This is version 1.1 of this FAQ, and it supersedes the previous

version entirely. The authors request that, in order to avoid

confusion resulting from multiple versions in circulation, the

reader not disseminate version 1.0 of the FAQ any further.

In fact, it is recommended that copies of version 1.0 which

you may have stored on your harddrive be deleted.

DISCLAIMER: THIS F.A.Q. WAS NOT WRITTEN BY A DOCTOR OR SOMEONE WITH

ANY FORM OF MEDICAL TRAINING. THE ADVICE CONTAINED HEREIN SHOULD NOT BE

SUBSTITUTED FOR THE ADVICE OF A PHYSICIAN WHO IS WELL-INFORMED IN THE

SUBJECT MATTER DISCUSSED HEREIN. BECAUSE THIS F.A.Q. IS NOT WRITTEN BY

A DOCTOR,ALL ADVICE CONTAINED HEREIN IS TO BE FOLLOWED AT YOUR OWN RISK.

This F.A.Q. is expressly placed into the public domain, and may be

freely disseminated by any who come into its possession. The identity

of its authors is irrelevant. It is a product of the effort of a few

among a community known as benzo@egroups.com (aka, benzo@onelist.com.)

It is also a product of the spirit of that entire community. It is both

a gift from its authors to that community, and a gift from that

community to anyone in the world whose life has been touched by

benzodiazepine dependency.

In order to avoid confusion, the authors request that in reproducing,

transmitting, or disseminating this document, no alterations of text be

made. Any proposed corrections or revisions should be stated on the

forum known as benzo@egroups.com. When the authors have accumulated

sufficient revision material to justify creating a new version, one will

issue. Legitimate revisions include spelling, grammar, and punctuation

errors; scientific and/or medical inaccuracies pointed out; new

questions; and information newly discovered through scientific research

or empirical observation, e.g. some new form of adjunct medication or

herbal therapy that is discovered to be helpful in withdrawal.

Differences of opinion with the authors are warmly accepted, but are

unlikely to alter the contents of the F.A.Q. unless supported by solid

factual data.

"Canst thou not minister to a mind diseas'd,

Pluck from the memory a rooted sorrow,

Raze out the written troubles of the brain,

And with some sweet oblivious antidote

Cleanse the stuff'd bosom of that perilous stuff

Which weighs upon the heart?"

-Shakespeare, Macbeth Act 5, Scene 3

TABLE OF CONTENTS:

1. WHAT IS A BENZODIAZEPINE?

2. HOW DO BENZODIAZEPINES AFFECT YOUR BODY?

3. HOW QUICKLY CAN I BECOME ADDICTED TO A BENZODIAZEPINE?

4. WHAT ARE THE DOSE EQUIVALENCIES AMONG VARIOUS BENZODIAZEPINES?

5. WHAT IS A "HALF-LIFE", AND HOW IS THE CONCEPT IMPORTANT TO

BENZODIAZEPINE DEPENDENCE?

6. WHAT DOES "TOLERANCE" MEAN?

7. IF MY DOCTOR HAS PRESCRIBED A BENZODIAZEPINE AND INSTRUCTED ME TO

TAKE IT FOR A MEDICAL AND/OR PSYCHOLOGICAL REASON, IS THERE ANY

REASON I SHOULD DISREGARD MY DOCTOR'S ADVICE AND DISCONTINUE THE

BENZODIAZEPINE?

8. WHAT IS BENZODIAZEPINE WITHDRAWAL SYNDROME?

9. WHAT ARE THE SYMPTOMS OF BENZODIAZEPINE WITHDRAWAL?

10. I AM EXPERIENCING ONE OR MORE OF THE SYMPTOMS LISTED ABOVE, BUT I

HAVE NOT BEGUN TAPERING MY BENZODIAZEPINE. IS IT POSSIBLE THAT THE

SYMPTOMS ARE NOT RELATED TO BENZODIAZEPINE USE, OR COULD I ALREADY

HAVE STARTED WITHDRAWAL WITHOUT EVEN TAPERING?

11. WHAT FACTORS DETERMINE HOW SEVERE MY WITHDRAWAL WILL BE?

12. IF I DISCONTINUE MY BENZODIAZEPINE, WON'T THE UNDERLYING CONDITION

THAT MY DOCTOR PRESCRIBED THE BENZODIAZEPINE FOR RETURN?

13. I HAVE DECIDED TO DISCONTINUE THE USE OF MY BENZODIAZEPINE. WHAT

ARE THE FIRST STEPS I SHOULD TAKE?

14. IS COLD TURKEY (ABRUPT, TOTAL DISCONTINUANCE OF THE DRUG) AN

ACCEPTABLE METHOD FOR DETOXING FROM A BENZODIAZEPINE?

15. OK, IF I AM GOING TO TAPER MY BENZODIAZEPINE, HOW SHOULD I STRUCTURE

THE TAPER?

16. SHOULD I SWITCH TO ANOTHER BENZODIAZEPINE SUCH AS VALIUM BEFORE

TAPERING?

17. MY DOCTOR HAS ASKED ME TO SWITCH TO A DRUG CALLED "PHENOBARBITOL"

FOR DETOXIFICATION? IS THIS A GOOD IDEA?

18. SHOULD I CONSIDER GOING INTO AN IN-PATIENT DRUG REHABILITATION

FACILITY OR DETOX CENTER TO GET OFF MY BENZODIAZEPINE?

19. WHAT IS THE LENGTH OF THE WITHDRAWAL PROCESS?

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?

21. WILL I NEED TO QUIT WORK OR GIVE UP OTHER IMPORTANT ASPECTS OF MY

LIFE DURING BENZODIAZEPINE WITHDRAWAL?

22. MY DOCTOR HAS PRESCRIBED AN ANTI-DEPRESSANT TO TAKE DURING MY

WITHDRAWAL. IS THAT A GOOD THING TO DO?

23. ARE THERE ANY OTHER DRUGS BESIDES ANTI-DEPRESSANTS TO CONSIDER USING

DURING BENZODIAZEPINE WITHDRAWAL?

24. ARE THERE ANY PARTICULAR DRUGS A DOCTOR MIGHT PRESCRIBE THAT

DEFINITELY DO NOT HELP WITHDRAWAL?

25. WHAT ABOUT HERBS AND OTHER HOMEOPATHIC REMEDIES - DO ANY OF THOSE

HELP THE WITHDRAWAL SYMPTOMS?

