Managing Benzodiazepine Withdrawal: Symptoms and Tapering

What does benzodiazepine withdrawal feel like?

Benzodiazepine withdrawal is the set of symptoms that appears when a body adapted to the drug gets less of it. The Ashton Manual, written by Professor C. Heather Ashton and published at benzo.org.uk, sorts the symptoms in its Chapter III table into two columns, psychological and physical, and the perceptual ones, which patients find the strangest, sit across both.

The psychological symptoms are the ones most people expect. Anxiety climbs past anything the person felt before the drug, panic attacks arrive without warning, sleep breaks into short stretches full of nightmares, and the mood swings between irritability, rage and a flat depression, with memory and concentration suffering alongside.

Unfortunately, the physical symptoms are the ones mistaken for another illness. Professor Ashton’s table lists headache, pain and stiffness, muscle twitches, jerks and tics, tremor, weakness that patients call jelly legs, fatigue and flu-like aching, tingling and numbness, dizziness, sweating, flushing, palpitations, stomach and bowel upset, changes in appetite and weight, a dry mouth and skin rashes. Her own note under the table matters as much as the list: different people get different combinations, and no one should expect them all. The perceptual symptoms are stranger still: hypersensitivity to light, sound, touch and smell, ringing in the ears, blurred vision, and a sense that the world or the self is not quite real.

None of this means the person has an addiction. Physical dependence is not addiction: dependence is the body’s adaptation to a drug taken as prescribed, while addiction is compulsive use that continues despite harm. Most of the patients who come to Dr. Mark Leeds for tapering never took more than they were told to.

Why does a lower dose cause so many symptoms?

Benzodiazepines strengthen the action of gamma-aminobutyric acid (GABA), the main calming signal in the brain. Over months of daily use the nervous system adapts: the GABA receptors become less responsive, and the excitatory systems that GABA holds in check are turned up to compensate. The calming effect fades, which is tolerance, while the adaptation underneath it stays.

When the dose falls faster than the brain can re-adapt, those excitatory systems run unopposed. Chapter III of the Manual describes rapid removal of the drug as opening the floodgates, leaving the nervous system hyperexcitable until new adaptations develop.

Patients often describe the result as adrenaline rushes: a racing heart, a surge of panic out of a quiet afternoon, and lying awake at three in the morning feeling wired. The cause is a nervous system with too little inhibition. Fortunately, the first remedy is usually not another dependence-forming drug but a smaller step, or a short hold at the current dose while the surges settle, with a hold that does not settle within a few weeks taken back to the prescriber rather than extended indefinitely.

Why is stopping cold turkey dangerous?

Chapter II of the Manual is blunt: abrupt or over-rapid withdrawal, especially from a high dose, can give rise to convulsions, psychotic reactions and acute anxiety states. Chapter III adds severe confusion and notes that these hardly ever occur with slow tapering. A seizure is a medical emergency, so anyone who has one during withdrawal, or who becomes severely confused or unable to stay safe, needs emergency services: call 911.

On September 23, 2020, the United States Food and Drug Administration (FDA) updated the boxed warning on every benzodiazepine label. It says that physical dependence can develop within days to weeks even when the drug is taken as prescribed, that stopping abruptly or reducing too quickly can cause life-threatening withdrawal reactions including seizures, and that no single tapering schedule suits every patient.

The Manual makes one exception to slow reduction, for triazolam and the very short-acting z-drugs zolpidem and zaleplon, because they leave the body within hours. Dr. Leeds tapers triazolam and these z-drugs like any other benzodiazepine, with a switch to diazepam where it makes sense because they are so short-acting, and each drug’s own label calls for a gradual taper.

How does a slow taper actually work?

People who search for benzodiazepine detox picture a short stay and a fast finish. Yet, safe discontinuation is the opposite: a gradual, medically supervised taper over months, and often a year or more, with the patient’s symptoms setting the pace. A two-week plan follows a calendar, and the nervous system has never read one.

While Chapter II of the Manual suggests reducing by up to one tenth of the dose at each step, it also says that the patient is usually the best judge of the pace and must be in control. Sometimes the taper stops for a while, and that pause, called a hold, is part of the method.

The Maudsley Deprescribing Guidelines describe hyperbolic dose reduction. Because the effect of a benzodiazepine on its receptors is not a straight line, the last small amounts do far more than the first, so the steps get smaller as the dose gets lower, and near the end a liquid or compounded form is often the only way to make them.

