18. SHOULD I CONSIDER GOING INTO AN IN-PATIENT DRUG REHABILITATION
FACILITY OR DETOX CENTER TO GET OFF MY BENZODIAZEPINE?
Only in a relatively small percentage of cases do people have successful
experiences detoxing from benzodiazepines on an in-patient basis. The
problems with detoxification centers are multi-fold. First and
foremost, detox facilities are geared towards treating drug abuse
behaviors, not providing support for withdrawal. The facilities often
do not understand the necessity of tapering your benzodiazepine slowly.
Often, they will require you to taper over a 3-6 week period. Some will
even take you off your benzodiazepine over a one week period with a
Valium or phenobarbitol substitute. These facilities usually will not
keep you in-patient for more than about 6 weeks. The result is that you
may end up being detoxed in an overly rapid fashion, while receiving
classes on drug abuse but no specific support for managing withdrawal.
The experience after leaving the facility can often be very rough, as you
may be left in a state of fairly intense withdrawal that can persist for
a long while. In short, people with benzodiazepine dependencies often
feel worse after they leave these facilities than before then entered.
Clinical experience suggests that benzodiazepine detoxification works
best where the patient controls his or her own taper schedule in
conjunction with the advise of a physician knowledgeable about
benzodiazepine dependency. Detoxification centers, even where they
might permit a relatively slow taper, will usually take the control
of the process away from the patient and force the patient into a
rigid protocol.
However, detox centers should be considered in two circumstances.
First, if you have a problem abusing benzodiazepines either alone or in
combination with other drugs, an in-patient setting is often appropriate
to enforce the discipline of tapering the drug, and to educate you on
how to avoid drug abuse. (But see the discussion on 12 step programs
below.) If you feel that you lack the necessary self-discipline to
taper yourself slowly and gradually and have no spouse or other
caretaker who will manage your taper for you, you may wish to consider a
facility.
Second, in the rare circumstance where your withdrawal syndrome is so
severe that you are unable to take care of yourself and you have no
live-in spouse or other caretaker, you may wish to consider the
in-patient option.
Before choosing a detox facility, you should call at least five
different facilities and make, at a minimum, the following inquiries:
a. Will they permit you to taper your benzodiazepine slowly?
b. Do they have staff who have direct experience with patients in
benzodiazepine withdrawal?
c. Do they have an in-house psychiatrist and/or psychologist to provide
support?
If the answer to these questions is yes, yes, and yes, the chances are
that you have found the best possible detox facility. However, it is
still inadvisable to detox yourself on an in-patient basis unless you
are in either of the two circumstances discussed above.
19. WHAT IS THE LENGTH OF THE WITHDRAWAL PROCESS?
It varies tremendously. For people with mild dependencies, the
withdrawal process typically encompasses 1-4 weeks of symptoms. This
generally applies to most, but not all, people who have used a benzodiazepine
for less than six months. It also applies to a percentage of people
who have used a benzodiazepine for more than one year. For people with severe
dependencies, 6 to 18 months total recovery time, including the taper
process, is typical. Generally, one may expect 6 months to a year of
diminishing symptoms after a taper is complete.
There is also an uncommon phenomenon called Protracted Withdrawal
Syndrome (see below).
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?
This is strictly a matter of opinion. In the opinion of this author,
anyone detoxing from benzodiazepines who has a history of abuse should
avoid the temptation to temporarily increase the dose at all costs,
unless it is to avoid seizures or psychosis. If one has poor
self-discipline, giving in on a single occasion to increase the dose in
order to better cope with some stressful event may lead to a pattern of
"giving in" which will ultimately lead to total relapse. If confronted
with a stressful event, my advice is avoid the stressful event if
possible. If not, make sure a supportive individual is there with you
and tough it out.
If, however, you are among the majority who have no history of abuse and
have never abused your benzodiazepine, it is probably not harmful to do
this on rare occasions, e.g. if you must attend a wedding or funeral or
are forced to attend a function in a crowded public place where you have
some fear of crowds and/or public places. If you have demonstrated
self-discipline in your taper, you can probably get away with increasing
your dose for one day on rare occasions, e.g. a few times during your
taper.
As clarification, it is always acceptable to "go sideways," (stay at
the same dose as opposed to cutting) for a while in order to stabilize
where your symptoms are particularly severe. This is different than the
issue of increasing your dose to cope with stressful events.
Finally, if you feel that you must increase your dose a little to
stabilize yourself because you have tapered too quickly, do so.
However, the better solution is to avoid tapering too quickly in the
first place. (See above.)
