Benzodiazepine Dependency and Withdrawal Frequently Asked Questions (FAQ) file, Version 1.2 

This is version 1.2 of this FAQ. It is based on version 1.1 of the FAQ. It has been amended to reflect the experiences of those in the Yahoo Benzo Group. Amendments are found in sections 15, 16, 25, 40 and 41.

 DISCLAIMER:  THIS FAQ WAS NOT WRITTEN BY A DOCTOR OR SOMEONE WITH ANY FORM OF MEDICAL TRAINING.  THE ADVICE CONTAINED HEREIN SHOULD NOT BE SUBSTITUTED FOR THE ADVICE OF A PHYSICIAN WHO IS WELL-INFORMED IN THE SUBJECT MATTER DISCUSSED.  BECAUSE THIS FAQ IS NOT WRITTEN BY A DOCTOR, ALL ADVICE IS TO BE FOLLOWED AT YOUR OWN RISK. 

This FAQ is expressly placed into the public domain, and may be freely disseminated by any who come into its possession.  The identity of its authors is irrelevant.  It is a product of the effort of a few among a community known as The Yahoo Benzo Group .It is also a product of the spirit of that entire community.  It is both a gift from its authors to that community, and a gift from that community to anyone in the world whose life has been touched by benzodiazepine dependency. 

In order to avoid confusion, the authors request that in reproducing, transmitting, or disseminating this document, no alterations of text be made.  Any proposed corrections or revisions should be stated on the forum known as The Yahoo Benzo Group. When the authors have accumulated sufficient revision material to justify creating a new version, one will be issued.  Legitimate revisions include spelling, grammar, and punctuation errors; scientific and/or medical inaccuracies pointed out; new questions; and information newly discovered through scientific research or empirical observation, e.g. some new form of adjunct medication or herbal therapy that is discovered to be helpful in withdrawal. 

Differences of opinion with the authors are warmly accepted, but are unlikely to alter the contents of the FAQ unless supported by solid factual data. 

"Canst thou not minister to a mind diseas'd,

Pluck from the memory a rooted sorrow,

Raze out the written troubles of the brain,

And with some sweet oblivious antidote

Cleanse the stuff'd bosom of that perilous stuff

Which weighs upon the heart?" 

Shakespeare, Macbeth Act 5, Scene 3 

 TABLE OF CONTENTS

1. WHAT IS A BENZODIAZEPINE?  4

2.  HOW DO BENZODIAZEPINES AFFECT YOUR BODY?  5

3.  HOW QUICKLY CAN I BECOME ADDICTED TO A BENZODIAZEPINE?  6

4.  WHAT ARE THE DOSE EQUIVALENCIES AMONG VARIOUS BENZODIAZEPINES?  6

5.  WHAT IS A "HALF-LIFE", AND HOW IS THE CONCEPT IMPORTANT TO    BENZODIAZEPINE DEPENDENCE?  7

6.  WHAT DOES "TOLERANCE" MEAN?  9

7.  IF MY DOCTOR HAS PRESCRIBED A BENZODIAZEPINE AND INSTRUCTED ME TO TAKE IT FOR A MEDICAL AND/OR PSYCHOLOGICAL REASON, IS THERE ANY REASON I SHOULD DISREGARD MY DOCTOR'S ADVICE AND DISCONTINUE THE BENZODIAZEPINE?  9

8.  WHAT IS BENZODIAZEPINE WITHDRAWAL SYNDROME?  10

9.  WHAT ARE THE SYMPTOMS OF BENZODIAZEPINE WITHDRAWAL?  11

10.  I AM EXPERIENCING ONE OR MORE OF THE SYMPTOMS LISTED ABOVE, BUT I HAVE NOT BEGUN TAPERING MY BENZODIAZEPINE.  IS IT POSSIBLE THAT THE SYMPTOMS ARE NOT RELATED TO BENZODIAZEPINE USE, OR COULD I ALREADY HAVE STARTED WITHDRAWAL WITHOUT EVEN TAPERING?  13

11.  WHAT FACTORS DETERMINE HOW SEVERE MY WITHDRAWAL WILL BE?  14

12.  IF I DISCONTINUE MY BENZODIAZEPINE, WON'T THE UNDERLYING CONDITION THAT MY DOCTOR PRESCRIBED THE BENZODIAZEPINE FOR RETURN?  14

