Benzodiazepines are approved to treat generalized anxiety disorder, insomnia, seizures, social phobia and panic disorder [1]. They also carry the U.S. Food and Drug Administration’s most prominent warning. That warning is about abuse, misuse, addiction, physical dependence and withdrawal reactions [1]. Both things are true at once. This page is for people trying to hold them together.
Below: what these drugs are, and what they do in the brain. How dependence builds, and why it is not addiction. What misuse looks like. The side effects, and the combinations that kill people. What an overdose looks like. What withdrawal involves. Why stopping alone is dangerous. And what treatment is, level by level. For more on the withdrawal course itself, our page on benzodiazepine withdrawal goes further than this one. If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental-health crisis call or text 988.
What Benzodiazepines Are and What They Treat
They are prescription depressants. The Drug Enforcement Administration says they produce sedation and hypnosis, relieve anxiety and muscle spasms, and reduce seizures [3]. The FDA adds that they are used as premedication before some medical procedures [1].
They work by slowing the brain down. All of them bind to gamma-aminobutyric acid receptors, usually shortened to GABA [1]. That is what produces the drowsy or calming effect [1]. They differ in how fast they start working, and in how long the effect lasts [1]. The mechanism is shared.
Chlordiazepoxide was the first one approved, in 1960 [1]. Many more followed through the 1960s and 1970s [1]. The names most people know are alprazolam, sold as Xanax; clonazepam, sold as Klonopin; diazepam, sold as Valium; lorazepam, sold as Ativan; and chlordiazepoxide, sold as Librium [1]. Temazepam and triazolam are in the same class [1]. We have separate pages on Xanax, Klonopin and Valium.
These are common drugs, not fringe ones. The FDA puts the 2019 figure at 92 million prescriptions from U.S. retail and mail-order pharmacies [1]. Alprazolam was the most common at 38 percent, then clonazepam at 24 percent and lorazepam at 20 percent [1].
One line in the FDA’s own description matters more than it looks. Most of these drugs are meant for periods of weeks or months [1]. The amount, the frequency and the length of treatment vary by patient and by condition [1]. Long-term use is not what the class was built around.
How Dependence and Addiction Develop, and Why They Are Different
Physical dependence is the body adapting. The FDA defines it as the body’s adaptation to repeated use of a drug [1]. That adaptation produces withdrawal when the drug is stopped abruptly or the dose is cut sharply [1]. It adds that dependence may lead some people to keep taking the drug just to avoid those symptoms [1].
Addiction is a different thing. The FDA is careful about the difference. Its position is that even at recommended dosages, use of these drugs can lead to misuse, abuse and addiction [1].
Dependence can build faster than people expect. The FDA says it can occur when they are taken steadily for several days to weeks, even as prescribed [1]. Note the hedge. The word is “can”, not “will”, and that is the honest shape of it.
How often is the exposure a long one? The FDA’s review found that in 2018 an estimated half of patients given oral benzodiazepines got them for two months or longer [1]. Its study of adverse event reports found most of the patients who described dependence had been prescribed the drug for therapeutic use [1]. Those reports gave a wide range of time to dependence [1]. Some put the onset as early as days to weeks after starting [1].
The risk of addiction itself is less settled. The FDA says the exact risk is uncertain [1]. It also says population data clearly show that both primary benzodiazepine use disorders and polysubstance addiction do occur [1]. Its review cites a published analysis of survey data from 2015 to 2016 [1]. That analysis put half a million U.S. adults living in the community at a benzodiazepine use disorder [1].
Signs That Benzodiazepine Use Has Become a Problem
The FDA separates two words that get used loosely. Abuse is taking the drug to produce a high or some other desired effect, rather than to manage a medical condition [1]. Misuse is taking it outside what was prescribed [1]. That covers taking more than a prescriber set, and taking a drug prescribed for somebody else [1].
Both are common. The FDA cites a national estimate for 2018 of 5.4 million people aged 12 and over who abused or misused these drugs in the previous year [1]. The DEA records that abuse is particularly high among people who use heroin or cocaine [3]. It also records that opioid use and benzodiazepine use often run together [3].
The most useful line here may be the one the FDA writes for prescribers. It tells them to watch for signs of abuse, misuse or addiction throughout treatment [1]. Where a substance use disorder is suspected, it says to evaluate the patient and start or refer them for early treatment [1]. A patient can open that conversation too. You do not need a diagnosis first.
What that conversation is about is usually a pattern, not a moment. Taking more than was prescribed. Running out early. Getting the same prescription from more than one place. Keeping it going because stopping feels impossible. Our guide to withdrawal symptoms covers the last of those in more detail.
