lorazepam (Ativan)

the boxed warning, part one: opioids

the first part says that using benzodiazepines with opioids "may result in profound sedation, respiratory depression, coma, and death", that the two should be prescribed together only "for patients for whom alternative treatment options are inadequate", at the lowest doses for the shortest time, with the patient followed for slowed breathing and sedation [label, boxed warning]. the warnings section adds the evidence sentence: "observational studies have demonstrated that concomitant use of opioid analgesics and benzodiazepines increases the risk of drug-related mortality compared to use of opioids alone", and a dosing instruction that in someone already on an opioid the starting dose of lorazepam should be lower than usual, and the other way round when an opioid is added to lorazepam [label, warnings]. the mechanism is in the interactions section: the two drugs slow breathing through different receptors, benzodiazepines at gaba-a sites and opioids mainly at mu receptors, so they add rather than overlap [label, drug interactions; label-row].

the numbers behind it are observational. among 315,428 insured american adults who filled an opioid prescription between 2001 and 2013, the share also filling a benzodiazepine rose from 9% to 17%, and those taking both had about twice the odds (adjusted odds ratio 2.14) of an emergency visit or admission for opioid overdose [sun-2017]. across 399,230 us opioid overdose deaths from 1999 to 2017, benzodiazepine involvement rose from 8.7% to 21.0%, and a benzodiazepine was present in 33.1% of prescription-opioid deaths in 2017 [tori-2020]. in cdc surveillance for the first half of 2018, 62.6% of opioid deaths in 25 states also involved cocaine, methamphetamine or a benzodiazepine, and illicitly made fentanyl was in about two thirds of them [gladden-2019]. none of these can prove the benzodiazepine caused the deaths; all of them count it there.

the boxed warning, parts two and three: abuse, misuse and addiction; dependence and withdrawal

the second part says benzodiazepines expose users to "risks of abuse, misuse, and addiction, which can lead to overdose or death", that abuse and misuse "commonly involve concomitant use of other medications, alcohol, and/or illicit substances", and that prescribers should assess each person’s risk before prescribing and throughout treatment [label, boxed warning]. the label adds that "even taking benzodiazepines as prescribed may put patients at risk for abuse and misuse of their medication", that misuse often but not always involves doses above the maximum, and that death "is more often associated with polysubstance use (especially benzodiazepines with other cns depressants such as opioids and alcohol)" [label, drug abuse and dependence].

the third part says continued use "may lead to clinically significant physical dependence", that the risks of dependence and withdrawal "increase with longer treatment duration and higher daily dose", and that stopping abruptly or cutting the dose quickly after continued use "may precipitate acute withdrawal reactions, which can be life-threatening", so the dose should come down by a gradual taper [label, boxed warning]. the fda required this wording on every benzodiazepine in september 2020; its point is that dependence can develop when the drug is taken exactly as prescribed, which is a reason not to stop on one’s own [fda-2020]. the label lists the acute withdrawal signs, from anxiety, insomnia, tremor, racing heart, raised blood pressure, panic attacks and sensitivity to light and sound to the severe ones: catatonia, convulsions, delirium tremens, hallucinations, mania, psychosis, seizures and suicidality. a protracted syndrome, with anxiety, cognitive impairment, depression, insomnia, crawling-skin sensations, weakness, tremor, muscle twitches, tingling and tinnitus, can persist beyond four to six weeks and "may last weeks to more than 12 months", and the label concedes "there may be difficulty in differentiating withdrawal symptoms from potential re-emergence or continuation of symptoms for which the benzodiazepine was being used" [label, warnings; drug abuse and dependence]. it also names one way to trigger acute withdrawal that is not a missed dose: flumazenil, the benzodiazepine antagonist used in overdose, which "may precipitate acute withdrawal reactions, including seizures" in someone who is physically dependent [label, warnings; overdosage].

on tolerance the label says it "may develop to the therapeutic effect", while "little tolerance develops to the amnestic reactions and other cognitive impairments caused by benzodiazepines" [label, drug abuse and dependence]. unlike the clonazepam label, this one reports nothing about how people fared when they came off it in trials; there is no clinical studies section at all [approval].

what the label says about tapering

quoted so that it is the label’s and not ours: "to reduce the risk of withdrawal reactions, use a gradual taper to discontinue lorazepam tablets or reduce the dosage. if a patient develops withdrawal reactions, consider pausing the taper or increasing the dosage to the previous tapered dosage level. subsequently decrease the dosage more slowly" [label, dosage and administration]. the warnings section adds that "a patient-specific plan should be used to taper the dose", and that people at the greatest risk of withdrawal are "those who take higher dosages, and those who have had longer durations of use" [label, warnings]. the label gives no step size and no schedule; the clonazepam label does, and that explainer quotes it [clonazepam-explainer].