26. WHAT ABOUT USING CAFFEINE DURING WITHDRAWAL?

27. WHAT ABOUT EATING SUGAR DURING WITHDRAWAL?

28. WHAT ABOUT CONSUMING ALCOHOL DURING WITHDRAWAL?

29. WHAT FOODS SHOULD I EAT (OR AVOID) DURING WITHDRAWAL?

30. I SMOKE CIGARETTES, SOULD I QUIT DURING WITHDRAWAL?

31. SHOULD I EXERCISE DURING BENZODIAZEPINE WITHDRAWAL?

32. I HAVE TERRIBLE INSOMNIA DURING MY WITHDRAWAL. SHOULD I TAKE

SOMETHING TO HELP ME SLEEP?

33. WHAT CAN I TAKE FOR PAIN MANAGEMENT DURING WITHDRAWAL?

34. ARE THERE ANY PARTICULAR DRUGS THAT ARE KNOWN TO COMPLICATE

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?

36. I HAVE COMPLETED MY TAPER, AND HAVE FELT MUCH BETTER FOR A WHILE,

BUT NOW I FEEL WORSE AGAIN. WHY?

37. WHAT IS PROTRACTED WITHDRAWAL SYNDROME?

38. SHOULD I USE A 12 STEP PROGRAM LIKE NARCOTICS ANONYMOUS TO HELP ME

RECOVER FROM MY BENZODIAZEPINE ADDICTION?

39. WHO IS DR. HEATHER ASHTON?

40. WHAT IS BENZO@EGROUPS.COM?

41. ARE THERE ANY OTHER RESOURCES THAT WOULD BE HELPFUL TO ME IN

UNDERSTANDING BENZODIAZEPINE DEPENDENCY AND WITHDRAWAL?

Benzodiazepines are a large class of commonly prescribed tranquilizers,

otherwise referred to as central nervous system (CNS) depressants.

They include alprazolam (Xanax), bromazepam (Lexotan), chlordiazepoxide

(Librium/Nova-Pam), clonazepam (Klonopin/Rivotril), clorazepate

(Tranxene), diazepam (Valium/D-Pam/Pro-Pam), estazolam, flunitrazepam

(Rohypnol), flurazepam (Dalmane), halazepam, ketazolam, loprazolam

(Dormonoct), lorazepam (Ativan), nitrazepam (Mogadon, Insoma, Nitrados),

oxazepam (Serax, Serapax, Seranid, Benzotran), trazepam, tuazepam,

temazepam (Euhypnos, Normison, Sompam), triazolam (Halcion, Hypam,

Tricam). There may be others as well.

All benzodiazepines have five primary effects. They are:

A. Hypnotic (tending to make you sleepy);

B. Anxiolytic (tending to reduce anxiety/produce relaxation);

C. Anti-seizure (tending to reduce the probability of having seizures

and convulsions);

D. Muscle relaxant (tending to reduce muscle tension and associated

pain);

E. Amnesic (tending to disrupt both long and short term memory).

There may be secondary effects as well. Different benzodiazepines

exhibit these primary effects to varying degrees. For example, diazepam

(Valium) is a relatively powerful hypnotic (sleep inducer), whereas the

more modern benzodiazepines such as alprazolam (Xanax), lorazepam (Ativan),

and clonazepam (Klonopin), are less powerful hypnotics, but are very

powerful anxiolytics. Do not assume that because one benzodiazepine

makes you sleepier than another that this benzodiazepine is more potent

than those which do not produce sleepiness to the same degree. Often,

the reverse is true.

Benzodiazepines have been referred to as being part of a larger class of

drugs known as "minor tranquilizers". As applied to benzodiazepines,

this is almost certainly a misnomer, and the label has fallen into

relative disuse in the past ten years. However, you may encounter this

term from time to time.

Benzodiazepines are most commonly prescribed for anxiety conditions,

especially panic disorder (PD) and generalized anxiety disorder (GAD).

They are also sometimes prescribed for seizure disorders. Klonopin, for

example, is often prescribed for epilepsy. Benzodiazepines are also

prescribed for insomnia and other sleep problems, such as restless leg

syndrome (RLS). Benzodiazepines are also occasionally prescribed as

muscle relaxants.

By far the most common benzodiazepines prescribed today are Valium,

Xanax, Ativan and Klonopin. Probably over 95% of the over 450 members

of benzo@egroups.com (see below) are using or have used one or more of

those four drugs. Valium is particularly common in the British Isles.

Valium has become less common in the United States over the past 15

years, while Xanax and Klonopin have experienced increased popularity in

the United States over this time. In certain Latin American countries,

it appears that the drug Lexotan (bromazepam) is very popular.

All benzodiazepines can cause physical dependency, otherwise commonly

known as addiction.

Benzodiazepines are general central nervous system (CNS) depressants.

They are all very similar chemically. Specifically, they all bind

directly to and act upon your GABA-A receptor sites in your brain.

There are also recognized subclasses of GABA-A receptors that different

benzodiazepines act upon to varying degrees. Those sites respond to the

neurotransmitter GABA (gamma-aminobutyric acid). The effect of

benzodiazepines in binding to and acting upon your GABA-A receptor sites

is to potentiate (heighten) the effect of GABA. GABA suppresses the action

of wide variety of other neurotransmitters and neural activity including,

for example, the action of norepinephrine (noradrenaline). The mechanism

of action of GABA is to send negatively charged chloride ions into your

brain cells, making those cells resistant to the effects of neurotransmitters

such as seratonin and norepinephrine that cause excitation.

GABA will perform this function with or without stimulation from a

benzodiazepine, but where a benzodiazepine binds to a GABA receptor site,

the action is heightened. This mechanism of action is what produces the

primary effects of this class of drugs. (See above.)

Contrary to a popular misconception (which was reinforced by some erroneous

language in the prior version of this FAQ), benzodiazepines do not actually

increase the organic synthesis of GABA. As stated, they heighten the action

of existing GABA. Actually, benzodiazepines can, over time, decrease the

synthesis of GABA in certain areas of your brain. This is one of numerous

theories attempting to explain the occurrence of "paradoxical" symptoms

(See below).

The time it takes to form a physical dependency on a given

benzodiazepine varies widely. The following variables may play a role:

the size of your dose, the regularity with which you consume your dose,

and most importantly, your personal body chemistry. People have been

known to form dependencies in as little as 14 days of regular use at

therapeutic dose levels. Your probability of forming some degree of

dependency is significant, probably at least 50%, by the time you have

been using them daily for 6 months. After a year of continuous use, it

is highly likely that you have formed a dependency. It is unclear

whether certain benzodiazepines are associated with a more rapid onset

of dependency than others.

