What benzodiazepines are
Benzodiazepines are a class of sedative medicines. The FDA explains that they slow brain activity by acting on GABA receptors, which produces drowsy or calming effects. They are approved to treat generalized anxiety disorder, panic disorder, social phobia, insomnia and seizures, and are also used before some medical procedures. Common names include alprazolam (Xanax), clonazepam (Klonopin), diazepam (Valium) and lorazepam (Ativan).
Cleveland Clinic notes that in the U.S. they are controlled substances: you need a prescription, and prescriptions are monitored. In Michigan, the Department of Licensing and Regulatory Affairs runs MAPS, the state's prescription monitoring program, which tracks controlled-substance prescriptions dispensed in or into Michigan. Prescribers and pharmacists use it to assess patient risk, so a prescriber checking it is routine, not a judgment about you.
What they can do well
Their main advantage is speed. NIMH notes that benzodiazepines begin working right away and can be very effective at rapidly decreasing anxiety and panic symptoms. For someone in a severe stretch, or facing a specific short-term situation, that relief can matter.
The medicines differ in how quickly they start and how long they last. Cleveland Clinic explains that stronger, short-acting benzodiazepines are usually used for short-term or emergency situations, while lower-strength, longer-acting ones are more often used for ongoing, non-emergency conditions. That is one reason two people with anxiety may be offered different drugs, or different instructions about when to take them.
They are usually not the long-term plan. NIMH says some people build up tolerance and need higher doses for the same effect, some become dependent, and providers therefore usually prescribe them for brief periods and taper slowly. For ongoing anxiety, NIMH notes providers typically start with SSRIs or other antidepressants, and buspirone is another option that can be used over longer periods. Therapy, Medication or Both for Anxiety? compares the choices.
What the FDA boxed warning says
In September 2020 the FDA required the boxed warning, its most prominent warning, to be updated for every benzodiazepine. It now covers the risks of abuse, misuse, addiction, physical dependence and withdrawal reactions. Key points from the FDA:
- Even at recommended doses, use can lead to misuse, abuse and addiction.
- Physical dependence can develop when benzodiazepines are taken steadily for several days to weeks, even exactly as prescribed.
- Stopping abruptly or cutting the dose too fast can cause withdrawal reactions, including seizures, which can be life-threatening. Some people have had withdrawal symptoms lasting many months.
- Overdose and death are more likely when benzodiazepines are combined with opioid pain or cough medicines, alcohol or illicit drugs. The FDA advises not drinking alcohol while taking them.
MedlinePlus's information on alprazolam adds that it can cause serious or life-threatening breathing problems, sedation or coma when used with certain cough or pain medicines, and that it may be habit-forming. Other benzodiazepines carry similar warnings.
Everyday side effects and safety
The FDA lists drowsiness, dizziness, weakness and slowed breathing as common side effects. Cleveland Clinic adds several practical cautions:
- Driving and work: benzodiazepines slow reflexes, so ask your prescriber whether and when it is safe to drive or use machinery.
- Falls: people with balance or movement problems may be more prone to falls.
- Pregnancy: they are generally avoided during pregnancy or when trying to conceive, though providers may still recommend them when options are limited.
- Follow-up: expect regular visits while you take them.
The FDA also recommends locking benzodiazepines up, disposing of unused pills properly and reading the Medication Guide every time you fill a prescription, since the information can change.
Coming off a benzodiazepine
If you have taken a benzodiazepine for weeks or months, the FDA says do not stop suddenly. Work out a plan with your prescriber to reduce the dose gradually. The FDA notes there is no single tapering schedule that suits everyone, so the plan should be individual, with monitoring and support. Even with a slow taper, withdrawal symptoms can occur, such as anxiety, insomnia, irritability, memory problems, muscle pain, panic attacks and tremors. Contact your prescriber if they appear or if your anxiety worsens. Seizures, hallucinations, or thoughts of harming yourself or someone else need urgent care.
Returning anxiety during a taper does not always mean you need the medicine indefinitely, and it does not mean you failed. Your prescriber can pause or slow the taper. Some people find therapy support for the anxiety itself helpful during this stage.
Questions to ask your prescriber
- Why this medicine, and why now? What is the plan for how long I take it?
- Should I take it daily or only in specific situations?
- Which of my other medicines, including sleep aids and pain or cough medicines, interact with it?
- Is it safe for me to drive or drink any alcohol?
- If I want to stop someday, how would a taper work, and what symptoms should I report?
- What longer-term treatment would you suggest alongside it?
How therapy fits
The FDA notes that treatments other than benzodiazepines may help with conditions such as stress, anxiety and insomnia. Psychotherapy is one of the main ones. Dr. Lehmann is a licensed clinical psychologist and does not prescribe; anxiety therapy with her can work alongside your prescriber's plan, including during a taper. If you also have panic attacks, How to Get Through a Panic Attack offers steps to use in the moment.