on how long to stay on it, the label says the physician "should periodically reassess the usefulness of the drug for the individual patient", having already said that effectiveness beyond four months has not been assessed [label, indications]. the uk guideline for these medicines says to taper in steps proportionate to the current dose, so the steps shrink as the dose falls, and to expect that withdrawal "may take several months or more" [nice-2022]. a cochrane review of 38 trials in 2,543 long-term benzodiazepine users found no add-on medication that reliably improved the chance of stopping, leaving the gradual taper as the mainstay [baandrup-2018]. lorazepam is absorbed with 90% bioavailability, peaks at about two hours, and has a mean half-life of about 12 hours; it is cleared by conjugation (glucuronidation) rather than by the liver’s cytochrome enzymes, and the label reports no accumulation with dosing for up to six months [label, clinical pharmacology].

the other warnings, in plain words

beyond the boxed warning, the label’s warnings and precautions sections carry:

• depression and suicide: "pre-existing depression may emerge or worsen during use of benzodiazepines including lorazepam", and lorazepam "is not recommended for use in patients with a primary depressive disorder or psychosis". in people with depression "a possibility for suicide should be borne in mind; benzodiazepines should not be used in such patients without adequate antidepressant therapy" [label, warnings; precautions]. this sits oddly beside the indication, which includes anxiety "associated with depressive symptoms"; the label does not reconcile the two, and this page does not try to.
• breathing: benzodiazepines "both used alone and in combination with other cns depressants, may lead to potentially fatal respiratory depression"; caution in anyone with compromised breathing such as copd or sleep apnea [label, warnings; precautions]. worsening of sleep apnea and of obstructive pulmonary disease are on the adverse-reaction list [label, adverse reactions].
• newborns: use late in pregnancy can leave a baby sedated (slow breathing, lethargy, floppiness) or in withdrawal (overactive reflexes, irritability, restlessness, tremors, inconsolable crying, feeding difficulties). published observational studies "do not report a clear association" with major birth defects; early reports of malformations with diazepam and chlordiazepoxide were not confirmed by the majority of later studies that adjusted for alcohol, tobacco and other drugs; rabbit studies showed occasional anomalies "without relationship to dosage" [label, warnings; pregnancy]. lorazepam is present in breast milk, with reports of sedation, poor feeding and poor weight gain in infants exposed through milk [label, nursing mothers].
• driving and alcohol: patients "should be warned not to operate dangerous machinery or motor vehicles and that their tolerance for alcohol and other cns depressants will be diminished" [label, warnings]. the interactions section lists what adds to the sedation: alcohol, barbiturates, antipsychotics, sleeping pills, other anxiety drugs, antidepressants, opioids, sedating antihistamines, anticonvulsants and anaesthetics [label, drug interactions; label-row].
• clozapine: the one named drug-drug combination. lorazepam with clozapine "may produce marked sedation, excessive salivation, hypotension, ataxia, delirium, and respiratory arrest" [label, drug interactions].
• valproate and probenecid: both raise lorazepam levels by blocking its conjugation, and the label says the lorazepam dose "should be reduced to approximately 50%" with either. theophylline and aminophylline may reduce its sedative effect [label, drug interactions].
• paradoxical reactions: anxiety, excitation, agitation, hostility, aggression, rage, sleep disturbance, sexual arousal and hallucinations "may occur", more likely in children and the elderly; "should these occur, use of the drug should be discontinued" [label, precautions; adverse reactions].
• older people: the trials were "not adequate to determine whether subjects aged 65 and over respond differently", but "the incidence of sedation and unsteadiness was observed to increase with age"; the starting dose for elderly or debilitated patients "should not exceed 2 mg" a day [label, precautions; geriatric use]. in one study of intravenous doses, clearance was 20% lower in 15 subjects aged 60 to 84 than in 15 aged 19 to 38 [label, clinical pharmacology].
• liver, blood and the gut: caution in severe liver disease, where lorazepam may worsen hepatic encephalopathy; some patients have developed low white cells (leukopenia) and raised ldh, so the label recommends periodic blood counts and liver tests during long-term therapy. rats dosed for more than a year developed dilation of the oesophagus, reversible only if treatment stopped within two months; the no-effect dose was about six times the maximum human dose, the label calls the clinical significance "unknown", and asks for "frequent monitoring for symptoms of upper gi disease" in prolonged use and in older people [label, precautions; laboratory tests].
• contraindications: hypersensitivity to benzodiazepines, and acute narrow-angle glaucoma [label, contraindications]. safety and effectiveness under 12 "have not been established" [label, precautions].

