Benzo withdrawal can be a stressful process, but it is often necessary for people trying to get themselves off benzodiazepine drugs. More severe reactions or withdrawals may also be more likely when taking strong drugs either for long periods or alongside other types of medications. Withdrawal symptoms may begin after as little as 3–6 weeks of use, even when a person uses the drugs as the doctor directed.
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The drug doses given are a guide only and should be adjusted to suit individuals. People using high doses of BZDs regularly (e.g. daily) over an extended period of time may experience a withdrawal syndrome when ceasing or reducing their benzodiazepines use. Because of the risk of withdrawal syndrome, benzodiazepines withdrawal requires good planning. For example, doctors may recommend flumazenil (Romazicon) to help with severe withdrawal symptoms and other drugs, such as buspirone (BuSpar), to help people with severe anxiety symptoms. Withdrawal symptoms occur during dose reduction and may include insomnia, anxiety, distress, weight loss, dizziness, night sweats, shaking, muscle twitches, aphasia, panic attacks, depression, numbness, dissociation, paranoia, indigestion, diarrhea, and photophobia. As withdrawal progresses, patients often find their physical and mental health improves with improved mood and improved cognition.
Harm reduction approaches for the use of benzodiazepines: a scoping review
A recent analysis of 14 drug cryptomarkets (1st February 2024 to 31st January 2025) revealed that benzodiazepines comprised the third-largest percentage (8.1%) of all drug listings 27. The growing presence and easy availability of novel benzodiazepines only add complexity to efforts aimed at reducing benzodiazepine-related harm. Patients in alcohol withdrawal should preferably be treated in a quiet room with low lighting and minimal stimulation. All patients with seizures or DT should have immediate intravenous access for administration of drugs and fluids. Adequate sedation should be provided to calm the patient as early as possible and physical restraints may be used as required in order to prevent injuries due to agitation. Adequate nutrition must be ensured with care to prevent aspiration in over-sedated patients.
Population-specific approaches
The key risk factors for overdose include homelessness, drug detoxification, and psychological distress. A later study reviewed harm reduction strategies for adolescents in public health settings 75. The authors provided recommendations for healthcare practitioners, including educating adolescents and caregivers about counterfeit pills, securing medication storage, and distributing naloxone and FTS. Three studies focused on a “safer supply” of substances during the COVID-19 pandemic to support individuals in isolation 32, 55, 56.
Specific Guides
If you have been using benzodiazepines for longer than six months, suddenly stopping your dose can cause grand mal seizures and delirium—this is why it’s best to involve your doctor or healthcare professional in your withdrawal process. Drug checking emerged as the most widely used harm reduction strategy, with nine studies employing various methods for drug sample analysis. These methods range from laboratory analyses to portable point-of-care methods. We tabulated the major recommendations from each source as regards the management of alcohol withdrawal with respect to severity of withdrawal, doses and regimen used in each study and the outcomes. Benzodiazepines are habit-forming prescription drugs used to treat several stress-related conditions, such as anxiety disorders, insomnia, epilepsy and even alcohol withdrawal. There are many different formulations of benzodiazepines, along with many different brand names.
Drug checking has emerged as a critical and adaptive harm reduction response to the growing challenges posed by novel benzodiazepines. The shift of drug use discussions and transactions to online spaces 66,67,68,69 highlights how use of unknown compounds when alone at home can render some traditional harm reduction advice insufficient. In this context, drug checking offers essential information about the substances people intend to use, further informing their decision-making and use of harm reduction strategies 44. One study reported that users discussed optimal dosing for desired effects and safety, drug formulation alterations, routes of administration, and effect durations 69. Although harm reduction information was shared, forum users also displayed a sense of superiority regarding their drug knowledge, which the authors suggested may promote risky practices. Two studies focused on reviews of drug vendors and strategies to reduce the harms of polysubstance use 70, 71.
The first study highlighted advocacy for home drug testing 70, whereas the second identified discussions on low dosing, controlling drug use frequency, and safer drug use at home 71. These criteria were refined during the screening calibration process to prioritise studies where benzodiazepines were central to the intervention or findings. Studies focusing primarily on other substances were excluded to maintain relevance and specificity. Formal exclusion based on study quality was not performed, consistent with scoping review methodology. Often marketed as ‘designer benzodiazepines’ or ‘research chemicals’ 22, these substances typically produce effects similar to, or stronger than, more well-known benzodiazepines, and are often developed or re-emerge in attempts to circumvent legal controls 21, 23. The presence of these drugs has increased significantly since they first appeared on online drug markets in 2007, with 36 novel benzodiazepines reported to the EU early warning system between 2007 and 2023 24.
