Welcome back, people! Last week we continued our foray into all things Xanax and talked about dependence and use disorder. The next step in the chain- withdrawal- can be a special kind of beastie, definitely deserving of its own blog, so this week will be all about Xanax withdrawal.
As I mentioned last week, some folks can take their bit of Xanax a couple of times a day as directed for umpteen years, and never develop a tolerance or pathological dependence. Others start out taking it as directed, but develop a tolerance and maybe start to abuse it- take too much too often- and then begin to develop a more pathological dependency. Others may abuse it recreationally on occasion, to netflix and chill, find they really like it, then develop a severe addiction. It may not sound like these people have much in common, but they do. When they stop taking it, they’re all going to go through withdrawal.
They won’t do so alone, though. In 2017, doctors wrote nearly 45 million prescriptions for Xanax, so it’s no surprise that these prescribing practices have contributed to thousands of cases of abuse and dependence. With those numbers, there has been all sorts of research and stats examined on benzos, and I read that in 2018, an estimated 5.4 million people over the age of 12 misused prescription benzodiazepines like Xanax. That’s a lot of people, people.
To many patients that take their Xanax exactly as prescribed, it seems to come as a surprise that they’re facing a withdrawal experience, but Xanax doesn’t discriminate- so anyone taking enough of it for more than a few weeks will develop a physical dependence. Once you have become physiologically dependent on a drug, you will experience withdrawal symptoms when you stop or reduce your dose. Simple as that.
Withdrawal is different for everyone. Depending on the dose and how often you’ve been using it, the withdrawal experience typically ranges from uncomfortable to very unpleasant, but it can also be medically dangerous. The only safe way to quit is to slowly taper down the dose under the direction of a physician, or in an in-patient treatment center setting, depending on the situation. If you’ve been taking high doses of Xanax several times a day, then quitting is going to take a great deal of time, patience, and determination. Please note that quitting cold turkey can cause extremely dangerous withdrawal symptoms. This can include delirium, which is a state characterized by abrupt, temporary cognitive changes that affect behavior; so you can be irrational, agitated, and disoriented- not a good combo. Sudden withdrawal can also cause potentially lethal grand mal (aka tonic-clonic) seizures. These are like electrical storms in the brain, where you lose consciousness and have violent muscular contractions throughout the body. It’s not a risk you want to take, people- so don’t do this on your own! Even if you’ve been taking Xanax illicitly, that doesn’t mean you have to go it alone. Just fess up to a physician and tell them exactly how much you’ve been taking so they can design a taper schedule for you, or help you find a treatment center. There is a lot of help available if you make the effort.
Tapering your dose is the best course of action for managing withdrawal symptoms, but that doesn’t mean it’s a picnic in the shade. While you taper down the dose, you’ll likely experience varying degrees of physical and mental discomfort. You may feel surges of anxiety, agitation, and restlessness, along with some unusual physical sensations, like feeling as though your skin is tingling or you’re crawling out of your skin. But keep in mind that these are all temporary.
Signs and Symptoms
The major signs and symptoms of Xanax withdrawal vary from person to person. Research indicates that roughly 40% of people taking benzodiazepines for more than six months will experience moderate to severe withdrawal symptoms, while the remaining 60% can expect milder symptoms. It’s very common to feel nervous, jumpy, and on edge during your taper. And because Xanax induces a sedative effect, when the dose is reduced, most people will experience a brief increase in their anxiety levels. Depending on the severity of your symptoms, you may experience a level of anxiety that’s actually worse than your pre-treatment level. Support from mental health professionals can be very beneficial during and after withdrawal, as therapy and counseling may help you control and manage the emotional symptoms of benzo withdrawal.
Physical Withdrawal Symptoms
As a central nervous system depressant, Xanax serves to slow down heart rate, blood pressure, and temperature in the body- in addition to minimizing anxiety, stress, and panic. Xanax may also help to reduce the risk of epileptic seizures. Once the brain becomes used to this drug slowing all of these functions down on a regular basis, when it is suddenly removed, these CNS functions generally rebound quickly, and that is the basis for most withdrawal symptoms. Symptoms can start within hours of the last dose, and they can peak in severity within 1 to 4 days. The physical signs of Xanax withdrawal can include: headache, blurred vision, muscle aches, tension in the jaw and/ or teeth pain, tremors, nausea, vomiting, diarrhea, numbness of fingers, tingling in arms and legs, sensitivity to light and sound, alteration in sense of smell, loss of appetite, insomnia, cramps, heart palpitations, hypertension, sweating, fever, delirium, and seizures.
