Discontinuation/withdrawal symptoms

Benzodiazepines and z-drugs: Quality prescribing - a guide for improvement
Scottish Government Effective Prescribing & Therapeutics Division

B-Z dependence is recognised as a major clinical problem.84 B-Z reduction should  be gradual and tapered – for some this will be ‘low and slow reductions’.69,85 Abrupt cessation may produce confusion, toxic psychosis, convulsions or a condition resembling delirium tremors.

Withdrawal symptoms may occur within a day of stopping a short-acting B-Z such as lorazepam, which is associated with more severe withdrawal than longer acting B-Z. However, withdrawal symptoms may occur at any time up to three weeks after stopping a long-acting B-Z.69

Management and supporting individuals

Withdrawal effects may include insomnia, anxiety, depression, cognitive impairment and can be similar to the original presentation. Some withdrawal symptoms may continue for weeks or months after stopping the medication. Most people experience infrequent, mild or no withdrawal symptoms if the withdrawal is slow and tapered to their needs. However, if individuals do experience withdrawal, consider increasing the dose back up to the previous dose without withdrawal effects and after stabilising on that dose reduce more slowly, using smaller dose reduction steps. Smaller reduction steps may require the use of liquid preparations in some cases.69,84

 

Acute symptoms

Most commonly anxiety

  • Panic attacks, agoraphobia
  • Insomnia, nightmares
  • Depression
  • Poor memory, loss of concentration
  • Tremor, sweating, palpitations

Others specific to B-Zs

  • Perceptual distortions, depersonalisation
  • Tingling and loss of sensation, formication (a feeling of ants crawling all over the skin)
  • Sensory hypersensitivity
  • Muscle twitches and fasciculations (flickering or writhing muscles)
  • Hallucinations (visual and auditory - rare and usually with rapid withdrawal from high doses),
  • Psychotic symptoms, confusion, convulsions (rare and usually with rapid withdrawal from high doses).

 

Protracted symptoms

May affect up to 15% of people

  • Anxiety - gradually recedes over a year
  • Depression - may be a few months
  • Insomnia - gradually recedes over 6-12 months
  • Sensory symptoms - gradually recedes but may be a year and occasionally several years
  • Motor symptoms - gradually recedes but may be a year and occasionally several years
  • Poor memory & cognition - gradually recedes but may be a year and occasionally several years
  • GI symptoms - Gradually recedes but may be a year and occasionally several years

Adapted from the Ashton Manual and Maudsley Prescribing guidelines84