One thing has to be said before anything else. Benzodiazepine and sedative withdrawal can kill, which is the reason this page never tells anyone to cut down or stop. Unlike alcohol and sedative withdrawal, uncomplicated opioid withdrawal is not life-threatening [4], and that contrast is the whole point: the sedative class sits on the dangerous side of it. That is not a claim that opioid withdrawal is safe. Withdrawal reduces a person’s tolerance to the drug, so someone who has just gone through it can overdose on a much smaller dose than before [6]. Changing a benzodiazepine prescription is a medical procedure, arranged with the prescriber.
If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental health crisis, or for thoughts of suicide, call or text 988. Veterans can reach the Veterans Crisis Line by calling 988 and pressing 1.
With that settled, the rest of this page is about the pairing. People with PTSD often have co-occurring conditions, such as depression, substance use, or anxiety disorders [1]. A benzodiazepine prescribed for sleep or panic after a traumatic event is one of the ordinary ways that overlap begins, and it is not a moral failure on anyone’s part.
What follows: why the order of arrival is less useful than it sounds, how trauma symptoms and sedative use hold each other in place, what the assessment weighs, what treating both at once looks like, and what the plan after discharge has to cover. Our hub on co-occurring disorders covers the wider category.
Which came first, and why the answer matters less than people think
With this pairing the sequence is usually visible, and it still does not decide the plan.
People may be diagnosed with post-traumatic stress disorder if their symptoms last for an extended period after a traumatic event and begin to interfere with aspects of daily life, such as relationships or work [1], and the prescription frequently comes after that, for sleep or for panic. So the order is often known. What it does not tell anyone is which problem to treat first, because by the time someone is reading this the answer is both.
There is also a quieter route in, and NIMH names it. Previous exposure to adversity and other traumatic experiences, especially in childhood, can increase a person’s chance of developing PTSD later in life [1]. Stress, trauma and genetics also push people toward substance use disorders [2]. Shared roots produce two conditions without either one causing the other.
Most people who live through a traumatic event do not develop PTSD [1]. That matters for a reader who is trying to work out whether what they are experiencing counts. It is a question for an assessment, not for a checklist on a website.
How PTSD and substance use reinforce each other
Sedatives work on exactly the symptoms trauma produces, which is the problem.
After a traumatic event, feeling anxious, sad, or angry, and having trouble concentrating and sleeping, are common reactions [1]. A medication that quiets those symptoms is doing what it was prescribed to do. The difficulty is what happens over months: the body adapts, the same dose does less, and the symptoms it was holding down come back louder between doses.
At that point the two conditions are hard to tell apart. Substance use can lead to changes in some of the same brain areas that are disrupted in other mental disorders, such as schizophrenia, anxiety, mood, or impulse-control disorders [3]. The arousal symptoms of PTSD and the rebound symptoms of sedative dependence look alike from the outside and feel alike from the inside.
And avoidance, which is part of the trauma picture, works against treatment for both. Trauma-focused therapy is not comfortable, and a medication that makes discomfort disappear is a ready-made reason to postpone it.
If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental health crisis, or for thoughts of suicide, call or text 988. Veterans can reach the Veterans Crisis Line by calling 988 and pressing 1.
A supervised place to start, in Georgia
Promises Atlanta, in Dacula, Georgia, publishes medical detox, residential rehab and aftercare planning, and describes itself as a place for people with substance use disorders and co-occurring mental health conditions. Its own what-to-expect page says medical detox there is offered on a case-by-case basis, so ask about it on the first call. Say on the first call that a benzodiazepine is involved, because sedative withdrawal changes what level of care is appropriate.
See treatment options in Georgia
Verify your insurance
Promises Atlanta is part of our family of treatment centers. See the Promises Atlanta campus.
Why treating one without the other usually fails
Each half-treatment fails in its own direction, and one of them is dangerous.
Treat the trauma and leave the sedative dependence alone, and the therapy competes with a chemistry that is still changing week to week. Treat the dependence without the trauma, and the symptoms the medication was managing arrive with nothing in their place. NIDA’s general finding applies squarely here: it is usually better to treat these health issues at the same time rather than separately, and research suggests this can make all the treatments more effective [3].