21. WILL I NEED TO QUIT WORK OR GIVE UP OTHER IMPORTANT ASPECTS OF MY
LIFE DURING BENZODIAZEPINE WITHDRAWAL?
Going through withdrawal while managing the demands of everyday life is
a difficult balancing act. It cannot be emphasized strongly enough the
extent to which stress can worsen your withdrawal symptoms. That means
stress related to jobs, relationships, or anything else. The key is
that you need to understand going into your withdrawal process is that
you will have to make adjustments in your life, including your level of
activity and the types of activities in which you engage. The amount of
adjustment will depend on the severity of your withdrawal on the one hand,
and the stress level brought on by the activities on the other. Some people
can work through withdrawal; others cannot. Some people quit their jobs,
some take leaves of absence, some work through it with considerable
difficulty, and still others work through it with mild difficulty. While
in withdrawal, the best advice is to reduce your stress by the maximum
amount that is feasible given the demands of your life. What that means
will vary tremendously from one case to the next.
22. MY DOCTOR HAS PRESCRIBED AN ANTI-DEPRESSANT TO TAKE DURING MY
WITHDRAWAL. IS THAT A GOOD THING TO DO?
Maybe. Most doctors who prescribe anti-depressants for benzodiazepine
withdrawal, or for any other purpose, will prescribe one of the modern
class of SSRIs (Selective Serotonin Reuptake Inhibitors) that includes
Prozac, Paxil, Zoloft, Celexa, and Serzone. Or they sometimes prescribe
one of two even more recently developed drugs: Effexor and Wellbutrin.
Doctors often prescribe these particular drugs because, in addition to
their anti-depressant properties, they are recognized as anxiolytics
(anti-anxiety agents). Ironically, all of these drugs are known to
heighten anxiety and agitation, though this side effect often diminishes
after the first few weeks of use. Even the SSRI's such as Paxil and
Zoloft which are thought to have a primary sedative effect often cause
heightened anxiety when you are in withdrawal. This heightened anxiety
may be one reason that people in benzodiazepine withdrawal often
discontinue the use of these drugs after a short period of time.
Among those who have taken anti-depressants for long periods of time
during withdrawal, the experiences are mixed. Some seem to benefit,
others do not. Still others feel that their symptoms are worsened.
Generally, due to the potential for creating complications of your other
withdrawal symptoms, anti-depressants should only be taken where you are
suicidally depressed. That does not mean that you are simply pondering
or even obsessing about suicide. It means that you feel that, barring
some kind of pharmacological intervention, you *will* do something
self-destructive. Otherwise, anti-depressants should generally be
avoided during withdrawal.
Another issue is that most anti-depressants are documented to be addictive
to varying degrees and, in fact, there is some evidence that the withdrawal
syndrome can be very pronounced and similar to benzodiazepine withdrawal
(though not nearly as protracted) in some cases of long term use.
There are a few scattered reports of people who have benefited from the
use of an earlier class of anti-depressants known as "tricyclics." One
of these is Doxepin, which has a primary sedative effect as opposed to
the stimulant effect of the SSRIs. Tricyclics also have their own set
of complications and side effects. Consult your physician and check the
written warnings for tricyclics to make sure that you do not have any of
a number of medical conditions that may be complicated by the use of
tricyclics. As with SSRI's, some are known to cause primarily sedation,
where others are known to have stimulant properties.
The best advice with anti-depressants or any other prescribed adjunct
drug is to proceed with caution. If you decide to take an
anti-depressant, you may want to start at a very low dose to see how
well you tolerate the drug before increasing to the dose recommended by
your physician.
23. ARE THERE ANY OTHER DRUGS BESIDES ANTI-DEPRESSANTS TO CONSIDER USING
DURING BENZODIAZEPINE WITHDRAWAL?
Yes. There are several. And your doctor may suggest one or more.
Again, the best advice is to proceed with caution and carefully research
any new drug you are considering. A few are mentioned below.
Tegretol (carbomazepine): an anti-seizure drug. Some studies have shown
this drug to be effective in reducing certain physical withdrawal
symptoms. Others have shown it to be ineffective. Testimonials
regarding the use of Tegretol are mixed.
Neurontin: primarily a pain medication, neurontin has been implicated as
alleviating certain physical withdrawal symptoms. Testimonials are
mixed and too few for reliable generalization.
Beta blockers (e.g. Inderal): beta blockers help with heart palpitations,
hypertension, as well as shakes/tremors. Some beta blockers cross the
blood/brain barrier, and may be mildly addictive, though the official
medical literature states that they are non-addictive. However, that
same literature also recommends that they not be discontinued abruptly.