13.  I HAVE DECIDED TO DISCONTINUE THE USE OF MY BENZODIAZEPINE.  WHAT ARE THE FIRST STEPS I SHOULD TAKE?  15

14.  IS COLD TURKEY (ABRUPT, TOTAL DISCONTINUANCE OF THE DRUG) AN      ACCEPTABLE METHOD FOR WITHDRAWING FROM A BENZODIAZEPINE?  15

15.  OK, IF I AM GOING TO TAPER MY BENZODIAZEPINE, HOW SHOULD I STRUCTURE THE TAPER?  15

16.  SHOULD I SWITCH TO ANOTHER BENZODIAZEPINE SUCH AS VALIUM BEFORE TAPERING?  17

17.  MY DOCTOR HAS ASKED ME TO SWITCH TO A DRUG CALLED "PHENOBARBITOL" FOR DETOX?  IS THIS A GOOD IDEA?  19

18.  SHOULD I CONSIDER GOING INTO AN IN-PATIENT DRUG REHABILITATION FACILITY OR DETOX CENTER TO GET OFF MY BENZODIAZEPINE?  19

19.  WHAT IS THE LENGTH OF THE WITHDRAWAL PROCESS?  20

20.  IS IT OK FOR ME TO SOMETIMES "CHEAT" DURING MY TAPER AND TAKE A LITTLE MORE OF MY BENZODIAZEPINE IF I HAVE TO GO THROUGH A STRESSFUL EVENT?  21

21.  WILL I NEED TO QUIT WORK OR GIVE UP OTHER IMPORTANT ASPECTS OF MY LIFE DURING BENZODIAZEPINE WITHDRAWAL?  21

22.  MY DOCTOR HAS PRESCRIBED AN ANTI-DEPRESSANT TO TAKE DURING MY WITHDRAWAL.  IS THAT A GOOD THING TO DO?  22

23.  ARE THERE ANY OTHER DRUGS BESIDES ANTI-DEPRESSANTS TO CONSIDER USING DURING BENZODIAZEPINE WITHDRAWAL?  23

24.  ARE THERE ANY PARTICULAR DRUGS A DOCTOR MIGHT PRESCRIBE THAT DEFINITELY DO NOT HELP WITHDRAWAL?  23

25. WHAT ABOUT HERBS AND OTHER HOMEOPATHIC REMEDIES - DO ANY OF THOSE HELP THE WITHDRAWAL SYMPTOMS?  24

26.  WHAT ABOUT USING CAFFEINE DURING WITHDRAWAL?  24

27.  WHAT ABOUT EATING SUGAR DURING WITHDRAWAL?  25

28.  WHAT ABOUT CONSUMING ALCOHOL DURING WITHDRAWAL?  25

29.  WHAT FOODS SHOULD I EAT (OR AVOID) DURING WITHDRAWAL?  25

30. I SMOKE CIGARETTES.  SHOULD I QUIT DURING WITHDRAWAL?  26

31.  SHOULD I EXERCISE DURING BENZODIAZEPINE WITHDRAWAL?  27

32.  I HAVE TERRIBLE INSOMNIA DURING MY WITHDRAWAL.  SHOULD I TAKE SOMETHING TO HELP ME SLEEP?  27

33.  WHAT CAN I TAKE FOR PAIN MANAGEMENT DURING WITHDRAWAL?  28

34.  ARE THERE ANY PARTICULAR DRUGS THAT ARE KNOWN TO COMPLICATE WITHDRAWAL?  28

35.  I AM WELL INTO MY TAPER, AND MY SYMPTOMS ARE EITHER NO BETTER OR ARE WORSE.  WHEN CAN I EXPECT MY SYMPTOMS TO GET BETTER?  28

36.  I HAVE COMPLETED MY TAPER, AND HAVE FELT MUCH BETTER FOR A WHILE, BUT NOW I FEEL WORSE AGAIN.  WHY?  29

37.  WHAT IS PROTRACTED WITHDRAWAL SYNDROME?  29

38.  SHOULD I USE A 12 STEP PROGRAM LIKE NARCOTICS ANONYMOUS TO HELP ME RECOVER FROM MY BENZODIAZEPINE ADDICTION?  30

39.  WHO IS DR. HEATHER ASHTON?  31

40.  WHAT IS THE YAHOO BENZO GROUP?   31

41.  ARE THERE ANY OTHER RESOURCES THAT WOULD BE HELPFUL TO ME IN UNDERSTANDING BENZODIAZEPINE DEPENDENCY AND WITHDRAWAL?  31

