Benzodiazepines consist of a very large class of drugs that are central nervous system depressants. A central nervous system depressant results in decreased firing of the neurons and nerves in the brain and spinal cord (the central nervous system).
The majority of these drugs work on a neurotransmitter GABA (gamma-aminobutyric acid), which is the most abundant inhibitory neurotransmitter in the central nervous system. An inhibitory neurotransmitter slows down the functioning of the neurons in the brain and spinal cord, and this has the effect of slowing down the functioning of the peripheral nervous system (the nervous system that is outside of the brain and spinal cord).
Benzodiazepines are used medicinally for a number of purposes, including anxiety reduction (in the treatment of anxiety disorders or anxiety that is not related to a psychiatric disorder), for the treatment of seizures, as temporary aides for insomnia (often their effectiveness is limited to only a few weeks). They are often used in surgery to relax people before they are given anesthesia.
Ativan (lorazepam) is a longer-acting benzodiazepine that is primarily used for the treatment of anxiety and seizure control. All benzodiazepines are classified by the United States Drug Enforcement Administration in the Schedule IV controlled substance class. This means that these drugs are considered to have a moderate risk for abuse and, in some individuals, may lead to the development of physical and/or psychological dependence. As controlled substances, these drugs can only be procured legally with a prescription.
As a side effect of their therapeutic effects, benzodiazepines like Ativan also produce a mild feeling of euphoria, relaxation, and a sense of wellbeing in individuals who take them. This feeling is similar to the sensation that alcohol produces. According to the book Benzodiazepine: Abuse and Therapeutic Uses, Pharmacology and Health Effects, several aspects of Ativan in particular make it an attractive drug of abuse.
Ativan is a high-potency drug, which means that even at very low doses, it produces very strong effects, and it also has a very short half-life. This means that individuals who take the drug get the effects quickly, and they also wear off quickly, compared to shorter acting benzodiazepines. Therefore, individuals who abuse Ativan will achieve its euphoric-producing effects very rapidly and often take increasingly larger amounts of the drug as the effects wear off.
There are a couple other drawbacks to using benzodiazepines as well. Benzodiazepine use and abuse lead to rapid tolerance. Tolerance occurs when the person no longer gets the same effects from the dosage of the drug that they had normally been taking. They need to take a higher dosage to mimic the effects that they once received at lower doses. People who abuse Ativan may develop tolerance to the point where they can take dangerously high levels of the drug without experiencing life-threatening effects. This tendency to develop tolerance is one aspect of the syndrome of physical dependence.
The other aspect of physical dependence is withdrawal syndrome. A withdrawal syndrome occurs with chronic use of certain types of drugs. These drugs affect the body such that the individual’s system adjusts itself to function only when there is a specific amount of the drug in its tissues. When an individual stops using the drug and normal metabolism decreases the amounts of the drug in the person’s system, this results in a situation of imbalance, and the person experiences a number of ill effects.
In general, the effects that occur with withdrawal syndromes are nausea, vomiting, insomnia, irritability, depression, anxiety, and cravings for the drug. Certain types of drugs have specific withdrawal effects as well. Withdrawal symptoms can be reversed very quickly if the individual begins taking the drug again, and this results in a continuing spiral of drug abuse.
Because Ativan has a short half-life, a person who has chronically abused the drug may begin experiencing withdrawal symptoms relatively quickly. The symptoms can motivate the person to try to find more Ativan or drugs similar to Ativan to reduce their discomfort.
A person who abuses a benzodiazepine like Ativan often gets caught up in a vicious cycle of drug abuse followed by short periods of abstinence. Individuals may even mistake normal variations in physical wellbeing, such as a slight headache, minor body aches, irritability, etc., as signs that withdrawal is about to occur and begin taking Ativan.
Benzodiazepines are very often abused in combination with other drugs, such as alcohol, other benzodiazepines, other central nervous system depressants, and even stimulant medications like cocaine and Adderall or Ritalin. Abusing multiple drugs in concert is a very dangerous practice and can lead to a number of potentially dangerous situations, including an increased potential for overdose, adverse reactions, the development of seizures, and accidents or harm due to poor judgment.
There is a good body of empirical research regarding withdrawal from Ativan and other benzodiazepines. The withdrawal process is very similar to withdrawal from alcohol and equally dangerous due to the possibility that the individual will develop seizures during withdrawal. It is relatively difficult to predict which individuals will develop seizures when withdrawing from alcohol or benzodiazepines. However, anyone who has abused benzodiazepines singularly or in combination with drugs runs the risk of serious complications during withdrawal that may result in seizures. The seizures associated with withdrawal from benzodiazepines like Ativan can be potentially fatal.
The general withdrawal process and timeline for withdrawal from Ativan are outlined below.
- An initial period of withdrawal may begin relatively quickly, depending on the amount and frequency of Ativan abuse. Because Ativan does have a relatively short half-life, withdrawal symptoms may occur within 24 hours after discontinuation. Withdrawal from Ativan often begins with a rise in blood pressure, an increase in heart rate, insomnia, and a rush of anxiety.