4. WHAT ARE THE DOSE EQUIVALENCIES AMONG VARIOUS BENZODIAZEPINES?

There are no clearly definitive equivalencies for various benzodiazepines.

This author has personally seen at least a dozen different benzodiazepine

equivalency charts and no two are alike. The table below has been chosen

because it reflects the clinical experience of Dr. Ashton in having detoxed

over 300 people from benzodiazepines by use of a Valium substitution

method (See below).

Alprazolam 0.5

Bromazepam 6

Chlordiazepoxide 25

Clonazepam 0.5

Clorazepate 15

Diazepam 10

Estazolam 1

Flurazepam 15

Halazepam 20

Ketazolam 15

Lorazepam 1

Nitrazepam 10

Oxazepam 30

Prazepam 20

Quazepam 20

Temazepam 20

Triazolam 0.5

Thus, 1 mg. of alprazolam (Xanax) or clonazepam (Klonopin) is the

equivalent of 20 mg. of Valium; 1 mg. of lorazepam (Ativan) is the

equivalent of 10 mg. of Valium.

These dose equivalencies are important for a number of reasons, the most

significant of which is the issue of switching to a different

benzodiazepine such as Valium prior to tapering (see below). These

figures are taken from Dr. Ashton's (see below) papers and several other

sources. A similar (though not identical) equivalency table can be found at

http://uhs.bsd.uchicago.edu/~bhsiung/tips/bzd.html.

There is some disagreement in the medical profession about these

equivalencies. You may find a doctor who will want to switch you from

Xanax to Valium at a 1 mg. to 10 mg. equivalency. This is a recipe for

a very difficult cross-over withdrawal. Whatever the precise

therapeutic dose equivalencies, the above equivalencies should be

observed in switching from one benzodiazepine to another for purposes of

detoxification. (See below.)

5. WHAT IS A "HALF-LIFE", AND HOW IS THE CONCEPT IMPORTANT TO

BENZODIAZEPINE DEPENDENCE?

Half-life is a numerical expression of how long it takes for a drug to

leave your body. Technically, the "half-life," expressed as a range, is

the time it takes for half of the amount consumed to be eliminated from

your body, and so on. There is some controversy as to how long

benzodiazepines may actually remain in your body after you have

discontinued them entirely. Benzodiazepines are fat soluble and can

persist in fatty tissues. However, benzodiazepines no longer show up in

blood screenings beyond 30 days after discontinuance. This either means

they are totally eliminated by that time, or that they persist in

amounts too small to have any long term effect.

The importance of half-life is that a longer half-life generally makes

for an easier withdrawal because your blood levels remain relatively

constant, as opposed to the up and down roller coaster that you

experience with short half life benzodiazepines. Furthermore, longer

half-life benzodiazepines require less dose micro-management. For

example, Valium can be taken once every 12 hours, or in some cases,

once every 24 hours. Xanax, however, must be taken once every 4-6 hours

to maintain constant blood levels. This is a practical impossibility

for some people.

The following is a list of benzodiazepines with their corresponding

half-lives, expressed as a range in hours:

Alprazolam 9 - 20

Bromazepam 8 - 30

Chlordiazepoxide 24 - 100

Clonazepam 19 - 60

Clorazepate 1.3 - 120

Diazepam 30 - 200

Estazolam 8 - 24

Flurazepam 40 - 250

Halazepam 30 - 96

Ketazolam 30 - 200

Lorazepam 8 - 24

Nitrazepam 15 - 48

Oxazepam 3 - 25

Prazepam 30 - 100

Quazepam 39 - 120

Temazepam 3 - 25

Triazolam 1.5 - 5

There is a misconception that longer half-life benzodiazepines prolong

the withdrawal recovery process by remaining in your bodily tissues for

longer. However, there is no evidence that longer half-life

benzodiazepines are any greater risk for Protracted Benzodiazepine

Withdrawal Syndrome (see below) than shorter half-life benzodiazepines.

This method of using a longer half-life equivalent is well understood in

addiction medicine circles, and is employed with other classes of drugs

as well. For example, people who are experiencing withdrawal symptoms

from an anti-depressant such as Paxil are often given Prozac as a

substitute for purposes of detoxification, because Prozac has a longer

half-life. Perhaps a more typical example is the use of the drug Methadone

in heroin detoxification which is employed in part because of its relatively

long half-life.

6. WHAT DOES "TOLERANCE" MEAN?

Tolerance is the process by which the receptors in your brain become

habituated to the action of a drug. When tolerance is reached, more of

the drug is required to achieve the same effect. With benzodiazepines,

and probably with many other classes of drugs as well, tolerance is

virtually always associated with some degree of physical dependence. If

you find that you are experiencing tolerance, this is a clear warning

sign that you may have formed a dependency.

7. IF MY DOCTOR HAS PRESCRIBED A BENZODIAZEPINE AND INSTRUCTED ME TO

TAKE IT FOR A MEDICAL AND/OR PSYCHOLOGICAL REASON, IS THERE ANY

REASON I SHOULD DISREGARD MY DOCTOR'S ADVISE AND DISCONTINUE THE

BENZODIAZEPINE?

Yes, there may be. Unfortunately, there are many well-intended

physicians who simply do not understand the seriousness of long-term

benzodiazepine use.

Regular benzodiazepine use almost always causes some degree of

deterioration in cognitive functioning, which progresses with continued

use.

Long term benzodiazepine use also causes lethargy, decreased energy

levels that result in impairment in work productivity and disinclination

towards exercise.

Furthermore, benzodiazepines, and all other classes of sedatives,

frequently cause and/or worsen depression. This is why people are often

given anti-depressants after being given a benzodiazepine for anxiety.

Anti-depressants, though therapeutically effective for many people, have

their own complications and potential for dependency. (See below)

Benzodiazepines can also cause what is sometimes referred to as a "flat

affect" or "emotional blunting," in which the user's ability to

experience powerful emotions is impaired. Long-term benzodiazepine

users often describe their experience as "sleepwalking through life."

Benzodiazepine use can also cause what is called "paradoxical" symptoms

in a minority of users. Paradoxical symptoms are contrary to the

intended therapeutic purpose, including outbursts of rage, increased

anxiety, and sleeplessness. Paradoxical symptoms can be caused by the

drug's interaction with the psychological makeup of the user, or may be

a biological reaction to use of the drug that people sometimes refer to

as "toxicity." Paradoxical symptoms are sometimes mistaken for

withdrawal, and vice versa.

