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Today's video is called Benzodiazepine Withdrawal Explained. My name is Dr. Andrew Kim. I'm a board-certified psychiatrist, and I hope that today's video can give you a fundamental understanding that benzodiazepine withdrawal exists and what that would look like.
Now, before we get started, I want to do some housekeeping. I appreciate all the comments and the emails, but again, I am not your personal physician. I am not providing you with direct medical advice. These videos are for educational and informative purposes only. Please, please consult with your own personal physician, nurse practitioner, licensed qualified prescriber before you decide to make any kind of changes to your own treatment plan and medications.
With that being out of the way, I appreciate everyone that's been watching my alcohol withdrawal videos, and I know many of you have asked for a benzodiazepine withdrawal for over a year now. So I'm finally here. Better late than never.
So, first, let's get started. Benzodiazepine withdrawal, is that possible? Yes, it is. So most of our society doesn't really know that term. Benzodiazepines. Most are familiar with the terms sedatives and tranquilizers, and that's what these meds are typically known as. And the most common ones, and some of you watching right now may be on some of these, are ones like Xanax, which is Alprazolam; Ativan, which is Lorazepam; Klonopin, which is Clonazepam; and Valium, which is Diazepam. There are many more, but these are the most common ones, and these are benzodiazepines, AKA tranquilizer sedatives. These are typically prescribed to kind of in-the-moment spot treat anxiety and insomnia to produce a calming effect and a sedative effect.
Now, I want to be crystal clear though. These are actually not considered first-line treatment for anxiety disorders or even insomnia. They're just, we just know that they can produce a sedative type of effect, a tranquilizing effect, and we just use them when needed.
So I want to be careful how I say this because, look, I'm not presenting this video to vilify these medications. Not saying that prescribers who prescribe these are being bad or irresponsible. I prescribe these all the time, okay? Patients who use them, I'm not doing this for shock factor or clicks. Not doing this to make you feel bad or fearful that you're on these meds, to make you feel guilty. I'm just saying that these can be used responsibly. And typically, responsible use is going to look like the lowest effective dose possible, trying to use them as sparingly as possible, and hopefully, in the long run, it's really meant for short-term use and other interventions will be used for chronic treatment.
Because I don't care what anyone says, the reality is science and math. Science and math tell us that if you use these long enough, regularly enough, at high enough doses, it's almost inevitable that most people will develop some level of physical tolerance and dependence, okay? I know I'm going to get comments that people are going to say, "Well, I've used it for 10 years. I've been using it every day." Well, that may be the case, and then you're fortunate, and that's great that you're not at high risk. But most people will develop a tolerance and dependence if used long enough, regularly enough, and high enough of a dose.
Now, here's the tricky part. There's no great blood test or scan or anything that can tell us, "You are the type of individual who will have mild versus severe withdrawal." "You are the type of individual that will have, you know, somewhat, you know, mildly just uncomfortable versus potentially lethal withdrawal." So the unpredictability is super frustrating for clinicians and patients. But things that factor in, uh, to the risk level for potential risk of withdrawal and the severity of withdrawal are going to be things like: How long have I been using this for? And the longer you have been, the higher the risk. What dose? The higher the dose, the higher the risk. Is this going to be a short-acting versus a long-acting benzodiazepine? Meaning, some of these, the moment you stop them, the levels crash. And some of them kind of have a smoother ride down. And the ones that are short-acting tend to have a harsher withdrawal effect or trickier withdrawal to detox from. Other things like even genetic factors can play a role in the level of risk of dependence, tolerance, and withdrawal. How fast or slow are you going to detox? Are you going to do this gradually? Or are you in a scenario where you forgot your meds or you ran out and you don't have a refill and the levels are going to crash? All these things factor into determining risk of withdrawal, how long, how short, how mild, how severe.
Now, before we describe the actual symptoms of withdrawal, why, why does this even happen? Why does withdrawal even occur? The best I can explain this is that in our bodies on a daily basis, whether we're on benzodiazepines or not, we have this balance between two chemical systems. One system is the slow-down inhibitory system, and usually the main chemical involved is called Gaba. G-A-B-A. Gaba. On the other side, we have excitatory signals, okay? These are signals that tell our bodies, "Go, go, go. Wake up. Be alert." And one of the main chemicals involved in this is something called glutamate. So on a daily basis, we have fluctuating balances of Gaba and glutamate, slow down and go, go.
Now, here's what happens though. When we introduce outside sources of Gaba, alcohol, benzodiazepines, it's one thing when we use them once in a while. But if we use them every day, regularly enough, then our bodies adapt, and our bodies try to maintain a balance. Our body says, "Hey, you know what? I'm getting all this Gaba, the slow-down signal from this benzodiazepine, from this Xanax, from this Valium, that I'm going to start producing less." So your body starts reducing the natural amount of Gaba being pumped out.
