Key Takeaways
- Protracted withdrawal is benzodiazepine withdrawal that continues for months, and sometimes longer, after the last dose.
- The drug leaves the body in days or weeks, but the brain’s adaptation to it reverses much more slowly.
- Symptoms often come and go in waves and windows, and over time the windows tend to get longer.
- It is not addiction, and it is not the old anxiety returning.
- Going back on the drug is a decision to make with a physician who understands withdrawal, never alone.
- A slow, medically supervised taper may lower the risk of protracted symptoms.
- In most cases, protracted withdrawal is not permanent.
What is protracted withdrawal, and why would symptoms continue after the last dose?
Protracted withdrawal is the name for benzodiazepine withdrawal symptoms that continue for months, and sometimes longer, after the last dose. Most people expect withdrawal to end soon after the drug is gone. For some people who have taken Xanax (alprazolam), Klonopin (clonazepam), Ativan (lorazepam), or Valium (diazepam) for a long time, it does not work that way.
You may also see the term BIND, or benzodiazepine-induced neurological dysfunction, which covers the wider set of neurological symptoms that can appear during and after benzodiazepine use. Protracted withdrawal is the part of that picture that continues after the last dose.
The Ashton Manual, written by the late Professor C. Heather Ashton, has a chapter on withdrawal symptoms, both acute and protracted. In 2020, the US Food and Drug Administration (FDA) updated the boxed warning on all benzodiazepines, and the agency now recognizes that withdrawal symptoms can last for many months. So, this is not a rumor from an internet forum. How can a drug that has left the body still cause symptoms?
How is protracted withdrawal different from acute withdrawal?
Acute withdrawal is what happens in the days and weeks after a dose is lowered or stopped. The brain has been relying on the drug to keep things calm, and suddenly there is less of it. Anxiety, insomnia, tremor, and a racing heart are common.
When a benzodiazepine is stopped abruptly, seizures are possible, which is why nobody should ever quit one cold turkey. Call 911 or go to an emergency department if you or someone near you:
- has a seizure
- becomes confused, or sees or hears things that are not there
- has thoughts of self-harm or suicide
You can also call or text 988, the Suicide and Crisis Lifeline, at any hour.
Protracted withdrawal is what remains after the acute phase has passed. Benzodiazepines work at the GABA-A receptor, where GABA, or gamma-aminobutyric acid, acts as the brain’s main calming chemical. With long-term use, the brain may adapt by making those receptors fewer and less sensitive.
The drug leaves the body in days or weeks, but the receptors do not return on the same schedule. While that slow repair is underway, people report ringing in the ears, burning skin, muscle twitching, the stomach trouble known as “benzo belly,” brain fog, and an anxiety unlike anything they felt before the drug. The adaptation outlasts the drug.
Why do the symptoms come in waves and windows?
Protracted withdrawal rarely improves in a straight line. People describe “windows,” stretches of hours or days when they feel almost like themselves, and “waves,” when the symptoms return as if nothing had changed. A wave after a good week can be crushing.
An analogy that might help is the ocean after a storm. The storm passes, the sky turns blue, the wind drops, and a day later the surf is still pounding the beach.
The storm is over, but the water is still carrying its energy. While this is not a perfect analogy, a nervous system recovering from a benzodiazepine behaves in a similar way. It settles unevenly, and over time the windows tend to get longer while the waves get shorter and less intense.
So, what do you do with a rough ocean? You do not decide that the storm has come back, and you do not try to fight the surf. You wait for the water to settle.
Unfortunately, protracted withdrawal is often mistaken for the old anxiety coming back.
A common pattern goes like this. Months after the last dose, a person still cannot sleep, their ears ring, and their skin burns. The doctor reasons that the drug left the body long ago, so the drug cannot be the cause. It is a tidy theory. It is also wrong.
The blood work and the scans are normal, so the patient is told that the original anxiety has returned, or that a new mental health condition has appeared. Often, the visit ends with a new prescription. Patients have told me that the symptoms were not the hardest part. The hardest part was hearing, from one doctor after another, that the symptoms could not be real.
