If you have been taking a benzodiazepine or Z drug long-term (for more than four weeks) then it can be difficult to stop it because of withdrawal effects. However, this can be overcome by a variety of ways. One method is to switch whatever medicine you are on to an equivalent dose of diazepam. You can then gradually reduce the dose of diazepam at a pace that suits you. This keeps any withdrawal effects to a minimum. The dose reduction is commonly done over several months before coming off diazepam completely
What are benzodiazepines and Z drugs?
Benzodiazepines are a group of medicines that are sometimes used to treat anxiety. Examples include: diazepam, lorazepam (Ativan®), chlordiazepoxide, alprazolam and oxazepam. Some are also used as sleeping tablets. These include: temazepam, loprazolam, lormetazepam, nitrazepam.
Zaleplon, zolpidem, and zopiclone are other sleeping tablets but, strictly speaking, are not benzodiazepines. They are known as the Z drugs. However, they act in a similar way (they have a similar effect to benzodiazepines on the brain cells).
When you first start taking a benzodiazepine or Z drug, it usually works well to ease the symptoms of anxiety, or to cause sleep. You can usually stop a benzodiazepine or Z drug without any problems if you take it for just a short time (less than 2-4 weeks).
What happens if you take a benzodiazepine or Z drug for longer?
After a few weeks of taking a benzodiazepine or Z drug each day, the body and brain often become used to the medicine. In many people it gradually loses its effect. The initial dose then has little effect and so a higher dose is needed for it to work. In time, the higher dose does not work, and so an even higher dose is needed, and so on. This effect is called tolerance.
There is a good chance that you will become dependent on a benzodiazepine or Z drug if you take it for more than four weeks. This means that withdrawal symptoms occur if the tablets are stopped suddenly. In effect, you need the medicine to feel 'normal'. Possible withdrawal symptoms include:
- Psychological symptoms - such as anxiety, depression, panic attacks, odd sensations, nightmares, feeling as if you are outside your body, feelings of unreality, or just feeling awful. Rarely, a serious mental breakdown can occur (psychosis).
- Physical symptoms such as sweating, being unable to sleep, headache, tremor, feeling sick, feeling unsteady, palpitations, muscle spasms, and being oversensitive to light, sound and touch. Rarely, convulsions (seizures) occur.
- In some cases the withdrawal symptoms seem like the original anxiety symptoms.
The duration of withdrawal symptoms varies, but often lasts up to six weeks and sometimes longer. Some people who have taken these medicines for a long time continue to have minor withdrawal symptoms for several months after stopping. Withdrawal symptoms can start a few hours after but can be up to two days after stopping the tablets. They tend to be worst in the first week or so before gradually easing.
You may end up continuing to take the medicine to prevent withdrawal symptoms but, because of tolerance, it no longer helps the original anxiety or sleeping problem.
Some people who take a benzodiazepine or Z drug on a long-term basis believe that the medicine is still helping to ease anxiety or sleeping problems. However, in fact, in many people the medicine is just preventing withdrawal symptoms.
Why should I stop taking a benzodiazepine or Z drug?
Studies have shown that coming off benzodiazepines and Z drugs can have many benefits. For example, the benefits of stopping long-term benzodiazepines in elderly people were investigated in a trial of 139 people over the age of 65 years. This study found that stopping treatment:
- Had no long-term adverse effects on sleeping or anxiety symptoms.
- Improved memory and reaction times, while people who continued taking benzodiazepines declined in both these areas.
- Increased levels of alertness.
- Improved quality-of-life measures for physical and social functioning, and vitality.
Studies have shown that in people who continue to take benzodiazepines long-term, there is:
- An increased risk of fractured hips in older people, especially when they are on other medicines that increase the effect of benzodiazepines.
- Impairment of mental function and memory in older people. This has sometimes been wrongly diagnosed as dementia.
- An increased risk of injury in car crashes (due to the affect on alertness).
So, in summary, coming off a long-term benzodiazepine or Z drug:
- Is likely to improve your memory, reaction time, alertness, and quality of life.
- Reduces your risk of falls, accidents, fractured bones, and other injuries.
How should I stop taking a long-term benzodiazepine or Z drug?
If you have been taking a benzodiazepine or Z drug for over four weeks and want to stop it, it is best to discuss the problem with a doctor.