The above effects occur to varying degrees, depending on the individual.

Some individuals may not experience certain of the effects at all.

However, one effect is common to virtually all users: a

physical dependency will eventually form. Benzodiazepine dependency is

particularly serious as the withdrawal syndrome (see below) can be

extremely difficult and protracted. Furthermore, the development of

tolerance often makes long term use non-feasible, and detoxification

becomes a necessary eventuality.

Benzodiazepines are often misprescribed for conditions to which they

are not appropriate, such as depression. Furthermore, they are often

prescribed for anxiety conditions for which the individual could be

treated effectively with a less addictive drug or with other therapeutic

techniques.

There are, however, legitimate therapeutic benefits for benzodiazepines,

particularly if they are used in the short term (no more than 2 weeks of

continuous use), or for situational anxiety/panic (for example, one dose

of Xanax per month as the need arises.) Furthermore, many users of

benzodiazepines, including some who have used them regularly for more than

a year, are able to discontinue them with little difficulty.

Nothing in this F.A.Q. is to be construed as advising any individual to

ignore the advice of his or her physician. Decisions regarding the use

or discontinuance of any benzodiazepine should be made in consultation

with a physician. However, in this area you must also undertake

considerable self-education in addition to listening carefully to your

doctor's advice. Fortunately, there are many available resources to

accomplish that (see below). Where a doctor does not appear to be up to

date with current medical literature regarding benzodiazepine dependency

and the withdrawal syndrome, seeking a second and third medical opinion

can be a desirable option.

8. WHAT IS BENZODIAZEPINE WITHDRAWAL SYNDROME?

Benzodiazepine withdrawal syndrome is believed to be caused by a dampening

of the action of GABA as neuroadaptivity causes GABA to become dependent

on stimulation from the benzodiazepine to initiate its primary action.

In other words, when you have become dependent upon a benzodiazepine,

your GABA is unable to perform its natural action without the presence of

the benzodiazepine. This results in a wide variety of over-activity in

different areas of your brain, causing a vast and diffuse array of symptoms.

These symptoms are believed to be various manifestations of neurological

over-excitation as the cells in your brain become especially sensitive to

the action of excitatory neurotransmitters. The most extreme manifestation

of this over-excitation a seizure event.

Benzodiazepine withdrawal syndrome is noted both for its relative severity

and, in some cases, its lengthy duration, as compared to withdrawal from

other classes of drugs.

Withdrawal either occurs through the development of tolerance without an

attendant increase in dose, or through a decrease in dosage below your

"tolerance point". Your tolerance point is the dose point below which

the functioning of your receptors becomes impaired due to a deficiency

in stimulation from the drug. Your tolerance point may be lower than

your actual dosage, such that you can sometimes cut your dose by some

amount without experiencing withdrawal symptoms. However, this does not

mean that you will not experience withdrawal symptoms by cutting the

dose further.

Generally, a drug's withdrawal syndrome is the mirror opposite of its

primary effects. Thus, for benzodiazepines, you can expect

sleeplessness (the mirror of its hypnotic effect), anxiety (the mirror

of its anxiolytic effect), muscle tension/pain (the mirror of its muscle

relaxant effect), and seizures in rare cases (the mirror of its

anti-seizure effect). The only exception is that benzodiazepine

withdrawal syndrome does not "mirror" the amnesic effect. To the

contrary, the withdrawal syndrome often results in increased impairment

of memory and cognitive functioning. However, in all cases, after

detoxification is complete and withdrawal is in total remission,

cognitive functioning will gradually return to the level that it was at

before you began using the drug.

For a more complete list of symptoms, see below.

9. WHAT ARE THE SYMPTOMS OF BENZODIAZEPINE WITHDRAWAL?

The following is a list of symptoms reported by enough individuals that

they are statistically likely to be legitimate withdrawal symptoms.

Keep in mind that there are a wide variety of other symptoms that have

been reported that may be legitimate withdrawal symptoms as well, but

have not been reported by enough individuals to be statistically

significant. The determination of statistical significance is not based

on hard data, but on the observations of this author in reading through

thousands of posts from people in withdrawal, as well as several books

and articles on the subject.

This list is broken down into psychological and physical symptoms. The

double asterisk indicates symptoms that occur to some degree or another,

at one time or another, in virtually every person experiencing

benzodiazepine withdrawal. Single asterisk are symptoms that are

common, and occur in most people. Others are symptoms that are common

enough to be verifiable withdrawal symptoms, but probably occur in a

minority of cases.

Psychological symptoms: anxiety** (including panic attacks),

depression**, insomnia*, derealization/depersonalization* (feelings of

unreality/detachment from self), abnormal sensitivity sensory stimuli*

(such as loud noise or bright light), obsessive negative thoughts*,

(particularly of a violent and/or sexual nature) rapid mood changes*

(including especially outbursts of anger or rage), phobias* (especially

agoraphobia and fear of insanity), dysphoria* (loss of capacity to enjoy

life; possibility a combination of depression, anxiety, and

derealization/depersonalization), impairment of cognitive functioning*,

suicidal thoughts*, nightmares, hallucinations, psychosis, pill cravings.

Note that it is far more common to fear psychosis than it is to actually

experience it.

Physical Symptoms: muscle tension/pain**, joint pain*, tinnitus*,

headaches*, shaking/tremors*, blurred vision* (and other complications

related to the eyes), itchy skin* (including sensations of insects

crawling on skin), gastrointestinal discomfort*, electric shock

sensations*, paresthesia* (numbness and pins and needles, especially in

extremities), fatigue*, weakness in the extremities (particularly the

legs)*, feelings of inner vibrations* (especially in the torso),

sweating, fluctuations in body temperature, difficulty in swallowing,

loss of appetite, "flu like" symptoms, fasciculations (muscle

twitching), metallic taste in mouth, nausea, extreme thirst (including

dry mouth and increased frequency of urination), sexual dysfunction (or

occasional increase in libido), heart palpitations, dizziness, vertigo,

breathlessness.

Here is a site with a far more comprehensive list of possible symptoms:

members.dencity.com/BenzoBusters/index.html. Here, I have cited only

the ones most commonly reported.

10. I AM EXPERIENCING ONE OR MORE OF THE SYMPTOMS LISTED ABOVE, BUT I

HAVE NOT BEGUN TAPERING MY BENZODIAZEPINE. IS IT POSSIBLE THAT THE

SYMPTOMS ARE NOT RELATED TO BENZODIAZEPINE USE, OR COULD I ALREADY

HAVE STARTED WITHDRAWAL WITHOUT EVEN TAPERING?

