In the news:
Drug that steals women's lives: It's more addictive than heroin, with horrifying side-effects. So why, 50 years after its launch, is Valium still given to millions?
What are the possible side effects of Diazepam?
Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects that are known to be associated with this medicine. Just because a side effect is stated here does not mean that all people using this medicine will experience that or any side effect.
Drowsiness, including drowsiness and lightheadedness the next day.
See warnings above.
- Shaky movements and unsteady walk (ataxia).
- Loss of memory (amnesia).
- Muscle weakness.
- Slurred speech.
- Skin rashes.
- Disturbances of the gut such as diarrhea, constipation, nausea, vomiting or abdominal pain.
- Slow, shallow breathing.
- Paradoxical effects such as restlessness, agitation, irritability, aggression.
- Difficulty passing urine (urinary retention).
- Urinary incontinence.
- Visual disturbances such as blurred vision.
- Changes in sex drive.
- Low blood pressure (hypotension).
- Blood disorders.
Talk to your doctor, nurse or pharmacist if you want any more information about the possible side effects of this medicine. If you think you have experienced a side effect, did you know you can report this using the yellow card website?
How can I stop diazepam (Valium)?
Furthermore, “rebound symptoms” can occur, which may manifest in high levels of anxiety. However, these symptoms should begin to decline about 6-8 weeks after quitting Valium. 24 – 72 hours Valium withdrawal: Withdrawal from Valium mimics that of alcohol. Your body will experience tremors, sweating, and agitation
What is Diazepam used for?
Short-term (two to four weeks only) treatment of severe anxiety that is disabling or subjecting the individual to unacceptable distress.
Short-term (two to four weeks only) treatment of severe insomnia that is disabling or subjecting the individual to extreme distress (oral forms of diazepam only).
Relieving anxiety and causing sedation before surgery or medical procedures (pre-med).
Managing symptoms of withdrawal from alcohol (used in combination with other treatment for alcoholism).
Controlling convulsions (fits) caused by poisoning (intravenous and rectal forms of diazepam only).
Controlling repeated fitting with no recovery of conciousness between seizures (status epilepticus) (intravenous and rectal forms of diazepam only).
Controlling fitting associated with fever (febrile convulsions).
Controlling muscle spasms, for example due to tetanus or poisoning.
How does Diazepam work?
Diazepam is a type of medicine called a benzodiazepine. Benzodiazepines are used for their sedative, anxiety-relieving and muscle-relaxing effects.
Diazepam works by acting on receptors in the brain called GABA receptors. This causes the release of a neurotransmitter called GABA in the brain.
Neurotransmitters are chemicals that are stored in nerve cells in the brain and nervous system. They are involved in transmitting messages between the nerve cells. GABA is a neurotransmitter that acts as a natural ‘nerve-calming' agent. It helps keep the nerve activity in the brain in balance, and is involved in inducing sleepiness, reducing anxiety and relaxing muscles.
As diazepam increases the activity of GABA in the brain, it increases its calming effect and results in sleepiness, a decrease in anxiety and relaxation of muscles.
Diazepam has several uses. Firstly, it can be used to calm severe anxiety and agitation. For example, benzodiazepines such as diazepam are effective at quickly reducing the symptoms of anxiety and agitation that occur in a manic episode of the psychiatric illness, bipolar affective disorder. A benzodiazepine may be given as part of the initial treatment of a manic episode, though they are not licensed specifically for this purpose. Benzodiazepines help calm the individual while the main medicines for this condition (mood stabilizers) begin to take effect.
Oral forms of diazepam are also used for short-term treatment of severe anxiety associated with insomnia. Diazepam decreases the time taken to fall asleep and wakings during the night, as well as increasing the total amount of time spent sleeping. However, it is only suitable for short-term treatment of insomnia and anxiety as it has a high potential for dependence and addiction. As diazepam remains active in the body for many hours, drowsiness may also last into the next day.
Diazepam is also given for its sedating and anxiety-relieving effects as a pre-med before surgery or medical investigations and procedures, and to alcoholics during acute alcohol withdrawal (‘cold-turkey').
