Valium (diazepam) is one of the most recognized of all the benzodiazepine drugs. Benzodiazepines were developed as a less additive alternative to barbiturate drugs; however, these drugs are significant drugs of abuse as well. They have a wide range of medicinal uses that include the management of anxiety, management of seizures, treatment of withdrawal syndromes for alcohol and other drugs, treatment of issues with muscle spasms or restless leg syndrome, and as sleep aids.
Valium is classified as a Schedule IV controlled substance by the United States Drug Enforcement Agency, indicating that while it does have significant medical uses, it also has a moderate potential for abuse and the development of physical and/or psychological dependence. Valium was the most popularly prescribed medication in the world at one time; however, because of its potential for abuse, it is no longer prescribed as freely as it once was, particularly for individuals with issues with anxiety. The abuse of benzodiazepines most often occurs in conjunction with abuse of other drugs, particularly drugs like alcohol, opiate drugs, cannabis products, and even stimulants.
Combining benzodiazepines like Valium with other drugs leads to a number of potential complications. First, individuals can develop a number of unpredictable side effects when these drugs are combined with other drugs. Second, the effects of one drug can be enhanced or diminished depending on the combination of drugs used. Taking Valium with other central nervous system depressants like alcohol enhances the effects of both drugs, including the potential for side effects in overdose. Taking Valium with drugs that have the opposite effect, such as stimulants, can result in the perception that the Valium is not working properly, and an individual may take dangerously high amounts of the drug. The rates of overdoses related to benzodiazepine abuse in the United States have increased, and this reflects in part many of these dangers.
Drugs like Valium produce feelings of relaxation, euphoria, giddiness, and a loss of inhibitions that make them attractive to potential abusers; however, they also have a significant potential for the development of tolerance (needing higher doses of the drug to get the effects that were once achieved at lower doses) and withdrawal. When an individual has developed tolerance and withdrawal symptoms, they have developed physical dependence on the drug.
Withdrawal from Valium
Even though the development of physical dependence on drugs like Valium can be signs that one has developed a substance use disorder, the development of tolerance and/or withdrawal are not symptoms that are necessary nor sufficient for an individual to be diagnosed with a substance use disorder. (The term substance use disorder is the clinical designation that applies to both conceptualizations of substance abuse and addiction.) Individuals who use drugs like Valium for control of chronic seizures will also be at risk to develop physical dependence on Valium; however, as long as they use these drugs under the supervision of a physician and according to the prescribed instructions, they are not considered to have substance use disorders. In addition, individuals who abuse drugs like Valium will typically take these drugs in higher amounts than individuals who use them in their prescribed manners, and will typically use them more frequently and in combination with other drugs. This results in the potential for individuals who abuse Valium to have significantly more complicated withdrawal syndromes than individuals who use the drug for medicinal purposes only.
There is a fair body of empirical literature describing the withdrawal process from Valium. A 1980 review article in the Western Journal of Medicine summarized a listing of all reported case studies of withdrawal from Valium at the time. The individuals in the studies had been using Valium for different rates of time, including periods as short as 10 days to as long as 10 years. The onset of the withdrawal symptoms in these individuals ranged from one day to 12 days. The symptom profile in all of these particular cases was quite varied and included issues with anxiety, confusion, disorientation, restlessness, insomnia, appetite loss, tremors, cramps, nausea, vomiting, slurred speech, dizziness, hostility, hallucinations, paranoid delusions, and seizures. It should be noted that a number of these individuals had co-occurring issues with other substance abuse (e.g., heroin abuse), anxiety disorders, depressive disorders, obsessive-compulsive disorder, neurosis (a general term to describe overall mental distress), and a number of different medical conditions, including cardiac problems, insomnia, and backache.