You are probably experiencing tolerance withdrawal. When you reach

tolerance, your brain needs more of the drug to stimulate the active of

GABA, and you begin to experience withdrawal symptoms. Some people find

that no matter how much they increase their dose, they are unable to obtain

complete relief. This may be caused by a fast, upward tolerance spiral,

or by toxicity (see above). Detoxification is necessary where this

occurs.

Some people mistakenly form a belief that the drug has "quit working" to

alleviate their anxiety disorder when in fact they are experiencing

anxiety brought on by tolerance withdrawal. Unfortunately, physicians

will sometimes reinforce this misperception and advise you to increase

your dose as a result.

11. WHAT FACTORS DETERMINE HOW SEVERE MY WITHDRAWAL WILL BE?

It is impossible to predict how severe your particular withdrawal will

be, or which of the 30 or so common symptoms you are likely to

experience. However, predictors of severity include duration of use,

dosage, type of benzodiazepine, age, your personal body chemistry, and

your method of detoxification. It is unclear which, if any, of these

factors relate to the duration of your withdrawal syndrome as opposed to

the severity. The data regarding factors correlating to duration is

less conclusive than the data correlating to severity.

There is some evidence that the more modern, high potency

benzodiazepines, especially Xanax, Klonopin, and Ativan may be

associated with more severe withdrawal syndromes. However, this

evidence remains anecdotal.

Keep in mind that there is wide variation from the above

generalizations. For example, one person may take a low dose of a

benzodiazepine for a short period of time, and have a very severe

withdrawal phase. Another individual may take a high dose of the same

drug for much longer, and experience very manageable withdrawal

symptoms. Furthermore, an individual Valium user may have a harder time

than an individual Xanax user. These variables are only very general

predictors.

12. IF I DISCONTINUE MY BENZODIAZEPINE, WON'T THE UNDERLYING CONDITION

THAT MY DOCTOR PRESCRIBED THE BENZODIAZEPINE FOR RETURN?

It may or may not. It depends on what your underlying problem was, and

what post-withdrawal measures you take to manage the condition, if

necessary. Sometimes, the underlying problem is simply "gone" by the

time you have detoxified yourself from a benzodiazepine. Many physical

and psychological conditions are a transitory response to a temporary

condition in your life, such as a traumatic event. Often, people take

habit forming drugs such as benzodiazepines to alleviate the symptoms

of these transitory conditions, and continue taking them long after the

condition would have gone away on its own.

Other conditions are less transitory, such as chronic, long term panic

disorder (PD). However, it is important to bear in mind that there are

other treatments for these conditions, both of a pharmacological and a

non-pharmacological nature. Anxiety and stress can be managed in a

variety of different ways that are not as harmful to your body as

benzodiazepines.

There is an ongoing debate in the medical profession as to whether there

is a narrow class of individuals with long-term, chronic panic disorder

(PD) who are justified in taking benzodiazepines for life. This F.A.Q is

for informative purposes only, and will not take a position on this

controversial issue.

Often, when people complete their benzodiazepine detoxification, they

find an emergence of an underlying psychological problem that was masked

by the benzodiazepine use for many years. People also often feel the

resurfacing of emotions that may have been suppressed for a long time.

Thus, there is sometimes a period of difficult adjustment even after the

withdrawal symptoms subside. However, people often find the end result

of this period of adjustment to be very rewarding.

13. I HAVE DECIDED TO DISCONTINUE THE USE OF MY BENZODIAZEPINE.

WHAT ARE THE FIRST STEPS I SHOULD TAKE?

Your first step is to educate yourself. That means reading this F.A.Q.

and seeking out many of the resources referred to herein. Your second

step is to see a doctor who understands the seriousness of benzodiazepine

dependency, and be as well armed with information as possible going into

that visit. Your third step is to approach your detoxification with a

clear plan in mind, to set goals for yourself, and to begin the

withdrawal process with confidence. Do not listen to horror stories

from others who have had unusually bad experiences in withdrawal.

Everyone's experience is different, and many people are able to withdraw

with very manageable symptoms.

14. IS COLD TURKEY (ABRUPT, TOTAL DISCONTINUANCE OF THE DRUG) AN

ACCEPTABLE METHOD FOR DETOXING FROM A BENZODIAZEPINE?

No. There is nearly complete uniformity of opinion both in the medical

profession and in the benzodiazepine recovery community that cold turkey

is a dangerous and unacceptable method of detoxification. Cold turkey

withdrawal may cause seizures, and is also associated with a higher

probability of withdrawal psychosis. Seizures are almost non-existent

in those employing a taper method, with the limited exception of people

who have taken a benzodiazepine for a seizure disorder. Furthermore,

psychosis is rare in those who taper their benzodiazepine slowly.

There is a misconception that cold turkey withdrawal, though it may

cause more severe symptoms, will bring about a faster remission of

symptoms. This is the idea that a slow taper "prolongs the agony of

withdrawal". This notion is almost certainly false. In fact, there is

some anecdotal evidence that cold turkey withdrawal may lengthen the

course of the withdrawal syndrome, and may even cause Protracted

Withdrawal Syndrome (see below).

15. OK, IF I AM GOING TO TAPER MY BENZODIAZEPINE, HOW SHOULD I STRUCTURE THE TAPER?

There are two very general rules, and one exception to the rule that is

discussed below. The first rule is, the slower the taper, the milder

the withdrawal symptoms. The second rule is, the smaller the cuts you

are able to make, the milder the withdrawal symptoms. These are

related, though separate, issues.

For example, you might decide to cut your dose by 1/4 mg. every month,

or in the alternative, cut your dose by 1/8 mg. every two weeks. Either

way, you are tapering at the same rate. In this author's opinion, the

second option is a far superior method of tapering. Any cut is a shock

to your brain and body. Cold turkey is the largest cut of all. It is a

spontaneous, total deprivation of your dependent substance. The shock

caused by cold turkey withdrawal is such that even after resumption of

your drug at the previous dose, it may take weeks or months to

"stabilize", and in some cases, you may never stabilize from a cold

turkey withdrawal until after you have completed your taper.

This logic further extends to the size of your cuts. The smaller the

cuts you make, the less the shock to your system, and the less

pronounced the withdrawal symptoms triggered by the cut. It is not

recommended that any individual cut represent more than 10% of your

total dose at a given time. Thus, it is preferable to make smaller and

smaller cuts as you go, though this can be very difficult as you

approach the end of your taper.