The second main use of diazepam is in controlling convulsions, for example, associated with poisoning, or seizures associated with fever in children (febrile convulsions). It is particularly useful for controlling repeated epileptic fits when the person doesn't recover consciousness between fits (status epilepticus). Diazepam helps control convulsions because the increased activity of GABA that it causes in the brain helps to calm the excessive electrical nerve activity that is responsible for causing seizures.
A further use of diazepam is in controlling muscle spasms due to tetanus or poisoning.
Treatments for anxiety
How do I take Diazepam?
Diazepam may be taken as tablets or syrup, or given by injection or rectal solution (enema), depending on what condition is being treated and how fast a response is needed.
Diazepam tablets and syrup can be taken either with or without food.
Always take the medicine as directed by your doctor. Do not exceed the dose prescribed by your doctor.
Things you should know before taking Diazepam?
This medicine causes drowsiness and muscle weakness and impairs concentration and alertness. These effects may continue into the following day and are made worse by drinking alcohol. If you are affected you should not drive or operate machinery.Do not drink alcohol while taking this medicine.
From March 2015 a new ‘drug driving' law comes into force, which makes it an offence to drive with certain drugs or prescription medicines above specified limits in your body. The list includes diazepam, which means it may be an offence to drive while you are taking this medicine. The new law will allow police to use roadside drug tests to check for the presence of the prohibited drugs in a driver's saliva. There are very low limits for illegal drugs, but higher limits for prescribed medicines. This should mean that most people taking diazepam as prescribed will not be breaking the law, provided they are not driving dangerously. If you are found to be above the limit for diazepam there is a medical defence if you are taking the medicine as prescribed, as long as your driving is not impaired. If you are taking a high dose of diazepam it may therefore be sensible to carry your prescription with you when driving, in case you are asked to take a test by the police. However, if you are driving dangerously while taking this medicine you will be breaking the law. You should not drive if you think this medicine affects your ability to drive safely, for example if it makes you feel sleepy, dizzy, unable to concentrate or make decisions, or if you have blurred or double vision.
This medicine is generally only suitable for short-term use. If it is used for long periods or in high doses, tolerance to and physical and psychological dependence upon the medicine may develop, and withdrawal symptoms may occur if treatment is stopped suddenly.
Treatment with this medicine should usually be stopped gradually, following the instructions given by your doctor, in order to avoid withdrawal symptoms such as rebound insomnia or anxiety, confusion, sweating, tremor, loss of appetite, irritability or convulsions.
Weak or debilitated people.
Decreased kidney function.
Decreased liver function.
People with disease affecting the airways or lungs (respiratory disease).
People with a history of alcoholism or drug abuse.
People with personality disorders.
It is important to tell your doctor if you have recently suffered a loss or bereavement, for example the death of a close friend or relative, before taking this medicine. Benzodiazepines such as this one can affect the way you adjust psychologically to events like this.
Who should not take Diazepam?
People who are allergic to other benzodiazepines.
People with a sudden worsening of any underlying lung disease (acute pulmonary insufficiency).
People with slow, shallow breathing (respiratory depression).
People who suffer from sleep apnoea syndrome, which is a problem involving short spells when breathing stops during sleep.
People with abnormal muscle weakness due to the condition myasthenia gravis.
Long-term psychotic illness.
Phobias or obsessional states.
People who are very restless or hyperactive.
Severely decreased liver function.
This medicine should not be used if you are allergic to one or any of its ingredients. Please inform your doctor or pharmacist if you have previously experienced such an allergy.
If you feel you have experienced an allergic reaction, stop using this medicine and inform your doctor or pharmacist immediately.
Can I take Diazepam while pregnant or breastfeeding?
Certain medicines should not be used during pregnancy or breastfeeding. However, other medicines may be safely used in pregnancy or breastfeeding providing the benefits to the mother outweigh the risks to the unborn baby. Always inform your doctor if you are pregnant or planning a pregnancy, before using any medicine.