1. WHAT IS A BENZODIAZEPINE?

Benzodiazepines are a large class of commonly prescribed tranquillisers, otherwise referred to as central nervous system (CNS) depressants, anxiolytics and sedative-hypnotics. They include alprazolam (Xanax), bromazepam (Lexotan, Lexomil), chlordiazepoxide (Librium, Nova-Pam), clonazepam (Klonopin, Rivotril), clorazepate (Tranxene), diazepam (Valium, D-Pam, Pro-Pam), estazolam (ProSom), flunitrazepam (Rohypnol), flurazepam (Dalmane), halazepam (Paxipam), ketazolam (Anxon), loprazolam (Dormonoct), lorazepam (Ativan), lormetazepam (Noctamid), medazepam (Nobrium), midazolam, (Versed, Hypnovel, Dormicum), nitrazepam (Mogadon, Insoma, Nitrados), oxazepam (Serax, Serapax, Serenid, Benzotran), prazepam (Centrax), quazepam (Doral), temazepam (Restoril, Euhypnos, Normison, Sompam), triazolam (Halcion, Hypam, Tricam). See: Benzodiazepine Drug Index for links to monograph and drug information sites.

Some of the lesser known benzodiazepines include: brotizolam, camazepam, clotiazepam, cloxazolam, delorazepam, etizolam, fludiazepam, haloxazolam, oxazolam, nimetazepam, nordazepam, pinazepam, tetrazepam, tofisopam. See: Benzodiazepine Drug Index.

All benzodiazepines have five primary effects.  They are: 

A.  Hypnotic (tending to make you sleepy); 

B.  Anxiolytic (tending to reduce anxiety/produce relaxation); 

C.  Anti-seizure (tending to reduce the probability of having seizures and convulsions); 

D.  Muscle relaxant (tending to reduce muscle tension and associated pain); 

E.  Amnesic (tending to disrupt both long and short term memory). 

There may be secondary effects as well.  Different benzodiazepines exhibit these primary effects to varying degrees.  For example, diazepam (Valium) is a relatively powerful hypnotic (sleep inducer), whereas the more modern benzodiazepines such as alprazolam (Xanax), lorazepam (Ativan), and clonazepam (Klonopin), are less powerful hypnotics, but are very powerful anxiolytics.  Do not assume that because one benzodiazepine makes you sleepier than another that this benzodiazepine is more potent than those which do not produce sleepiness to the same degree.  Often, the reverse is true. 

Benzodiazepines have been referred to as being part of a larger class of drugs known as "minor tranquilizers".  As applied to benzodiazepines, this is almost certainly a misnomer, and the label has fallen into relative disuse in the past ten years.  However, you may encounter this term from time to time. 

Benzodiazepines are most commonly prescribed for anxiety conditions, especially panic disorder (PD) and generalized anxiety disorder (GAD). They are also sometimes prescribed for seizure disorders.  Klonopin, for example, is often prescribed for epilepsy.  Benzodiazepines are also prescribed for insomnia and other sleep problems, such as restless leg syndrome (RLS).  Benzodiazepines are also occasionally prescribed as muscle relaxants. 

The most common benzodiazepines prescribed today are Valium, Xanax, Ativan and Klonopin.  Valium is particularly common in the British Isles. Valium has become less common in the United States over the past 15 years, while Xanax and Klonopin have experienced increased popularity in the United States over this time.  In certain Latin American countries, it appears that the drug Lexotan (bromazepam) is very popular. 

All benzodiazepines can cause physical dependency, otherwise commonly known as addiction.

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2.  HOW DO BENZODIAZEPINES AFFECT YOUR BODY?

Benzodiazepines are general central nervous system (CNS) depressants. They are all very similar chemically. All benzodiazepines act by enhancing the actions of a natural brain chemical, GABA (gamma-aminobutyric acid). GABA is a neurotransmitter, an agent which transmits messages from one brain cell (neuron) to another. The message that GABA transmits is an inhibitory one: it tells the neurons that it contacts to slow down or stop firing. Since about 40% of the millions of neurons all over the brain respond to GABA, this means that GABA has a general quietening influence on the brain: it is in some ways the body's natural hypnotic and tranquillizer. This natural action of GABA is augmented by benzodiazepines which thus exert an extra (often excessive) inhibitory influence on neurons.

