Challenges and Best Practices for Overcoming Benzo Withdrawal – Part 1

By: Michael Lam, MD, MPH; Justin Lam, ABAAHP, FMNM

benzo withdrawal helpBenzodiazepines, also called “benzos” or BZD for short, are tranquilizers. They are most often given for anxiety and insomnia, but also as muscle relaxants and anticonvulsants. They are also used for alcohol withdrawal symptoms. Although benzos are meant for medical use only, some people use them recreationally. If taken for long enough, you can develop a benzodiazepine dependency, which leads to benzo withdrawal symptoms when trying to cut down or discontinue use. This is why it’s not a good idea to take them on a daily basis for three months or longer, as this increases the chance of dependency.

You’ve probably heard of some of these benzodiazepine meds and sleeping aids, as well as the similar-in-action yet chemically different “Z-drugs”:

  • Ambien (zoldipem)
  • Ativan (lorazepam)
  • Dalmane (flurazepam)
  • Imovane (zopiclone)
  • Klonopin / Rivotril (clonazepam)
  • Librium (chlordiazepoxide)
  • Lunesta (eszopiclone)
  • Restoril (temazepam)
  • Rohypnol (flunitrazepam)
  • Valium (diazepam)
  • Xanax (alprazolam)

There are other types and brands of benzodiazepines as well. If your doctor ever recommends tranquilizers or sleeping aids, it’s a good idea to check to see if they are benzos, so you know what you’re dealing with.

Although some are taken through intravenous injections, most benzo drugs are taken in oral form. When ingested, they are absorbed by the stomach and small intestines, then metabolized by the liver. They are excreted through urine, saliva, sweat, and feces. These drugs are fat-soluble and stored in fatty tissues.

Benzo withdrawal is known to be one of the more difficult to experience, and if coupled with a condition like adrenal fatigue, it can be quite a complex challenge. For those with adrenal fatigue and chronic stress, this article covers what benzodiazepines are and how they affect the body, as well as their relationship to the adrenal glands, cortisol, and the overall stress response.

How Benzodiazepines Affect The Nervous System

Benzodiazepines act by enhancing the effect of the neurotransmitter gamma-aminobutyric acid (GABA) throughout the brain and nervous system. Neurotransmitters are chemicals that transmit impulses between brain cells, either exciting or inhibiting reactions by the receiving brain cells.

the effects of benzo withdrawal on the nervous systemGABAs are the body’s primary inhibitory neurotransmitters. They decrease the excitability of neurons in the nervous system and regulate the muscle tone. By binding to GABAA receptors, they help calm anxiety, induce sleep, and relax the muscles. They affect memory, emotions, coordination, thinking, and consciousness.

GABAs do an important job calming down nervous system responses. To understand their function, it helps to understand how the nervous system operates.

The autonomic nervous system (ANS) is composed of five branches, including the parasympathetic nervous system (PNS), the sympathetic nervous system (SNS), and the sympathoadrenal hormone system (SHS).

Each system controls a certain response depending on what’s needed at the time. When there is stress, the SNS and SHS are activated, creating the “fight or flight” response. The degree of activation corresponds to the degree of stress perceived by the body.

It is all part of the NeuroEndoMetabolic (NEM) Stress Response that helps the body deal with stress. This holistic and functional perspective on stress explains how the whole body reacts. When there is no stress, the PNS activates the “rest and digest” response.

Although the “fight or flight” response is necessary in dangerous situations, most stress in modern times is not due to a threat to survival. Your SNS and SHS can be triggered to release norepinephrine and epinephrine (also called adrenaline) deal with stress that can be emotional or psychological as well as physical.

the adrenals and benzo withdrawalAdrenaline is a hormone that is excreted by the adrenal medulla which acts on metabolism. It is the most powerful hormone in the body when it comes to dealing with stress. Norepinephrine is both a neurotransmitter and a hormone. In the brain, it acts as a neurotransmitter, putting us on alert mentally. Peripherally, outside the central nervous system, norepinephrine acts on the cardiovascular system’s sympathetic nerves. Together, they increase heart rate and breathing and release a shot of energy into the body, so that you can fight off danger or run away from it.