One classic study of Valium withdrawal occurring in the Canadian Medical Association Journal in 1982 followed 10 individuals who had significant and lengthy periods of Valium abuse, but no other substance abuse issues or a diagnosis of any other mental health disorder. Some of individuals in the study were treated with medication, and some were given a placebo during the withdrawal process. Overall, the symptoms of withdrawal peaked within a few days following discontinuation, started to lessen over the next three weeks, and then peaked again at 3-4 weeks before steadily decreasing. The symptoms of withdrawal were relatively absent by the end of the fifth week following discontinuation. Regardless of whether the subject received treatment for their symptoms, nearly all the subjects displayed the following withdrawal symptoms:
- Decreased appetite and weight loss
- Agitation and restlessness
- Excessive perspiration
- Inability to sleep
- Tremors, which were mostly postural tremors that occur when an individual attempts to maintain a position against gravity, such as holding one’s arms out
- Myoclonus, which are jerky movements of the limbs when one contracts their muscles
- Anxiety, which is often termed as being “rebound anxiety” because the primary use of Valium at the time was to control anxiety
The classic model of withdrawing from benzodiazepines follows the notion of initial or acute effects and then longer more protracted effects, with the potential of rebound effects occurring. In general, withdrawal from Valium can be expected to follow a pattern that includes the following:
- An acute period: Individuals will begin to experience the effects within 24-96 hours after they discontinue use of the drug. Because Valium has a half-life that can be quite variable and may be as long as 48 hours in some people, the withdrawal effects may not appear in some individuals for a few days following discontinuation. Obviously, individuals who have developed significant tolerance to the drug and have higher levels of the drug in their system will often have different withdrawal presentations than individuals who do not have significant tolerance to the drug. The symptoms in the acute phase often peak within a few days and consist of:
- A number of physically based symptoms that include many common withdrawal symptoms, such as headache, nausea, vomiting, stomach cramps, diarrhea, insomnia, appetite loss, sweating, fever, and chills
- Increases in blood pressure and heart rate
- Mental health symptoms that include rebound anxiety (which is often the first symptom individuals express and includes feelings of jitteriness, nervousness, or even full-blown anxiety and panic), cravings for the drug, depression, mood swings, and, in rare cases, psychotic symptoms, such as hallucinations and delusions
- Neurological symptoms that can include issues with movement, tremors, issues with cognition (e.g., confusion, issues with memory, and even delirium), and the potential to develop seizures
Because there is a potential for the development of seizures associated with discontinuation of benzodiazepines like Valium, and seizures can lead to very serious or even fatal complications, medical detox is required for the acute phase of Valium withdrawal.
- Lessened but lengthy symptoms: A longer and more extended period of withdrawal symptoms follows. These symptoms are typically not perceived as being as intense as the acute phase of withdrawal; however, there is a potential for an exacerbation of symptoms like anxiety and seizures several weeks after discontinuation. The symptoms in this phase will mostly consist of the types of symptoms that can occur in the acute phase but they are less intense. For many individuals, the protracted phase can last up to 10 days to several weeks following discontinuation.
- Protracted withdrawal: Many sources discussing withdrawal from Valium discuss a much lengthier period of time involving issues with depression, anxiety, problems with motivation, mood swings, and cravings for the drug that are often referred to as post-acute (or protracted) withdrawal syndrome (PAWS). PAWS is reported to have a very variable length and can last for weeks, months, and even years. However, the research on PAWS has never been able to substantiate these symptoms as a formal withdrawal syndrome. It is not included in diagnostic manuals such as the Diagnostic and Statistical Manual for Mental Disorders. Certainly, a number of individuals recovering from substance use disorders will experience chronic issues with mood and cravings for significant periods of time after they have negotiated the withdrawal process; however, these most likely do not reflect a formal withdrawal syndrome but instead reflect more chronic issues that are associated with multiple factors, including one’s past substance use.
Medically Assisted Withdrawal Management
Because individuals who withdraw from Valium are likely to experience distressing withdrawal symptoms and can potentially experience seizures that can lead to serious physical and mental complications including the potential for fatalities, it is strongly suggested that individuals who have developed substance use disorders as a result of Valium abuse discontinue the drug under the supervision of a physician. Physicians trained in addiction medicine can develop a formal medically assisted withdrawal management program (also referred to as medical detox) to ensure that the recovery process is safe and negotiable. The physician can administer a benzodiazepine during the withdrawal process on a tapering schedule, which results in the drug being tapered down over scheduled intervals. This reduces the effects of the withdrawal process and helps to eliminate the potential for the individual to develop seizures.
The withdrawal management process is typically personalized for each individual. The supervising physician will begin by following a general overall plan of withdrawal management and then customize the plan based on the individual’s particular needs. Participating in a formal physician-assisted withdrawal management program reduces the severity of the withdrawal symptoms one will experience, reduces any potential dangers associated with the withdrawal process, and significantly reduces the rates of relapse that occur during the withdrawal process.
Nonetheless, unless an individual seeks out formal substance use disorder treatment following the withdrawal management program, their overall long-term success rates are not significantly better than individuals who do not participate in withdrawal management. Thus, even though the withdrawal management process can reduce complications with withdrawal and relapse during the withdrawal period, individuals with substance use disorders fare better when they engage themselves in a formal long-term aftercare program that includes therapy designed to address their issues.