Resource D. Communication with patients

What are benzodiazepines?

Benzodiazepines are a group of prescription-only medicines that have a sedating and calming effect on the brain and nervous system. They are also known as sedatives or tranquillisers. Examples of benzodiazepines include medicines containing one of the following active ingredients: diazepam, lorazepam, oxazepam, temazepam and alprazolam.

They come in tablet and capsule form, and some are available for intravenous use in hospital settings.

How do benzodiazepines work?

Benzodiazepines differ in how quickly the active ingredient starts to work and how long the effect lasts. The effect of the medicine also depends on the prescribed dose, and on the individual (eg height, weight, health status and previous experience with benzodiazepines), which can impact on how the medication will work.

Benzodiazepines can help treat symptoms of anxiety and sleeping problems (eg insomnia). As non-medicine therapies have proven benefit in these conditions, benzodiazepines are generally considered only if these options are inappropriate or have failed.

If you have been diagnosed with an anxiety disorder, benzodiazepines can make you feel calmer. If you have insomnia, benzodiazepines may help you fall asleep. They are sometimes used for other reasons, such as a medication before an operation to alleviate nervousness.

After taking benzodiazepines, people can describe feeling drowsy, relaxed, confused/fuzzy and having a heavy sensation in their arms and legs. Coordination and reflexes can be effected too, which means you should not take benzodiazepines if you need to be focused and coordinated (eg drive a car or operate heavy machinery).

Benzodiazepines are usually taken for a set period until the intended therapeutic effect is achieved. Then, the dose is reduced and plans to stop it are made.

If you take benzodiazepines for a prolonged time, the body may adapt and get used to the effects of the medication. Stopping the medication can lead to withdrawal symptoms that includes anxiety and restlessness. Withdrawal symptoms are often mild, but can be severe if you are on high doses of a benzodiazepine. Serious side effects, including seizures, can occur if you stop taking high doses suddenly.

Can benzodiazepines be addictive?

Although addiction (cravings, abuse, misuse, compulsive or uncontrollable benzodiazepine-seeking behaviour) is possible with benzodiazepines, it is rare in people who are taking therapeutic doses for a specific reason over a short period as prescribed by their doctor.

You may be at a greater risk of developing an addiction to benzodiazepines if you have a history of drug dependence, or if you are currently misusing any substance including alcohol or strong pain killers (opioid drugs).

Before prescribing a benzodiazepine, your doctor will ask you questions about these sorts of things to help prevent addiction.
 

What are the possible side effects of benzodiazepines?

Benzodiazepines are associated with a number of side effects including:

• drowsiness and unsteadiness, potentially increasing the risk of a fall 
• mpairment in judgement and dexterity, making tasks such as driving or using heavy machinery more difficult
• forgetfulness, confusion, irritability
• paradoxical aggression and excitability (although this is rare, it is the opposite effect to what is expected with these medicines).

Taking benzodiazepines in combination with other drugs or alcohol can be very dangerous, and in some cases fatal.

Can I take benzodiazepines for a long time?

Benzodiazepines are usually taken for a short length of time. In rare instances, some patients will require long-term therapy with benzodiazepines. This is after a serious consideration of risks and benefits of long-term therapy between you and your doctor. If you and your doctor have decided that benzodiazepines are an important part of your long-term treatment, then you should continue to take them as prescribed and keep checking in with your doctor for review.

If you have been taking benzodiazepines regularly for longer than 4 weeks and wish to stop them, your doctor would be happy to advise you on how to do this. Do not stop or significantly alter the dose abruptly. Many people can stop taking benzodiazepines without difficulty. For others, gradual reduction helps prevent or reduce any withdrawal symptoms.

Where can I get more information?

Reconnexion, an Australian not-for-profit organisation that offers programs, counselling, telephone information and support for people with anxiety, stress, depression and benzodiazepine dependence and related conditions.
• The Victorian Government’s Better Health Channel website
• The Australian Drug Foundation’s help and support page lists sources of information and advice.

