Benzodiazepine withdrawal is a significant health concern that arises when individuals who have been using benzodiazepines, often prescribed for anxiety or sleep disorders, reduce or discontinue their use. Effective Benzo Withdrawal Treatment is crucial to manage the potentially serious symptoms and ensure patient safety. This article provides a detailed guide to understanding and managing benzodiazepine withdrawal, drawing upon established medical protocols and guidelines.
What is Benzodiazepine Withdrawal?
Benzodiazepines are a class of psychoactive drugs with sedative, anxiety-reducing, muscle relaxant, and anticonvulsant properties. Regular use, even as prescribed, can lead to physical dependence. When benzodiazepine use is reduced or stopped, the body can experience withdrawal symptoms as it readjusts to functioning without the drug. The severity and duration of these symptoms vary significantly depending on the specific benzodiazepine used, its dosage, and the duration of use. This variability is largely due to the differences in half-lives and the presence of active metabolites in some benzodiazepines, which affect how long the drug remains active in the body.
Symptoms of Benzo Withdrawal
Benzodiazepine withdrawal symptoms are broad-ranging and can be categorized into several key areas:
Anxiety and Related Symptoms
These are common and distressing symptoms that reflect the brain’s readjustment to the absence of benzodiazepines. They include:
- Anxiety, which can be intense and pervasive.
- Panic attacks, sudden episodes of intense fear that can be overwhelming.
- Hyperventilation, rapid and deep breathing often associated with panic.
- Tremor, involuntary shaking, particularly in the hands.
- Sleep disturbance, ranging from insomnia to disrupted sleep patterns.
- Muscle spasms and stiffness, leading to discomfort and pain.
- Anorexia and weight loss, due to reduced appetite and potential gastrointestinal distress.
- Visual disturbance, including blurred vision or increased sensitivity to light.
- Sweating, often excessive and unrelated to physical exertion or ambient temperature.
- Altered mood, which can encompass irritability, depression, or emotional instability.
Perceptual Distortions
These symptoms indicate a heightened and altered sensory experience, often disconcerting for the individual:
- Hypersensitivity to loud noises, where normal sounds become unbearable.
- Abnormal body sensations, such as tingling, burning, or crawling sensations on the skin (paresthesia).
- Depersonalisation/derealisation, feelings of detachment from oneself or the surrounding environment, making reality feel unreal.
Major Events
These are the most severe and potentially dangerous withdrawal symptoms, requiring immediate medical attention:
- Generalised seizures, which can be life-threatening and are a significant risk in benzodiazepine withdrawal, particularly with abrupt cessation.
- Precipitation of delirium or psychotic symptoms, including confusion, disorientation, hallucinations, and delusions. These symptoms are more likely in severe withdrawal cases or individuals with pre-existing psychiatric conditions.
Predictors of Benzodiazepine Withdrawal Severity
The likelihood and severity of benzodiazepine withdrawal are not uniform and depend on several factors related to usage patterns and individual characteristics.
Withdrawal is less likely to be severe if benzodiazepine use is intermittent or follows a binge pattern without consistent daily use. However, more severe withdrawal is typically associated with:
- Abrupt cessation of benzodiazepines, especially after prolonged use, as the body is suddenly deprived of the drug.
- Short-acting benzodiazepine agents, such as alprazolam, which are eliminated from the body more quickly, leading to a more rapid onset of withdrawal symptoms.
- High doses of benzodiazepines, as higher doses lead to greater physiological dependence.
Benzodiazepine withdrawal can often be managed safely in an outpatient setting. However, inpatient management is necessary in certain higher-risk situations:
- Co-existing major medical or psychiatric problems that could complicate withdrawal management.
- Polydrug dependence, involving dependence on multiple substances, which can complicate withdrawal and require more intensive monitoring.
- Concurrent prescription of other Central Nervous System (CNS) depressants, such as opioids, gabapentinoids, antipsychotics, or tricyclic antidepressants, which can increase the risk and severity of withdrawal symptoms and interactions.
