The Impact of Benzodiazepine Withdrawal on Family and Friends

What does benzodiazepine withdrawal do to a family?

Benzodiazepine withdrawal reaches the whole household. A spouse who slept soundly for years is awake at 3 a.m., a parent who was easygoing turns sharp and fearful, and a friend who never missed a dinner stops answering the phone. The family sees the behavior. It cannot see the nervous system behind it.

So, relatives reach for the explanations they know, which are a lack of effort, an old anxiety coming back, or an addiction. Usually, all three are wrong. Withdrawal from a prescribed benzodiazepine is a medical process, it takes months, and the way through is a slow taper directed by the person taking the medication.

What should family and friends understand, and what is their part?

Withdrawal is a medical process, not a test of willpower.

Benzodiazepines such as alprazolam (Xanax), clonazepam (Klonopin), lorazepam (Ativan), and diazepam (Valium) strengthen the effect of gamma-aminobutyric acid (GABA), the brain’s main calming chemical. With regular use, the brain adapts to the drug and turns down its own calming system.

When the dose falls faster than the brain can adapt back, the result is withdrawal. Professor C. Heather Ashton described it in Chapter III of the Ashton Manual: nearly all the excitatory mechanisms in the nervous system go into overdrive, and the brain is left hyperexcitable and extremely vulnerable to stress. Effort does not override that.

No one asks a person with a leg in a cast to walk it off. The family can see the cast, so the family believes the injury. In benzodiazepine withdrawal, there is no cast to see.

The person did nothing wrong, either. In most cases, the medication was taken as a doctor prescribed it, often for years. Physical dependence is not addiction. Dependence is the body’s adaptation to a medication taken as directed, which is why the addiction label is wrong.

Withdrawal can begin while the medication is still being taken.

Many families assume that withdrawal starts on the day the pills stop. In fact, it has four forms, and two of them appear while the person is still taking every dose.

The first is tolerance withdrawal. Over time, the same dose does less, and in Chapter I of the Manual Professor Ashton wrote that withdrawal symptoms can emerge even in the continued presence of the drug.

The second is interdose withdrawal, in which symptoms rise as a short-acting drug such as alprazolam wears off before the next dose is due. A person can seem well at noon and unwell by late afternoon.

The third form arrives during a taper, when symptoms follow dose reductions, even gradual ones. The fourth is protracted withdrawal, in which symptoms continue after the last dose.

Chapter III describes a minority of people whose symptoms do not go away for months or even years. Fortunately, it also says that with slow tapering, symptoms disappear within a few months in the majority, and that protracted symptoms gradually recede.

What will family and friends actually see?

The symptom list in Chapter III (Table 1) reads like a description of a different person. It includes insomnia and nightmares, panic attacks, fear of leaving the house, rage and irritability, poor memory and concentration, feelings of unreality, and hypersensitivity to light and sound, along with pain, tremor, and tingling.

The pattern confuses families more than the symptoms do. Professor Ashton wrote that symptoms wax and wane from day to day and week to week, with “windows” of normality that grow more frequent and last longer. A good Saturday followed by a terrible Monday is not exaggeration. It is the usual course, and people in withdrawal often call the bad stretches waves.

Of course, from the outside, withdrawal can look like the original anxiety coming back. Professor Ashton wrote that nearly all the acute symptoms of withdrawal are those of anxiety, but that certain clusters are particularly characteristic of withdrawal, sensory hypersensitivity among them. Sorting it out belongs to the patient and the prescriber. A relative’s part is to describe what was seen, and when.

Irritability lands hardest on the people nearby. Anger during a taper comes from the withdrawal and not from the person, and between the waves the same person is still there.

Unfortunately, the first instinct is to make it stop fast.

A frightened family wants the problem over. The usual ideas are to throw the pills away, to hide them, or to find a facility that will finish the job in a few weeks. The word people search for is “detox.” For a benzodiazepine, the safe meaning of that word is a gradual, medically supervised taper over months, not a facility stay with a discharge date.

Professor Ashton gave the reason in Chapter II. Abrupt or over-rapid withdrawal, especially from a high dose, can give rise to convulsions, psychotic reactions, and acute anxiety states, and it may increase the risk of protracted symptoms. She also wrote that withdrawal in a hospital is usually fairly rapid and often takes control away from the patient.

A 30-day stay sets the pace by the calendar. The nervous system does not read calendars.

So, a family member should never withhold, hide, or discard the medication, and should never press for a cold turkey stop. A seizure is a 911 call.

Fortunately, a slow taper is the way through.

A taper lowers the dose in small steps, with time between steps for the brain to adjust. Chapter II speaks of reductions of up to one tenth of the dose at each step, so the steps get smaller as the dose gets lower.

How long does it take? Months, and sometimes longer. Professor Ashton wrote that many people have taken a year or more, and that whether a taper takes 6, 12, or 18 months is of little significance after years on the medication.

Dr. Mark Leeds, an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida, supervises tapers on these principles. The plan is built for one person, the patient sets the pace, and a hard stretch is answered with a hold at the current dose. In his practice, a hold is not a failure, and neither is a small step back up after a cut that proved too large.

What can family and friends do?

The first job is to believe the symptoms. Chapter III says that understanding the reasons for the symptoms does much to allay the bewilderment and fear of withdrawal. A relative who says plainly that the symptoms are real, and that they come from the medication, has already done the most useful thing.

The second is a calm house. A hyperexcitable nervous system does badly with noise, bright light, conflict, and surprises. Arguments and large decisions can wait for a window.

The third is practical help. Rides to appointments, trips to the pharmacy, meals on bad days, and help with measuring a liquid dose or keeping a written log all take weight off a person whose memory is not at its best.

Encouragement has to be repeated, too. In the same chapter, Professor Ashton wrote that supporters should be prepared to repeat it again and again, week after week, because the words are soon forgotten.

The taper belongs to the person tapering.

Support turns into supervision easily. Counting pills, asking every day whether the dose has gone down, or setting a deadline around a wedding puts the family in charge of a taper that is not the family’s to run. In Chapter II, Professor Ashton wrote that the person tapering must be in control and must proceed at a comfortable pace, and she warned against letting even a doctor impose a deadline.

Holding or handing out the medication is help only when the person tapering asks for it. The decision to taper at all belongs to the patient as well, and an adult who has heard the risks and the alternatives may choose to wait.

Family members are allowed to be tired and frightened, too. Stepping out of the room during a hard hour is not abandonment.

When is it an emergency?

Most bad days are waves, and they pass with time, a hold, and a call to the prescriber. Some situations cannot wait. Call 911 for a seizure, for a person who is severely confused or has lost contact with reality, or for any other medical emergency.

Depression can be part of withdrawal. Chapter III records that it is sometimes severe enough to pose a risk of suicide, though this is unusual with slow tapering. Anyone with thoughts of suicide, and any family member worried about them, can call or text 988, the Suicide and Crisis Lifeline, at any hour, and should call 911 if the danger is immediate.

Emergency care should never be delayed out of worry about the taper. The staff should be told which benzodiazepine the person takes and at what dose.

None of this is quick, and a family does not get to see most of it. Yet, with time and a pace the person can tolerate, the windows tend to grow longer and the household gets its evenings back.

Dr. Leeds’ practice in Fort Lauderdale provides medically supervised benzodiazepine and z-drug tapering for patients in Florida, at a pace the patient directs. A family member in Florida who is helping a relative find that care may write as well. Contact the office to ask about a gradual, 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.