[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Conditions](https://durgical.com/en/conditions/) › Sedative-hypnotic (benzodiazepine) use disorder and withdrawal

[Conditions](https://durgical.com/en/conditions/) · [Psychiatry](https://durgical.com/en/conditions/)

# Sedative-hypnotic (benzodiazepine) use disorder and withdrawal

Problematic use of sleeping pills or anxiety medicines such as benzodiazepines. Stopping suddenly after long use can cause dangerous withdrawal with seizures.

Updated 2026-11-01

## Structures involved

Tap one to see what it is and open it in 3D.

- [Frontal lobe](https://durgical.com/en/anatomy/superior-frontal-gyrus/)
- [Medulla oblongata](https://durgical.com/en/anatomy/medulla-oblongata/)
- [Hippocampus](https://durgical.com/en/anatomy/hippocampus/)
- [Amygdala](https://durgical.com/en/anatomy/amygdaloid-body/)
- [Cerebellum](https://durgical.com/en/anatomy/anterior-quadrangular-lobule/)
- [Pons](https://durgical.com/en/anatomy/pons/)

## Why it happens

- [The main neurotransmitters](https://durgical.com/en/physiology/the-main-neurotransmitters/)
- [Synaptic transmission](https://durgical.com/en/physiology/synaptic-transmission/)

## What it is

A substance use disorder involving sedatives, hypnotics or anxiolytics, mainly benzodiazepines, the related 'Z-drugs' and barbiturates. Use often starts with a prescription for anxiety or insomnia and escalates. Like alcohol, these drugs cause tolerance and physical dependence, and abrupt withdrawal can be life-threatening.

## Who gets it

Benzodiazepines are among the most prescribed psychotropic drugs in Latin America, frequently used long term by older adults and women. Non-medical use is found in young people combining them with alcohol or opioids. In Colombia, illicit benzodiazepines are also used to incapacitate victims for robbery or assault, together with scopolamine.

## Causes

- Long-term prescription for anxiety or insomnia, with gradual dose escalation
- Non-medical use to self-medicate or to enhance the effects of other drugs
- Use to counteract the 'crash' of stimulants or withdrawal from alcohol or opioids
- Genetic and psychological vulnerability to addiction

## Risk factors

- Anxiety, panic or insomnia disorders
- Other substance use disorders, especially alcohol and opioids
- Older age and long-term prescribing
- Short-acting, high-potency benzodiazepines
- Chronic pain and personality disorders

## Pathophysiology

Benzodiazepines bind the GABA-A receptor and increase the frequency of chloride channel opening (barbiturates increase the duration). With chronic use, GABA-A receptors adapt and become less sensitive. When the drug is stopped suddenly, the brain is left in a hyperexcitable state, similar to alcohol withdrawal, causing anxiety, tremor, seizures and delirium. In overdose, depression of the brainstem respiratory centres in the medulla is rarely fatal alone but becomes dangerous combined with alcohol or opioids.

## Classification

- Severity by DSM-5 criteria: mild, moderate or severe
- Sedative intoxication: slurred speech, ataxia, drowsiness, nystagmus, memory impairment, stupor
- Sedative withdrawal: autonomic hyperactivity, tremor, insomnia, anxiety, hallucinations, seizures, delirium

## Symptoms and signs

- Taking higher doses or for longer than prescribed; visiting several prescribers
- Drowsiness, slurred speech, poor coordination and memory gaps
- Rebound anxiety and insomnia between doses
- Withdrawal: anxiety, insomnia, tremor, sweating, tachycardia, nausea and perceptual disturbances
- Severe withdrawal: generalised seizures, delirium and psychosis

## Red flags

- Respiratory depression or coma, especially when combined with alcohol or opioids
- Seizures or delirium during withdrawal
- Falls and hip fractures in older adults
- Suicidal thoughts or intentional overdose

## Diagnosis

**Clinical**
History of sedative use (amount, duration, source), DSM-5 criteria and review of prescribing records. In intoxication, a sedative toxidrome with normal pupils or mild changes and relatively preserved vital signs; pinpoint pupils suggest co-ingestion of opioids.

**Tests**
Urine drug screen (some benzodiazepines such as clonazepam may not be detected by routine screens), blood alcohol, glucose, arterial blood gases in respiratory depression, and paracetamol and salicylate levels in intentional overdose. ECG.

