hinder progress. When they do, that is a conversation for the patient’s own physician, who can decide whether anything beyond a slower pace is needed.

When should the prescriber hear about chest symptoms?

The emergency signs at the top of this article go to 911, not to an office voicemail. Chest pain that is new, that comes on with exertion, or that feels different from before needs a medical evaluation right away, even without those signs, and when there is any doubt, that means 911. A normal test last month does not cover a new pain this week.

Once the heart has been checked, tightness that returns after dose reductions is information about the taper. The prescriber should hear about it before the next reduction, so that the plan can change. In most cases, with time and a pace the nervous system can keep up with, these symptoms fade.

Dr. Mark Leeds is an osteopathic physician and deprescribing specialist in Fort Lauderdale, and his practice provides medically supervised benzodiazepine and z-drug tapering for patients in Florida. The pace of each taper is set together with the patient. In Dr. Leeds’ practice, a symptom that flares after a reduction is a reason to slow down, never a reason to push on. Contact the office to ask about a gradual, medically supervised taper in Florida.

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.