- The anxiety that occurs in the withdrawal process is often called the rebound effect. This occurs when symptoms that the drug is originally designed to control return or appear after one stops using the drug. Ativan is primarily designed for the treatment of anxiety, and many individuals will experience severe anxiety and even panic attacks during withdrawal from moderate to severe Ativan abuse.
Various other symptoms may or may not occur during the withdrawal process and include:
- Continued cardiovascular effects, such as an increase in blood pressure, increased heart rate, and irregular heartbeat
- Nausea, vomiting, difficulty eating, stomach cramps, dehydration, and weight loss
- Anxiety, depression, mood swings, and, in some rare instances, potential delusions and hallucinations
- Headache, tremors, profuse sweating, fever, chills, confusion (The combination of severe mental confusion, irritability or extreme lethargy, and hallucinations is often referred to as ), and potential to develop seizures
- Cravings to use the drug
Individuals will be motivated to take Ativan to relieve whatever withdrawal symptoms they are experiencing. In addition, individuals with moderate to severe substance use disorders that involve Ativan abuse have developed a habitual practice of using Ativan to cope with stress or to escape, and will most likely experience the desire to use the drug in situations where they used the drug previously (e.g., such as when feeling stressed).
- The initial phase of withdrawal from Ativan can be variable in its length and may last 3-5 days or as long as four weeks. The symptoms will usually peek within a week or two and then decrease in their intensity. Following the peak of the symptoms, individuals may also experience a period of withdrawal symptoms that is far less intense, but lingers for two weeks or longer. Typically, these symptoms consist of flulike issues, such as headache, upset stomach, mild fever or chills, and mild sweating or dizziness. Issues with mood often continue, including anxiety and depression. Individuals will continue to experience intermittent cravings for Ativan and may also experience a significant increase in rebound anxiety following a period of less intense withdrawal symptoms.
Some sources still refer to a prolonged period of withdrawal that follows the acute withdrawal syndrome, termed post-acute withdrawal syndrome. The syndrome may last for weeks, months, or even years, and consists mostly of emotional issues, such as mood swings, issues with motivation, apathy, and intermittent cravings to return to drug use.
This set of experiences that most likely does occur in many individuals who have negotiated the withdrawal process from a number of different drugs has never had the research support to label it is a formal withdrawal syndrome. Instead, these symptoms most likely represents a number of emotional and psychological factors that occur following recovery from substance abuse and may also represent a number of factors, some preexisting, that initially helped to foster the individual’s substance abuse. It is well accepted that individuals with substance use disorders have high rates of co-occurring psychological disorders or conditions, and individuals who have psychological disorders also have high rates of co-occurring substance use disorders.
Addressing the Withdrawal Syndrome from Ativan
The first thing to understand is that physical dependence to drugs like benzodiazepines can occur in individuals who use these drugs for lengthy periods for medicinal purposes and in those who abuse them. People who need to use benzodiazepines for long periods of time or on an ongoing basis, such as for the control of seizures, may develop physical dependence; however, if they use the drugs within the confines of their prescription and under the supervision of a physician, they do not get diagnosed with a substance use disorder. A substance use disorder represents the nonmedicinal use of the medication or drug, loss of control regarding use, and the development of a number of negative ramifications that result from the individual’s drug use. Treatment for withdrawal from Ativan would be similar in either case.
The treatment for the withdrawal syndrome from Ativan consists of the following components:
- Participation in a formal physician-assisted withdrawal management program: Depending on the particular case, the withdrawal management program may be performed in an inpatient or outpatient environment. The physician will administer another benzodiazepine or may even administer Ativan at specific doses to control the withdrawal symptoms. Then, over time, the physician will initiate a tapering strategy where the dosage is reduced slowly at specific time intervals to allow the person system to slowly wean off the drug. This will significantly reduce or even eliminate any negative withdrawal symptoms and result in a slow transition to sobriety. The process also will most likely take far longer than simply withdrawing “cold turkey,” but it is significantly safer.
- Other medications and medical interventions: These can be used to address symptoms that may not be completely controlled by the initiation of a tapering strategy for benzodiazepine withdrawal. The withdrawal management process should be closely supervised by a physician and medical personnel to address any issues that can lead to relapse.
- A formal substance use disorder treatment program: This treatment can include therapy and participation in social support groups, such as Narcotics Anonymous or other relevant groups. The simple completion of a withdrawal management program without a therapy component and participation in social support groups will not satisfy the requirements needed to recover from a substance use disorder. Individuals who simply go through the withdrawal management process without engaging in ongoing treatment most often relapse.
- Treatment for co-occurring disorders: This includes treatment for any co-occurring psychological conditions or relevant physical conditions that may increase the risk for relapse (e.g., chronic pain; endocrine conditions that may produce psychological effects such as hypothyroidism, hyperthyroidism, or cardiovascular issues that produce anxiety; etc.).
- Other relevant interventions: These should be used as needed, depending on the particular case. They may include assistance with housing, education, vocational rehabilitation, occupational therapy, etc.