Do not take a beta blocker unless you are seriously troubled by any of
the above-mentioned symptoms. Even then, you should either take them at
the lowest dose possible, or take them situationally (as the symptom
emerges). Beta blockers do not directly reduce anxiety, but they can
alleviate some of the physical symptoms associated with panic attacks,
which may indirectly help to reduce the associated anxiety level.
24. ARE THERE ANY PARTICULAR DRUGS A DOCTOR MIGHT PRESCRIBE THAT
DEFINITELY DO NOT HELP WITHDRAWAL?
Yes. Buspar, a commonly prescribed anti-anxiety agent, is virtually
certain to be totally ineffective in alleviating withdrawal symptoms.
This conclusion is supported by studies. Furthermore, this
author has never heard a single testimonial from anyone who claims to
have benefited from this particular drug in withdrawal.
25. WHAT ABOUT HERBS AND OTHER HOMEOPATHIC REMEDIES - DO ANY OF THOSE
HELP THE WITHDRAWAL SYMPTOMS?
Maybe. Everyone's experience is different. Acupuncture, massage
therapy and chiropractic have been commented on, but there is little
conclusive data as to their effectiveness in relieving withdrawal
symptoms. As for herbal remedies, all of the following have been
mentioned as helpful to one person or another: valerian, kava kava,
st. john's wort, 5htp, SAMe, melatonin, GABA, chamomile, and Rescue
Remedy****.
With very few exceptions, the majority of these have been found to be
helpful in only a few cases, and several people have felt that their
withdrawal symptoms were heightened by taking one or more of
these substances. Of the entire group mentioned, only two have been
singled out by a fairly large number of people as especially helpful:
chamomile tea and Rescue Remedy****. Keep in mind that even those
herbal substances which you find helpful may only work where your
symptoms are relatively mild. For example, chamomile tea might
relieve mild agitation, but is very unlikely to bring you out of a full
blown panic attack. However, there are breathing and relaxation methods
that can help to alleviate panic attacks.
Kava is noted as creating more adverse reactions than some of these
other substances, and is probably the least recommended of the group
for experimentation. However, all herbal drugs have been noted by one
person or another as producing unpleasant side effects or as simply being
ineffective. Herbal drugs are generally not regulated and there are
occasional reports of these substances containing toxins, though these
occurrences are becoming particularly rare in industrialized countries
in recent years due to heightened media scrutiny of homeopathic drugs.
It is also important to understand that herbal medicines are drugs.
These plants contain organic, bioactive substances that cross the blood
brain barrier and act upon your brain just as synthetic drugs do. In fact,
many pharmaceuticals are synthesized versions of bioactive substances
naturally occurring in plants and animals. The only difference is, you get
a much higher purity of the substance in synthetic form than you would
in organic form.
Because herbs are drugs, they can also have toxic and deleterious
effects. Fortunately, most herbal medicines are low enough in potency
that they are well tolerated and non-addictive.
However, it is important to start at a low dose and pay close attention to
your body's reaction to the use of an herbal medicine just as it is with a
synthetic one. Generally speaking, you will have a strong sense of how well
you are tolerating a particular substance shortly after you beginning taking
it, often after the very first dose.
This FAQ does not recommend, negatively or positively, the use of herbal
remedies for anxiety disorders such as GAD or PD. This FAQ is about
benzodiazepine dependency and withdrawal, not about alternative treatments
for anxiety disorders. The only opinion intimated herein is that some
people may experience some relief from certain herbal remedies during the
withdrawal process. Many, if not most, others, experience no relief at all.
In general, herbal medicines are safer to experiment with during
withdrawal than are synthetic ones. Therefore, you may wish to consider
these possibilities before trying another potentially addictive
synthetic drug. However, keep in mind that even if you experience some
form of relief from an herbal remedy, there are no panaceas for
benzodiazepine withdrawal syndrome, and only time will ultimately
produce total recovery.
26. WHAT ABOUT USING CAFFEINE DURING WITHDRAWAL?
You should *totally* abstain from the use of caffeine during
benzodiazepine withdrawal. It is a stimulant and is known to worsen
withdrawal symptoms. If you use caffeine to ward off migraine
headaches, try to find another remedy that does not contain caffeine.
You should refrain from the use of all other stimulants as well. For
example, do not use "non drowsy decongestants" that contain the drug
"pseudophedrine." That is a stimulant that will likely cause heightened
agitation, which is the last thing you need during withdrawal.
27. WHAT ABOUT EATING SUGAR DURING WITHDRAWAL?
There is considerable anecdotal evidence in the form of testimonials
from people in withdrawal that sugar can exacerbate withdrawal symptoms.
