Alcohol Withdrawal Medication: Who Are Benzodiazepines Right For?
In 2019, outpatient pharmacies in America dispensed 92 million benzodiazepine prescriptions. For many, this class of medication offers relief from symptoms of anxiety, insomnia, and alcohol withdrawal. A benzodiazepine is a common choice by physicians for alcohol withdrawal medication. When used as an adjunct to other therapies, benzodiazepines can be a valuable piece to a comprehensive addiction treatment plan.1
In this Article:
- What Are Benzodiazepines?
- How Are Benzodiazepines Used to Treat Alcohol Use Disorder?
- What’s The Difference Between Short– and Long-Acting Benzodiazepines?
- How Do Benzodiazepines Help with Alcohol Withdrawal?
- Who Can Benefit from Benzodiazepines as Alcohol Withdrawal Medication?
- Who Should Not Take Benzodiazepines for Alcohol Withdrawal?
- What Are the Potential Side Effects of Benzodiazepines?
- How Are Benzodiazepines Administered for Alcohol Withdrawal?
- What Combinations and Alternatives of Alcohol Withdrawal Medication Are Used?
- How to Start Alcohol Withdrawal Medication Treatment
What Are Benzodiazepines?
The American Psychological Association defines benzodiazepines as a drug introduced in the 1960s and became a drug to replace barbiturates, a drug seen in numerous overdoses of recreational users.
How Are Benzodiazepines Used to Treat Alcohol Use Disorder?
Treatment for alcohol use disorder happens in stages, starting with medical detox to manage withdrawal symptoms.
Symptoms of withdrawal can range from mild to severe, from uncomfortable to unbearable. Reports state there are risk factors that make it more likely you will have severe withdrawal symptoms, including:3
- Previous history of severe withdrawal symptoms
- Co-morbid medical diagnoses
- Number of years with alcohol use disorder or alcohol misuse
- Age-related changes
- Physical problems such as dehydration, electrolyte imbalance, and unusual liver enzyme count
Physicians in many treatment facilities provide supervised medical detox. They utilize medicines such as benzodiazepines to alleviate withdrawal symptoms.
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What’s The Difference Between Short– and Long-Acting Benzodiazepines?
Doctors treat withdrawal symptoms by assessing individuals’ medical, psychological, and biological factors. They determine if short–, intermediate–, or long-acting benzodiazepines are more likely to address the person’s specific needs.
Short-acting means the effects of the drug will last for a short period, usually no longer than 12 hours. The half-life of long-acting medicine can last for two or three days.4
Common short-acting benzodiazepines include:5
- Alprazolam (Xanax)
- Triazolam (Halcion)
- Oxazepam (Serax)
- Midazolam (Versed)
Intermediate-acting benzodiazepines include: 5
- Temazepam (Restoril)
- Lorazepam (Ativan)
- Clonazepam (Klonopin)
Common long-acting benzodiazepines include:5
- Chlordiazepoxide (Librium)
- Clorazepate (Tranzene)
- Diazepam (Valium)
- Flurazepam (Dalmane)
How Do Benzodiazepines Help with Alcohol Withdrawal?
Benzodiazepines depress the central nervous system by enhancing the sedating and hypnotic effects of the neurotransmitter GABA. It decreases electrical activity in the brain. GABA neurotransmitters are the most common in the central nervous system and inhibit all other neurotransmitters from becoming over-active or too excited.4
Physicians prescribe benzodiazepines to prevent alcohol withdrawal symptoms such as anxiety, panic attacks, insomnia, seizures, tremors, muscle tension or spasm, and delirium tremens.6
Benzodiazepines are available in various forms, including tablets, capsules, syrup, and injectables. A doctor may administer the medicine through an IV in a hospital setting for alcohol medical detox. How quickly medicine takes effect depends on the route of administration. How long medicinal effects last depends on the properties of the drug, the amount, and your body’s metabolism.4
Who Can Benefit from Benzodiazepines as Alcohol Withdrawal Medication?
Certain people make better candidates than others to treat alcohol withdrawal symptoms with benzodiazepines. Those who can benefit the most are those who:7
- Have a diagnosable anxiety disorder, such as panic disorder or social anxiety, that would interfere with their ability to participate in recovery treatment
- Have trouble falling asleep or staying asleep or not sleeping for long periods
- Have withdrawal symptoms such as agitation, insomnia, tremors, seizures, or convulsions
- Have post-traumatic stress disorder (PTSD) symptoms
Who Should Not Take Benzodiazepines for Alcohol Withdrawal?
Warnings for doctors regarding benzodiazepines as alcohol withdrawal medication include considering other medication for patients who:8
- Are pregnant or breastfeeding
- Are allergic to any of the ingredients of the medicine
- Are taking other central nervous system depressants, including illicit use
- Have respiratory illness or disease
- Have certain medical problems such as liver or kidney disease
- Have a nervous system disorder
- Have severe depression or suicidal ideation
- Are elderly
Benzodiazepines are also contraindicated for anyone taking them for another condition or taking other medication for alcoholism.
What Are the Potential Side Effects of Benzodiazepines?
All drugs, including benzodiazepines, have the potential for adverse effects. Some who are taking the medication for alcoholism will not have any side effects. Many factors other than the drug play a role in how it reacts with the body. A few examples are allergies, underlying medical conditions, and interactions with other medicines.