Now, let's say one day I just stop my Xanax or my Valium cold turkey, I ran out, whatever, but I just stop it. Now I don't have this external source of Gaba, and my body reduced the levels that it was pumping out. But what it didn't reduce was the excitatory chemicals. So now you have a lot of excitatory signals, but not much Gaba or slow down. And now things are out of whack. And now, because your body has the signal, your brain and your body has this "go, go, go, go, go," things are out of whack, and it tends to produce a lot of imbalances. And this is at least some of the theory of why some of these withdrawal symptoms can occur, including dangerous ones like withdrawal seizures, because this excitatory signal is now going unchecked.
Now, ideally, you typically don't ever want to just abruptly and suddenly stop your benzodiazepines cold turkey. Obviously, sometimes it's out of your control. But when it's within your influence, you want to do this under the guidance of a medical professional. Consult with them and understand, is this, are you at a level where they think it's safe enough to do on an outpatient basis? Or are they concerned enough that you need to be admitted somewhere into a hospital, into a detox facility, into an inpatient psych unit to do this under 24/7 monitoring where you are given benzodiazepines gradually in a supervised setting to minimize the risk of withdrawal? Or can this be done on an outpatient basis?
Now, let's try our best to categorize these, and these are very arbitrary terms, into mild, moderate, and severe withdrawal, okay? So if one were to do this too abruptly, too suddenly, on the mild end of things, you may experience mild withdrawal, and that will include things like rebound anxiety and rebound insomnia. Meaning, for two to three days, insomnia may be way worse. I'm having a hard time falling asleep. I'm waking up multiple times. I'm waking up too early and not being able to go back to sleep. I'm more on edge. I'm more panicky. And it may last several days in mild withdrawal.
Now, in moderate benzodiazepine withdrawal, this can last days to weeks, unfortunately, even a couple weeks, okay? And in addition to the rebound anxiety and rebound insomnia, which may be even worse in intensity, you can experience other things like sweating, increased agitation and irritability, nausea, shakiness, vomiting, diarrhea and loose stools. You just don't feel as lucid, poor concentration and attention, headaches, muscle tension, muscle aches. So all of these things obviously equal suckiness. It feels really crappy, really sucky. You feel like you're basically physically ill, under the weather, exhausted, and on edge. Not a great scenario to be in, right? And typically, then it's very easy to say, "Well, I'm going to go right back to taking my Xanax and my Valium or my Ativan to soothe these symptoms and calm it down." And then it may create this never-ending cycle of making it tough to come off of, right?
Now, in the severe category, and this is what I meant, in the severe category of symptoms is in particular is why we typically recommend patients be in a facility when this is done. Because in severe cases of benzodiazepine withdrawal, patients are at risk of withdrawal seizures, withdrawal psychosis, and withdrawal delirium. So let's break these down. Withdrawal seizures. Even if you do not have a history of epilepsy, you don't have a history of seizure disorders, you can literally have seizures by coming off of benzodiazepines too quickly. And you may be at risk of this. And this may not just be one isolated seizure. You may have a cluster of several seizures in a row, which is what puts people at risk of even death, okay? Withdrawal psychosis. You may temporarily and transiently experience auditory or visual hallucinations or even paranoid delusions. This does not mean you have a primary psychotic disorder like schizophrenia, but this again is a severe form of withdrawal of coming off of benzodiazepines. Finally, withdrawal delirium can occur. This is a state where your state of lucidness goes from being lucid to disoriented and confused. Lucid, disoriented, and confused. And you kind of have this waxing and waning course. You may be disoriented to where you are, what year it is, why you're even at this place, and you may be very agitated as a result of this confusion that's coming and going. Again, not a great scenario for you and those around you. Trust me when I say patients find being delirious and being psychotic in this process super traumatizing for them and the loved ones who witness what you're going through. And again, there is an actual lethality risk, and this is why this needs to be done in a supervised setting.
In summary, benzodiazepine withdrawal can occur if you have developed a physical dependence and a physical tolerance to benzodiazepines. I explained how it ranges from mild to even potentially lethal and severe. Again, the point of this video was not to freak you out for shock value or clicks or to make you feel bad or vilify anyone who's prescribing these. I prescribe them. When I used to be in a different practice in my clinic, I tried my best to do it responsibly. I'm not saying I was perfect. Patients of mine would take it responsibly. I'm just illustrating and portraying the reality. This is why benzodiazepines are a controlled substance. This is why the DEA regulates these tighter than other non-controlled substances because there is abuse potential, there is dependency potential, okay? And there is this potential risk when coming off of these.
So I hope that you found this educational. And again, please, please, I'm not giving you direct medical advice. I'm giving you education, trying to raise awareness. Hopefully, you found this helpful. If you have other types of topics and scenarios you'd like me to explain, uh, as you know, fundamentally as I can, please let me know in the comments below. Thank you. Please subscribe. Please like. Hopefully, I can keep bringing you some more educational topics like these. Dr. Andrew Kim. God bless everybody.
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