Some people can stop taking benzodiazepines and Z drugs without any difficulty, as they have only minor withdrawal effects which soon ease off. However, for a lot of people the withdrawal effects are too severe to cope with if the medicine is stopped suddenly. Therefore, it is often best to reduce the dose gradually over several months before finally stopping it. Your doctor can advise on dosages, time scale, etc.
Diazepam withdrawal plan
A common plan is to switch from whatever benzodiazepine tablet or Z drug that you are taking to diazepam. Diazepam is a 'long-acting' benzodiazepine that is commonly used. With diazepam, the dose can be altered very gradually and with greater ease compared to other benzodiazepines.
Your doctor will be able to prescribe the dose of diazepam equivalent to the dose of your particular type of benzodiazepine or Z drug. After this, you can decide with your doctor a plan of how to reduce the dose gradually. A common plan is to reduce the dose by a small amount every 1-2 weeks. The amount the dose is reduced at each step may vary, depending on how large a dose you are taking to start with. Also, the last few dose reductions before finally stopping completely may be less than the original dose reductions, and done more gradually.
The gradual reduction of dose keeps any withdrawal symptoms to a minimum.
Sometimes other medication may be prescribed to help you cope with symptoms while you are coming off benzodiazepines. For example, you may be offered antidepressants if depression emerges whilst you are on a withdrawal programme, or beta-blockers if you need help to control anxiety.
Some tips that may help
- Before coming off a benzodiazepine or Z drug it may be best to wait until any life crisis has passed, and your level of stress is as low as can be.
- Consider starting whilst on holiday, when you have less pressure from work, fewer family commitments, less stress, etc.
- Consider telling family or friends that you are coming off a benzodiazepine or Z drug. They may give you encouragement and support.
- Consider joining a local self-help group. Advice and support from other people in similar circumstances, or who have come off a benzodiazepine or Z drug, can be very encouraging.
- If you are taking other addictive medicines in addition to benzodiazepines, then you may need specialist help for coming off the various medicines. Your doctor will be able to advise you or refer you on to local services which can help.
Other ways of tackling anxiety and sleeping problems
Benzodiazepines and Z drugs are not the long-term answer to anxiety or sleep problems.
If you have anxiety symptoms, there are other ways of tackling your symptoms. For example, learning to relax, or joining an anxiety management group. If anxiety symptoms persist or are severe, your doctor may advise on other treatments such as cognitive behavioural therapy (CBT).
There are separate leaflets that may help called 'Anxiety - Generalised Anxiety Disorder', 'Anxiety Disorders', 'Cognitive Behavioural Therapy (CBT)', and 'Stress - Tips on How to Avoid It'.
Tips on how to improve sleep can be found in our leaflets 'Insomnia (Poor Sleep)', 'Insomnia - Sleeping Tablets', and 'Sleeping Problems - Self Help Guides'.
A final note
Most people who have taken a benzodiazepine or Z drug can successfully come off it. After switching to diazepam (described above), the pace and speed of withdrawal varies greatly from person to person. Go at a pace that is comfortable for you after discussion with your doctor. For many people, the gradual withdrawal and eventual stopping of diazepam takes several months. However, some people take up to a year to reduce the dose gradually before finally stopping it.
Further help & information
Further reading & references
- Benzodiazepine and z-drug withdrawal, NICE CKS, March 2009
- British National Formulary
- Davidson B et al; NHS Grampian: Guidance for prescribing and withdrawal of benzodiazepines and hypnotics in general practice, 2006
- Ashton CH, The Ashton Manual Supplement, 2011
- Sola CL et al, Sedative, Hypnotic, Anxiolytic Use Disorders, Medscape, Jun 2011
- CH Ashton. Benzodiazepines: How they Work and How to Withdraw ('The Ashton Manual'), revised August 2002
- Zint K, Haefeli WE, Glynn RJ, et al; Impact of drug interactions, dosage, and duration of therapy on the risk of hip Pharmacoepidemiol Drug Saf. 2010 Dec;19(12):1248-55. doi: 10.1002/pds.2031. Epub
- Beland SG, Preville M, Dubois MF, et al; The association between length of benzodiazepine use and sleep quality in older Int J Geriatr Psychiatry. 2011 Sep;26(9):908-15. doi: 10.1002/gps.2623. Epub 2010
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Tim Kenny
Dr Laurence Knott
Dr Tim Kenny