Psychological Withdrawal Symptoms
Xanax, as a benzodiazepine, acts on the reward and motivation regions of the brain, and when a dependency is formed, these parts of the brain will be affected as well. When an individual dependent on Xanax then tries to quit taking the drug, the brain needs some time to return to normal levels of functioning. Captain Obvious says that whenever you stop a benzo, because it acts as an anxiolytic, you’re going to experience a sudden increase in anxiety levels. While there are degrees of everything, the psychological symptoms of Xanax withdrawal can be significant, as the lack of Xanax during withdrawal causes the opposite of a Xanax calm, which is to say something akin to panic. At the very least, that can make you overly sensitive, and less able to deal with any adverse or undesired feelings. Withdrawal can leave people feeling generally out of sorts, irritable, and jumpy, while some individuals have also reported feeling deeply depressed. Unpredictable shifts in mood have been reported as well, such as quickly going from elation to being depressed. Feelings of paranoia can also be associated with Xanax withdrawal.
Nightmares are often reported as a side effect of withdrawal. I included insomnia in physical symptoms, but trouble sleeping can also be a psychological symptom, as it is both mentally and physically taxing. People can be overtaken by anxiety and stress during withdrawal, and that may cause this trouble sleeping at night, which then contributes to feelings of anxiety and agitation, so it’s a cycle that can be tough to break free of. Difficulty concentrating is also reported, and research has found that people can have cognitive problems for weeks after stopping Xanax. Ditto for memory problems. Research shows that long-term Xanax abuse can lead to dementia and memory problems in the short-term, although this is typically restored within a few months of the initial withdrawal. Hallucinations, while rare, are sometimes reported when people suddenly stop using Xanax as well. Suicidal ideation is sometimes reported, as the anxiety, stress, and excessive nervousness that can occur during withdrawal can lead to, or coexist with suicidal thoughts. Finally, though rare, psychosis may occur when a person stops using Xanax cold turkey, rather than being weaned off of it.
Xanax Withdrawal Timeline
Xanax is used so commonly for anxiety and panic disorders because it works quickly, but that also means it stops working quickly and leaves the body quickly. Xanax is considered a short-acting benzodiazepine, with an average half-life of 11 hours. As soon as the drug stops being active in the plasma, usually 6 to 12 hours after the last dose, withdrawal symptoms can start. Withdrawal is generally at its worst on the second day, and improves by the fourth or fifth day, but some symptoms can last significantly longer. If you go cold turkey and don’t taper your dose, your withdrawal symptoms will grow increasingly intense, and there really is no way to predict how bad they may get, or how you’ll be affected.
Unfortunately, five days doesn’t signal the end of withdrawal for some people, as some may experience protracted withdrawal. Estimates suggest that about 10% to 25% of long-term benzodiazepine users experience protracted withdrawal, which is essentially a prolonged withdrawal experience marked by drug cravings and waves of psychological symptoms that come and go. Protracted withdrawal can last for several weeks, months, or even years if not addressed by a mental health professional. In fact, these lasting symptoms may lead to relapse if not addressed with continued treatment, such as regular therapy.
Factors Affecting Withdrawal
Withdrawal is different for each individual, and the withdrawal timeline may be affected by several different factors. The more dependent the body and brain are to Xanax, the longer and more intense withdrawal is likely to be. Regular dose, way of ingestion, combination with other drugs or alcohol, age at first use, genetics, and length of time using or abusing Xanax can all contribute to how quickly a dependence is formed and how strong it may be. High stress levels, family or prior history of addiction, mental health issues, underlying medical complications, and environmental factors can also make a difference in how long withdrawal may last for a particular individual and how many side effects are present.
