Addiction Treatment
Why Benzodiazepines Are So Addictive, and Why Stopping Takes a Plan
Alprazolam (Xanax), clonazepam (Klonopin), diazepam (Valium), and lorazepam (Ativan) work quickly on the problems that send people to a doctor, such as anxiety and panic. That is why they are prescribed, and part of why they are hard to walk away from. The FDA estimated that about 92 million benzodiazepine prescriptions were dispensed in the U.S. in 2019, and it warns that physical dependence can develop when a benzodiazepine is taken steadily for several days to weeks, even exactly as prescribed.
Far more people become physically dependent on a benzodiazepine than develop an addiction to one, and dependence alone is enough to make stopping hard.
If you take a benzodiazepine every day, do not stop suddenly. Stopping abruptly or cutting the dose too fast can cause withdrawal reactions, including seizures, which the FDA warns can be life-threatening. Any change to the dose should be planned with the prescriber.
How do benzodiazepines affect the brain?
GABA (gamma-aminobutyric acid) is the brain’s main quieting signal. According to the National Institute on Drug Abuse, benzodiazepines increase activity at GABA receptors (the GABA-A type), which slows brain activity and produces the drowsy, calm effect that helps with anxiety and sleep.
Think of GABA as a brake. A benzodiazepine presses it harder than the brain would, and someone in the middle of a panic attack remembers that relief.
Why does the same dose stop working?
NIDA describes the first few days on a depressant as sleepy and uncoordinated, with those side effects fading as tolerance develops. With long-term use, a person may need larger doses for the same therapeutic effect.
The reason is adaptation. The 2025 Joint Clinical Practice Guideline on Benzodiazepine Tapering, led by the American Society of Addiction Medicine (ASAM), says physical dependence results from downregulation of benzodiazepine receptors and changes in how those receptors respond. The brain, in effect, turns down its own brake to make room for the drug, so without the drug the brake is weaker than before. NIDA notes that stopping these drugs can produce a rebound effect, including seizures.
Alprazolam gets there faster. The ASAM guideline links its very short half-life, rapid onset, and lack of active metabolites to a faster onset of physical dependence, and says a taper may be appropriate for someone taking it daily for as little as two to four weeks.
Is physical dependence the same as addiction?
Physical dependence is the body’s adaptation to repeated use of a drug, so that stopping or sharply cutting the dose causes withdrawal. The ASAM guideline calls it an expected consequence of ongoing benzodiazepine use. Someone taking clonazepam nightly for a year, exactly as prescribed, may well be dependent. That alone is not addiction.
Addiction, clinically a sedative, hypnotic, or anxiolytic use disorder (often called benzodiazepine use disorder), is a chronic disease of the brain circuits that handle stress, decision-making, and reinforcement of behavior. The guideline identifies it by criteria including impaired control over use and continued use despite harm.
In a study of U.S. adults surveyed in 2015–2016 and cited in the guideline, about 1.5% of people who had used a benzodiazepine in the past year met criteria for a benzodiazepine use disorder, and the guideline says people who are physically dependent far outnumber people with a use disorder. Misuse is a separate measure: in 2025, an estimated 3.3 million people in the U.S. aged 12 and older (1.1%) misused prescription benzodiazepines in the past year, according to SAMHSA’s National Survey on Drug Use and Health.
The line can blur. The FDA notes that dependence may lead some people to keep using just to avoid withdrawal.
What did the FDA’s 2020 boxed warning change?
In September 2020 the FDA required the boxed warning, its most prominent label warning, to be updated on all benzodiazepines to address abuse, misuse, addiction, physical dependence, and withdrawal reactions. The agency said that even at recommended doses, benzodiazepine use can lead to misuse, abuse, and addiction. It also found serious withdrawal reactions in patients whose benzodiazepine was stopped suddenly or reduced too quickly. In some of those cases, patients reported that the prescriber had stopped it abruptly instead of tapering.
Why is stopping suddenly dangerous?