The way in which GABA sends its inhibitory message is by a clever electronic device. Its reaction with special sites (GABA-receptors) on the outside of the receiving neuron opens a channel, allowing negatively charged particles (chloride ions) to pass to the inside of the neuron. These negative ions "supercharge" the neuron making it less responsive to other neurotransmitters which would normally excite it. Benzodiazepines also react at their own special sites (benzodiazepine receptors), situated actually on the GABA-receptor. Combination of a benzodiazepine at this site acts as a booster to the actions of GABA, allowing more chloride ions to enter the neuron, making it even more resistant to excitation. Various subtypes of benzodiazepine receptors have slightly different actions. One subtype (alpha 1) is responsible for sedative effects, another (alpha 2) for anti-anxiety effects, and both alpha 1 and alpha 2, as well as alpha 5, for anticonvulsant effects. All benzodiazepines combine, to a greater or lesser extent, with all these subtypes and all enhance GABA activity in the brain.

As a consequence of the enhancement of GABA's inhibitory activity caused by benzodiazepines, the brain's output of excitatory neurotransmitters, including norepinephrine (noradrenaline), serotonin, acetyl choline and dopamine, is reduced. Such excitatory neurotransmitters are necessary for normal alertness, memory, muscle tone and co-ordination, emotional responses, endocrine gland secretions, heart rate and blood pressure control and a host of other functions, all of which may be impaired by benzodiazepines. Other benzodiazepine receptors, not linked to GABA, are present in the kidney, colon, blood cells and adrenal cortex and these may also be affected by some benzodiazepines. These direct and indirect actions are responsible for the well-known adverse effects of dosage with benzodiazepines.

Contrary to a popular misconception, benzodiazepines do not actually increase the organic synthesis of GABA. As stated, they enhance the action of existing GABA. Actually, benzodiazepines can, over time, decrease the synthesis of GABA in certain areas of the brain. This is one of numerous theories attempting to explain the occurrence of "paradoxical" symptoms (see FAQ 7).

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3.  HOW QUICKLY CAN I BECOME ADDICTED TO A BENZODIAZEPINE? 

The time it takes to form a physical dependency on a given benzodiazepine varies widely.  The following variables may play a role: the size of your dose, the regularity with which you consume your dose, and most importantly, your personal body chemistry.  People have been known to form dependencies in as little as 14 days of regular use at therapeutic dose levels.  Your probability of forming some degree of dependency is significant, probably at least 50%, by the time you have been using them daily for 6 months.  After a year of continuous use, it is highly likely that you have formed a dependency.  It is unclear whether certain benzodiazepines are associated with a more rapid onset of dependency than others. 

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4.  WHAT ARE THE DOSE EQUIVALENCIES AMONG VARIOUS BENZODIAZEPINES? 

There are no clearly definitive equivalencies for various benzodiazepines. This author has personally seen at least a dozen different benzodiazepine equivalency charts and no two are alike.  The table below has been chosen because it reflects the clinical experience of Dr. Ashton in having withdrawn over 300 people from benzodiazepines by use of a Valium substitution method (See Ashton Manual).    

 Thus, 1 mg. of alprazolam (Xanax) or clonazepam (Klonopin) is the equivalent of 20 mg. of Valium; 1 mg. of lorazepam (Ativan) is the equivalent of 10 mg. of Valium. 

These dose equivalencies are important for a number of reasons, the most significant of which is the issue of switching to a different benzodiazepine such as Valium prior to tapering (see FAQ 15). These figures are taken from Dr. Ashton's (see Ashton Manual) papers and several other sources.   

You may find a doctor who will want to switch you from Xanax to Valium at a 1mg. to 10 mg. equivalency.  This is a recipe for a very difficult cross-over withdrawal.  Whatever the precise therapeutic dose equivalencies, the above equivalencies should be observed in switching from one benzodiazepine to another for purposes of withdrawal.  (See FAQ 15). 

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5.  WHAT IS A "HALF-LIFE", AND HOW IS THE CONCEPT IMPORTANT TO BENZODIAZEPINE DEPENDENCE? 

Half-life is a numerical expression of how long it takes for a drug to leave your body.  Technically, the "half-life," expressed as a range, is the time it takes for half of the amount consumed to be eliminated from your body, and so on.  There is some controversy as to how long benzodiazepines may actually remain in your body after you have discontinued them entirely.  Benzodiazepines are fat soluble and can persist in fatty tissues.  However, benzodiazepines no longer show up in blood screenings beyond 30 days after discontinuance.  This either means they are totally eliminated by that time, or that they persist in amounts too small to have any long-term effect. 

The importance of half-life is that a longer half-life generally makes for an easier withdrawal because your blood levels remain relatively constant, as opposed to the up and down roller coaster that you experience with short half-life benzodiazepines.  Furthermore, longer half-life benzodiazepines require less dose micro-management.  For example, Valium can be taken once every 12 hours, or in some cases, once every 24 hours.  Xanax, however, must be taken once every 4-6 hours to maintain constant blood levels.  This is a practical impossibility for some people. 

