Medically Reviewed By: Benjamin Caleb Williams RN, BA, CEN
Written By: Phillippe Greenough
Article Updated: 01/24/2021
Number of References: 35 Sources
The symptoms of Ativan withdrawal can be very unpleasant, and sometimes even dangerous. The symptoms are both physical and psychological and may be quite protracted in some cases. Here, we will take a look at how Ativan works, the symptoms and effects of withdrawal, the timeline involved, and some effective treatments.
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The timeline for Ativan withdrawal can be somewhat protracted compared to many other drugs, often taking around a week or two for the acute symptoms to dissipate. Ativan, being an intermediate-acting benzo, has an intermediate withdrawal timeline that is shorter than Klonopin and Valium and roughly similar to Xanax in duration. With a half-life of between 12 to 14 hours, it will be roughly 24 hours since the last Ativan use before withdrawal symptoms begin to appear. While some benzos seem to have variable half-lives depending on genetics or age, Ativan seems to exhibit a fairly consistent half-life among different populations. That being said, there are still individuals differences based on age, genetics, gender, and underlying health conditions although these may not play as large a role in Ativan withdrawal as they do with other benzos. There are exceptions, such as in cases of Gilbert’s syndrome which can increase the time-to-clearance of Ativan by 20-40% resulting in a longer half-life, but this is uncommon.
Below, we will take a look at the average week-by-week timeline of the appearance and resolution of Ativan withdrawal symptoms:
Within a day or so of the last Ativan use, withdrawal symptoms will begin to appear. Anxiety will be highest in the days immediately after ceasing Ativan use, caused by a phenomenon known as rebound anxiety. The middle of the first week is when the risk of seizures, delirium, and hallucinations is greatest, and if they are to occur, it is often during days three, four, or five after the last time someone used Ativan. The second week may start out rough, as Ativan withdrawal symptoms are usually at their peak during this time. The risk of seizure and delirium is often reduced, although hallucinations may persist through the first half of the second week. While rebound anxiety may have dissipated, anxiety levels often remain very high and panic attacks are not uncommon. Towards the end of the second week, the worst of the physical symptoms may begin resolving.
Some of the symptoms of Ativan withdrawal that may be expected during the first 2 weeks could include:
The symptoms of Ativan withdrawal are not usually fatal, although in cases of very heavy or long-term users or those with pre-existing health conditions, dangerous and possibly deadly complications may arise. The risk of seizure is particularly noteworthy, as it is possible to suffer injuries secondary to the seizure if one occurs while someone is standing, or even simply laying in bed. Additionally, these seizures may progress to a very dangerous seizure state known as status epilepticus. This is considered a medical emergency by healthcare workers, as it can frequently result in brain damage or death if left untreated.
The beginning of the third week often marks the first sign of relief for someone experiencing Ativan withdrawal. The physical symptoms may be well on their way to resolution, although as this happens the psychological symptoms may become more apparent. With the physical symptoms no longer taking up so much of someone’s attention, they may begin to focus more on the psychological symptoms. By the fourth week, the physical symptoms are usually fully resolved, although the psychological symptoms will often persist for some time longer. While the worst may be in the past, there are still challenges ahead. Relapse is very common in the weeks immediately after withdrawal and detox has been completed, and it will take effort and continuing care if someone is to avoid relapse. As the memory of the pain and discomfort of withdrawal fades, it may seem more and more tempting to return to Ativan use. This is where recovery programs and treatment can make a huge difference. Also, medications and therapy can greatly reduce psychological symptoms and help someone continue their recovery.
Some of the more common symptoms of Ativan withdrawal that may remain into weeks 3 and 4 could include:
These symptoms will begin resolving over time, although this may be a slow process. Continued abstinence along with psychiatric care and clinical therapy can greatly reduce the severity of these symptoms while the body and brain recover.
The post-acute symptoms of Ativan withdrawal are not physically dangerous, aside from the increased risk of suicide, but they can still pose a threat to someones continuing recovery. Isolationist tendencies are commonly seen during post-acute Ativan withdrawal, as someone may struggle to overcome these symptoms without help. This can prevent a person from taking the steps needed and making personal connections with those who may be able to help them. These symptoms are psychological in nature and can manifest both depressive and hyperactive symptoms.
Some of the most common post-acute Ativan withdrawal symptoms include:
These symptoms may not be as directly dangerous, but they may still pose risks. Aside from possibly acting as a barrier to recovery, the sometimes deep depression that people may experience can lead to thoughts of suicide. This can lead to potentially fatal consequences if these thoughts are acted upon, and great care should be taken to reduce these risks, and improve someone’s chances of continued sobriety. Both medications and therapy can be very effective at treating these symptoms, but continued abstinence from Ativan is required for the brain to heal from the changes made during Ativan addiction.