Integrated care combines mental health and substance use treatment so patients can receive more convenient, coordinated care [2]. In this pairing that has a specific meaning. A prescriber managing the medication and a trauma clinician doing the therapy have to be working from one plan, because a change on either side moves the other.
People who have co-occurring disorders often have symptoms that are more persistent, severe, and resistant to treatment [3]. That is a reason to expect the work to take time, not a reason to expect it to fail.
Assessment: separating substance-induced symptoms from an independent disorder
The assessment has a safety half and a diagnostic half, and the safety half comes first.
Accurate diagnosis is key for treating co-occurring substance use and mental disorders, since symptoms may overlap [2]. Insomnia, hypervigilance, irritability and panic all belong to PTSD and all belong to sedative dependence between doses. A clinician works with the history: what was happening before the prescription, what changed after it, and what happens in the hours before the next dose is due.
The safety half is not a matter of opinion. Alcohol and sedative withdrawal can produce seizures and delirium, and TIP 45 puts both on the side of withdrawal that can be fatal [4]. That is why the sequence here is examination first, plan second, and why nothing on this page is a schedule. We publish no doses, no reduction rates and no day-by-day plan, because a person acting on one alone is the exact risk this section exists to prevent.
If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental health crisis, or for thoughts of suicide, call or text 988. Veterans can reach the Veterans Crisis Line by calling 988 and pressing 1.
Our explainers on medical detox and withdrawal symptoms describe what supervision involves.
Integrated dual diagnosis treatment, level by level
The medical stage is longer here than people expect, and the trauma work starts later.
Where withdrawal management is indicated, it is medical, monitored and not hurried. Trauma-focused therapy during that stage is generally not the priority, for the practical reason that the nervous system is not in a state to do it.
Inpatient rehab is where the two strands are supposed to be braided together by one team. That is the integrated care NIMH describes, delivered in one place [2]. This is the stage worth interrogating when comparing programs. Ask who manages the medication, who does the trauma work, and how often those two people speak about the same person.
Step-down and outpatient care is where most of the trauma treatment actually happens, because it needs continuity more than it needs intensity. Our guide to levels of care explains how the rungs relate to one another.
Medication considerations when both are present
Two prescribing decisions, both belonging to clinicians who have examined the person.
NIMH funds research aimed at more effective medications, psychotherapies and device-based treatments for trauma survivors [1], which is a statement about where the evidence is going rather than a list of what a program will offer. What NIMH does state plainly is that medications can effectively treat addictions to opioids and alcohol and lessen the symptoms of many other mental disorders [2]. Treatment for a co-occurring presentation may include medications, psychosocial interventions, or a combination, depending on the needs of the individual and the substance or substances involved [3].
What this page will not do is compare medications, suggest one, or describe how a prescription might be changed. Those decisions require an examination, a history and a relationship with a prescriber, and in the sedative class getting them wrong has consequences that are not reversible by reading a better website.
The useful preparation is administrative. Bring every current prescription and the name of whoever wrote it. Say how long the benzodiazepine has been prescribed and whether the amount taken matches the amount written. That second question is the one people dread and the one the plan most depends on. Our page on medication assisted treatment covers how medication sits alongside therapy.
Therapies with evidence for co-occurring presentations
The named approaches are unglamorous and the sequencing is the skill.
Cognitive behavioral therapy, contingency management, and motivational interviewing can help individuals build coping skills [2]. Family-based interventions, such as Multisystemic Therapy and Functional Family Therapy, can be particularly effective [2]. For trauma specifically, NIMH’s own statement is about its research program: it funds work toward more effective medications, psychotherapies and device-based treatments for trauma survivors [1].
Sequencing is where the judgment sits. Trauma-focused work asks someone to approach memories they have spent years avoiding, and doing that while the medication picture is still unstable can be counterproductive. A good plan says when the trauma work starts and what has to be true first. Our overviews of substance abuse counseling techniques and dialectical behavior therapy describe what those sessions involve.