The following is a list of benzodiazepines with their corresponding half-lives, expressed as a range in hours: 

There is a misconception that longer half-life benzodiazepines prolong the withdrawal recovery process by remaining in your bodily tissues longer.  However, there is no evidence that longer half-life benzodiazepines are any greater risk for Protracted Benzodiazepine Withdrawal Syndrome (see FAQ 37) than shorter half-life benzodiazepines. This method of using a longer half-life equivalent is well understood in addiction medicine circles, and is employed with other classes of drugs as well.  For example, people who are experiencing withdrawal symptoms from an anti-depressant such as Paxil are often given Prozac as a substitute for purposes of detoxification, because Prozac has a longer half-life. Perhaps a more typical example is the use of the drug Methadone in heroin detoxification which is employed in part because of its relatively long half-life.

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6.  WHAT DOES "TOLERANCE" MEAN? 

Tolerance is the process by which the receptors in your brain become habituated to the action of a drug.  When tolerance is reached, more of the drug is required to achieve the same effect.  With benzodiazepines, and probably with many other classes of drugs as well, tolerance is virtually always associated with some degree of physical dependence.  If you find that you are experiencing tolerance, this is a clear warning sign that you may have formed a dependency.

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7.  IF MY DOCTOR HAS PRESCRIBED A BENZODIAZEPINE AND INSTRUCTED ME TO TAKE IT FOR A MEDICAL AND/OR PSYCHOLOGICAL REASON, IS THERE ANY REASON I SHOULD DISREGARD MY DOCTOR'S ADVICE AND DISCONTINUE THE BENZODIAZEPINE? 

Yes, there may be.  Unfortunately, there are many well-intentioned physicians who simply do not understand the seriousness of long-term benzodiazepine use. 

Regular benzodiazepine use almost always causes some degree of deterioration in cognitive functioning, which progresses with continued use. 

Long-term benzodiazepine use also causes lethargy, decreased energy levels that result in impairment in work productivity and disinclination towards exercise. 

Furthermore, benzodiazepines, and all other classes of sedatives, frequently cause and/or worsen depression.  This is why people are often given anti-depressants after being given a benzodiazepine for anxiety.  Anti-depressants have their own complications and potential for dependency.  (See FAQ 22)

Benzodiazepines can also cause what is sometimes referred to as an "emotional anaesthesia", or "emotional blunting," in which the user's ability to experience powerful emotions is impaired. This has been described as "the inability to feel pleasure or pain" in the medical literature (e.g. Toxicity and Adverse Consequences Of Benzodiazepine Use 1995). Long-term benzodiazepine users often describe their experience as "sleepwalking through life".

Benzodiazepine use can also cause what are referred to as "paradoxical" symptoms in a minority of users. Paradoxical symptoms are contrary to the intended therapeutic purpose, including outbursts of rage, increased anxiety, and sleeplessness. Paradoxical symptoms can be caused by the drug's interaction with the psychological makeup of the user, or may be a biological reaction to use of the drug that people sometimes refer to as "toxicity". Paradoxical symptoms are sometimes mistaken for withdrawal, and vice versa.  

The above effects occur to varying degrees, depending on the individual.

Some individuals may not experience certain of the effects at all. However one effect is common to virtually all users; a physical dependency will eventually form.  Benzodiazepine dependency is particularly serious as the withdrawal syndrome (see FAQ 8) can be extremely difficult and protracted.  Furthermore, the development of tolerance often makes long-term use non-feasible, and withdrawal becomes a necessary eventuality. 

Benzodiazepines are often misprescribed for conditions to which they are not appropriate, such as depression. Furthermore, they are often prescribed for anxiety conditions for which the individual could be treated effectively with other therapeutic techniques. 

There are, however, legitimate therapeutic benefits for benzodiazepines, particularly if they are used in the short term (no more than 2 weeks of continuous use), or for situational anxiety/panic (for example, one dose of Xanax per month as the need arises.) Furthermore, many users of benzodiazepines, including some who have used them regularly for more than a year, are able to discontinue them with little difficulty.  

Nothing in this FAQ is to be construed as advising any individual to ignore the advice of his or her physician.  Decisions regarding the use or discontinuance of any benzodiazepine should be made in consultation with a physician.  However, in this area you must also undertake considerable self-education in addition to listening carefully to your doctor's advice.  Fortunately, there are many available resources to accomplish that (see FAQ 41).  Where a doctor does not appear to be up to date with current medical literature regarding benzodiazepine dependency and the withdrawal syndrome, seeking a second and third medical opinion can be a desirable option.