**Imaging**
Head CT in coma of unclear cause, head trauma or a first seizure.

## Differential diagnosis

- Alcohol intoxication or withdrawal
- Opioid intoxication (pinpoint pupils, more respiratory depression)
- Hypoglycaemia, stroke or other causes of altered consciousness
- Primary anxiety or insomnia disorder returning after stopping (relapse rather than withdrawal)

## Goal of treatment

Treat overdose and withdrawal safely, then taper to stop the drug, and treat the underlying anxiety or insomnia with safer options.

## Treatment

**Acute**
Overdose: airway and breathing support; flumazenil only in selected cases, because it can provoke seizures in dependent patients or in co-ingestion with proconvulsant drugs

**Medical**
Withdrawal: switch to a long-acting benzodiazepine and taper slowly over weeks to months; never stop abruptly after long use

**Conservative**
Cognitive behavioural therapy for insomnia and for anxiety disorders, to support the taper

**Follow-up**
Nursing: seizure and fall precautions, monitoring of vital signs, consciousness and respiratory rate, especially with alcohol or opioid co-use

**Medical**
Long-term treatment of anxiety disorders with SSRIs or SNRIs instead of benzodiazepines

## Complications

- Respiratory depression and death, mostly with alcohol or opioids
- Withdrawal seizures and delirium
- Falls, fractures, traffic accidents and cognitive impairment in older adults
- Anterograde amnesia and vulnerability to assault
- Neonatal withdrawal or 'floppy infant' syndrome after use in late pregnancy

## Prognosis

With a slow supervised taper and psychological support, many patients stop successfully. Relapse is more common with coexisting alcohol or opioid use and untreated anxiety. Mortality rises sharply when benzodiazepines are combined with opioids.

## Prevention

- Prescribe benzodiazepines for short periods at the lowest effective dose
- Avoid them in older adults and in combination with opioids
- Review long-term prescriptions and teach patients not to stop suddenly

## Test yourself

Think of the answer, then tap the question to see it.

## How do benzodiazepines differ from barbiturates at the GABA-A receptor?

Benzodiazepines increase the frequency of chloride channel opening; barbiturates increase the duration.

## Why is flumazenil not given routinely in benzodiazepine overdose?

It can precipitate seizures in dependent patients or in mixed overdoses with proconvulsant drugs.

## Which two withdrawal syndromes can cause fatal seizures and delirium?

Alcohol and sedative-hypnotic (benzodiazepine or barbiturate) withdrawal.

## What is the standard strategy to stop long-term benzodiazepine use?

Switch to a long-acting benzodiazepine and taper slowly, with psychological support.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/conditions/sedative-hypnotic-use-disorder-and-withdrawal/)

## Related conditions

- [Benzodiazepine overdose](https://durgical.com/en/conditions/benzodiazepine-overdose/)
- [Alcohol withdrawal and delirium tremens](https://durgical.com/en/conditions/alcohol-withdrawal-and-delirium-tremens/)
- [Alcohol use disorder](https://durgical.com/en/conditions/alcohol-use-disorder/)
- [Opioid use disorder, overdose and withdrawal](https://durgical.com/en/conditions/opioid-use-disorder-overdose-and-withdrawal/)
- [Opioid overdose](https://durgical.com/en/conditions/opioid-overdose/)
- [Delirium](https://durgical.com/en/conditions/delirium/)
- [Status epilepticus](https://durgical.com/en/conditions/status-epilepticus/)
- [Insomnia disorder](https://durgical.com/en/conditions/insomnia-disorder/)
- [Generalized anxiety disorder](https://durgical.com/en/conditions/generalized-anxiety-disorder/)
- [Panic disorder](https://durgical.com/en/conditions/panic-disorder/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [What classes of prescription drugs are commonly misused?](https://nida.nih.gov/publications/research-reports/misuse-prescription-drugs/what-classes-prescription-drugs-are-commonly-misused) (National Institute on Drug Abuse (NIDA), 2025); [Prescription Medicines](https://nida.nih.gov/research-topics/prescription-medicines) (National Institute on Drug Abuse (NIDA), 2025).

[← All conditions](https://durgical.com/en/conditions/)

## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake

Representative model, for educational purposes only.

---
Source: https://durgical.com/en/conditions/sedative-hypnotic-use-disorder-and-withdrawal/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/sedative-hypnotic-use-disorder-and-withdrawal/