Coping with Xanax Withdrawal
The best way to avoid a difficult and potentially dangerous withdrawal is to slowly taper down your dose of Xanax, meaning to take progressively smaller doses over the course of up to several weeks. By keeping a small amount of a benzo in the bloodstream, drug cravings and withdrawal may be controlled for a period of time until the drug is weaned out of the system completely. It may sound like designing a taper would be a no-brainer, but it’s definitely not recommended to taper without a physician’s guidance. Why? Because Xanax is a short-acting drug, your body metabolizes it very quickly. Controlling that is challenging because the amount of drug in your system goes up and down with its metabolism. To help you avoid these peaks and valleys, doctors often switch you from Xanax to a longer acting benzo during withdrawal, as it may make the process easier. And believe me, that’s what you want. If the physician goes this switch route, once you’ve stabilized on that med, you’ll slowly taper down from that a little bit at a time, just as you would with Xanax.
Another reason not to play doctor on this one is if you start to have breakthrough withdrawal symptoms when your dose is reduced, your physician can pause or stretch out your taper. It’s up to him or her, through discussion with you, to design the best tapering schedule for your individual needs. Sometimes it’s a fluid and changing beastie.
In addition, adjunct medications like antidepressants, beta-blockers, or other pharmaceuticals/ nutraceuticals may be effective in treating specific symptoms of Xanax withdrawal, and you’ll need a physician to recommend and/ or prescribe those as well.
Alleviating Symptoms of Withdrawal
An individual may notice a change in appetite and weight loss during Xanax withdrawal, so it’s important to make every attempt to eat healthy and balanced meals during this time. It may sound obvious, but a multivitamin including vitamin B6, thiamine, and folic acid is especially helpful, as these are often depleted in addiction and withdrawal. There are some herbal remedies that may be helpful during withdrawal, such as valerian root and chamomile for sleep. Meditation and mindfulness are very useful for managing blood pressure and anxiety during withdrawal, so be sure to check out my March 15 blog for more on mindfulness. Considering the insomnia and fatigue that may occur during withdrawal, it may seem counterintuitive to commit to exercise, but it has been shown to have positive effects on mitigating withdrawal symptoms and decreasing cravings. Exercise stimulates the same pleasure and reward systems in the brain, so it stands to reason that it can also help to lift feelings of depression or anxiety that may accompany physical withdrawal symptoms.
Xanax Withdrawal Safety
Some of the things I’ve mentioned are so important they bear repeating. Xanax should not be stopped suddenly, or cold turkey, and vital signs like blood pressure, heart rate, respiration, and temperature need to be closely monitored during withdrawal. This is because these may all go up rapidly during this time, and this can contribute to seizures that can lead to coma and even death.
People with a history of complicated withdrawal syndromes and people with underlying health issues should work very closely with their physician during withdrawal, as should the elderly and people with cognitive issues, as there can be unique risks involved. If you have acquired your Xanax illicitly, you can still work with a doctor to taper down your dose. Start by visiting a primary care physician or urgent care center and tell them that you are in, or are planning to be in, benzodiazepine withdrawal. If you don’t have insurance, visit a community health center. If you plan to or have become pregnant, you will need to discuss your options with your prescribing physician and OB/GYN about the risks and benefits of continuing versus tapering Xanax or other benzos. Some women continue taking them throughout their pregnancy, while others follow a dose tapering schedule.
The key to achieving the goal of getting off of Xanax is to follow the tapering schedule to the very end. By the end of your taper, you might be cutting pills into halves or quarters. Note that some individuals may be better suited for a harm reduction approach, in which the taper leads to a maintenance dose rather than abstinence. If you’re very concerned about the risks involved in Xanax tapering for any reason, discuss these concerns with your physician, because you may be better suited for inpatient detoxification. While this is more expensive, it is covered by many insurance plans.
No matter how you slice it, quitting Xanax takes time, patience, and determination. If you’ve been using it for longer than a few months, quitting can be hard, and there will be days where you want to give up and give in. But with medical supervision and support, you can be successful, and in the long-term, the health benefits are considerable. Withdrawal isn’t a picnic, but if Xanax is both the alternative to it, and a problem for you, it beats that alternative hands down.