Always make the smallest cuts possible. That means taking the smallest

dose size available and splitting it into 4 pieces, which can be done

easily with or without a razor blade. For example, with Valium, you can

split the smallest (2 mg.) tablet into 4 .5 mg. pieces. With Klonopin,

you can split the smallest (.5 mg.) tablet into 4 pieces of .125 or

1/8th mg. If you are on a high dose and feel that you are able to taper

rapidly at first because you are above your tolerance point (see above),

space your cuts close together (no closer than 1 cut every 3 days), but

make the smallest cuts possible. If or when you begin to feel

withdrawal symptoms, you can start to space your cuts further apart (up

to about 4 weeks). Generally, the higher potency benzodiazepines such

as Xanax, Klonopin, and Ativan force you to make larger cuts (see

below), and therefore you must space your cuts at least 3 weeks apart

toward the end of your taper. Of course, even where you are able to make

very small cuts with lower potency benzodiazepines such as Valium, you can

make these small cuts relatively far apart if this is your most comfortable

method of detoxification.

There is a method of tapering that involves mixing the drug with either

water or a dry carrier like sugar to produce a "titration" which allows

for very minute reductions, such as 1% every other day. This method has

been employed with success by some people. In England, doctors have

created a liquid titration kit to assist users in withdrawing

comfortably. There is some promise that this method can substantially

diminish, if not eliminate, the withdrawal syndrome. Unfortunately,

these titration kits are not available in North America.

If you are unable to use a titration method, you may wish to consider

switching to Valium, assuming, of course, that you are not already using

that particular benzodiazepine. (See below) This method has been used

with success, particularly in England, for many years.

Dr. Heather Ashton has detailed taper schedules available that are based

on switching to Valium. (Also see below.)

There seems to be a limited exception to the slow taper rule where

people find that they have a "toxic" reaction to taking the

benzodiazepine (see "paradoxical symptoms" above). There is a tricky

distinction between toxic symptoms and withdrawal symptoms. The usual

way to tell the difference is to try increasing your dose. If the

symptoms reduce or stay the same, your symptoms are likely attributable

to withdrawal. If your symptoms increase, you may be experiencing

toxicity, and should probably consider a faster taper (6 to 8 weeks).

However, do not make a hasty decision to taper fast. Make certain that

you are experiencing toxicity first. Generally speaking, your symptoms

are far more likely to be related to withdrawal than toxicity.

One cause of toxicity may be the taking of more than one psychoactive

drug simultaneously. For example, taking a benzodiazepine with an

anti-depressant and a narcotic (pain killer).

16. SHOULD I SWITCH TO ANOTHER BENZODIAZEPINE SUCH AS VALIUM BEFORE

TAPERING?

Keep in mind that some people feel that switching to Valium is not for

everyone; and many have tapered their drug of dependency and have

recovered very well. However, if you are considering this alternative,

there are three reasons that are often cited for switching to Valium for

purposes of detoxification.

First, Valium has a far longer half-life than most other

benzodiazepines. (See above). This allows for a steady, smooth

reduction in dose over time. It also permits you to take your dose less

often. In some cases, you can take your entire daily dosage before

bedtime. This reduces problems of micro-managing your dose by taking

another pill every few hours. It also can aid in sleep, which can be a

large issue during withdrawal.

Second, Valium is low in potency relative to most other benzodiazepines

and comes in tablets of 2 mg., 5 mg. and 10 mg. As a practical matter,

you can make cuts as small as .5 mg. This is the equivalent of somewhere

between 1/20th and 1/40th mg. of Xanax or Klonopin. Given the importance

of making the smallest cuts possible, particularly as you approach the end

of your taper, this is a very large benefit.

Finally, Dr. Ashton and some others believe that the more modern, high

potency benzodiazepines such as Xanax, Klonopin, and Ativan tend to

produce more difficult withdrawal syndromes. So far the evidence of

this is anecdotal, meaning that it is based on clinical observation and

patient self-reports. There do not appear to be any studies that

conclusively correlate severity of withdrawal with type of

benzodiazepine.

If you do decide to switch to Valium, it is important that you have an

idea of what to expect. First of all, because each benzodiazepine has a

unique chemical composition, one benzodiazepine will not completely

cover the withdrawal syndrome of another. Medical literature

indicates that lower potency benzodiazepines cover fewer subclasses of

GABA-A receptors (see above) than the modern, high potency

benzodiazepines such as Xanax and Klonopin. This is why it is important

to observe the proper dose equivalencies. (See above.) These are

special equivalencies for purposes of switching to Valium, and are

sometimes called "loading doses" or "suppression doses." The consequence

of taking a loading dose is that although your withdrawal symptoms may be

suppressed very well, you might also experience the side effect of over

sedation. This is particularly so as Valium is a more potent sleep

agent than most high potency benzodiazepines even at the equivalent

therapeutic dose, and these equivalencies are probably well above the

therapeutic dose equivalencies. However, most benzodiazepine users

rapidly develop a tolerance to the sleep inducing (hypnotic) effects of

benzodiazepines, so that it is likely that this over-sedation will

recede within the first few weeks.

Because it is important to manage this problem of over sedation and to

avoid cross-over withdrawal symptoms, it is a very good practice to use

a gradual dose substitution method rather than simply discontinue your

drug of dependency and begin taking Valium at the full equivalency dose.

Depending on the size of your dose, the period of dose substitution may

be anywhere from 3 weeks to about 3 months.

During this period of dose substitution, sometimes cuts to your total

dose are made, and other times, slight increases are made. If you

experience extreme over-sedation and no withdrawal symptoms, that is a

sign that the equivalency dose is too high for you, and you may wish

make a small cut in your total dose as you cross-over. If, on the other

hand, you begin to experience heightened withdrawal symptoms during

cross-over, you may wish to make a small increase in your dose during

cross-over. Because the proper equivalencies vary from person to

person, the cross-over process can be a matter of trial and error.

However, it is important to understand that the end result of switching

to Valium should be that you are relatively stable after the switch is

complete, meaning that you are experiencing either no withdrawal or very

mild withdrawal symptoms.

Dr. Ashton has circulated detailed protocols based upon switching to

Valium and explaining the method in detail. (See above and below.)