Some of the most common side effects of benzodiazepines include:9
- Breathing issues
- Impaired motor skills
- Drop in blood pressure that may cause a loss of consciousness
- Digestive problems
There are contraindications or times when taking benzodiazepines could result in dangerous or toxic reactions. For example, during pregnancy taking benzodiazepines could lead to congenital malformations.9
More severe, yet rare, side effects can occur with benzodiazepine toxicity. Complications can lead to:10
- Food, saliva, liquids, or vomit is breathed into the lungs rather than into the stomach, also called aspiration pneumonia
- Respiratory arrest
- A breakdown of muscle tissue that leaks proteins that can damage kidneys into the blood is also called rhabdomyolysis.
Fortunately, there is a medicine that can reverse the adverse effects of benzodiazepines, flumazenil if toxicity or overdose occurs.10
How Are Benzodiazepines Administered for Alcohol Withdrawal?
Benzodiazepines are a top choice medicine when treating severe alcohol withdrawal symptoms.
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Doctors administer medication for alcoholism in one of three treatment regimens, including fixed-dose, loading dose, and symptom-triggered dose. Doctors calculate doses using the average daily alcohol intake and the current withdrawal symptoms.
Fixed-Dose Treatment Regimen
Medical staff breaks the total dose into four smaller amounts with fixed-dose treatments. For example, if a doctor prescribed 40mg benzodiazepines a day, the doses are given in 10mg doses four times a day.
Once symptoms subside, the doctor uses a tapering-off method for a week or longer to avoid any withdrawal symptoms from the benzodiazepine. This regimen is helpful in outpatient or inpatient treatment settings. 11
Loading-Dose Treatment Regimen
Loading-dose regimens involve doctors administering long-acting benzodiazepines in two-hour intervals. Close monitoring by medical staff includes checking the severity level of withdrawal symptoms. This regimen works best in an inpatient environment.
Reports indicate this type of treatment reduces complications and the amount of benzodiazepines needed for alcohol withdrawal during medical detox.11
Symptom-Triggered Treatment Regimen
Monitoring trigger symptoms of alcohol withdrawal should take place in an inpatient medical detox. As triggers occur, medical staff administer benzodiazepines. This method can decrease a person’s time in medical detox.
However, if someone has a history of seizures or other complications of medical detox, this regimen is considered too high-risk for potential seizure activity.11
What Combinations and Alternatives of Alcohol Withdrawal Medication Are Used?
Alcohol use disorder often co-occurs with other conditions, including medical and psychological conditions. Combining or substituting medicines can potentially address these concerns more holistically than the typical first-line treatments for either condition.
While benzodiazepines are considered one of the best choices for alcohol withdrawal medication, there are other options. For example, tricyclic antidepressants can be combined with benzodiazepines to reduce negative symptoms related to mood. Prescribing benzodiazepines with anti-anxiety and antidepressant medication for alcoholism can boost serotonin production.12
Other medicines used with benzodiazepines or in place of them include:3
- Acamprosate—Acamprosate is an FDA-approved medication for alcoholism that reduces cravings.
- Anticonvulsants—Certain anticonvulsants help regulate brain activity during medical detox.
- Opioid antagonists—Opioid antagonists are used to help those detoxing from opioid misuse.
- Barbiturates—Barbiturates work similarly to benzodiazepines and may be used when benzodiazepines are contraindicated.
- Beta-blockers—Beta-blockers are sometimes used for acute anxiety or sleep issues and may be used in place of benzodiazepines.
- GABA agonists—GABA agonists are typically prescribed to assist with sleep issues and seizures.
- Antipsychotics—In low doses, some antipsychotics may be useful in medical detox.
Nutritional therapy may also be part of medical detox and addiction treatment. For example, lack of thiamine, or vitamin B1, leads to cognitive impairments. Because many people with alcohol use disorder are vitamin B1 deficient, replacing it is crucial.12
How to Start Alcohol Withdrawal Medication Treatment
Treatment for alcohol withdrawal using benzodiazepines and any other medicinal combinations should always be under the supervision of a board-certified physician or psychiatrist. You should never try to withdraw from alcohol using benzodiazepines on your own.
- U.S. Food and Drug Administration. (2020, September 23). FDA Requiring Labeling Changes for Benzodiazepines.
- American Psychological Association. (2020). Benzodiazepines. ADA Dictionary of Psychology
- Sachdeva, A., Choudhary, M., & Chandra, M. (2015). Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond. Journal of Clinical and Diagnostic Research: JCDR, 9(9), VE01-VE07.
- Griffin, C. E., 3rd, Kaye, A. M., Bueno, F. R., & Kaye, A. D. (2013). Benzodiazepine Pharmacology and Central Nervous System-Mediated Effects. The Ochsner Journal, 13(2), 214-223.
- Hoxha, S. (2018). Pharmaceutical Mnemonics. Pharmwar.
- U.S. Drug Enforcement Administration. (2019). Benzodiazepines.
- Guina, J., & Merrill, B. (2018). Benzodiazepines I: Upping the Care on Downers: The Evidence of Risks, Benefits, and Alternatives. Journal of Clinical Medicine, 7(2), 17.
- Pfizer Pharmaceutical. (2021). Xanax XR, Alprazolam Extended-Release.
- Bounds, C.G. & Nelson, V.L. (2020). Benzodiazepines. Treasure Island (FL): StatPearls Publishing.
- Kang, M., Galuska, M.A., & Ghassemzadeh, S. (2021). Benzodiazepine Toxicity. Treasure Island (FL): StatPearls Publishing.
- Kattimani, S., & Bharadwaj, B. (2013). Clinical Management of Alcohol Withdrawal: A Systematic Review. Industrial Psychiatry Journal, 22(2), 100-108.
- Zindel, L. R., & Kranzler, H. R. (2014). Pharmacotherapy of Alcohol Use Disorders: Seventy-Five Years of Progress. Journal of Studies on Alcohol and Drugs, 75, 79-88.