One study found that positive FTS results were linked to safer drug use behaviours over a 28-day period, including using smaller amounts, and having naloxone on hand. Particularly when FTS were used on benzodiazepines, which resulted in a 20-fold reduction in use after a positive FTS result 54. Our aim was to review the evidence base for the appropriate management of the alcohol withdrawal syndrome using pharmacotherapy.
If you stop or reduce your dose suddenly, you will experience withdrawal symptoms. Benzodiazepines are a group of central nervous system depressants used to treat anxiety, insomnia, and seizures. Benzodiazepines are among the most commonly prescribed medications in the United States. Several types of benzodiazepines are sold under popular brand names like Valium (diazepam), Xanax (alprazolam), and Klonopin (clonazepam). Technological and analytical limitations remain a challenge, especially when detecting novel benzodiazepines at low concentrations. Low-cost tools such as FTS (~ $1 USD) provide rapid, albeit less specific, results 51, whereas more sophisticated methods such as PS-MS offer higher sensitivity at greater expense and complexity 44.
Long term management of BZD withdrawal
Protracted withdrawal is a long-term withdrawal syndrome that may come and go for several months. Benzodiazepine withdrawal can Benzodiazepine withdrawal also lead to disturbances in mental function that persist for several months or years after onset of symptoms (referred to as post-acute-withdrawal syndrome in this form). A systematic search was conducted by RML, with articles reviewed by CH, IN, CM and RML. The main manuscript text was written by CM and IN; all authors reviewed the manuscript.
- The third study from EDNAV focused on drug toxicity at music festivals 67, reviewing 1603 medical presentations, of which 228 involved illicit drug toxicity.
- The presence of these drugs has increased significantly since they first appeared on online drug markets in 2007, with 36 novel benzodiazepines reported to the EU early warning system between 2007 and 2023 24.
- Long acting BZD’s generally have a less severe withdrawal starting at 2-7 days, peaking around 20 days, and abate after a few weeks.
- A common finding across the included drug checking studies was the detection of unexpected substances.
- Benzodiazepine users may present requesting a script for a specific BZD or they may present in a variety of other ways e.g. stating they need BZDs to assist in heroin or alcohol withdrawal, or to treat an anxiety disorder or sleep problems.
Longer-acting benzodiazepines like Klonopin (clonazepam) can stay in the system longer, which means it can be one to two days or even longer before withdrawal symptoms start. According to the British National Formulary, it is better to withdraw too slowly rather than too quickly from benzodiazepines.67 The rate of dosage reduction is best carried out so as to minimize the symptoms’ intensity and severity. Anecdotally, a slow rate of reduction may reduce the risk of developing a severe protracted syndrome.
The third study explored harm reduction service provision across 34 cities during the pandemic, and highlighted the introduction and continuation of a prescribed benzodiazepine stabilisation protocol in Dublin 32. Approximately 5 mg of diazepam equivalents Table 5 is prescribed for every standard drink consumed. However, it needs to be based upon the severity of withdrawals and time since last drink. For example, a person presenting after 5 days of abstinence, whose peak of withdrawal symptoms have passed, may need a lower dose of benzodiazepines than a patient who has come on the second day of his withdrawal syndrome. However, in the presence of co-morbidities shorter acting drugs such as oxazepam and lorazepam are used.
- The Recovery Village aims to improve the quality of life for people struggling with substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes.
- To reduce overdose deaths, the clinics removed benzodiazepines from the approved medication list and provided patients with individualised treatment plans, including psychoeducation, psychotherapy, slow taper, and inpatient detoxification.
- The diagnosis requires adequate history of the amount and frequency of alcohol intake, the temporal relation between cessation (or reduction) of alcohol intake and the onset of symptoms that may resemble a withdrawal state.
- Table 2 gives a clinical description of alcohol withdrawal syndrome by severity and syndromes.4,5,6 Figure 2 depicts the time course of symptom evolution.
- Though rapid loading is advised in DT, the few trials and retrospective chart reviews in DT have used a loading dose regimen.
Though rapid loading is advised in DT, the few trials and retrospective chart reviews in DT have used a loading dose regimen. One study evaluated a ‘no benzodiazepine’ policy that was implemented across six outpatient mental health clinics in 2016 in the United States 62. To reduce overdose deaths, the clinics removed benzodiazepines from the approved medication list and provided patients with individualised treatment plans, including psychoeducation, psychotherapy, slow taper, and inpatient detoxification.
In patients who present with seizures, a thorough neurological and general medical evaluation is a must to detect alternative cause of seizures. They may be considered in mild withdrawal states due to their advantages of lower sedation and lower chances of dependence or abuse potential. However, they may not have the expected advantage of preventing seizures or DT in alcohol withdrawal states18 and their use is not recommended in severe withdrawal states. Alcohol dependence is a severe form of alcohol use disorder and it may first manifest when a person develops withdrawal symptoms after stopping alcohol – either due to family pressure, self-motivation, physical ill health or difficulty in procuring alcohol.