Diazepam (Valium)

What it treats

Diazepam is approved by the U.S. Food and Drug Administration to treat anxiety disorders and to provide short-term relief of anxiety symptoms. It is also used for muscle spasm, for certain types of seizures, and to help manage alcohol withdrawal. This guide focuses on its use for anxiety, and mentions the other uses only briefly.

Because of the dependence risk described below, benzodiazepines like diazepam are generally used short-term rather than as an everyday, long-term treatment. For ongoing, day-to-day anxiety, SSRIs or SNRIs are the usual first-line medications. Diazepam often has a role alongside that, for instance during the weeks before an antidepressant takes effect, or for specific situations a prescriber identifies.

How it works

Diazepam is a benzodiazepine. It strengthens the effect of GABA, which is the brain's main calming, or inhibitory, chemical messenger. By boosting GABA's signal, diazepam quiets nerve activity and produces a fast reduction in anxiety.

Diazepam is long-acting. It, and the active substances the body makes from it, stay in the body for a long time. That is the main difference from shorter-acting benzodiazepines such as alprazolam, where the effect comes and goes more quickly.

What to expect

Relief from diazepam comes on relatively quickly, often within an hour of a dose. You do not need to wait weeks for it to start working the way you would with an SSRI.

Because diazepam is long-acting, its effect is steady and lasts a long time, rather than coming and going quickly. People are less likely to notice anxiety returning between doses than they are with a shorter-acting benzodiazepine. How a dose is timed and how often it is taken are decisions a prescriber makes.

Common side effects

The most common side effects come from diazepam's calming, sedating action:

• Drowsiness and sedation.
• Tiredness.
• Reduced coordination.
• Dizziness.
• Memory and concentration effects, especially at higher doses.

These effects are more noticeable early on and at higher doses. If they interfere with daily activities such as driving or work, that's a conversation to have with the prescriber.

Serious side effects and warnings

Diazepam is useful, and it also needs more caution than most medications on this site. The most important warnings are two FDA boxed warnings.

Boxed warning: dependence and withdrawal. Benzodiazepines, including diazepam, carry an FDA boxed warning about the risks of abuse, misuse, addiction, physical dependence, and withdrawal. These risks can develop even when the medication is taken exactly as prescribed.

Boxed warning: combining with opioids. Benzodiazepines also carry an FDA boxed warning about the serious dangers of combining them with opioid medications. Together they can cause extreme sedation, slowed breathing, coma, and death. Diazepam and opioids should not be used together unless a prescriber has specifically decided there is no alternative.

Beyond the boxed warnings, a few points are worth knowing:

• Physical dependence can develop with regular use. This is not the same as misuse. The body adjusts to diazepam over time, so that it comes to expect the medication.
• Stopping abruptly can cause serious withdrawal. Withdrawal can include seizures and can be dangerous. For that reason diazepam must be tapered slowly under medical supervision rather than stopped on your own.
• Tolerance can build. Over time the same dose may work less well, which is one reason long-term daily use is generally avoided.
• Alcohol and other sedatives sharply increase the risks. Combining them with diazepam adds to sedation and slowed breathing.
• Older adults are more affected. They are more prone to falls, confusion, and memory problems on benzodiazepines. Because diazepam is long-acting, it can build up in the body over time, so extra caution applies in older adults.

Because of the dependence risk, benzodiazepines are generally used short-term, and SSRIs or SNRIs are the first-line medications for ongoing anxiety.

Sexual side effects

Diazepam is not particularly associated with sexual side effects, unlike SSRIs. This is one area where it differs from the antidepressants used for anxiety. If you do notice a change, it is worth mentioning to your prescriber, since other factors, including anxiety itself, can play a part.

Weight, appetite, and sleep

Diazepam is not a notable cause of weight change. It does not typically affect appetite the way some other psychiatric medications can.

It is sedating, which is its intended effect on anxiety but also why it can leave people drowsy or low on energy during the day. If daytime sleepiness is a problem, a prescriber can review the dose and timing.

Starting and dosing basics

This section is general background, not a dosing instruction for any individual. The right dose and the length of treatment are decisions for a prescriber.

Diazepam comes as tablets and as a liquid. It is generally prescribed at the lowest effective dose for the shortest reasonable time. A prescriber sets the starting dose and any changes based on the condition being treated and how a person responds.

Missed doses and interactions

Follow the prescriber's guidance on what to do about a missed dose, since the right approach depends on how diazepam is being used.

The most important interactions are opioids and alcohol. Both are dangerous combined with diazepam, because all three slow breathing and deepen sedation. Other sedating medications add to the same risk. Some medications change how the body processes diazepam and can raise its levels. Give every prescriber and pharmacist a full list of your medications and supplements, including over-the-counter ones, so these combinations can be checked.

Stopping and tapering

This is the most important section on this page. Diazepam should not be stopped suddenly.

After regular use, the body adjusts to diazepam. Stopping abruptly can cause withdrawal, which can include rebound anxiety, trouble sleeping, agitation, and, in serious cases, seizures. That is why coming off diazepam means a slow, gradual taper, planned and supervised by a prescriber.

One point is worth noting. Because diazepam is long-acting, it is sometimes used to help people taper off shorter-acting benzodiazepines more smoothly, since its steady, slow-clearing effect makes the steps down easier to tolerate. Any taper schedule depends on the dose, how long the medication has been taken, and how a person responds. If you want to stop, the safe path is to talk with your prescriber and plan it together, not to stop on your own.

Pregnancy and breastfeeding

Benzodiazepines are generally avoided during pregnancy and while breastfeeding, unless a clinician judges that they are needed. This is an area where individual circumstances matter and the decision belongs with a clinician. Anyone who is pregnant, planning a pregnancy, or breastfeeding should discuss diazepam with their prescriber so the specific risks and benefits can be weighed for their situation.

Cost and generic availability

Diazepam has been available as a generic for many years and is inexpensive. The brand name Valium and generic diazepam contain the same active medication and work the same way. Most insurance plans cover it, and for people paying out of pocket, generic diazepam is low-cost.

Common questions

How is diazepam different from shorter-acting benzodiazepines like alprazolam? Diazepam is long-acting, so it and the substances the body makes from it stay in the body for a long time. Its effect is steady and lasts longer, while a shorter-acting benzodiazepine like alprazolam comes on and wears off more quickly.

Is diazepam addictive? It carries a real risk of physical dependence, which can develop even with regular prescribed use. That is why it is usually used short-term and why stopping needs a planned taper. Used carefully and with a prescriber, it can still be a helpful medication.

Can I drink alcohol while taking it? No. Alcohol and diazepam together are a dangerous combination, because both slow breathing and deepen sedation.

Why is it usually prescribed only short-term? Because the body can develop dependence and tolerance over time. For ongoing, day-to-day anxiety, SSRIs or SNRIs are the usual first-line treatment.

What happens if I stop suddenly? Stopping abruptly can cause withdrawal, including rebound anxiety, trouble sleeping, agitation, and, in serious cases, seizures. Don't stop on your own. Plan a gradual taper with your prescriber.

Questions to ask your prescriber

• What are we hoping this treats, and how long do you expect I'll take it?
• How and when should I take it, and how often?
• Which medications and substances should I avoid while on it?
• What signs of dependence or tolerance should I watch for?
• When the time comes to stop, how would we taper it safely?

Sources

• U.S. Food and Drug Administration. Diazepam (Valium) prescribing information.
• MedlinePlus, U.S. National Library of Medicine. Diazepam.
• National Institute of Mental Health. Mental health medications.