Side Effects and the Risks That Matter Most
The common side effects are the ones the class is named for. The FDA lists drowsiness, dizziness, weakness and slowed breathing [1]. The DEA adds sleepiness and a relaxed mood [3]. It also links these drugs to amnesia, hostility, irritability and vivid or disturbing dreams [3].
At higher exposure the picture looks familiar. SAMHSA’s detox protocol says people intoxicated on sedative-hypnotics look like people intoxicated on alcohol [2]. Slurred speech, unsteady movement and poor coordination are prominent [2].
The risk that kills people is combination. The FDA warns that particular caution is needed when these drugs are prescribed with opioids [1]. The same goes for other drugs that depress the central nervous system [1]. That mix has caused severe respiratory depression and death [1]. The FDA also tells patients not to drink alcohol with them at all, because alcohol raises the risk of serious and life-threatening side effects [1]. Its instruction is direct. Go to an emergency room or call 911 if you have trouble breathing or other serious side effects [1].
If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental-health crisis call or text 988.
Treatment for benzodiazepine use in Florida
The Recovery Village Umatilla is our campus in Umatilla, Florida, and its own page cards medical detox, inpatient treatment for substance abuse, inpatient rehab for mental health, partial hospitalization programming, outpatient programming and aftercare planning. Its outpatient card says clients live at home or in a sober living home and commute to rehab during the week, and its inpatient mental health card says patients live on site and then move to outpatient care in the community.
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The Recovery Village Umatilla is part of our family of treatment centers. See the Recovery Village Umatilla campus.
Overdose: What It Looks Like and What to Do
The DEA lists the overdose effects. Extreme drowsiness, confusion, impaired coordination, decreased reflexes, respiratory depression, coma and possible death [3]. Where these drugs and opioids have been taken together, it lists profound sedation, respiratory depression, coma and death [3].
If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental-health crisis call or text 988. Do not wait to see whether it passes.
The question people ask next is whether these drugs alone can kill. Two federal sources answer it. They answer it the same way, in two halves that have to be read together.
SAMHSA’s detox protocol says they rarely lead to death by themselves, taken alone in overdose, whether on purpose or by accident [2]. It follows that at once with the other half. Most people who take them in overdose may also be using alcohol, other sedative-hypnotics or other drugs [2]. That combination could be fatal if it is not managed properly [2].
The FDA’s numbers say the same thing in a different register. Its review found that benzodiazepine-involved overdose deaths rose from 1,298 in 2010 to 11,537 in 2017 [1]. The share of those deaths involving these drugs alone was small, and it fell over that period, from 3.7 percent in 2010 to 2.7 percent in 2017 [1]. Between 2013 and 2017, 55 percent of them also recorded prescription opioids [1]. The FDA’s own summary of the pattern is blunt. The harms are substantial, but they occur primarily when people use these drugs in combination with others [1].
So “rarely fatal on its own” and “involved in thousands of deaths a year” are both true. Almost nobody takes only one thing.
There is a hospital treatment for this kind of overdose. It has limits worth knowing. SAMHSA describes a competitive antagonist that acts at the benzodiazepine receptor [2]. It can reverse the sedative and overdose effects of these drugs, but not those of alcohol or other sedative-hypnotics [2]. In a person who is physically dependent, SAMHSA warns, it may induce seizures, high blood pressure and delirium [2]. Someone in a coma from these drugs can move quickly into acute withdrawal when it is given [2]. That is an emergency department decision, not a bedside one. If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental-health crisis call or text 988.
Withdrawal in Outline, and Why Stopping Abruptly Is Dangerous
This is the part of the page to read twice. The FDA states that stopping abruptly can cause withdrawal reactions including seizures [1]. So can reducing the dosage too quickly [1]. Those reactions can be life-threatening [1].
SAMHSA is more specific about the shape of the danger. It says the medical complications of this withdrawal are similar to those in alcohol withdrawal [2]. Seizures are particularly worrisome [2]. They may arrive without any other evidence of withdrawal coming first [2]. As in alcohol withdrawal, seizures and delirium are the most extreme pathology seen [2].
If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental-health crisis call or text 988.
Even a gradual decrease can be hard. The FDA lists what patients may still get. Abnormal involuntary movements, anxiety, blurred vision, memory problems, irritability, insomnia, muscle pain and stiffness, panic attacks and tremors [1]. It lists the more severe reactions separately, and tells patients to contact a prescriber if they appear. Catatonia, seizures, delirium tremens, depression, hallucinations, thoughts of harming yourself or someone else, mania and psychosis [1].
If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental-health crisis call or text 988.