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8.  WHAT IS BENZODIAZEPINE WITHDRAWAL SYNDROME? 

Benzodiazepine withdrawal syndrome is believed to be caused by a dampening of the action of GABA as neuroadaptivity causes GABA to become dependent on stimulation from the benzodiazepine to initiate its primary action. In other words, when you have become dependent upon a benzodiazepine, your GABA is unable to perform its natural action without the presence of the benzodiazepine. This results in a wide variety of over-activity in different areas of your brain, causing a vast and diffuse array of symptoms. These symptoms are believed to be various manifestations of neurological over-excitation as the cells in your brain become especially sensitive to the action of excitatory neurotransmitters. The most extreme manifestation of this over-excitation is a seizure event.   

Benzodiazepine withdrawal syndrome is noted both for its relative severity and, in some cases, its lengthy duration, as compared to withdrawal from other classes of drugs. 

Withdrawal either occurs through the development of tolerance without an increase in dose, or through a decrease in dosage below your "tolerance point".  Your tolerance point is the dose point below which the functioning of your receptors becomes impaired due to a deficiency in stimulation from the drug.  Your tolerance point may be lower than your actual dosage, such that you can sometimes cut your dose by some amount without experiencing withdrawal symptoms.  However, this does not mean that you will not experience withdrawal symptoms by cutting the dose further. 

Generally, a drug's withdrawal syndrome is the mirror opposite of its primary effects.  Thus, for benzodiazepines, you can expect sleeplessness (the mirror of its hypnotic effect), anxiety (the mirror of its anxiolytic effect), muscle tension/pain (the mirror of its muscle relaxant effect), and seizures in rare cases (the mirror of its anti-seizure effect).  The only exception is that benzodiazepine withdrawal syndrome does not "mirror" the amnesic effect.  To the contrary, the withdrawal syndrome often results in increased impairment of memory and cognitive functioning.  However, in all cases, after withdrawal is complete and withdrawal is in total remission, cognitive functioning will gradually return to the level that it was at before you began using the drug. 

For a more complete list of symptoms, see FAQ 9.

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9.  WHAT ARE THE SYMPTOMS OF BENZODIAZEPINE WITHDRAWAL? 

The following is a list of symptoms reported by enough individuals so that they are statistically likely to be legitimate withdrawal symptoms. Keep in mind that there are a wide variety of other symptoms that have been reported that may be legitimate withdrawal symptoms as well, but have not been reported by enough individuals to be statistically significant.  The determination of statistical significance is not based on hard data, but on the observations of this author in reading through thousands of posts from people in withdrawal, as well as several books and articles on the subject. 

This list is broken down into psychological and physical symptoms.  The double asterisk (**) indicates symptoms that occur to some degree or another, at one time or another, in virtually every person experiencing benzodiazepine withdrawal.  Single asterisk (*) are symptoms that are common, and occur in most people.  Others are symptoms that are common enough to be verifiable withdrawal symptoms, but probably occur in a minority of cases. 

Psychological symptoms: 

Note that it is far more common to fear psychosis than it is to actually experience it. 

Physical Symptoms: 

Sites with a far more comprehensive list of possible symptoms are: http://www.benzo.org.uk/slistz.htm and http://www.geocities.com/benzobusters/  Here, I have cited only the ones most commonly reported.

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10.  I AM EXPERIENCING ONE OR MORE OF THE SYMPTOMS LISTED ABOVE, BUT I HAVE NOT BEGUN TAPERING MY BENZODIAZEPINE.  IS IT POSSIBLE THAT THE SYMPTOMS ARE NOT RELATED TO BENZODIAZEPINE USE, OR COULD I ALREADY HAVE STARTED WITHDRAWAL WITHOUT EVEN TAPERING? 

You are probably experiencing tolerance withdrawal.  When you reach tolerance, your brain needs more of the drug to stimulate the active of GABA, and you begin to experience withdrawal symptoms.  Some people find that no matter how much they increase their dose, they are unable to obtain complete relief.  This may be caused by a fast, upward tolerance spiral (see FAQ 6) , or by toxicity (see FAQ 7).  Complete withdrawal is necessary where this occurs. 

Some people mistakenly form a belief that the drug has stopped working, and no longer alleviates their anxiety disorder when in fact they are experiencing anxiety brought on by tolerance withdrawal. Unfortunately, physicians will usually reinforce this misperception and advise you to increase your dose as a result or prescribe an additional benzodiazepine and/or anti-depressants.