For short-acting drugs such as alprazolam (Xanax) and lorazepam (Ativan), the Manual describes a crossover taper to diazepam (Valium), whose slow elimination gives a smooth fall in blood level instead of a daily peak and trough. A crossover to diazepam is Dr. Leeds’ preferred approach. A same-drug taper is used when diazepam does not suit the patient, for example because of how the patient metabolizes it or an adverse reaction to it. The Ashton Manual as Dr. Leeds applies it is a framework, not a timetable.

How are anxiety and insomnia handled during a taper?

Anxiety and insomnia are the symptoms that most tempt a patient, or a doctor, to add something. The first answer in Dr. Leeds’ practice is pace: a smaller step, a short hold, and patience while the nervous system catches up. Any medication for a symptom is decided patient by patient. The Manual warns specifically against taking zolpidem, zopiclone or zaleplon for sleep during withdrawal, because they cause the same kind of dependence.

Sleep is rebuilt with basics rather than pills: the same waking time every day, a dark and cool room, no screens in the last hour, no caffeine after midday, and getting out of bed rather than lying in it worrying. A panic surge passes faster when the person knows it comes from an overexcited nervous system, and slow breathing helps until it does. Chest pain, fainting or trouble breathing that is new or different still needs emergency care: call 911. The Manual observes that panic attacks usually fade within weeks.

What about food, drink and movement during a taper?

Appetite can go in either direction, and Chapter III of the Manual notes that some people lose weight in withdrawal, others gain it, and normal weight returns afterward. Steady meals with some protein help, because a skipped meal adds a blood-sugar dip to an already jumpy nervous system. Caffeine drives the same hyperarousal that withdrawal produces, so it belongs low or gone.

Alcohol acts on the same GABA system as the benzodiazepine, so it is best avoided during a taper: it can unsettle the taper, worsen symptoms and raise the risk of a seizure. The Manual’s own caution is never to replace a falling benzodiazepine dose with a rising glass. The Manual finds no general need for supplements, the evidence for calming supplements is limited, and any of them is a decision to talk through with the prescriber, since some interact with medication.

Gentle movement that the person can tolerate, such as walking or stretching, helps mood and sleep, and the Manual recommends regular moderate exercise during withdrawal. When symptoms flare, the movement is scaled back, not pushed through.

What if withdrawal lasts longer than expected?

In fact, some people have lost nearly all of their symptoms by the last tablet, the Manual notes, and in the majority the symptoms fade within a few months. Symptoms wax and wane along the way, with windows of feeling normal that appear and then lengthen, and a bad week is not a step backward.

A minority of people who have taken a benzodiazepine long term develop protracted withdrawal, symptoms that continue for a year or more and occasionally longer. Chapter III lists the ones most likely to linger: anxiety, insomnia, depression, sensory and motor symptoms, stomach trouble, and poor memory. The Manual says the reasons are not clear and probably many, and it links the sensory and motor symptoms, anxiety and insomnia to persisting changes at the GABA receptors.

Does that mean the damage is permanent? The Manual’s verdict is that a steady decline in symptoms almost always continues after withdrawal, and it finds no evidence that benzodiazepines cause permanent damage to the brain, nervous system or body. For a person still tapering whose symptoms are outlasting the plan, the plan changes.

Smaller steps, a short hold, or for some people a steady pace onward rather than a longer wait are the tools, never a jump to zero, and a fixed timeline is the first thing to give up. Dr. Leeds sets no deadline on a taper, because the patient’s nervous system is the one keeping time.

Depression deserves its own warning. The Manual warns that depression in withdrawal can become severe enough to carry a risk of suicide, though this is unusual with slow tapering, and that severe depression may need treatment rather than waiting it out. Anyone having thoughts of suicide should call or text 988, the Suicide and Crisis Lifeline, at any hour, and anyone in immediate danger should call 911.

How does Dr. Leeds’ practice approach a taper?

Dr. Leeds is an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida. His practice focuses on medically supervised tapering off of benzodiazepines and z-drug sleeping pills, for patients in Florida, concierge rather than insurance. He works with every patient himself.

Informed consent comes before the first step: the risks first, then the alternatives, including staying at the current dose, then an exit plan, and the patient’s right to decline or slow down at any point. There is no schedule to follow. There is a plan that patient and physician revise together as the body answers.

A person who has decided to come off of a benzodiazepine, or who is in withdrawal now, does not have to guess at the next step. Dr. Leeds’ practice begins with a conversation about where the patient is and what pace is safe from there. Contact the office to start that conversation.

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.