Librium is another long acting benzodiazepine that is sometimes (but

rarely) used as a substitute. This author has insufficient information

regarding the effectiveness of Librium substitution to provide a

meaningful comment at this time. It is not necessary to switch from

Librium to Valium. Librium should be tapered directly, although there

is a problem in that it comes only in 5 mg. capsules in North America.

Ideally, for Librium detoxification, the capsule should be opened and

the contents halved to make 2.5 mg. cuts. Of course, if it possible

to make even smaller cuts, that is most preferable.

17. MY DOCTOR HAS ASKED ME TO SWITCH TO A DRUG CALLED "PHENOBARBITOL" FOR DETOX? IS THIS A GOOD IDEA?

Some doctors, particularly in the United States, use a detoxification

method of switching the patient to phenobarbitol, then tapering the

phenobarbitol, usually over a period of 2 to 6 weeks. Phenobarbitol is

a long acting barbiturate (another class of sedatives). It acts upon

many of the same GABA-A receptors as benzodiazepines, but binds to the

receptors at a different location. Phenobarbitol is very cross-tolerant

with the benzodiazepine class, and if taken in a proper "loading dose"

(see above) will probably suppress withdrawal symptoms fairly well.

Phenobarbitol detoxification is "medically safe," in that Phenobarbitol

is a potent anti-seizure agent so that you will likely not have any risk

of seizures with this method.

Phenobarbitol also has a very long half-life, similar to that of Valium,

and can be broken down into very small cuts. The equivalency is 3 mg.

of Phenobarbitol to 1 mg. of Valium.

Reported results from Phenobarbitol substitution are mixed but

inconclusive due to the small number of people at benzo@egroups.com who

have experienced this method. Doctors using this method generally

observe the practice of using a heavy "loading dose," but they usually

do not employ a gradual dose substitution method. More importantly,

when this method is used, the detoxification is usually done very

rapidly (e.g. 4-6 weeks). The problem with Phenobarbitol detoxification

may not be so much the use of Phenobarbitol itself as the rapidity of the

taper that is usually employed. Where information is discovered related

to the effectiveness of Phenobarbitol using a slow taper method, this F.A.Q.

will be revised to reflect that information.

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.

37. WHAT IS PROTRACTED WITHDRAWAL SYNDROME?

Protracted With Syndrome (PWS) is not a phenomenon with a single,

unitary definition. Many people who have no experience with

benzodiazepine dependency, which includes almost half of the medical

community, do not recognize any form of withdrawal syndrome as

persisting beyond about 30 days. Part of the problem is that the

average physician sees very few people with serious benzodiazepine

dependency, and when they do, the symptoms are often misinterpreted or

misdiagnosed. Another problem is that statistics actually show that,

indeed, about 70% of people with a benzodiazepine dependency are able to

complete withdrawal in less than a month. However, it is important to

understand that this statistic takes into account large numbers of

people who have used a benzodiazepine for only a few weeks or months.

For people who have used benzodiazepines for years, a 6 to 18 month

course of withdrawal is actually the norm. For doctors who have not

seen significant numbers of people in this circumstance, that scenario

is viewed as "protracted," because withdrawal syndromes rarely persist

more than 30 days for virtually every other class of drug.

What those few doctors and recovering victims who truly understand

benzodiazepine dependence know is that the 6 to 18 month scenario is

just a typical outcome for any serious dependency. In those circles,

PWS is roughly defined as significant, debilitating, and continuous (not

minor or occasionally occurring) symptoms persisting beyond about one

year after total cessation of the drug. One of the true ironies here is

that just as there is debate among the truly ignorant as to whether the

very common 6 to 18 month scenario exists, there is also a debate among

people in recovery and addiction medicine circles as to whether true PWS

(beyond about 18 months) is a real phenomenon. Most people in these circles

believe it is. However, some would attribute symptoms several years

out to a re-emergence of an underlying condition, to some other

undiagnosed medical or psychiatric condition, or to psychosomatic

complaints.

Dr. Ashton and others believe that PWS is a real phenomenon. What

causes it is at this point is unknown. However, there are two things to

keep in mind about PWS. First, even if you are in the category of

people with a serious dependency, the statistical likelihood of you

experiencing PWS is quite small, probably less than 1 in 10. If you are

two years out and have occasional, mild symptoms, that is not PWS. It

is typical. If you have significant, debilitating symptoms beyond a

year, that is PWS and it is atypical but not unheard of. However, the

second thing to keep in mind is that there is no evidence that

benzodiazepine withdrawal syndrome can ever be permanent. Even in the

rare cases that symptoms persist for years, they gradually diminish over

time until they are gone.

As you taper, do not concern yourself with whether or not you will

experience PWS. You probably will not. And even if you do, that is

something to manage if or when you get there.

38. SHOULD I USE A 12 STEP PROGRAM LIKE NARCOTICS ANONYMOUS TO HELP ME RECOVER FROM MY BENZODIAZEPINE ADDICTION?

This is a personal choice, and opinions vary considerably in the

benzodiazepine recovery community. In fact, the issue has been debated

on the benzo@egroups.com (see below) more than once. Some feel that

most people who have a benzodiazepine dependency are not drug abusers.

Rather, they are people who have taken a medication according to their

doctor's instructions for a specific medical and/or psychological

condition, have never exceeded the recommended dosage, have never

experienced a "high" or intoxication from the drug, and have never

experienced a specific craving for the drug. This is where the term

"accidental addict" is rooted. Often, people who fit this mold feel

that 12 step programs such as NA are not a proper fit for them, because

those programs are aimed at conditioning people to avoid abuse type

behaviors. People with a benzodiazepine dependency are often seeking

support and guidance on how to manage their withdrawal syndrome, not

training on how to avoid drug abuse.

Still others not only feel that these types of programs have helped

them, but feel that they would not be alive today without them. It is

important to note that a sizable percentage of benzodiazepine dependents

do exhibit patterns of abuse. The clearest sign is taking dosages far

in excess of what your doctor has prescribed, and/or having a history of

abusing other drugs in the past or simultaneously with your

benzodiazepine. 12 step programs may be a better fit for people in that

category.

One factor that many have found helpful in the withdrawal process is

spirituality, e.g. a connection with some form of Higher Power(s). Some

have found that 12 step programs help them understand the importance of

spirituality. Others have found their own spirituality without the

assistance of any such program.

39. WHO IS DR. HEATHER ASHTON?

Dr. C. Heather Ashton D.M. is a British psycho-pharmacologist (an expert on

psychiatric drugs) who ran a benzodiazepine detoxification clinic in Newcastle,

England between 1982 and 1994. During that time, she detoxified over 300

patients,

with a high rate of success. Her DM degree is a Doctorate in Medicine.