- High benzodiazepine dose, generally defined as exceeding 50mg diazepam equivalent per day, indicating a higher degree of dependence and withdrawal risk.
- Injecting benzodiazepines, a less common route of administration but associated with more severe dependence and potential complications.
- Requirement for stabilisation of other medications, such as methadone or buprenorphine, often used in opioid dependence treatment, where benzodiazepine withdrawal management needs to be coordinated with other medication regimens.
- History of seizures, as benzodiazepine withdrawal can lower the seizure threshold, and a history of seizures increases the risk during withdrawal.
Inpatient Benzo Withdrawal Treatment Protocol
Patients using more than 50mg diazepam equivalent daily should ideally commence benzo withdrawal treatment in an inpatient setting due to the higher risk of severe withdrawal symptoms.
Medications (Inpatient)
- Diazepam Conversion: The first step is to convert the patient’s current daily benzodiazepine intake into an equivalent dose of diazepam. This conversion is crucial as diazepam is often used as a long-acting benzodiazepine for tapering due to its longer half-life and available formulations. Conversion charts are essential tools for accurate dose equivalency. Specialist consultation is recommended for complex cases, such as patients with poor hepatic function, which can affect drug metabolism.
- Dosage Determination and Initiation: Determine the total daily diazepam equivalent and divide it into a four times daily (QID) regimen for consistent drug levels. Initiate treatment with half the determined initial dose to assess the patient’s tolerance. For example, if the estimated daily dose is 80mg diazepam equivalent (20mg QID), the initial dose would be 10mg. This initial dose can be repeated after 2 hours if no significant sedation is observed, after which the previously determined QID regimen can be continued.
- Sedation Management: Closely monitor for sedation. If the patient becomes excessively sedated (sedation score of 2 or more, indicating difficulty staying awake), withhold the next dose and reassess.
- Daily Dose Reduction: Reduce the daily diazepam dose gradually, typically by 10mg per day (e.g., 5mg twice daily). This slow taper minimizes withdrawal symptoms and allows the body to adjust gradually.
- Discharge Criteria: Once the patient’s daily dose is reduced to below 50mg diazepam equivalent, and they are stable, discharge to outpatient management can be considered. Continued tapering in the outpatient setting is necessary, with arrangements for restricted dispensing from a community pharmacy to ensure medication adherence and prevent misuse.
- Co-administration of CNS Depressants: If the patient is also taking other CNS depressants, reduce the diazepam equivalency and initial doses by half due to increased sensitivity to sedation and respiratory depression. Increase the frequency of observations to every 2 hours, particularly at the start of treatment. Consult with a Drug and Alcohol Clinical Advisory Service for guidance in these complex scenarios.
Monitoring (Inpatient)
- CIWA-B Scale: Utilize the CIWA-B (Clinical Institute Withdrawal Assessment for Benzodiazepines, Revised) scale to regularly monitor the severity of benzodiazepine withdrawal symptoms. This standardized tool helps quantify withdrawal severity and guide medication adjustments.
- Sedation Score: Monitor sedation levels before each dose and one hour after administration using a sedation scoring system. This helps prevent over-sedation, especially during the initial dose titration.
Sedation Score Table:
| Score | Descriptor | Stimulus | Response | Duration |
|---|---|---|---|---|
| 3 | Difficult to rouse | Pain, shoulder squeeze, jaw thrust | Brief eye opening OR any movement OR no response | n/a |
| 2 | Easy to rouse, difficult staying awake | Voice, light touch | Eye opening and eye contact | |
| 1 | Easy to rouse | Voice, light touch | Eye opening and eye contact | |
| 0 | Awake, alert | n/a | n/a | n/a |
Outpatient Benzo Withdrawal Treatment Protocol
For patients using less than 50mg diazepam equivalent daily, benzo withdrawal treatment can typically be managed in an outpatient setting.