Did your original anxiety ever come with burning skin, ringing ears, or the feeling of insects crawling under your skin? For most people, it did not. Symptoms that were never there before the drug point toward withdrawal, not toward the old condition.
I do not blame doctors who were never taught this. Many of us were trained to believe that these medications were safe for long-term use. Still, a patient who is told that their suffering is imaginary has been failed.
Is protracted withdrawal a sign of addiction?
No. Physical dependence is not addiction. Physical dependence means that the body has adapted to a drug, so that lowering or stopping it causes symptoms, and it happens to people who took their medication exactly as prescribed.
Addiction is a different medical condition, defined by compulsive use despite harm, and people who have it deserve respect and good medical treatment as well. The problem here is a mismatch. When a person in protracted withdrawal is sent to an addiction program, they receive treatment for a condition they do not have, and nothing for the one they do have.
Should you go back on the benzodiazepine to make the symptoms stop?
This is a good question, and nearly everyone asks it during a bad wave. Going back on the drug is called reinstatement. While it may look like the obvious fix, Professor Ashton cautioned that the original dose often does not work the second time around, and it means becoming dependent again, with another taper ahead.
That does not mean the answer is always no. It means the decision belongs in a conversation with a physician who understands benzodiazepine withdrawal, not alone at 3 am with an old bottle from the medicine cabinet.
The same caution applies to anything new. People in protracted withdrawal are often sensitive to medications and supplements, and understandably hesitant about another prescription, given how they got here. Alcohol also acts on GABA receptors and is best avoided. Talk any change through with your doctor first.
What tends to help while the nervous system heals?
I wish I could tell you that there is a treatment that speeds up healing. There is no proven shortcut. What helps is time, and the things that make time easier to get through.
Sleep comes first, even when it is poor. A regular bedtime, a dark room, and patience with bad nights will do more than chasing the perfect night. A gentle routine helps too, such as a short walk, simple meals, and rest without guilt. Rest is not laziness. It is how a nervous system recalibrates.
Understanding helps more than people expect. Fear keeps the stress system switched on and makes every symptom louder. When you know that a wave is a wave, and not a new disease, some of that fear lets go.
It also helps to hear from people who have lived it. Nicole Lamberson came on the show to talk about surviving protracted benzodiazepine withdrawal over the long term, and I spoke with Christy Huff, M.D., about the Benzodiazepine Information Coalition, which educates patients and doctors about benzodiazepine harm.
Fortunately, a slow taper may lower the risk.
If you are still taking a benzodiazepine, how you come off it matters. Professor Ashton believed that a slow, gradual taper makes protracted symptoms less likely, and that matches what I have seen. Rapid tapers and cold turkey stops, including the ones run on an insurance company’s timetable in a detox facility, are where much of the trouble starts.
The Ashton Manual describes a crossover taper to a long-acting benzodiazepine, such as diazepam, followed by small reductions over many months. The Maudsley Deprescribing Guidelines describe hyperbolic tapering, in which each reduction gets smaller as the dose gets lower. Both are sound approaches, and there are others.
What the good methods share is that the taper is medically supervised and the patient sets the pace. If a reduction proves to be too much, the doctor should slow down. Holding a dose is not failure.
Does protracted withdrawal ever end?
Is it permanent? In most cases, it is not, although after many months of symptoms coming and going, it can certainly feel that way. I cannot tell you why one person recovers in a few months and another takes far longer. No honest doctor can give you a date.
What I can tell you is that the direction is toward healing. These are regulating systems that were pushed out of balance by a prescribed drug, not structures that were destroyed, and regulating systems can find their balance again.
The first signs are usually small. You sleep a little better, a wave ends a day sooner, or a sound that was unbearable last month is only annoying now. Notice those signs when they come. The water does calm down.
Readers who want help with a taper can contact the office today.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.