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11.  WHAT FACTORS DETERMINE HOW SEVERE MY WITHDRAWAL WILL BE?

It is impossible to predict how severe your particular withdrawal will be, or which of the 30 or so common symptoms you are likely to experience.  However, predictors of severity include duration of use, dosage, type of benzodiazepine, age, your personal body chemistry, and your method of withdrawal.  It is unclear which, if any, of these factors relate to the duration of your withdrawal syndrome as opposed to the severity. 

There is some evidence that the more modern, high potency benzodiazepines, especially Xanax, Klonopin, and Ativan may be associated with more severe withdrawal syndromes.  However, this evidence remains anecdotal. 

Bear in mind that there is wide variation in people's withdrawal experiences.  For example, one person may take a low dose of a benzodiazepine for a short period of time, and have a very severe withdrawal phase.  Another individual may take a high dose of the same drug for much longer, and experience very manageable withdrawal symptoms.  Furthermore, an individual Valium user may have a harder time than an individual Xanax user. 

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12.  IF I DISCONTINUE MY BENZODIAZEPINE, WON'T THE UNDERLYING CONDITION THAT MY DOCTOR PRESCRIBED THE BENZODIAZEPINE FOR RETURN?

It may or may not.  It depends on what your underlying problem was, and what post-withdrawal measures you take to manage the condition, if necessary.  Sometimes, the underlying problem is simply "gone" by the time you have withdrawn yourself from a benzodiazepine.  Many physical and psychological conditions are a transitory response to a temporary condition in your life, such as a traumatic event. Often, people take habit forming drugs such as benzodiazepines to alleviate the symptoms of these transitory conditions, and continue taking them long after the condition would have gone away on its own. 

Other conditions are less transitory, such as chronic, long-term panic disorder (PD).  However, it is important to bear in mind that there are other treatments for these conditions. Anxiety and stress can be managed in a variety of different ways that are not as harmful to your body as benzodiazepines. 

Sometimes, when people complete their benzodiazepine withdrawal, they find an emergence of an underlying psychological problem that was masked by the benzodiazepine use for many years.  People also often feel the resurfacing of emotions that may have been suppressed for a long time. Thus, there is sometimes a period of difficult adjustment even after the withdrawal symptoms subside.  However, people often find the end result of this period of adjustment to be very rewarding.

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13.  I HAVE DECIDED TO DISCONTINUE THE USE OF MY BENZODIAZEPINE.  WHAT ARE THE FIRST STEPS I SHOULD TAKE? 

Your first step is to educate yourself.  That means reading this FAQ and seeking out many of the resources referred to herein.  Your second step is to see a doctor who understands the seriousness of benzodiazepine dependency, and be as well armed with information as possible going into that visit.  Your third step is to approach your withdrawal with a clear plan in mind, to set goals for yourself, and to begin the withdrawal process with confidence.  Do not listen to horror stories from others who have had unusually bad experiences in withdrawal. Everyone's experience is different, and many people are able to withdraw with very manageable symptoms.

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14.  IS COLD TURKEY (ABRUPT, TOTAL DISCONTINUANCE OF THE DRUG) AN      ACCEPTABLE METHOD FOR WITHDRAWING FROM A BENZODIAZEPINE?

No.  There is nearly complete uniformity of opinion both in the medical profession and in the benzodiazepine recovery community that cold turkey is a dangerous and unacceptable method of detoxification.  Cold turkey withdrawal may cause seizures, and is also associated with a higher probability of withdrawal psychosis.  Seizures are almost non-existent in those employing a taper method, with the limited exception of people who have taken a benzodiazepine for a seizure disorder.  Furthermore, psychosis is rare in those who taper their benzodiazepine slowly. 

There is a misconception that cold turkey withdrawal, though it may cause more severe symptoms, will bring about a faster remission of symptoms.  This is the idea that a slow taper "prolongs the agony of withdrawal".  This notion is almost certainly false.  In fact, there is some anecdotal evidence that cold turkey withdrawal may lengthen the course of the withdrawal syndrome, and may even cause Protracted Withdrawal Syndrome (see FAQ 37). 

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15.  OK, IF I AM GOING TO TAPER MY BENZODIAZEPINE, HOW SHOULD I STRUCTURE THE TAPER?

There are two very general rules, and one exception to the rule that is discussed below.  The first rule is, the slower the taper, the milder the withdrawal symptoms.  The second rule is, the smaller the cuts you are able to make, the milder the withdrawal symptoms.  These are related, though separate, issues. 

