Why We Will Ask You to Come Off One of Them

Taken together, an opioid and a benzodiazepine suppress breathing synergistically, more than the two effects added together, so the drive to breathe can simply fail to show up. The FDA puts a boxed warning, its strongest, on exactly this combination. Many patients arrive on both, often from different prescribers. One of them has to come off, slowly and under a doctor’s care.

Many of the patients who come here take both an opioid for pain and a benzodiazepine for anxiety or sleep. Benzodiazepines include alprazolam, clonazepam, diazepam and lorazepam. Often a different prescriber started each one, for a sound reason. Neither one saw the whole list.

One of the first conversations we have is that this combination needs to come apart. Patients understandably ask why another physician started it if it is dangerous. This is the longer answer.

The two drugs fail your breathing in different ways

Opioids work at opioid receptors: mu, kappa and delta. Among other effects, they dull the brainstem’s response to rising carbon dioxide. Benzodiazepines work somewhere else entirely. They boost GABA-A, the main “slow down” signal in the brain and spinal cord.

Two different mechanisms, one shared result. Both weaken the drive to breathe.

Taken alone at prescribed doses, an opioid usually brings drowsiness and pain relief. Serious breathing problems are rare without a large overdose. A benzodiazepine alone is also survivable in most overdoses of that one drug.

Together they are synergistic rather than additive. The combined effect is bigger than the two separate effects added up. The way it fails: the drive to breathe simply does not show up. Carbon dioxide builds up, and the person never feels the air hunger that would warn them.

This is not a fringe position. The FDA carries a boxed warning on the concurrent use of opioids and benzodiazepines, citing exactly this risk.

Alcohol belongs in this conversation too. It works on the same GABA-A system. That is why patients who can’t get a benzodiazepine sometimes use alcohol instead. And it is why alcohol with an opioid carries the same danger.

Coming off a benzodiazepine is harder than coming off an opioid

This surprises most patients, and it is the reason we treat the taper so carefully.

Opioid withdrawal is miserable, but it is rarely dangerous. It looks like sympathetic overdrive, the body’s alarm system running too hot: feeling cold, goosebumps, nausea, vomiting, cramps, no sleep. It is truly awful, but it does not usually threaten life.

Benzodiazepine withdrawal can cause seizures. Stopping suddenly after steady use is a medical emergency, not a test of willpower. In the clinic, we see more serious harm from people stopping benzodiazepines on their own than from people stopping opioids on their own.

So: do not stop a benzodiazepine abruptly, and do not taper it without medical supervision. Not after years, not after six months, not after one month. Do not start, stop, or change any medication without consulting your physician.

Dependence also sets in faster and holds on harder than most patients expect. In our experience, it is harder to undo than opioid dependence.

What the taper actually looks like

A benzodiazepine wean is slow, and the bigger cuts come first on purpose. Early cuts are larger and easier to handle. The last part of the dose is far harder. Six months or more is normal, and rushing the end is how tapers fail.

Some patients cannot be fully weaned. Severe PTSD and some psychiatric conditions are real exceptions. In those cases, the taper may be very slow or may stop short of zero. Getting there takes a lot of emotional support and real relearning, not just a dosing schedule. That is why this work sits alongside the mental side of pain, not apart from it. See the neurobiology of a stuck alarm.

There are also valid cases where a benzodiazepine is still the right drug. The main one is severe spasticity (muscles locked tight), including sphincter spasticity, where the antispasmodics we have can’t do what a benzodiazepine does. We judge those cases on their own merits.

The memory problem nobody mentions

Benzodiazepines impair the formation of new memories. This is not sedation and it is not aging.

Patients describe waking to signs of an evening they can’t recall: crumbs in the bed, a kitchen that was used. Worse, some have driven and have no memory of it. These are not rare oddities. They are a known effect of this drug class.

Sleep deserves special attention, because that is where most of this quietly happens. Patients often use a benzodiazepine to sleep. And several common sleep drugs work at the same GABA-A benzodiazepine site, including zolpidem and eszopiclone. Carisoprodol is not a benzodiazepine itself. But the body turns it into meprobamate, which acts in a similar way.

These drugs do not give you restoring sleep. They warp the structure of sleep, especially REM (dream sleep). You feel like you slept better mostly because your brain does not record the memory of lying awake. We covered a related mechanism in common sleep aid could hinder brain waste removal.

Why this is a pain conversation at all

Most of what this practice does is cut down the drugs patients take. Our interventional and metabolic work exists so that patients have something to step onto as the drugs come down. See opioid tapering: medication is a bridge, not a destination and why opioids stop working.

Poor sleep turns pain up. Poor memory undercuts every self-care skill we might teach. And weak breathing at night ruins the very sleep the drug was meant to fix. Untangling this combination is not a roadblock to pain treatment. It is part of it.

Frequently asked questions

Why did another doctor prescribe both if it is dangerous?

Usually because each was started separately, for a good reason, without one prescriber seeing the full list. That is a failure of teamwork, not of skill. But the combined risk is real no matter how it started, and the FDA’s boxed warning reflects it.

Can I just stop my benzodiazepine?

No. Stopping suddenly after steady use can cause seizures. This needs a slow taper under a doctor’s care. Do not start, stop, or change any medication without consulting your physician.

Which is worse to come off, opioids or benzodiazepines?

Benzodiazepines, by a wide margin. Opioid withdrawal is severe but rarely dangerous. Benzodiazepine withdrawal can be life-threatening. See opioid tapering: medication is a bridge, not a destination.

Is my sleeping pill a benzodiazepine?

Maybe not by name. But several work at the same receptor site, including zolpidem and eszopiclone. And the body turns carisoprodol into a compound that acts in a similar way. Bring the actual bottles to your visit. See common sleep aid could hinder brain waste removal.

Are there cases where a benzodiazepine is the right drug?

Yes. Severe spasticity, including sphincter spasticity. And some psychiatric conditions where a full wean can’t be done. We decide those case by case.

Where can I be evaluated?

Padda Institute, 4477 Woodson Rd, Suite 100, St. Louis, MO 63134, serving the St. Louis region across Missouri and Illinois. Call (314) 481-5000 or text (314) 886-5902.

Key takeaways

• Opioids work at opioid receptors, benzodiazepines at GABA-A. Both weaken the drive to breathe, and together the effect is synergistic: bigger than the two added up.
• The FDA carries a boxed warning on concurrent use. Alcohol carries the same interaction.
• Benzodiazepine withdrawal can cause seizures. Never stop suddenly or without a doctor.
• A realistic wean is six months or longer, front-loaded, with the final portion the hardest.
• Several common sleep drugs work at the same receptor site and cause the same memory gaps.
• Severe spasticity and some psychiatric cases are real exceptions.

This article is educational and is not a substitute for evaluation, diagnosis, or treatment by a physician. Individual results vary. Do not start, stop, or change any medication without consulting your physician.

Medically reviewed by Gurpreet Singh Padda, MD, MBA, MHP — Board Certified in Anesthesiology, Pain Medicine, Interventional Pain Management, Addiction Medicine, and Obesity Medicine. Last reviewed August 2026.

Dr. Gurpreet Singh Padda, MD, MBA, MHP