Benzodiazepines for Alcohol Withdrawal

September 8, 2022

Table of Contents

Benzodiazepines are used acutely for alcohol withdrawal, either in the hospital or at certain detox facilities. They are usually used for patients with severe symptoms of withdrawal to prevent the more dangerous symptoms of seizures, changes in blood pressure, and respiratory suppression. Currently, benzodiazepines are considered the “gold standard” medication for acute alcohol withdrawal. 

What are Benzodiazepines?

Benzodiazepines are a class of medications that are nervous system depressants. They are used for a few different indications, including severe/refractory anxiety, seizure disorders, and for the treatment of acute alcohol withdrawal. 

How Are Benzos Given for Alcohol Detox?

Benzodiazepines may not be necessary for mild withdrawal symptoms. They are more commonly used when a patient has a history of complicated or severe withdrawal. They are usually administered in the inpatient setting (in the hospital) for patients undergoing withdrawal. They may occasionally be given in the outpatient setting in an acute detox facility, assuming the facility has the ability to do medical monitoring, checking regular vital signs, etc. Benzodiazepines are usually given orally but can also be administered intravenously for severe symptoms.

Benzodiazepines can typically be given in one of three ways when treating withdrawal:

The first is through what is called a symptom triggered regimen (STR) where a person’s withdrawal symptoms are rated via a scale, and drug doses are administered based on withdrawal severity.[2] This is typically the preferred treatment method as it involves the least use of medication.

Another option is a fixed tapering dose regimen (FTDR), where a patient receives fixed doses of benzodiazepine on a schedule, tapering off them over time. This method is helpful when a patient can’t be monitored as closely by a trained professional or when they may be unable or unwilling to rate their withdrawal symptoms on a scale.

The last option is what is called a loading dose regimen (LDR), where long-acting benzodiazepines are given in high doses immediately, usually in the case of someone with a history of severe withdrawal in anticipation of another complicated withdrawal. This method requires very close monitoring and may require admission to the intensive care unit (ICU). [1]

What Are The Symptoms of Alcohol Withdrawal?

Alcohol withdrawal can cause a number of symptoms, including:

  • Tremors
  • Irritability
  • Anxiety
  • Agitation
  • Nausea/vomiting

In severe cases, alcohol withdrawal leads to hallucinations, seizures, and eventually a syndrome called Delirium tremens (DTs) in which the patient develops low  blood pressure, fast heart rate, and other vital sign abnormalities that can eventually lead to death. For this reason, alcohol withdrawal is considered dangerous and can even be life threatening.

Benzodiazepines reduce the severity of alcohol withdrawal and the risk of seizures and DT. 

Dangers of Benzodiazepines

Benzodiazepines are not without their own dangers, and therefore it is always a balance between treating alcohol withdrawal but not giving too many benzodiazepines. They can cause respiratory suppression and therefore must be given carefully, particularly in patients with other medical conditions such as COPD, cardiovascular problems, or dementia. In particular, these risks increase if given concurrently with other sedating medications such as opioids. For example, In 2020, 16% of overdose deaths related to opioids also involved benzodiazepines.[3]

Benzodiazepines also have addiction potential. The rate of benzodiazepine misuse among people using the drugs is fairly low compared to other substances such as opioids, however the risk is still there: Of about 30.5 million American users, an estimated 17.1% engaged in what could be considered misuse of their benzodiazepine prescription. Fewer than 2% developed what would be considered a benzodiazepine use disorder. [4]

Which Benzos Are Used in Withdrawal Treatment?

Many benzodiazepines are suitable choices for alcohol withdrawal treatment, with the goal generally being an option that works quickly and is long-lasting. Common choices include the following:

  • Chlordiazepoxide
  • Diazepam (long-acting)
  • Lorazepam (short/intermediate acting)
  • Oxazepam (short/intermediate-acting)

Dos & Don’ts of Benzo Use for Alcohol Withdrawal

Do Keep Hopeful

Many people who struggle with alcohol may have attempted to quit in the past. Alcohol withdrawal can be an intensely uncomfortable and even potentially dangerous experience. However, with proper supervision, alcohol withdrawal is safe and do-able. Alcohol withdrawal usually lasts for no longer than 1-5 days. After that, your symptoms should greatly improve. 