The ASAM guideline says clinicians should not stop benzodiazepines abruptly in anyone likely to be physically dependent, because rapid dose reduction can cause life-threatening withdrawal symptoms such as seizures and delirium. The FDA’s list of more severe reactions includes seizures, delirium tremens, hallucinations, mania, psychosis, and thoughts of suicide or of harming someone else. If any of these happen, use the emergency guidance below.
For prescribers, the guideline sets a slow starting pace: dose reductions of 5 to 10% every two to four weeks, typically not more than 25% every two weeks, adjusted to how the person responds. Those numbers describe how a clinician plans and adjusts a taper. They are not a schedule to follow on your own. Slow is not the same as symptom-free. According to the FDA, even a gradual reduction can bring anxiety, insomnia, panic attacks, tremors, and memory problems. The FDA also describes a protracted withdrawal syndrome lasting beyond four to six weeks, with symptoms that may last as long as 12 months, and the ASAM guideline says some patients have them for months or years.
The guideline says most patients can complete a taper in outpatient care. It tells clinicians to consider inpatient or medically managed residential care when the risk is too high to manage safely outside a hospital or residential setting, and for people who also have a substance use disorder it names very high doses, other substance use, and a history of withdrawal seizures as reasons for a more intensive setting.
Why are opioids, alcohol, and street pills so risky with benzos?
In 2016 the FDA added its strongest warnings to opioid and benzodiazepine labels after finding that combined use had resulted in slowed or difficult breathing and deaths. In one study the FDA cited, patients dispensed both opioid painkillers and benzodiazepines died of overdose at 10 times the rate of patients dispensed opioids alone. The FDA is just as direct about alcohol: do not drink it with benzodiazepines.
Street pills add a different risk. The DEA warns that fake pills made to look like Xanax may contain fentanyl, and the CDC found that in the overdose deaths it tracked across 30 jurisdictions, the share with evidence of counterfeit pill use more than doubled, from 2.0% in July–September 2019 to 4.7% in October–December 2021. Those pills often mimic oxycodone or alprazolam and often contain fentanyl or illicit benzodiazepines such as bromazolam, which the New York City Health Department notes is not approved for human use in the United States. The ASAM guideline adds that novel benzodiazepines like these may not be detected by standard drug tests.
A “Xanax bar” from a friend or a website is not a known dose of alprazolam. It may not be alprazolam at all.
What are the signs of a problem?
Signs to take seriously, in yourself or someone close to you:
- Taking more than prescribed, or running out early
- Pills from another person or from the street
- A higher dose needed for the same calm
- Anxiety, shakiness, or sleeplessness when a dose is late
- Combining it with alcohol or opioids
- Attempts to cut down that do not stick
- Continued use despite problems at work, at home, behind the wheel, or with memory
One or two may simply mean dependence that needs a conversation with the prescriber. Several together, especially loss of control and continued use despite harm, point toward a use disorder.
When to get emergency help
Call 911 if someone who has taken a benzodiazepine, or stopped one, has a seizure, is hard to wake, is breathing slowly or not at all, is confused, hallucinating, or out of touch with reality, or is in immediate danger of hurting themselves or someone else. The FDA tells patients to go to an emergency room or call 911 for trouble breathing or seizures.
If opioids or a street pill might be involved, give naloxone (Narcan) while you wait for help. If normal breathing has not returned after 2 to 3 minutes, give another dose with a new device, and keep repeating every 2 to 3 minutes until the person breathes normally or help arrives. Lay the person on their side and stay with them. Naloxone reverses only the opioid part of an overdose. It is not expected to reverse bromazolam or other benzodiazepines, or sedatives such as xylazine and medetomidine, so a person may stay sedated after naloxone. Give it anyway and follow the dispatcher’s instructions.
Call or text 988 for thoughts of suicide or a mental health crisis, including during withdrawal. For questions about a possible poisoning, call Poison Control at 1-800-222-1222. For help finding treatment, the SAMHSA National Helpline is free and open 24 hours a day at 1-800-662-4357.
What does treatment look like?
