Sleeping pills and sedatives: dependence and withdrawal

What is it about ?

Most sleeping pills and pain relievers are benzodiazepines.

When you take these medicines, you may become dependent on them. Dependence can even occur at a normal dose. This phenomenon mainly affects the elderly or people who receive long-term treatment.

Dependence is characterized by:

• Tolerance to the drug: gradual decrease in the efficacy of the drug;
• A need to increase the dose (to achieve the same effect);
• Continued consumption despite the appearance of side effects.

When you stop taking benzodiazepines, you may experience withdrawal symptoms:

• Relapse (relapse): complaints for which you were prescribed a benzodiazepine keep coming back;
• Rebound: the complaints for which you were prescribed a benzodiazepine come back more strongly but this is only transient;
• Symptoms of withdrawal.

How often and where do we find it?

In Belgium, 1 in 10 people would take long-term treatment with benzodiazepines at normal doses. It is estimated that half of these users are involuntarily addicted.

People who use these drugs for a long time are mostly

• Elderly people who live at home, especially women, who take benzodiazepines to sleep well;
• People who live in retirement homes
• People with psychiatric illness.

A small group of benzodiazepine users take higher doses on their own. To get prescriptions, they often go to different doctors and different hospitals.

A third group, which continues to grow, consists of people who use benzodiazepines as a drug. In the West, this would affect 3 to 4 people in 1000. Often, they consume several drugs. The doses they take are usually very high.

How to recognize it?

You are dependent (addicted) to benzodiazepines if:

• You always need more medicine to stay calm or to fall asleep;
• You go to great lengths to get the medicine;
• You are constantly thinking about the drug;
• You have already lied to the doctor to get an additional prescription;
• You see several doctors to receive a prescription;
• You have tried to reduce the dose in the past, but you did not succeed due to increased anxiety or trouble sleeping;
• You have one or more of the following symptoms when you skip a dose or stop the medicine: anxiety, irritability, recurring obsessive thoughts, insomnia, disturbed sleep / wake patterns, daytime fatigue, rapid heartbeat (more than 110 beats per minute), high blood pressure, muscle tension, tremors, abnormal muscle movements, restlessness, nervousness, muscle pain, joint pain, nausea, stuffy nose, sweating, ringing in the ears, seizures, impaired perception, blurred vision, hallucinations.

How is the diagnosis made?

The doctor will ask you:

• How long have you been using benzodiazepines and at what dose;
• If you are taking other substances which affect the brain;
• If you are suffering from withdrawal symptoms;
• If you have been addicted to other substances in the past (which substances, number of relapses, were you able to quit permanently, for how long did you not take any substances?);
• List all healthcare providers who have ever treated you or prescribed the medicine for you. It is indeed very important that only one doctor follows the treatment of addiction.

You may be referred to a specialist, a specialist center or a specialist hospital if:

• You have a psychiatric condition that requires additional care;
• You are taking high doses;
• Your attempts to quit your use have failed several times;
• You are addicted to several substances at the same time (drugs, illegal drugs or alcohol);
• You also have serious physical ailments;
• You are using other medicines which prevent the brain from working properly;
• You have had a seizure or other nervous system condition that could be treated with benzodiazepines.

What can you do ?

Take the prescribed dose. If the prescribed dose no longer works, do not go to several doctors for more medicine, but go back to your doctor. Tell her that the medicine is less effective. Your doctor will prescribe another medicine, recommend another form of treatment, or refer you to a specialist.

At the start of treatment, decide with him when and how you will stop taking the medicine. From the first prescription, discuss with him the other possible treatments, the possible side effects and the dangers of the drug.

Always be honest with your doctor about your drug and alcohol use. Benzodiazepines and alcohol can form a dangerous cocktail.
If you are addicted to illegal drugs or use others occasionally (for example, marijuana), talk to your doctor.

Do not use sedatives or sleeping pills offered by your neighbors, friends or relatives.

If you have been addicted to drugs, alcohol or other substances in the past, tell your doctor.

If your doctor suspects or notices a problem with addiction, be honest and fully cooperate with the treatment.

Never stop taking benzodiazepines suddenly or without telling someone. Withdrawal symptoms can be severe (for example, severe seizures). Benzodiazepines should be stopped slowly and gradually.

What can your doctor do?

Avoid addiction

When you start treatment with benzodiazepines, your doctor will take steps to prevent addiction from developing:

• From the first prescription, he will explain how and when the treatment will be stopped;
• If you suffer from anxiety disorders or sleep disorders, he will first suggest other treatments;
• He will prescribe the smallest effective dose possible;
• He will prescribe a slow-acting benzodiazepine;
• He will renew your prescription for small boxes;
• The reasons for prolonged use should be reassessed at least once a year.