While there are minor differences between withdrawal intensity and duration between individuals, for the most part the symptoms of Ativan withdrawal are fairly standard. That being said, there are factors that can contribute to the severity of symptoms and the duration of symptoms. These are mainly behavioral in nature and have to do with someone’s Ativan use habits. While several benzo drugs exhibit great variability in drug metabolism depending on genetic factors, Ativan is not counted among them, as it undergoes extensive metabolism and does not produce any significant metabolites.
Some of the most common contributing factors to the intensity of Ativan withdrawal symptoms include:
By far, the greatest contributors to the symptoms of Ativan withdrawal are directly dependent upon someone’s Ativan use habits. The amount of Ativan someone used can most strongly affect the intensity of withdrawal symptoms. The more Ativan someone uses, the more downregulation will be performed. Since downregulation is responsible for the most intense physical symptoms, the more Ativan someone used regularly, the more intense their withdrawal symptoms will be. Similarly, the amount of time someone used Ativan can strongly affect the duration of withdrawal symptoms. The further neurological remodeling that the brain undergoes to adapt to GABA downregulation is a slow process that takes time to produce noticeable changes. This process is quite slow to reverse as well. The longer someone uses Ativan, the more complete the process of remodeling becomes, thus the longer it takes to reverse.
Someone’s mental health can also contribute to the intensity, and possibly the duration, of Ativan withdrawal symptoms as well, albeit in a more indirect manner. Ativan is commonly prescribed for anxiety disorders, so it is quite common for those who abuse Ativan to at least have issues with heightened anxiety in the first place. Since depression and anxiety are such common effects of Ativan withdrawal, if someone had suffered from either of these issues before Ativan use, they would most likely experience more severe anxiety or depression than someone who had no such mental health issue. Additionally, the symptoms may persist longer than in an otherwise mentally healthy person. While this influence is indirect and tangential, it can contribute to the experience of Ativan withdrawal.
Ativan is a fairly potent and intermediate-acting benzodiazepine (benzo) medication that is commonly used to treat anxiety disorders, used as a pre-anesthesia treatment, and for the treatment of certain types of seizures. It may also be used off-label in the treatment of alcohol withdrawal and medical emergencies involving seizures. The active ingredient in Ativan is lorazepam, and this drug is ~5 times as potent as diazepam milligram-per-milligram. Similar to other benzos, Ativan works by increasing the impact of the neurotransmitter GABA, a major inhibitory neurotransmitter. Ativan use produces sedation, relaxation, and drowsiness and in large doses, it can lead to memory and coordination impairment. Ativan use can also produce downstream effects and changes in other neurotransmitter systems such as serotonin, dopamine, and possibly norepinephrine.
Ativan produces its major depressive effects in a roundabout way and is not technically a GABA agonist. Through binding at GABA-α receptor subunits, also known as benzodiazepine receptors, it can increase the GABA receptors affinity for GABA, thus leading to stronger binding, and a greater effect produced by GABA transmission. The increased impact of GABA leads to overall psychological and physical depression and calming. When used chronically, the brain will begin to undergo a process known as downregulation in an attempt to maintain balance and reduce the level of inhibition. This, in effect, is the act of the brain turning down its sensitivity to GABA and this will initially produce a tolerance to Ativan. Downregulation can begin happening quite soon, sometimes in just a few weeks of regular use. Continued use will result in further downregulation which can lead to physical dependence on the drug.
The brain can also make further changes, known as remodeling, although this takes a longer time to produce noticeable effects than with downregulation. Remodeling is the act of the brain making structural changes so that it will prioritize Ativan use while it is operating in a GABA-downregulated environment. This takes some time to occur and, likewise, takes time to reverse. Downregulation is responsible for the short-term, or acute, symptoms of Ativan withdrawal, while remodeling is the major cause of long-term, post-acute symptoms. Once downregulation has occurred, someone will begin to feel physically and psychologically unwell if they go too long without using Ativan. The changes made in the brain to operate in the continued presence of Ativan will leave the brain in a hyperactive state if the drug is withheld. The symptoms that this produces can range from simply uncomfortable, to potentially life-threatening in the case of heavy or long-time Ativan users.
Aside from the almost certain discomfort, Ativan withdrawal can often be quite dangerous. If someone is expecting to go through withdrawal from Ativan, it is very highly recommended that they enter an Ativan detox center. These programs offer medications and medical monitoring to reduce the risks and discomfort of the physical symptoms, as well as therapy and treatment for the psychological symptoms as well. Having the support of trained medical and psychiatric professionals at these facilities can be a huge benefit for anyone trying to recover from an addiction to Ativan.
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