This medicine may be harmful to a developing baby and it should be avoided during pregnancy unless considered essential by your doctor. This is particularly important during the first and third trimesters of pregnancy and before or during labour. Regular use during pregnancy should especially be avoided, as the baby could become dependent on the medicine and then suffer withdrawal symptoms after the birth. If this medicine is used in late pregnancy or during labour it may cause floppiness, low body temperature and breathing or feeding difficulties in the baby after birth. Ask your doctor for further information.
Significant amounts of this medicine may pass into breast milk. It should not be used by breastfeeding mothers as it may be harmful to the nursing infant. Seek medical advice from your doctor.
Over-the-counter medicines in pregnancy
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Can I use other medicines with Diazepam?
It is important to tell your doctor or pharmacist what medicines you are already taking, including those bought without a prescription and herbal medicines, before you start treatment with this medicine. Similarly, check with your doctor or pharmacist before taking any new medicines while taking this one, to make sure that the combination is safe.
Is it dangerous to take different medicines at the same time?
There may be an increased risk of drowsiness and sedation if diazepam is taken with any of the following (which can also cause drowsiness):
antipsychotics, eg chlorpromazine, clozapine
antipsychotics, eg chlorpromazine, clozapine
barbiturates, eg phenobarbital
barbiturates, eg phenobarbital
other benzodiazepines, eg temazepam
other benzodiazepines, eg temazepam
MAOI antidepressants, eg phenelzine
MAOI antidepressants, eg phenelzine
sedating antihistamines, eg chlorphenamine
sedating antihistamines, eg chlorphenamine
sleeping tablets, eg zopiclone
sleeping tablets, eg zopiclone
strong opioid painkillers, eg morphine, codeine, dihydrocodeine
tricyclic antidepressants, eg amitriptyline.
The following medicines may prevent the breakdown of diazepam in the body. As this could increase the blood level of diazepam and its sedative effects, as well as the risk of its side effects, your doctor may need to prescribe you a lower than normal dose of diazepam if you are taking any of these medicines:
oestrogens and progestogens, for example in contraceptives like the pill
ritonavir (diazepam should preferably not be used in people taking ritonavir)
Diazepam may enhance the blood pressure lowering effect of medicines that lower blood pressure, particularly medicines used to treat high blood pressure (antihypertensives), diuretic medicines and nitrates for angina. This may cause dizziness, which can usually be relieved by lying down until the symptoms pass.
The following medicines may decrease the blood level of diazepam. As this could make it less effective, your doctor may need to prescribe you a larger than normal dose of diazepam if you are taking any of these medicines:
Caffeine and theophylline may reduce the sedative and anxiety-reducing effects of diazepam.
Diazepam may reduce the effectiveness of levodopa in treating Parkinson's disease.
Diazepam may increase or decrease blood levels of the anticonvulsant medicine phenytoin.
People who break free from benzodiazepine addictions tend to feel a lot better: Studies show that quitting leads to improvements in cognitive performance, mood and sleeping, and since the prolonged use of a benzodiazepine often causes as many anxiety problems as it’s supposed to solve, quitting generally makes very good sense.
But though quitting is sensible, it’s certainly not easy,especially if you don’t start with a reasonable understanding of the process and a solid plan for success.
So read on to learn more about…
- The nature of benzodiazepine withdrawal symptoms (when they arise, why you get them, what they feel like, how long they last, etc.)
- Why a dangerous cold turkey detox makes no sense at all
- Different tapering methods and schedules (including how and why you might want to switch to long-acting diazepam)
- How to cope with withdrawal symptoms (self-help, medications, counseling etc.)
Benzodiazepine Withdrawal Symptoms
Not everyone quitting benzos will experience withdrawal symptoms and most people experience only a few, not the complete list of possible symptoms.
Typical withdrawal symptoms include:1
- Sleeping problems
- Feeling anxious or tense
- Paranoia – thinking other people want to do you harm
- Feelings of disassociation
- Abnormal sensory perception (noises sound loud, colors seem odd, etc.)
- Shaking, or more rarely, convulsions
- Muscle aches, pains and spasms
- Symptoms that mimic flu
See the end of this article for a comprehensive list of less commonly experienced withdrawal symptoms.
Why Do You Get Withdrawal Symptoms?