* Kenny T, Harding M. Benzodiazepines and Z Drugs [Internet]. London: patient.co.uk; 2014 [updated October 2014]. [Accessed 11 June 2015].

How would I benefit by stopping benzodiazepines?

People who have been on long-term benzodiazepines often feel like they need to stay on them. This may be because of fears about returning symptoms of anxiety or sleeplessness, or due to withdrawal symptoms or needing the medication to feel normal.

While you might feel ‘normal’ when you take benzodiazepines, studies have found people who stopped taking them have:

• improved memory and reaction times
• increased levels of alertness
• improved quality of life (more vitality, better ability to function).

Stopping benzodiazepines also reduces your risk of falls, accidents, fractures and other injuries.

How should I stop taking benzodiazepines?

The best place to start is by talking to your general practitioner (GP). Some people can stop quickly and easily; others need a more gradual approach with additional support. Your GP can advise you on the rate at which you should reduce the dose and help you to consider other ways of dealing with your worries or sleeping problems. Sometimes your GP will change your prescription to a different benzodiazepine before withdrawing.

If you are taking other addictive medicines, in addition to benzodiazepines, you may need specialist help to come off the various medicines. Your GP will be able to advise you or refer you to local services that can help.

Some tips for withdrawing from benzodiazepines:

• Choose when to start reducing – If you have been taking benzodiazepines to help you cope with a personal crisis, it may be advisable to wait until things settle down before starting to reduce the dose. Consider starting while on holiday, when you have less pressure from work, fewer family commitments or less stress.
• Do not try to stop suddenly – Unless your GP has advised you to do so. You should reduce your medication in a slow, gradual process, as this often gives a better chance of long-term success. You can go as slowly as you need to.
• Do not increase the dose – It is common to have a bad patch at some time during the withdrawal.

You might be tempted to go back to the higher dose, but it is best to stick with the current dose. Don’t consider a further reduction until you feel ready; this may take several weeks.

• Get help and support – Consider asking family or friends for encouragement and support, or consider joining a self-help group. Advice and support from other people in similar circumstances, or those who have come off a benzodiazepine, can be very encouraging.
• Keep a record – Keeping a diary can help as it records your progress and achievements. This in itself will give you more confidence and encouragement to carry on.

How do I cope with withdrawal symptoms?

Not everyone experiences the same degree or type of symptoms when withdrawing from benzodiazepines. The best way to cope is to go slowly to minimise the withdrawal symptoms. It can also help to know what to expect and know that these will pass.

• Panic attacks commonly occur due to the effects of adrenaline and rapid, shallow breathing (hyperventilation). When this happens, you may experience palpitations, sweating, unsteady legs and trembling. Regaining control of your breathing can help to alleviate the symptoms.
• Anxiety is also common upon withdrawal, especially if dose reduction is not gradual enough.
• Agoraphobia can present in a range of forms from a reluctance to go out in public to feeling completely unable to do so. However agoraphobic feelings usually lessen as withdrawal continues.
• Aches and pains are very common during withdrawal.
• Problems with sleeping can occur during withdrawal. Strategies such as ensuring enough exercise during the day, resolving concerns before bedtime and not trying to force sleep can help.
• Stomach and bowel problems such as diarrhoea and irritable bowel syndrome are very common during withdrawal and can be very distressing. Your GP may be able to recommend a diet and indigestion remedies that can improve these symptoms, which usually disappear after withdrawal is complete.
• Hot flushes and shivering are also common.
• Sinus problems are experienced by many people as they withdraw.
• Vivid dreams and nightmares are another common occurrence during withdrawal. However this may in fact be a good sign, as it can indicate your sleep and your body are re-adjusting to normal.

Where can I get some more information and help?

Reconnexion, an Australian not-for-profit organisation that offers programs, counselling, telephone information and support for people with anxiety, stress, depression and benzodiazepine dependence and related conditions.