Medications (Outpatient)
- CNS Depressant Co-use: If the patient is also taking other CNS depressants, consult with a Drug and Alcohol Clinical Advisory Service for specific guidance due to potential complexities.
- Patient-Doctor Agreement: Establish a written patient-doctor agreement example agreement outlining the treatment plan, patient responsibilities, and expectations for safe withdrawal.
- Controlled Dispensing: Arrange controlled dispensing of diazepam from a community pharmacy. This can be daily, every other day, or weekly, depending on the patient’s circumstances and risk of misuse.
- Diazepam Conversion: Convert the patient’s current benzodiazepine dose to a diazepam equivalent using a conversion chart.
- Dose Splitting: Divide the total daily diazepam dose into a split dose regimen to maintain more stable blood levels and reduce fluctuations in withdrawal symptoms.
- Tolerance Test: Administer the first dose under medical supervision, ideally in the clinic or surgery, to assess tolerance and observe for any adverse reactions. Review the patient 1-2 hours post-dose. If tolerated, continue with the planned regimen.
- Tapering Schedule: Prescribe diazepam with dose reductions of approximately 10% of the original dose per week. As the patient approaches the final stages of withdrawal (around 15mg diazepam equivalent per day), the tapering rate can be slowed to 5-10% monthly to minimize discomfort and protracted withdrawal symptoms.
- Medication History Review: Review the patient’s medication history, ideally using electronic health records, although be aware these may sometimes be incomplete. In regions where available, ScriptCheck or similar real-time prescription monitoring programs offer a more reliable source of information on prescribed and dispensed controlled medications.
- Weekly Medical Review: Consider weekly medical reviews to monitor progress, assess withdrawal symptoms, and provide support and adjustments to the tapering plan as needed.
Additional Considerations (Outpatient)
- Driving Advice: Advise patients to avoid driving while taking benzodiazepines, especially at higher doses, due to the potential for impaired cognitive and motor function. Refer to resources on prescription drugs and driving.
- Flexibility in Tapering: A dose reduction period can be extended by one to two weeks (e.g., 5-10% reduction over 6 weeks instead of 4) if acute withdrawal issues arise. However, avoid increasing the dose back to previous levels, as this can hinder progress and reinforce dependence.
- Avoid Pharmacological Treatment of Withdrawal Symptoms: Minimize the use of additional medications to treat individual withdrawal symptoms like sleep difficulties or anxiety. This is because a core feature of benzodiazepine dependence is the learned association of medication with symptom relief. Specifically, pregabalin should be avoided due to its potential for dependence, overdose, and reported misuse in combination with benzodiazepines.
- Non-Pharmacological Interventions: Emphasize non-pharmacological strategies to manage withdrawal symptoms. Interventions such as regular physical activity, social engagement, and weekly counselling can be highly beneficial in reducing anxiety and improving coping mechanisms during withdrawal.
Resources and Further Information
For additional support and information, please refer to the following resources:
Alcohol and Drug Information Services (ADIS) 1300 13 1340
ADIS provides confidential telephone information, counselling, and referral services. Operating hours are 8:30 am to 10:00 pm, seven days a week.
Drug and Alcohol Clinical Advisory Services (DACAS)
DACAS offers a telephone and email service for healthcare professionals in South Australia seeking clinical advice and clarification on procedures, guidelines, and evidence-based practice in substance misuse.
Telephone: (08) 7087 1742 – 24 hours a day, 7 days a week, including public holidays.
Email enquiries: [email protected]
Please note: DACAS does not provide proxy medical cover and cannot assume responsibility for direct patient care.
Conclusion:
Effective benzo withdrawal treatment is essential for minimizing the risks and discomfort associated with benzodiazepine discontinuation. This guide outlines key considerations for both inpatient and outpatient management, emphasizing careful medication tapering, symptom monitoring, and supportive care. If you or someone you know is struggling with benzodiazepine withdrawal, seeking professional medical guidance is crucial for safe and successful treatment.