All benzodiazepines work by increasing the activity of the neurotransmitter GABA. Since GABA is an inhibitory transmitter, which slows or stops the firing of other neurotransmitters, by increasing GABA activity you quiet the brain’s overall activity level. GABA is the brain’s natural sedative, and benzodiazepines simply enhance its functioning.
GABA suppresses excitatory neurotransmitters like dopamine, serotonin, epinephrine (noradrenaline) and acetylcholine. These excitatory transmitters play important roles in memory, muscle movement, alertness, emotional regulation, heart rate and blood pressure and hormonal secretions. When taking benzodiazepines you quiet your whole brain’s activity level. This reduces anxiety and insomnia, but also causes changes to many of the body’s essential systems. This is why taking chronic high doses of benzos can cause such a variety of health problems and why people experience such a wide array of withdrawal symptoms after stopping.
Benzodizepine users quickly develop a tolerance and start needing increasingly larger doses to achieve any desired effects. Because of this, most prescribing guidelines advise against the use of benzos for more than 3 or 4 consecutive weeks.
- The GABA and benzodiazepine receptors compensate for the medication’s continual presence by becoming less responsive to the medication (so less GABA)
- The excitatory systems that are naturally controlled by GABA also adapt by becoming less responsive to GABA inhibition (So less GABA and the GABA that's left doesn't do as much)
So once you’ve developed a tolerance you need large doses of benzos to just get the GABA system functioning at a ‘normal’ level. If a person with a benzo tolerance suddenly stops taking their medication, GABA activity drops substantially and this causes equally substantial increases in the activity of the brain's excitatory dopamine, serotonin, noradrenalin etc. systems.2
In some cases, as your tolerance rises, you can start to experience withdrawal symptoms on a steady dose, and you need to up your daily dosage to keep these withdrawal symptoms at bay.
Do All Benzo Users Get Withdrawal Symptoms?
According to the benzodiazepine dependency advocacy group Reconnexion, between 50% and 80% of people who use benzos for 6 months or longer will experience at least some withdrawal symptoms after stoppage.
The duration of withdrawal symptoms can also vary a great deal, but people who have longer histories of use are more likely to experience longer withdrawal periods than people with shorter use histories.3
You are more likely to have difficult withdrawal symptoms when quitting:4
- After a very long period of use
- When trying to come off a very high daily dosage
- When you have been using potent, fast acting benzodiazepines
When Do Withdrawal Symptoms Start to Occur?
You will start to feel withdrawal symptoms sooner if using a shorter acting benzo, like Xanax, and later, if using a long acting benzo, like valium.
- Users of short acting benzos may start to experience withdrawal symptoms within 2 days of the last dose
- Users of longer acting benzos may start to experience withdrawal symptoms between 2 and 10 days of the last dose5
Withdrawal symptoms may persist for a few days or weeks. Some people experience withdrawal symptoms that persist for months or even years after cessation of use.
How to Quit? Taper Down or Cold Turkey?
Taper. Without a doubt.
If you have been using benzodiazepines on a daily basis for more than three weeks, you should not stop using suddenly – you need to taper down instead.
- A cold turkey detox can be dangerous, or even deadly, and it increases the odds of an agonizing and lengthy withdrawal.
- A slow taper maximizes safety and minimizes discomfort.
You may have an impulse to try to power through quickly and tough it out. Although this is understandable – it's a very bad idea.
Tapering should be slow and gradual (months, not weeks) – it doesn’t really matter how long it takes (it probably took you a long time to build up your tolerance) and what’s most important is making steady progress towards your goal while minimizing your discomfort along the way (see below for example tapering schedules).
By tapering you can
- Minimize your withdrawal symptoms – by reducing at a rate that’s comfortable to you
- Stay in control – you decide how fast you want to go forward and you don’t have to endure strong withdrawal symptoms if you don’t want to
You can do:
- A direct taper – where you make steady reductions off whatever benzo you’ve been using
- A substitution taper – where, if you’ve been using a short-acting benzo like Xanax, you first switch off to a longer acting benzo like diazepam, and then once stable on the diazepam, start to taper down
The Benefits of a Substitution Taper (to Diazepam)
Many clinicians recommend switching to diazepam prior to initiating a tapering program.