Shirley Trickett, in her book Freeing Yourself From Tranquilizers,
indicates that benzodiazepine withdrawal causes hypoglycemia. This is
one theory as to why sugar may cause problems during withdrawal.
Another is that sugar may stimulate the production of adrenaline. In
much the same way that it may cause hyperactivity in children, it can
cause heightened agitation during withdrawal.
Whatever the reason, there is substantial anecdotal evidence that
consuming sweets, particularly in large quantities, can greatly
complicate withdrawal.
28. WHAT ABOUT CONSUMING ALCOHOL DURING WITHDRAWAL?
Alcohol consumption, even in relatively small amounts, is not advised
during benzodiazepine withdrawal. Many people report that alcohol, a
sedative that should cause a reduction in anxiety, actually heightens
withdrawal symptoms, particularly those of derealization and
depersonalization.
Even if you find that alcohol has a calming effect on withdrawal
symptoms, regular alcohol use creates a toxicity that will almost
certainly prolong your recovery process. And even if you are able to
successfully withdraw from benzodiazepines while consuming alcohol on a
regular basis, which is unlikely, you will have probably substituted one
addiction for another.
29. WHAT FOODS SHOULD I EAT (OR AVOID) DURING WITHDRAWAL?
First of all, you should probably drink lots of liquid, perhaps double
your ordinary intake. Some people feel that this may hasten the
recovery process. The evidence of this is inconclusive. However,
drinking large quantities of liquids helps to flush toxins from your
system and is a generally good for digestion. Even if it provides no
specific relief in withdrawal, it is generally a healthy practice.
As for food, there are various theories about what should and should not
be consumed. Some people develop fixations about their diets during
withdrawal, associating a new withdrawal symptom with whatever food they
consumed most recently, and concluding that this food is something to be
avoided during withdrawal.
Shirley Trickett (see above), in her book Freeing Yourself From
Tranquilizers, recommends a hypoglycemic diet. This consists of eating
three small meals per day, and having at least 2-3 snacks spaced out
between the meals. The regimen consists of roughly equal parts complex
carbohydrates, protein, and fat, with very little or no sugar intake.
Whatever diet you decide is appropriate, the most important
consideration during withdrawal is that it is a healthy diet. While the
evidence regarding the effect of one particular food versus another is
not conclusive, there is strong evidence that a healthy diet makes for
an easier withdrawal. Another way of looking at it is in the converse:
when you eat junk, your body rebels and causes you to experience
discomfort. While this is true even when you are not in withdrawal, it
is true more so in withdrawal because your body is already in a state of
trauma. That trauma is virtually certain to be compounded by an
unhealthy diet.
There are a wide variety of opinions about proper diet and nutrition
during withdrawal, and to discuss all of them is outside the scope of
this F.A.Q. If you are interested in eliciting opinions on this
subject, inquire to
benzo@egroups.com wherein you will find no shortage
of ideas on the subject.
30. I SMOKE CIGARETTES. SHOULD I QUIT DURING WITHDRAWAL?
Nicotine, the primary drug contained in tobacco, is an addictive sedative
drug like benzodiazepines, although it is vastly different in its chemical
structure and mechanism of action. Unlike benzodiazepines, the primary
symptom of Nicotine withdrawal is a craving for the drug. However, other
symptoms, especially agitation and insomnia, have been noted as Nicotine
withdrawal symptoms. Therefore, it is inadvisable to withdraw from Nicotine
while you are in the process of benzodiazepine detoxification. If you plan
to quit smoking (which is always a good idea for health reasons), it is
preferable that you accomplish this before you begin benzodiazepine
detoxification. Failing that, you should wait until you have fully recovered
from benzodiazepine withdrawal before discontinuing cigarettes.
The only exception to this guideline is where you are carrying a child. In
that circumstance, it is critical that you quit smoking immediately.
Benzodiazepine detoxification should also be accomplished during pregnancy,
as there is clear medical evidence that a child born of a benzodiazepine
dependent parent may experience symptoms consistent with benzodiazepine
withdrawal. Where you are dependent on a benzodiazepine and carrying a
child, a more rapid taper schedule that is generally desirable may be
advisable. Detoxification during pregnancy, as in all other situations,
should be done with close consultation with a physician who is
knowledgeable regarding benzodiazepine dependency.
31. SHOULD I EXERCISE DURING BENZODIAZEPINE WITHDRAWAL?
Yes. Aerobic exercise has consistently been found in studies to reduce
both anxiety and depression. Some people believe that aerobic exercise
may even shorten the course of withdrawal.