For example, you might decide to cut your dose by 1/4 mg. every month, or in the alternative, cut your dose by 1/8 mg. every two weeks.  Either way, you are tapering at the same rate.  In this author's opinion, the second option is a far superior method of tapering.  Any cut is a shock to your brain and body.  Cold turkey is the largest cut of all.  It is a spontaneous, total deprivation of your dependent substance.  The shock caused by cold turkey withdrawal is such that even after resumption of your drug at the previous dose, it may take weeks or months to "stabilize", and in some cases, you may never stabilize from a cold turkey withdrawal until after you have completed your taper. 

This logic further extends to the size of your cuts.  The smaller the cuts you make, the less the shock to your system, and the less pronounced the withdrawal symptoms triggered by the cut.  It is not recommended that any individual cut represent more than 10% of your total dose at a given time.  Thus, it is preferable to make smaller and smaller cuts as you go, though this can be very difficult as you approach the end of your taper. 

Always make the smallest cuts possible.  That means taking the smallest dose size available and splitting it into 4 pieces, which can be done easily with or without a razor blade.  For example, with Valium, you can split the smallest (2 mg.) tablet into four .5 mg. pieces.  With Klonopin, you can split the smallest (.5 mg.) tablet into 4 pieces of .125 or 1/8th mg.  If you are on a high dose and feel that you are able to taper rapidly at first because you are above your tolerance point (see FAQ 6), space your cuts close together, but make the smallest cuts possible.  If or when you begin to feel withdrawal symptoms, you can start to space your cuts further apart (up to about 4 weeks).  Generally, the higher potency benzodiazepines such as Xanax, Klonopin, and Ativan force you to make larger cuts, and therefore you must space your cuts at least 3 weeks apart toward the end of your taper. Of course, even where you are able to make very small cuts with lower potency benzodiazepines such as Valium, you can make these small cuts relatively far apart if this is your most comfortable method of withdrawal. 

There is a method of tapering that involves mixing the drug with either water or a dry carrier like sugar to produce a "titration" which allows for very minute reductions, such as 1% every other day.  This method has been employed with success by some people as it allows the body to adjust to the reductions in a very subtle and gentle way and allows a greater control over the rate of a taper. The water titration methodology is explained here at this site Water Titration. Alternatively you can go to http://www.geocities.com/benzobuddy/watertitration.html to find the same information. 

 In England, doctors have created a liquid titration kit to assist users in withdrawing comfortably.  There is some promise that this method can substantially diminish, if not eliminate, the withdrawal syndrome.  Unfortunately, these titration kits are not available in North America. 

If you are unable to use a titration method, you may wish to consider switching to Valium, assuming, of course, that you are not already using that particular benzodiazepine.  (See Ashton Manual) . This method has been used with success, particularly in England, for many years. 

Dr. Heather Ashton has detailed taper schedules available that are based on switching to Valium. A copy of the manual can be purchased at http://www.ashtonmanual.com/ and it can be read without charge at http://www.benzo.org.uk/manual/ . 

There seems to be a limited exception to the slow taper rule where people find that they have a "toxic" reaction to taking the benzodiazepine (see "paradoxical symptoms" above).  There is a tricky distinction between toxic symptoms and withdrawal symptoms.  The usual way to tell the difference is to try increasing your dose.  If the symptoms reduce or stay the same, your symptoms are likely attributable to withdrawal.  If your symptoms increase, you may be experiencing toxicity, and should probably consider a faster taper (6 to 8 weeks). However, do not make a hasty decision to taper fast.  Make certain that you are experiencing toxicity first.  Generally speaking, your symptoms are far more likely to be related to withdrawal than toxicity. 

One cause of toxicity may be the taking of more than one psychoactive drug simultaneously: for example, taking a benzodiazepine with an anti-depressant and a narcotic (pain killer).

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16.  SHOULD I SWITCH TO ANOTHER BENZODIAZEPINE SUCH AS VALIUM BEFORE TAPERING?

Keep in mind that some people feel that switching to Valium is not for everyone and many have tapered their drug of dependency and have recovered very well. However, if you are considering this recommended method, there are three reasons that are often cited for switching to Valium for purposes of withdrawal.

First, Valium has a far longer half-life than most other benzodiazepines (See FAQ 5). This allows for a steady, smooth reduction in dose over time.  It also permits you to take your dose less often.  In some cases, you can take your entire daily dosage before bedtime.  This reduces problems of micro-man