- Diazepam has a very long half-life (between 20 and 100 hours). Because of this, benzo levels in the bloodstream remain very constant and you avoid the peak and valley levels seen with shorter acting benzos like alprazolam. These more constant benzo levels facilitate neural recovery (the brain ‘heals’ faster) and minimize withdrawal symptoms.
- Diazepam has very low tablet strengths, and this low potency allows you to easily make very small dose reductions. For example, It’s quite easy to take one fewer 2mg diazepam per day – it’s much harder to shave 0.1 mgs of Xanax off a 0.5 mg tablet.6
Because of diazepam’s long half-life, and difficulties in finding exact equivalent dosages between benzos, it is generally recommended that you switch over to diazepam gradually, in a step-wise fashion over a period of weeks, and then once stable on diazepam, start your tapering from there.7
Roughly Equivalent Diazepam Dosages
Because of the wide variations in half-life and thus variations in how people respond to different benzodiazepines (influenced by factors such as age and hepatic impairment) it’s quite difficult to provide an exactly equivalent diazepam to other benzodiazepine dosage.
According to the Victorian (Australia) Gov. drug withdrawal practice guidelines, as of 2009, 5 mgs of diazepam was approximately equivalent to:8
- Alprazolam (Xanax, Kalma) 0.5 mg
- Oxazepam (Serepax, Murelax) 30 mg
- Clonazepam (Rivotril) 0.5 mg
- Nitrazepam (Mogadon, Aldorm) 5 mg
- Flunitrazepam (Hypnodorm) 1 mg
- Lorazepam (Ativan) 0.5 mg
So, for example, if you wanted to switch from 2mgs of Xanax to an equivalent amount of diazepam you would need to take 20 mgs of diazepam.
- However, this is just a rough guideline and you won’t necessarily feel exactly the same on a theoreticallyequivalent dosage of a different benzodiazepine.
- So, what you need to do, is transfer gradually off your current benzo to diazepam, and then dial in a minimum dose of diazepam that keeps withdrawal symptoms at bay but doesn’t leave you feeling over sedated. Once stable on this dose, you can start your tapering regimen.
Example Tapering Schedules
- Reduce your dose by 10% every 1 or 2 weeks until you’re at 20% of your original dose, and then taper down by 5% every 2 to 4 weeks9
Or, a more aggressive approach, endorsed by the Oregon State College of Pharmacy10
- Taper by 25% per week for the first 2 weeks and then start a 12.5% reduction per week for the next to 6 weeks (note, tapering usually gets harder as you progress to smaller doses). This aggressive approach may not be suitable for people who have tried and failed in the past with a tapering regimen. For such people a 6 month tapering regimen is recommended.
As a general rule, it doesn’t really matter how slowly you taper and it’s a good idea to stabilize at a dosage before moving further down. Reductions tend to get harder in the second half of the process, so it’s OK to slow down as you need to, as you approach the finish line.
However, you should definitely avoid:
- Taking extra pills in times of great stress
- Going back up to an earlier plateau, if a new dosage seems difficult
- Using other substances that mimic the GABA effects of benzos (this obviously corrupts the tapering process)
Avoiding Alcohol during Benzo Withdrawals
Drinking may worsen your withdrawal symptoms (especially the morning after) but there’s another important reason to avoid alcohol until you feel better.
- You experience withdrawal symptoms because your GABA system is all messed up and it needs to normalize before you’ll feel better
- Alcohol increases GABA activity, just like benzos do
- So if you drink, you slow your brain’s healing and there’s a risk that you’ll just start to drink more and more as you taper further as a way to compensate, without really allowing your brain a chance to heal
And if you do this, at the end of it all not only is your GABA system still out of whack – now you’ve got an alcohol problem too!