Do See a Doctor 

Getting through alcohol withdrawal on your own can be very difficult and even dangerous in the case of severe withdrawal. If you are attempting to discontinue alcohol use and you have a history of complicated withdrawal - hallucinations, seizures, intubations or prior hospitalizations - you should talk to your doctor prior to attempting to stop “cold turkey”. It may be appropriate and safer for you to be admitted to the hospital or to another medical facility so you can undergo detox under medical supervision. 

Don’t Self-Prescribe

You should never take someone else’s prescription medication or purchase benzodiazepines illicitly in order to self-treat alcohol withdrawal. Instead, you should always talk to your doctor about the safest way to go through withdrawal. Medications can be prescribed for support. 

Don’t Detox on Your Own

While it isn’t impossible to detox from alcohol on your own, it can be dangerous particularly if you have a history of complicated withdrawal. If you have a history of severe symptoms, reach out to your doctor to ensure you have adequate medical supervision while undergoing detox. They may recommend you be admitted to the hospital or to a supervised detox facility. 

MAT for AUD

Benzodiazepines are not a long term treatment for AUD, but rather used short term for alcohol withdrawal/detox. There are, however, several FDA approved medications for alcohol use disorder to help prevent cravings and relapse to alcohol use long term. These medications include Naltrexone (Vivitrol), Disulfiram and Acamprosate.

Where to Get Help for Alcohol Withdrawal

A good place to start seeking help for struggles with any kind of substance misuse is the Substance Abuse and Mental Health Services Administration’s national helpline. This is a confidential, free addiction and mental health resource you can call at 1-800-662-4357. The service is designed to refer people to relevant resources for their needs, including helping them find local treatment facilities and support groups.

Additionally, various treatment centers for substance use disorder can help you get through the difficult withdrawal process safely and in comfort. They can also provide counseling and other important services as part of a long-term addiction treatment process. They can additionally offer medications for AUD, including Naltrexone, acamprosate or disulfiram.

If you have an AUD and are attempting to detox, reach out to your doctor or go to your nearest emergency room for support.

Medically Reviewed By Elena Hill, MD, MPH

Elena Hill, MD; MPH received her MD and Masters of Public Health degrees at Tufts Medical School and completed her family medicine residency at Boston Medical Center. She is currently an attending physician at Bronxcare Health Systems in the Bronx, NY where she works as a primary care physician as well as part time in pain management and integrated health. Her clinical interests include underserved health care, chronic pain and integrated/alternative health.

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Citations

  1. Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond. Journal of Clinical & Diagnostic Research. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4606320/. September 2015. Accessed August 2022.
  2. Symptom-Triggered Therapy for Alcohol Withdrawal Syndrome: A Systematic Review and Meta-Analysis of Randomised Clinical Trials. Journal of General Internal Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6544709/. June 2019. Accessed August 2022.
  3. Benzodiazepines and Opioids. National Institute on Drug Abuse. https://nida.nih.gov/research-topics/opioids/benzodiazepines-opioids. April 2022. Accessed August 2022.
  4. Research Suggests Benzodiazepine Use Is High While Use Disorder Rates Are Low. National Institute on Drug Abuse. https://nida.nih.gov/news-events/science-highlight/research-suggests-benzodiazepine-use-high-while-use-disorder-rates-are-low. October 2018. Accessed August 2022.
  5. Treating Alcohol Withdrawal with Benzodiazepines: Safe if Mindful. Psychology Today. https://www.psychologytoday.com/us/blog/all-about-addiction/201205/treating-alcohol-withdrawal-benzodiazepines-safe-if-mindful. May 2012. Accessed August 2022.
  6. SAMHSA’s National Helpline. Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/find-help/national-helpline. March 2022. Accessed August 2022.

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