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A woman named Marianne messaged me wanting to know how to get off of Klonopin, which is a benzodiazepine, or benzo for short. She has been taking them regularly for more than twenty years, which is a very long time to be on a benzo. That will certainly complicate things. Before I go into how to stop taking benzos, I want to tell you what they are and what they do.
What are they?
Benzos are medications designed to treat anxiety, panic disorders, seizures, muscle tension, and insomnia. Some of the most commonly prescribed benzos include: Xanax (alprazolam), Klonopin (clonazepam),Valium (diazepam), Restoril (temazepam),
Librium (chlordiazepoxide), and Ativan (lorazepam). A 2013 survey found that Xanax and its generic form alprazolam is one of the most prescribed psychiatric drugs in the United States, with approximately 50 million prescriptions written that year. Unfortunately, this class of drug is also highly abused. Another 2013 survey found that 1.7 million Americans aged 12 and older were considered current abusers of tranquilizer medications like benzos. When abused, benzos produce a high in addition to the calm and relaxed sensations individuals feel when they take them.
How do they work?
Benzos increase the levels of a chemical in the brain called GABA. Meaningless trivia: GABA stands for gamma amino-butyric acid. GABA works as a kind of naturally occurring tranquilizer, and it calms down the nerve firings related to stress and the stress reaction. Benzos also work to enhance levels of dopamine in the brain. Dopamine is the feel good chemical, the chemical messenger involved in reward and pleasure in the brain. In simple terms, benzos slow down nerve activity in the brain and central nervous system, which decreases stress and its physical and emotional side effects.
Why can using them be problematic?
Benzos have multiple side effects that are both physical and psychological in nature, and these can cause harm with both short-term and extended usage. Some potential short-term side effects of benzos include, but are not limited to: drowsiness, mental confusion, trouble concentrating, short-term memory loss, blurred vision, slurred speech, lack of motor control, slow breathing, and muscle weakness. Long-term use of benzos also causes all of the above, but can also cause changes to the brain as well as mental health symptoms like mood swings, hallucinations, and depression. Fortunately, some of the changes made by benzos to the different regions of the brain after prolonged use may be reversible after being free from benzos for an extended period of time. On the scarier flip side of that coin, benzos may in fact predispose you to memory and cognitive disorders like dementia and Alzheimer’s. They’re many studies currently focusing on these predispositions. A recent study published by the British Medical Journal (BMJ) found a definitive link between benzo usage and Alzheimer’s disease. People taking benzos for more than six months had an 84% higher risk of developing Alzheimer’s dementia, versus those who didn’t take benzos. Long-acting benzos like Valium were more likely to increase these risks than shorter-acting benzos like Ativan or Xanax. Further, they found that these changes may not be reversible, and that the risk increased with age. Speaking of age, there are increased concerns in the elderly population when it comes to benzo usage. Benzos are increasingly being prescribed to the elderly population, many of which are used long-term, which increases the potential for cognitive and memory deficits. As people age, metabolism slows down. Since benzos are stored in fat cells, they remain active in an older person’s body for longer than in a younger person’s body, which increases the drug effects and risks due to the higher drug concentrations, like falls and car accidents. For all of these reasons, benzos should be used with caution in the elderly population.
A big problem with taking benzos for an extended period is tolerance and dependency. Benzos are widely considered to be highly addictive. Remember that benzos work by increasing GABA and dopamine in the central nervous system, calming and pleasing the brain, giving it the feel goods. After even just a few weeks of taking benzos regularly, the brain may learn to expect the regular dose of benzos and stop working to produce these feel good chemicals on its own without them. Your brain figures, “why do the work if it’s done for me?” You really can’t blame the brain for that! It has become dependent on the benzo. But as you continue to use benzos, you develop higher and higher tolerance, meaning that it takes more and more of the drug to produce the regular desired effect. This tolerance and dependence stuff really ticks off your brain. It’s screaming “why aren’t these pills working anymore?!” The answer is that it has become dependent and tolerant, so it needs more. Just to prove its point, it makes you feel anxious, restless, and irritable as it screams “gimme gimme more more more!!!” The problem is that the body is metabolizing the benzo more quickly, essentially causing withdrawl symptoms, and a higher dose is needed. The longer you’re on a benzo, the more you’ll need. It’s a vicious cycle and it’s sometimes tough to manage clinically.