Strenuous aerobic exercise is often difficult for people in withdrawal,
as it causes an influx of adrenaline that can heighten withdrawal
symptoms. In some cases, people have reported experiencing panic
attacks after intensive exercise. Where you are unable to engage in
vigorous exercise, it is recommended that you engage in as much low
impact aerobic exercise as possible. Brisk walking is a good form of
aerobic exercise that some people have reported as having an immediate,
calming effect. Relatively non-strenuous swimming is also a good
option.
32. I HAVE TERRIBLE INSOMNIA DURING MY WITHDRAWAL. SHOULD I TAKE
SOMETHING TO HELP ME SLEEP?
Opinions vary on the subject. While it should not slow your recovery
process to take an over-the-counter drug with sedative properties, some
people feel that taking virtually any other drug makes their withdrawal
symptoms worse. Many others, however, have found that various synthetic
and organic drugs are helpful as sleep aids. These include, but are not
limited to, antihistamines (such as Benadryl), Dramamine, valerian root,
5Htp, chamomile, warm milk, and melatonin.
It is important to be cautious regarding your decision to ingest any
psychoactive chemicals, be they organic or synthetic, during withdrawal.
Therefore, it is prudent to avoid taking sleep aids if you are suffering
from only mild insomnia. If, however, your insomnia is severe, as it
often can be during certain stages of withdrawal, you may wish to
consider taking one or more sleeping aids, particularly as serious sleep
deprivation may worsen withdrawal symptoms.
It should go without saying that you cannot take a different benzodiazepine
for sleep. That might be effective in inducing sleep, but it is the
equivalent of increasing your dose and reversing your recovery process.
The same holds true to varying degrees for barbiturates, alcohol, opiates
and narcotics.
You should also avoid the drug Ambien, a sedative not technically in the
benzodiazepine class, but very similar chemically.
Any of the above-mentioned over-the-counter sleep aids or herbal
sedatives may be useful. However, it has often been observed that
tolerance to the sleep effects of these substances, including for
example melatonin, can develop rapidly. It is therefore recommended
that you alternate more than one sleep remedy, so that no one remedy is
employed more than 2 or 3 times per week.
It is important to note that virtually all tranquillizers, including
antihistamines, can produce paradoxical symptoms of agitation and heightened
insomnia for some users. If you feel that any substance you are consuming
as a sleep aid is making your withdrawal symptoms worse, discontinue that
substance immediately.
32. WHAT CAN I TAKE FOR PAIN MANAGEMENT DURING WITHDRAWAL?
Many people experience muscle and joint pain during withdrawal. This
can occur to varying degrees. Only a very small fraction of people have
reported bad reactions to over-the-counter pain relievers. These should
be used as a first resort. Do not use prescription pain relievers
unless your pain is extremely debilitating.
34. ARE THERE ANY PARTICULAR DRUGS THAT ARE KNOWN TO COMPLICATE
WITHDRAWAL?
There is some evidence that antibiotics can complicate withdrawal.
However, it is not recommended that you refrain from taking antibiotics
where they are prescribed by a doctor for a potentially serious
condition. Some people have actually refused to take antibiotics for
pneumonia while in withdrawal. Be advised that if you choose to make
this kind of decision, you do so at your own risk.
There are undoubtedly other drugs that may complicate withdrawal as
well. Be cautious, but also be sensible about health problems you may
have that are unrelated to withdrawal.
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?
There is no way to tell. Sometimes, people's symptoms begin to diminish
before their taper is complete; sometimes shortly after the taper is
complete; sometimes quite a while after the taper is complete. The
important thing to remember is that in all cases the healing process is
moving forward, whether it is immediately apparent or not, and that you
will eventually begin to feel better.
36. I HAVE COMPLETED MY TAPER, AND HAVE FELT MUCH BETTER FOR A WHILE,
BUT NOW I FEEL WORSE AGAIN. WHY?
This is a typical experience. Benzodiazepine withdrawal recovery occurs
in fits and starts. The fact that you have experienced relief for a
time means that you will experience it again. As time goes on,
generally these recurring episodes are spaced further apart, and are
less in intensity. Benzodiazepine withdrawal leaves you vulnerable to
stress for quite a long time even after you are almost totally healed.
It is often reported that people who have felt withdrawal free for six
months have had sudden, intense withdrawal episodes brought on by
traumatic or stressful events. It is probably helpful to get counseling
if you continue to have ongoing anxiety issues long after your taper is
complete. This does not mean that you are not still experiencing
withdrawal. It means that the purpose of detoxifying yourself in the
first place was to find alternative, less toxic methods of managing
anxiety problems.