Use or stop: advantages and disadvantages

If you suffer from mood disorders, your doctor may prescribe a specific medicine a few weeks before you gradually stop taking benzodiazepines.

If you are only dependent on a normal dose, your doctor will discuss with you whether it is best to wean you off or to temporarily continue the benzodiazepines. You will assess the pros and cons with it: in some cases, another treatment is not enough to control anxiety or sleep disturbances, but benzodiazepines have harmful effects with prolonged use:

• Risk of dependence and tolerance, leading to ever-increasing needs;
• Decreased vigilance and increased risk of road accidents or occupational accidents;
• Confusion and agitation in people with dementia;
• Decreased ability to control urges, leading to substance abuse and violent behavior;
• Increased craving for alcohol in people who are sensitive to it;
• During pregnancy, the product crosses the placenta and is transmitted to the child;
• Using very high doses or using more than one substance at the same time can be fatal.

Treatment plan

The doctor or specialist can, with your consent, work out a written treatment plan to stop the medicine in collaboration with the other healthcare providers involved, including pharmacists.

Weaning modalities
He will warn you that the only prescriptions that will be issued to you are those provided for at the start of the withdrawal treatment. So be careful with your medicines, do not waste them and use them as agreed with your doctor. Your doctor will only treat your withdrawal symptoms when necessary.

The doctor may ask you to keep a journal of your medication use. This will help you recognize risky situations in order to avoid them.

The doctor may also ask you to make an agreement with a specific pharmacy. This way, you will only be able to receive your medicines at this one pharmacy if there is a fear that another treatment will fail.

Initial dose
An initial dose is set at the start of the withdrawal treatment. This dose should be sufficient to reduce withdrawal symptoms. Withdrawal symptoms are screened for on the basis of heart rate, blood pressure, sweating, tremors. There is a special questionnaire to assess withdrawal symptoms after the use of benzodiazepines: the CIWA-B (Clinical Institute Withdrawal Assessment – Benzodiazepines).

The initial dose is gradually reduced. If your symptoms increase, the dose will be reduced a little more slowly. After stopping short-acting benzodiazepines, withdrawal symptoms may already appear within 1 to 2 days. When using long-acting benzodiazepines, withdrawal symptoms may appear within 2 to 14 days. Other drugs are sometimes prescribed as a supplement.

Monitoring and control
While you are gradually stopping benzodiazepines, you should regularly visit a doctor. It is thus possible to intervene quickly in the event of a problem associated with stopping treatment. Often, simply reducing the doses more slowly resolves the problem.

After successful withdrawal, it is important to schedule a few more follow-up appointments with the doctor. He assesses the risk of relapse, examines whether there are any psychiatric symptoms, and, if necessary, quickly treats a relapse of anxiety symptoms or sleep disturbances in another way.

There are support groups and discussion groups for people who are addicted to benzodiazepines. They offer support and help both during and after weaning. Among people who are dependent on a low (normal) dose of benzodiazepines, 7 to 8 in 10 are successful with their withdrawal without too much difficulty by gradually reducing the dose. Among people who abuse multiple substances, only 1 in 4 succeed despite their strong motivation to quit. People with severe personality disorders usually have more difficulty stopping benzodiazepines.

Want to know more?

• Sleeping pills and sedatives, think before consuming – FAMHP – Federal Agency for Medicines and Health Products
• Sleeping pills and sedatives, think of other solutions first (video) – SPF Public health, food chain safety and the environment
• Cognitive-behavioral therapy for insomnia – Hôpital Erasme ULB

• Half-angel Half-demon Good use of medication for teenagers – Solidaris – Mutualité Socialiste

• Sleeping pills or tranquilizers, the point on your consumption – Stop or else?
• Benzodiazepines – CBIP – Belgian Center for Pharmacotherapeutic Information

• Drugs and driving a vehicle – Federal Agency for Drugs and Health Products

Are you looking for more specialized help?

• Mental Health Services – The Social Guide
• Find a therapist – AEMTC – Association for the Study, Modification and Therapy of Behavior

Sources

• Foreign clinical practice guide ‘Long-term use of benzodiazepines and withdrawal’ (2007), updated on 07/25/2017 and adapted to the Belgian context on 05/16/2019 – ebpracticenet
• Belgian practice guide ‘Drug addiction’ (2009) – SSMG – Scientific Society of General Medicine
• Guide ‘Richtlijnen bij het voorschrijven van benzodiazepines aan illegale druggebruikers’ (2008) – VAD – Vlaams expertisecentrum Alcohol en andere Drugs
• Bode T, De Lepeleire J. Benzodiazepinen afbouwen via minimal interventionstrategy. Huisarts Nu 2008; 37 (10)