Some of it lasts. The FDA describes a protracted withdrawal syndrome that goes on beyond 4 to 6 weeks after the first withdrawal [1]. Its symptoms may last weeks, or as long as 12 months [1]. It names anxiety, poor thinking, depression, insomnia, crawling or tingling skin, tremor, muscle weakness and tinnitus [1]. Its review of adverse event reports found some patients whose symptoms lasted many months [1].
One complication is specific to this class. Many people taking these drugs have an underlying anxiety disorder. SAMHSA notes that during withdrawal it is often hard to tell withdrawal from panic symptoms coming back [2]. Older adults face a different set of risks. SAMHSA says patients withdrawn from these drugs late in life are at risk of falls and heart attacks [2]. It adds that delirium without the usual pulse and blood pressure changes may be seen in them too [2].
Neither federal source on this page prints an hour-by-hour or day-by-day timeline for this withdrawal. So this page does not print one either. What the course looks like depends on the drug and on the person. Our page on benzodiazepine withdrawal covers it at length. Our page on how long benzodiazepines stay in your system answers the detection question.
Why Coming Off Benzodiazepines Needs a Prescriber
No schedule fits everybody, and the FDA says so in terms. Its guidance to prescribers is that no standard tapering schedule is suitable for all patients [1]. A patient-specific plan should be built instead, with ongoing monitoring and support as needed [1]. Its guidance to patients is the mirror image. Do not suddenly stop without first agreeing a plan with your health care professional for slowly decreasing the dose and frequency [1].
SAMHSA goes further on supervision. It says managing this withdrawal is not recommended without medical supervision [2]. It says all of these drugs should be tapered rather than stopped abruptly, whatever the dose or duration of use, unless they have been taken for only a few days [2].
What a clinician needs from you is mostly history. SAMHSA lists the specific drug, the dose and how long it has been taken as vital [2]. Confirming the length of treatment with a pharmacy or the treating physician is useful [2]. Alcohol use matters, and so does the use of other sedatives [2]. So does any co-occurring psychiatric condition, such as panic disorder [2]. The assessment includes a physical exam, with attention to mental status, and a neurological exam [2].
Where the withdrawal happens is a clinical judgment. SAMHSA gives the rule of thumb. For patients who have used high doses over a long period, hospital care is always prudent [2]. Outpatient withdrawal should be reserved for people whose use stayed mainly within therapeutic ranges [2]. They should also not be dependent on several substances, and they need reliable people around them to help monitor progress [2]. Even then, SAMHSA says families have to be told that seizures and delirium are possible with sound treatment [2]. It says the person should not drive or use dangerous machinery during treatment, and perhaps for several weeks after [2]. Pregnant patients need to come off slowly, in consultation with an obstetrician [2].
If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental-health crisis call or text 988. Our guide to medical detox sets out what a supervised setting involves.
Treatment: Levels of Care and What the Evidence Supports
Start with what detox is, and what it is not. SAMHSA defines it as a set of interventions aimed at managing acute intoxication and withdrawal [4]. It has three parts, which can run together or in order: evaluation, stabilization, and fostering the patient’s entry into treatment [4]. Evaluation tests for substances and screens for other mental and physical conditions [4]. It also assesses the person’s medical and social situation, to decide what level of care should follow [4].
Then the sentence the field keeps having to repeat. A detox program is not designed to resolve the longstanding psychological, social and behavioral problems tied to alcohol and drug use [4]. Detoxification is not substance abuse treatment and rehabilitation [4]. NIDA puts the result plainly. Detox alone, without treatment after it, generally leads to a return to drug use [5].
What follows is a choice of setting rather than one program. Our guides to inpatient rehab and outpatient rehab describe what each asks of a week. Our guide to the levels of care sets out the five treatment levels.
The treatment itself is largely behavioral. NIDA names cognitive-behavioral therapy, which helps people recognize, avoid and cope with the situations where they are most likely to use [5]. It names contingency management, which rewards staying drug-free and attending sessions [5]. It also names motivational enhancement therapy and family therapy [5]. SAMHSA describes techniques used alongside a supervised taper in particular [2]. They work on negative beliefs about stopping the drug, and give other ways to reduce anxiety and improve sleep during withdrawal [2]. That last point matters most here. Sleep and anxiety are usually why the prescription started. Our pages on types of therapy and cognitive behavioral therapy explain the methods.
Where medicine has a defined role, NIDA names it. Its list of common medications used to treat drug addiction and withdrawal covers opioid, nicotine and alcohol use disorders [5]. Where no such medication is available for a drug, NIDA says treatment consists of behavioral therapies [5]. Our page on medication-assisted treatment sets out where medicine does have a role. For this class, the medicine question belongs to the prescriber running the withdrawal. Ask it directly rather than assuming the answer.