*  Kenny T, Harding M. Stopping Benzodiazepines and Z Drugs [Internet]. London: patient.co.uk; 2014 [updated October 2014].  [Accessed 11 June 2015]. 
Welsh Medicines Partnership. Educational pack – Material to support appropriate prescribing of hypnotics and anxiolytics across Wales. Wales: Welsh Medicines Partnership; 2011. Available at [Accessed 12 June 2015].

Sleep hygiene

Good sleep hygiene refers to actions you can take to improve and maintain good sleep. These actions include:

• Sleep as long as necessary to feel rested (usually 7–8 hours for adults), then get out of bed.
• Maintain a regular sleep schedule.
• Try not to force sleep.
• Avoid caffeinated beverages after lunch.
• Avoid alcohol near bedtime (late afternoon and evening).
• Avoid smoking or other nicotine intake, particularly during the evening.
• Adjust the bedroom environment as needed to decrease stimuli (eg reduce ambient light, turn off the television or radio).
• Resolve concerns or worries before bedtime.
• Exercise regularly for at least 20 minutes, preferably more than 4–5 hours prior to bedtime.
• Avoid daytime naps, especially if they are longer than 20–30 minutes or occur late in the day.
• Avoid going to bed until you are drowsy and ready to sleep.
• If you are not asleep within 15–20 minutes, get out of bed and return only when drowsy.

Stimulus control

People with insomnia may associate their bed and bedroom with the stress of not sleeping, rather than the more pleasurable anticipation of sleep. The longer you stay in bed trying to sleep, the stronger the association becomes. This perpetuates the difficulty of falling asleep.

Stimulus control therapy is designed is to disrupt this association by enhancing the likelihood of sleep. Your sleep may not improve immediately. However, sticking with this should improve your ability to get to sleep.

Stimulus control instructions

• Go to bed only when sleepy.
• Get out of bed if unable to sleep after 15–20 minutes, leave the bedroom and do something relaxing (eg reading or listening to soothing music). Avoid stimulating activities such as eating or watching TV. Return to bed only when sleepy. (Repeat as necessary.)
• Use the bed/bedroom only for sleep (not reading, watching TV or worrying).
• Arise at the same time each day (including weekends).
• Do not take naps during the day.

Sleep restriction therapy

Some people with insomnia stay in bed longer to try to make up for lost sleep. This causes a shift in your day/night cycle. It makes sleep onset the following night more difficult and results in the need to stay in bed even longer.

Sleep restriction therapy limits the total time allowed in bed, including naps and other sleep periods outside of bed, in order to increase your drive to sleep and improve the efficiency of your sleep.

Sleep restriction therapy begins by decreasing the time you spend in bed to the same amount of time that you actually sleep (usually this is determined from a sleep diaries or logs), but not less than 5 hours per night.

On a daily basis, you record the amount of sleep obtained the previous night and the amount of time spent in bed. Once you are spending more than 85% of the time in bed asleep, you increase the time spent in bed (by 15–30 minutes).

You repeat this process until you achieve improved sleep without residual daytime sleepiness.

Naps are not permitted.

Relaxation

You may implement relaxation therapy before going to sleep. There are two common techniques for relaxation therapy:

• Progressive relaxation is based upon the theory that you can learn to relax one muscle at a time until the entire body is relaxed. Beginning with the muscles in your face, you contract the muscles gently for 1–2 seconds and then relax. You repeat this several times. Use the same technique for other muscle groups, usually in the following sequence: jaw and neck, upper arms, lower arms, fingers, chest, abdomen, buttocks, thighs, calves and then feet. Repeat this cycle for approximately 45 minutes, if necessary.
• The relaxation response begins by lying or sitting comfortably. Close your eyes and allow relaxation to spread throughout your body. Use relaxed, abdominal breathing and redirect your thoughts away from everyday worries and toward a something like a peaceful word or image.¹⁰⁸