The most severe form of physical harm caused by benzos is overdose. This occurs when a person takes too much of the drug at once and overloads the brain and body. The Centers for Disease Control and Prevention (CDC) cites drug overdose as the number one cause of injury death in the United States. A 2013 survey reported that nearly 7,000 people died from a benzo overdose in that year. Since benzos are tranquilizers and sedatives, they depress the central nervous system, lowering heart rate, core body temperature, blood pressure, and respiration. Generally, in the case of an overdose, these vital life functions simply get too low.
When combining other drugs with benzos, obviously the risk of overdose or other negative outcome increases exponentially. But mixing benzos with alcohol is a special case, deserving of a strong warning as it is life-threatening. BENZOS + ALCOHOL = DEAD. One of the most common and successful unintentional and intentional suicide acts in my patient population is mixing benzos with alcohol. The combo is lethal, plain and simple. The body actually forgets to breathe. People pass out and just never wake up. If you’re reading this and you take benzos with alcohol and you’re thinking that you don’t know what the big deal is, you do it all the time and have never had a problem, then my response to you is that you’re living on borrowed time, and I strongly suggest you stop one of the two, the booze or the benzos, take your pick.
What about withdrawl from benzos?
Benzo withdrawal can be notoriously difficult. It is actually about the hardest group of drugs to get off of. The level of difficulty is based on what benzo you’ve been taking, how much you’ve been taking, and how long you’ve been taking it. Obviously, if you’ve been on benzos for 25 years, it’s not going to be a walk in the park. To be honest, it’s going to be a rough road. Sorry Marianne. But it can be done. The first and most important thing is that you should never just stop benzos on your own, as it can be very dangerous and can include long or multiple grand mal seizures. Withdrawal from benzos should be done slowly through medical detox with a professional. It is best done with an addiction specialist like myself, because a specialist has the most current knowledge and experience. This is the safest way to purge the drugs from the brain and body while decreasing and managing withdrawal symptoms and drug cravings. As for the symptoms of withdrawl, these can include mood swings, short-term memory loss, seizure, nausea, vomiting, diarrhea, depression, suppressed appetite, hallucinations, and cognitive difficulties. Stopping benzos after dependency may also lead to a rebound effect. This is a sort of overexcitement of the nerves that have been suppressed for so long by the benzos, and symptoms can include an elevated heart rate, blood pressure, and body temperature. There may also be a return of the issues that lead you to take the benzos in the first place, insomnia, anxiety, and panic symptoms, and they can possibly be even worse than before.
I’m sure that just about everyone currently taking benzos is thinking “I’m NEVER stopping!” right about now. It is not easy to do, but there is a way to manage all of this, to come off of the benzo and deal with all of the physical and cognitive aspects of withdrawl. I do it everyday. I set up a tapering schedule to lessen the specific benzo dosage over time, sometimes over a period of months. I will also often add or switch to a long acting benzo, which can be very helpful. I use several drugs to deal with the withdrawl symptoms: clonidine for tremor and high blood pressure, neurontin for pain and to help prevent seizures, anti-psychotic like seroquel for sleep, and an anti-depressant for depression, thank you Captain Obvious. The drug regimen varies from patient to patient. I also utilize psychotherapy to help work out the psychological kinks associated with withdrawl and rebound effect symptoms. Another trick I strongly recommend to many of my patients, not just those withdrawing from alcohol or any drugs, is transcranial magnetic stimulation or TMS. This is a non-invasive procedure done in the office that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression and anxiety, and I’ve found that it seems to calm the nerves and offer relief to some people in withdrawl. Electrodes are placed on the forehead and behind the ears and painless stimuli are passed into certain regions of the brain for 40 minutes in each daily session for about a month. Many patients say it’s the best 40 minutes of their day.
I’d like to wish Marianne good luck. Please feel free to call me at the office at 561-842-9950 if you have any questions.
To everyone else: If you can avoid ever having to take benzos, I strongly suggest that you do. If you’re currently taking them, give some serious thought to finding an alternative medication. I can help with that. For more information and stories about benzos, other drugs, and the process of medical detox, check out my book Tales from the Couch on Amazon.com.Learn More