The underlying anxiety belongs in the plan, not after it. SAMHSA says a plan to manage an underlying anxiety disorder is one of the things that matters in detox [2]. So does starting during a period of low external stress, and the patient’s own commitment [2]. NIDA frames the same idea more broadly. Treatment should address the whole person, across medical, mental, social, occupational, family and legal needs [5]. If someone returns to use, NIDA’s position is that this does not mean treatment has failed [5]. It means talking to a doctor about resuming treatment, changing it, or trying another one [5]. Our page on how long rehab takes covers the length question. Our guide to the rehab process covers the shape of a week.
Paying for Treatment and Verifying Benefits
Our own cost page publishes ranges by level of care. They are our figures, not federal ones. It puts medical detox at $250 to $800 per day. It puts basic residential treatment at $2,000 to $20,000, and partial hospitalization at $350 to $450 per day. It puts intensive outpatient at $3,000 to $10,000 for a 30-day program. Read how much rehab costs for the rest, including what gets billed separately.
Insurance is the bigger variable. It is worth settling before the admissions call rather than after. What a plan pays depends on the plan, so the only reliable answer is a benefits check on your own policy. Our guide to insurance coverage for rehab explains how a plan usually treats a withdrawal stay and the care that follows it.
Then the practical steps. Our guide to the admissions process sets out what a facility needs before it can give you a date. Our treatment center directory has a map you can browse by state.
Frequently Asked Questions
Are benzodiazepines addictive if I take them as prescribed? They can be. The FDA’s position is that even at recommended dosages, use of these drugs can lead to misuse, abuse and addiction. It also says physical dependence can occur when they are taken steadily for several days to weeks, even as prescribed. Dependence is not the same as addiction. But it is the reason stopping is hard, and it is worth raising with a prescriber early.
Can benzodiazepine withdrawal kill you? It can. The FDA says stopping abruptly, or cutting the dosage too quickly, can cause withdrawal reactions including seizures, which can be life-threatening. SAMHSA adds that seizures may arrive with no other warning signs first, and that seizures and delirium are the most extreme forms of it. If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental-health crisis call or text 988.
How do I know if I need medical detox? A clinician decides that, and SAMHSA gives the shape of the judgment. Hospital care is always prudent for people who have used high doses over a long period. Outpatient withdrawal is reserved for people whose use stayed mainly in therapeutic ranges, who are not dependent on several substances, and who have reliable support around them. Bring the drug name, how long you have taken it, and any alcohol use to that conversation.
Is there a medication that treats benzodiazepine addiction? The medicine question belongs to the prescriber running your withdrawal. NIDA’s list of common medications used to treat drug addiction and withdrawal covers opioid, nicotine and alcohol use disorders. Where no such medication exists for a drug, NIDA says treatment consists of behavioral therapies. SAMHSA describes behavioral techniques used alongside a supervised taper to manage anxiety and sleep. Ask directly what role medicine plays in your plan.
Will insurance cover benzodiazepine treatment? Usually some of it. The only reliable answer comes from a benefits check on your own policy. What a plan pays depends on the plan, the level of care and whether the stay is authorized. Nobody can give you that number from a web page. Our own published ranges put medical detox at $250 to $800 per day and basic residential treatment at $2,000 to $20,000 before insurance.
Sources
- U.S. Food and Drug Administration. (2020). FDA Requiring Boxed Warning Updated to Improve Safe Use of Benzodiazepine Drug Class. U.S. Food and Drug Administration. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class
- Center for Substance Abuse Treatment. (2006). Detoxification and Substance Abuse Treatment, Chapter 4: Physical Detoxification Services for Withdrawal From Specific Substances — Benzodiazepines and Other Sedative-Hypnotics. Substance Abuse and Mental Health Services Administration. https://www.ncbi.nlm.nih.gov/books/NBK64116/
- U.S. Drug Enforcement Administration. Benzodiazepines Drug Fact Sheet. U.S. Drug Enforcement Administration. https://www.dea.gov/factsheets/benzodiazepines
- Center for Substance Abuse Treatment. (2006). Detoxification and Substance Abuse Treatment, Chapter 1: Overview, Essential Concepts, and Definitions in Detoxification. Substance Abuse and Mental Health Services Administration. https://www.ncbi.nlm.nih.gov/books/NBK64119/
- National Institute on Drug Abuse. (2020). Drugs, Brains, and Behavior: The Science of Addiction — Treatment and Recovery. National Institute on Drug Abuse. https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/treatment-recovery
This page is for general information and is not medical advice. Only a licensed clinician who
knows your history can tell you what is right for you. If you or someone you know is in
immediate danger, call 911. For free, confidential support 24/7, call or text 988.
Author
Chief Medical Officer,
The Recovery Village