One of her papers is an observation of the outcome of her first 50 cases.

In that study, only three patients relapsed, and the others made it through

with varying long term outcomes - mostly positive. Dr. Ashton is undoubtedly

one

of the world's foremost authorities on benzodiazepine addiction and recovery.

Dr. Ashton always switches her patients to Valium (see above) unless, of

course,

Valium is their drug of dependency. She also recommends a very slow taper.

She has written a manual for consumption by the general public. It is

available for purchase at

http://members.dencity.com/ashtonpapers/index.html. This manual is an

excellent resource for anyone beginning the process of detoxification.

Dr. Ashton is not the only expert on the subject, but she is one of the

more knowledgeable ones. She is far more knowledgeable than this

author.

39. WHAT IS BENZO@EGROUPS.COM?

Benzo@egroups.com (aka benzo@onelist.com) is a listserver (an e-mail

message board) that consists of people who are at various stages of

benzodiazepine dependency and recovery. Some have not even begun a

taper, others are tapering, others have completed their taper and are

still experiencing withdrawal. Still others are completely recovered

and post to the group to support those still in the recovery process.

Benzo@egroups.com is a tremendous source of both support and information

regarding all aspects of benzodiazepine dependency. You can sign up for

the listserver by going to www.egroups.com. There are other listservers

on a variety of different topics at the egroups site, including

benzofree@egroups.com. This group is for people who have completely

discontinued their benzodiazepine. It is a forum for celebrating

freedom from dependency and tends to be oriented towards the 12 step

philosophy more so than benzo@egroups.com. There is, however,

considerable cross-membership between the groups.

40. ARE THERE ANY OTHER RESOURCES THAT WOULD BE HELPFUL TO ME IN UNDERSTANDING BENZODIAZEPINE DEPENDENCY AND WITHDRAWAL?

Yes. There are lots.

Get the Ashton manual with detailed detoxification protocols here:

http://members.dencity.com/ashtonpapers/index.html.

Here is perhaps the single best website regarding benzodiazepine

dependency and withdrawal: http://homepage.ntlworld.com/raymond.nimmo/or

http://www.benzo.org.uk This is growing very fast and should be consulted

frequently for updated information on this issue.

Here again is the extremely comprehensive list of possible withdrawal

symptoms mentioned above: members.dencity.com/BenzoBusters/index.html.

Here is an excellent site that contains references to hundreds of

articles and books on benzodiazepines: www.benzodiazepines.net.

Here is a good site that addresses the issue of managing and recovering

from panic disorder without the use of benzodiazepines. It contains

many helpful links and references. http://home1.gte.net/panicdoc/

The "Benzodiazepine Angst Webring" contains these sites and many other

helpful ones. You can start here:

http://www.slipperysquid.simplenet.com/benzo.html or at any of the

individual sites.

Here are some other websites of interest:

Detoxification: Principles and Protocols

http://www.asam.org/publ/detoxification.htm

(This is the website for the American Society of Addiction Medicine.

There is some valuable information here, but you have to separate the

wheat from the chaff. For example, there is a benzodiazepine

equivalency chart here that is extremely inaccurate.)

KLONOPIN: Little Known Facts

http://neuro-www.mgh.harvard.edu/forum/PanicDisordersF/1.16.991.40AMKLONOPIN.Lit\

tleKn

Bristol and District Tranquilliser Project

http://www.epost.co.uk/charities/bdtranq.html

HYPNOTICS, SEDATIVES AND ANXIOLYTICS

http://www.mssm.edu/pharmacology/PharmCourse/Syllabus1998/56-57/56-57.html

ICFDA Klonopin

http://www.drugawareness.org/klonopin.html

Roche's latest Klonopin Monograph:

http://www.rocheusa.com/products/klonopin/pi.html

(This is the pharmaceutical company's own information. There is

detailed pharmacological information here. However, bear in mind that

Roche and other companies who manufacture benzodiazepines offer slanted

views on the severity of withdrawal for long time users, for obvious

reasons.)

The Merck Manual - Home Edition, Sec. 7, Ch. 92, Drug Dependence and

Addiction:

http://www.merck.com/pubs/mmanual_home/sec7/92.htm

(Again, you need to separate the wheat from the chaff here. For

example, the Merck Manual, a mainstream publication, takes the position

that barbiturate withdrawal is more severe than benzodiazepine

withdrawal. This is almost certainly false. Although the symptom

profile is very similar, barbiturate withdrawal typically passes in no

more than 30 days after discontinuance, and usually less time than

that.)

Management of Withdrawal Symptoms and Relapse in Drug and Alcohol

Dependence:

http://www.aafp.org/afp/980700ap/miller.html

American Family Physician: Addiction - Part I Benzodiazepines:

http://www.aafp.org/afp/20000401/2121.html

Classification of Tremor and Update on Treatment - American Academy of

Family Physicians:

http://www.aafp.org/afp/990315ap/1565.html

Two particularly excellent books on benzodiazepine dependence and recovery:

The Accidental Addict by Porritt and Russell. This one is essentially

out of print, but can be ordered here:

http://members.dencity.com/BenzoBusters/index.html. Copies are running

out, so get it while you can. It is excellent.

Freeing Yourself From Tranquillizers, by Shirley Trickett. This one is

in general circulation and can be ordered from www.amazon.com or on

special order through any reputable book store. The title of this book

in the UK is "Coming off Tranquillizers, Sleeping Pills &

Anti-depressants." It is an odd title, because the book has very little

to do with coming off of anti-depressants. It is basically a book about

benzodiazepine dependency and withdrawal.

Council for Involuntary Tranquilizer Addiction: C I T A

Cavendish House, Brighton Road, Waterloo, Liverpool L22, ENGLAND 5NG

Tel: 0151 474 9626, FAX 0151 284 8324, Helpline: 0151 949 0102

It is rumored that there will be other books on the subject published soon.

The above list of references, along with the entire archived history of

posts at benzo@egroups.com, also serves as the bibliography for this

F.A.Q. It is this body of information that this author has used as a

basis for the facts and opinions stated herein.

The reader is encouraged to do his or her own research, as there are

undoubtedly more resources both on the Internet and in print which are

relevant to this topic. Any reader who uncovers such information is

encouraged to bring it to benzo@egroups.com.

****Rescue Remedy is a product name. This FAQ neither promotes nor

discourages the use of any specific product.

End of F.A.Q. version 1.1.