Coping with Withdrawal Symptoms: Self Help
To minimize your symptoms:12
- Strive to eat a healthy diet with lots of fresh fruits and vegetables. Drink lots of water
- Avoid caffeine
- Exercise (as much as you can…you can’t do too much)
- Rest up as well as you can
- Keep a recovery diary and chart the progress you make
- Ask for help and support from friends or family for things like household chores and general responsibilities
- If interested, explore alternative healing, such as acupuncture or Chinese medicine11
- Avoid using alcohol or drugs. They may help in the short term but will exacerbate symptoms over the long run
- Avoid making major decisions or adding unnecessary stress to your life while going through withdrawals
- Relax in a hot bath
- Practice relaxation techniques, like deep breathing exercises
- Meditate and practice mindfulness
- Learn Cognitive Behavioral Therapy (CBT) techniques (with a therapist or in a group, or on your own through a self help program or books) and learn to challenge negative thoughts and harmful inaccurate beliefs
Keeping Things in Perspective
Staying focused on how bad you’re feeling won’t help you feel better, and the more you obsess about your symptoms, the worse you’ll perceive those symptoms to be – in fact, sometimes worrying about how you’ll feel after dose reductions causes more negative symptoms than the dose reduction itself!13
One trick you can use to minimize the worry is to accept that after each dose reduction you might catch a touch of ‘Benzo Flu’
Think objectively about how you feel after a dose reduction and compare these symptoms to how you feel when you catch a cold or flu. Are they comparable? When you get a flu do you worry a lot about how terrible you’re feeling or do you just accept that you’ll feel crummy for a few days and that you’ll feel better in time.
With benzo withdrawal symptoms it’s pretty much the same thing. You may feel crummy for a short time after a dose reduction, but you’ll feel better quickly enough, so why not just think of your symptoms as a case of benzo flu – and since you know that this flu will pass quickly enough, you don’t need to get too stressed about how bad you feel.
Should You Consider Counseling?
You should, ideally, seek a doctor’s medical supervision to help you with the withdrawal process, but on top of this, should you also seek out some form of counseling support?
Anxiety is the most commonly experienced benzo withdrawal symptom. This anxiety is temporary and will go away as your body readjusts, but if you find it very uncomfortable you may find counseling helpful.
- A counselor or psychologist can help you learn behavioral and cognitive behavioral techniques to manage anxiety. These techniques can be learned in a handful of sessions and can be practiced and implemented as needed, on your own.
- You may also find a community or online support group helpful. It can be reassuring to hear from others who are going through or have gone through similar experiences.People in support groups, or even within online support forums, can provide helpful information and support.
Basically, this is a tough process, and if you’re having trouble coping with your withdrawal symptoms, it’s entirely reasonable to seek out extra helpful support and advice.
Medications That Can Ease Withdrawal Symptoms
Your doctor may prescribe you medications that can reduce the severity of some withdrawal symptoms. Medications sometimes prescribed include:14
- Propranolol – to help reduce tremor and sweating (for up to about 3 weeks)
- Non-benzodiazepine sedatives like antihistamines or sedative antidepressants – to help reduce insomnia (short duration, about 2 weeks)
- Carbamezepine (and other anticonvulsants) – to reduce the risk of convulsions
Less Common Withdrawal Symptoms
In addition to the more commonly experienced withdrawal symptoms from the list above, some people may experience one or more of the following:15
- Tiredness and lethargy – heavy limbs
- Breathing problems or tightness in chest
- Blurry vision, sore eyes, sensitivity to light or seeing spots
- Becoming very sensitive to sounds, or hearing a ringing in ears
- Dizziness or feeling like the ground is moving
- A lack or co-ordination or balance
- Feeling like things aren’t real (depersonalization)
- Heart palpitations
- Digestive problems, diarrhea, constipation or nausea
- Headaches or a sense of tightness in the head
- Urinary problems – urgency, incontinence
- Excessive sweating
- Psychotic symptoms (hallucinations)
- Anger or rage
- Changes in libido
- Change in appetite, loss of taste, weight gain or loss
- Menstrual changes
- Difficulty swallowing, soreness in mouth and tongue
- Intrusive thoughts or memories
- Feelings of numbness or pins and needles
- Increased emotional reactivity
- Suicidal thoughts
- Impulsive behaviors
- Many others