Norepinephrine, adrenaline, and dopamine fall into a class of chemical compounds called catecholamines. GABAs help to reduce the effect of catecholamine-driven responses so that you’re not constantly “switched on”, enabling you to relax in mind and body. They are like an antidote to adrenaline and norepinephrine.

Taking a benzodiazepine will enhance the GABAs’ ability to neutralize this “fight or flight” response, letting your “rest and digest” response activate. In other words, GABA is a natural opponent and balancer of catecholamines.

Types of Benzo Drugs

There are short-acting, intermediate-acting and long-acting benzos. Short-acting benzos, like Tranxene, can last for three to eight hours. Intermediate-acting benzos, like Ativan, can last from eleven to twenty hours. And long-acting benzos, like Librium, can last one to three days. Some benzo drugs have a very fast onset of action, like Valium for example, which can have an effect within an hour.

Unlike other psychiatric medications, such as antidepressants (which may take weeks to begin having an effect), benzos are effective almost immediately.

Different types of benzos can be taken for short-term, intermediate-term, or long-term use. After understanding their potential side effects and withdrawal symptoms, however, you will most likely feel that short-term is the best option.

Short-term use can be for things like sedation during surgery, or just for a few days during a challenging life situation such as a death in the family or losing a job. These types of benzos should not be taken for more than a few days if possible.

Intermediate use could be to help with alcohol withdrawal symptoms, for example.

Long-term benzo use is usually reserved for chronic anxiety and panic attacks, although in some people this can worsen the very symptoms they are meant to help.

Long-term use of benzos can damage the GABA receptors. Development of dependency and resistance can make dosage reduction difficult. Not only that, but long-term use, over years for example, actually induces withdrawal-like symptoms, even if you do not reduce the dose.

One peculiar symptom that long-term users can experience, with or without going through benzo withdrawal, is something called ‘depersonalization’. It’s a feeling of not being quite real, that parts of your body are not attached to the rest, or that you are outside of yourself as an observer. It can also seem like the world itself is less real.

Some people with depersonalization feel like they are looking at someone familiar in the mirror but that this person is not actually themselves. What is most disturbing about depersonalization is the emotional reaction to it. Feeling this way can be very frightening, making you think you’re going crazy. These reactions will depend on the severity of the symptom and how long it lasts.

A Common Benzodiazepine Scenario

A patient goes to a doctor complaining of anxiety and insomnia and is given a benzodiazepine. At first, it works so well that this patient feels she has found an easy and effective solution to her problems. After a little while, though, she begins to experience some unwanted side effects and hears that these drugs are addictive.

benzo withdrawal and doctor prescriptionsShe then goes back to her doctor with concerns, where she is promptly told that these drugs are perfectly safe, non-addictive, and can be taken for life. So she keeps renewing her prescription and taking the medication.

However, as her tolerance builds, she needs to increase her dosage or take the drugs more often for them to work. On challenging days, she might even take double what she normally takes. At some point, that dose may become the norm.

After a while, this patient begins to worry about her health and considers getting off the drug completely. However, as she starts to experience benzo withdrawal symptoms, she mistakes these symptoms for her original state of panic and insomnia, and she feels she needs to be taking the medication again.

This dance may go on for many years if she is not well informed about the effects and symptoms of benzo withdrawal.

Because of this common scenario, it is highly recommended that if you are considering or taking benzos, you get the full picture before deciding what steps to take next. The best approach is to make a plan and have some realistic expectations of how this journey will unfold.

Benzo Withdrawal Symptoms

There are many benzo withdrawal symptoms experienced by long-time users, with variations in severity. Symptoms can come and go in waves, which makes it difficult to predict when the symptoms will stop for good.

Some users experience a lessening of symptoms over the course of a few days or weeks. Then suddenly, symptoms recur with the same severity as they had at the beginning, making them feel hopeless about their progress.