Relapse risk and what aftercare needs to cover
The risk here is not only a return to use. It is a return to use without supervision.
Symptoms that are more persistent, severe and resistant to treatment [3] mean the months after an intensive stay carry real weight. Sleep is usually the pressure point. Trauma disrupts it [1], the medication used to solve it, and a bad run of nights is where people reach for something.
So the plan has to be specific and written down. The prescriber, named, with an appointment already booked. The trauma clinician, named, with the first session already in the calendar. A person to call at 3am. A worked-out response for a night of no sleep that does not involve finding a tablet. And the crisis numbers written somewhere findable, because a trauma response does not keep office hours [1].
Anyone in this position should also know that a return to use is information, not a verdict. It changes the plan. Our page on how to get into rehab sets out what the first call involves.
Frequently Asked Questions
Why is stopping a benzodiazepine suddenly dangerous? Because sedative withdrawal sits on the dangerous side of the line. TIP 45 draws the contrast directly: unlike alcohol and sedative withdrawal, uncomplicated opioid withdrawal is not life-threatening. That does not make opioid withdrawal safe: it reduces tolerance, so a dose that used to be ordinary can be fatal afterwards. Seizures and delirium are the outcomes that make the difference for the sedative class. Any change to a benzodiazepine prescription is arranged and supervised by the prescriber, and this page publishes no schedule for doing it. If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental health crisis, call or text 988.
Will my PTSD medication change in treatment? That depends on an examination, not on a policy. NIMH funds research aimed at more effective medications, psychotherapies and device-based treatments for trauma survivors, and separate medications treat substance use disorders, so the usual outcome is one plan holding both rather than a trade between them. Bring every prescription and prescriber detail to the assessment so nothing is decided from an incomplete list.
Does treating the PTSD make the substance use easier to treat? That is the case for doing both at once. NIDA reports that it is usually better to treat co-occurring conditions at the same time rather than separately, and that research suggests this can make all the treatments more effective. Keep the hedge in that sentence; it says the treatments work better together, not that either one becomes easy. Integrated care exists so the two halves are not working against each other.
Do I need a psychiatrist as well as a counselor? In this pairing, usually yes, and they need to be talking. Prescribing in the sedative class is a medical decision that should not sit with the therapist, and trauma-focused therapy is not something a prescriber does in a fifteen-minute review. Integrated care combines mental health and substance use treatment in one coordinated place. Ask any program how those two roles communicate and how often.
Does insurance cover treatment for PTSD and substance use together? Usually in some form, though the plan decides the detail. Marketplace policies must include mental health and substance use services among the essential health benefits, and cannot apply yearly or lifetime dollar limits to that care. Authorization still depends on the policy, the employer and the level of care. Marketplace plans must also provide parity protections, so limits on this care cannot be more restrictive than the limits on medical and surgical care. Those limits include care management, such as being required to get authorization of treatment before getting it. We claim no network status with any carrier, so check your own member ID before admission.
Sources
- National Institute of Mental Health. Traumatic Events and Post-Traumatic Stress Disorder (PTSD). National Institutes of Health. https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd
- National Institute of Mental Health. Finding Help for Co-Occurring Substance Use and Mental Disorders. National Institutes of Health. https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health
- National Institute on Drug Abuse. Co-Occurring Disorders and Health Conditions. National Institutes of Health. https://nida.nih.gov/research-topics/co-occurring-disorders-health-conditions
- Center for Substance Abuse Treatment (2006). Detoxification and Substance Abuse Treatment, TIP 45, Chapter 4: Physical Detoxification Services for Withdrawal From Specific Substances. SAMHSA, NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK64116/
- HealthCare.gov. Mental health and substance abuse health coverage options. US Centers for Medicare and Medicaid Services. https://www.healthcare.gov/coverage/mental-health-substance-abuse-coverage/
- MedlinePlus. Opiate and opioid withdrawal. U.S. National Library of Medicine, National Institutes of Health. https://medlineplus.gov/ency/article/000949.htm
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