Treatment usually runs on two tracks: a prescriber-managed taper or medically supervised withdrawal, and treatment for the use disorder and whatever drove it. The ASAM guideline recommends offering behavioral therapy tailored to the underlying condition during a taper, such as cognitive behavioral therapy or CBT for insomnia. It also recommends treating a substance use disorder at the same time as the taper, not after it.
The anxiety, panic, trauma, or insomnia behind the first prescription is still there when the drug is gone. Treating those co-occurring conditions is a large part of recovery.
How South Jersey Recovery Program can help
South Jersey Recovery Program is an outpatient program in Berlin, NJ. We do not provide detox or manage benzodiazepine tapers. If you need medically supervised detox or residential care, we will tell you and help you find it.
Where we fit is alongside a supervised taper or after withdrawal is complete. We offer partial care Monday through Friday, 9:30 a.m. to 3:30 p.m.; an intensive outpatient program from 9:30 a.m. to noon, five days a week to start and three as you step down; and standard outpatient therapy one or two sessions a week. Clients live at home and keep working where they can. We are licensed by the New Jersey Department of Health (license #2001009).
Treatment includes individual therapy, group therapy, and relapse prevention. If alcohol or opioids are also involved, see our substance abuse treatment page.
Call us at (856) 788-6914 for a confidential assessment, or contact us online.
At a glance
- Benzodiazepines strengthen GABA, the brain’s brake. With daily use the brain adapts, and tolerance and dependence can follow within weeks.
- Physical dependence is not addiction, and it is far more common.
- If you take one daily, do not stop suddenly. Withdrawal can cause seizures, and tapers are gradual and prescriber-supervised.
- Mixing with opioids or alcohol can stop breathing. Street pills may contain fentanyl or bromazolam.
- Call 911 for a seizure, slow breathing, or someone who is hard to wake.
Sources
- U.S. Food and Drug Administration. FDA requiring Boxed Warning updated to improve safe use of benzodiazepine drug class. Drug Safety Communication, September 23, 2020. fda.gov
- U.S. Food and Drug Administration. FDA warns about serious risks and death when combining opioid pain or cough medicines with benzodiazepines; requires its strongest warning. Drug Safety Communication, August 31, 2016 (archived copy linked from FDA’s 2020 communication). web.archive.org
- Brunner E, et al. Joint Clinical Practice Guideline on Benzodiazepine Tapering: Considerations When Risks Outweigh Benefits. J Gen Intern Med. 2025;40(12):2814-2859. pmc.ncbi.nlm.nih.gov/articles/PMC12463801
- American Society of Addiction Medicine. Benzodiazepine Tapering. asam.org
- National Institute on Drug Abuse. What classes of prescription drugs are commonly misused? Misuse of Prescription Drugs Research Report. nida.nih.gov
- O’Donnell J, et al. Drug Overdose Deaths with Evidence of Counterfeit Pill Use, United States, July 2019–December 2021. MMWR. 2023;72(35). cdc.gov/mmwr
- U.S. Drug Enforcement Administration. Fake Prescription Pills. dea.gov
- New York City Department of Health and Mental Hygiene. 2025 Health Advisory #12: Poisoning by Medetomidine and Bromazolam in Suspected Opioid Overdose. nyc.gov
- Centers for Disease Control and Prevention. 5 Things to Know About Naloxone. cdc.gov
- Centers for Disease Control and Prevention. What You Should Know About Xylazine. cdc.gov
- Blanco C, Han B, Jones CM, Johnson K, Compton WM. Prevalence and Correlates of Benzodiazepine Use, Misuse, and Use Disorders Among Adults in the United States. J Clin Psychiatry. 2018;79(6):18m12174. pubmed.ncbi.nlm.nih.gov/30403446
- Substance Abuse and Mental Health Services Administration. Results from the 2025 National Survey on Drug Use and Health: Detailed Tables, Table 1.1A. samhsa.gov
- National Institute on Drug Abuse. Naloxone DrugFacts. nida.nih.gov
- NARCAN (naloxone hydrochloride) nasal spray, prescribing information. DailyMed. dailymed.nlm.nih.gov
- SAMHSA National Helpline. samhsa.gov
- 988 Suicide & Crisis Lifeline. 988lifeline.org