Though not everyone experiences withdrawal, the majority of long-term users do. The symptoms of benzo withdrawal include:

  • Anxiety
  • Insomnia
  • Nightmares
  • Panic attacks
  • Fearfulness
  • Loss of appetite
  • Abdominal cramps
  • Depression
  • Sleep disturbances
  • Frequently changing moods
  • Weight loss
  • Indigestion
  • Agoraphobia
  • Tremors
  • Restlessness
  • Blurry vision
  • Sore eyes
  • Dizziness
  • Lethargy
  • Irritability
  • Headaches and pressure in the head
  • Flu-like symptoms
  • Breathing difficulties and tightness in the chest
  • Sweating
  • Heart palpitations
  • Brain fog and impairment of cognitive functions
  • Nausea
  • Distortions in perception
  • Stiffness and muscle pain
  • Heaviness in the limbs
  • Loss of coordination and balance
  • Sensitivity to light

This is not a full list. No one experiences all of these symptoms at the same time. Most people will experience a combination of a few of them on an on-again-off-again basis. The intensity of symptoms also varies from person to person. One of the most frequently overlooked symptoms is the onset of adrenal crashes. This is when the body undergoes a massive loss of energy, resulting in extreme fatigue that may incapacitate a person.

In addition, some people experience psychosis, blackouts, and hallucinations. Rarely, people can experience physical symptoms of nosebleeds, hair loss, rectal bleeding, hemorrhoids, sinus pain, and sensitivity to touch. Depersonalization can also be a benzo withdrawal symptom.

Due to some of these symptoms, other problems may also arise, such as an increased risk of accidents and falling. Those going through very challenging withdrawals can experience suicidal ideation.

Benzo withdrawal can take weeks, months, or even years, depending on how long and how often the drugs were used. For long-term users, it can take two years for the brain and nervous system to fully return to a healthy state. The damage done to GABA receptors and the different hormonal systems in the body needs time to regain balance.

GABA and the HPA Axis

The hypothalamic-pituitary-adrenal (HPA) hormonal axis is the system of interactions between the hypothalamus and pituitary glands. The adrenal glands sit on top of the kidneys and have important functions such as regulating the immune system, digestion, sexuality, energy, emotions, and the stress response.

benzo withdrawal effects on the brainThe HPA axis is basically a hormone cascade, releasing a hormone that then signals for the release of the next hormone that then signals for the release of the next.

This begins in the paraventricular nucleus (PVN) of the hypothalamus, which contains neurons that “switch on” when there is stress or a change in the physiological state. Depending on the input signal to the brain, the PVN will secrete the appropriate peptides.

The PVN releases two hormones that begin the hormone cascade of the HPA axis: the anti-diuretic hormone (ADH) and the corticotropin releasing factor (CRF). These peptides leave the hypothalamus and, upon arrival, stimulate the pituitary gland to secrete the adrenocorticotropic hormone (ACTH).

ACTH then binds to the receptors in the adrenal glands, signaling them to release pregnenolone, which then is converted into a variety of other hormones, and ultimately, cortisol. Over 50 hormones are produced in the entire cascade. Once the cortisol has completed its job (neutralizing stress, for example), any excess will then signal the hypothalamus to stop its production of CRF.

GABAs inhibit the PVN, which is what releases the hormones that activate the HPA hormone cascade in the first place. It does this by suppressing the output of CRF and ADH, the two hormones that stimulate the pituitary gland to secrete ACTH.

When functioning properly, this inhibition is part of the natural balance between the GABAs and the excitatory glutamates that stimulate the PVN and therefore the HPA axis. This is part of the body’s regulatory system to ensure no single hormone dominates during normal daily living. However, a disturbance in this equilibrium will also disrupt the normal functioning of the HPA axis. This imbalance can have many causes, including the use of benzodiazepines and excessive stress.

Read Part 2

© Copyright 2017 Michael Lam, M.D. All Rights Reserved.

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