what the label says about its own trials, which is almost nothing

the marketed tablet label has no clinical studies section. it does not say how many trials supported the 1977 approval, how long they ran, what they measured or what they showed; the fda has not published its original review, as for most approvals of that era [approval]. the only trial-scale figure anywhere in the label is the side-effect sample, "about 3500 patients treated for anxiety", reported without a placebo group, a duration or a study design [label, adverse reactions]. the one statement about duration is the four-month line in the indications [label, indications].

the dosing section describes a usual range of 2 to 6 mg a day in divided doses, "the largest dose being taken before bedtime", within a span of 1 to 10 mg; for anxiety most patients start on 2 to 3 mg a day in two or three doses; "for insomnia due to anxiety or transient situational stress, a single daily dose of 2 to 4 mg may be given, usually at bedtime"; for elderly or debilitated patients, 1 to 2 mg a day [label, dosage and administration]. so sleep is on this label in a way it is not on, for example, the trazodone label, but only as a dose for insomnia that is itself caused by anxiety or situational stress, not as an indication [label, indications; dosage and administration].

the two largest randomised trials of lorazepam in the library are not of the tablet and not of anxiety. in 518 people with generalised convulsive status epilepticus, intravenous lorazepam stopped the seizure in 64.9% against 43.6% with phenytoin [treiman-1998]; in 205 people treated by paramedics before reaching hospital, intravenous lorazepam ended the seizure in 59.1% against 21.1% on placebo, an odds ratio of 4.8, without more respiratory complications [alldredge-2001]. the injection has its own label, which this page does not read. a cochrane review of 20 small trials in 695 people found benzodiazepines, most often lorazepam, calmed acute psychotic agitation about as well as antipsychotics with fewer movement side effects, and rated the evidence poor: most trials were underpowered, randomisation was poorly reported, and 6 of the 20 were industry-funded [zaman-2017]. neither emergency seizures nor agitation is an approved use of the tablet [label, indications].

side effects, with the label’s numbers

the label gives four figures, all from the uncontrolled sample of about 3,500 people treated for anxiety: sedation 15.9%, dizziness 6.9%, weakness 4.2%, unsteadiness 3.4%, with "the incidence of sedation and unsteadiness increased with age" [label, adverse reactions]. there is no placebo rate to set beside any of them, no dropout rate and no figure by dose; the label says only that most benzodiazepine reactions "are dose dependent, with more severe effects occurring with high doses" [label, adverse reactions].

the rest of the list is unquantified: fatigue, drowsiness, amnesia and memory impairment, confusion, disorientation, depression and "unmasking of depression", disinhibition, euphoria, suicidal ideation or attempt, ataxia, extrapyramidal symptoms, seizures, tremor, vertigo, double or blurred vision, slurred speech, change in libido, impotence, decreased orgasm, headache, coma; respiratory depression and apnea; nausea, appetite change, constipation, jaundice and raised liver enzymes; allergic and anaphylactoid reactions, hair loss; low sodium from inappropriate antidiuretic hormone; low platelets, white cells or all blood cell lines; and hypothermia [label, adverse reactions]. small drops in blood pressure "are usually not clinically significant, probably being related to the relief of anxiety" [label, adverse reactions]. in overdose the picture runs from drowsiness to coma, and overdose "in combination with other cns depressants (including alcohol and opioids) may be fatal" [label, overdosage].

what the research says, in both directions

in favour. in the two emergency-seizure trials, intravenous lorazepam outperformed phenytoin and placebo by wide margins, 64.9% against 43.6% and 59.1% against 21.1%, which is why it is a first-line emergency drug in that setting [treiman-1998; alldredge-2001]. for acute agitation in psychosis, the cochrane review found it about as effective as antipsychotics with fewer movement side effects, on poor-quality evidence [zaman-2017]. its pharmacology is simpler than some benzodiazepines’: 90% bioavailability, a 12-hour half-life, clearance by conjugation rather than cytochrome enzymes, and no accumulation over six months of dosing, so the label names only valproate and probenecid as drugs that raise its level [label, clinical pharmacology; drug interactions].

against, or smaller than it sounds. the approved use rests on trials the label does not describe, with no controlled efficacy figure anywhere on it, and the label itself says effectiveness beyond four months "has not been assessed" [label, indications; approval]. the emergency trials are of a different product in a different situation and say nothing about daily tablets for anxiety [treiman-1998; alldredge-2001]. a meta-analysis of 13 observational studies of people who had taken benzodiazepines for about 10 years found them scoring moderately worse than controls across every cognitive domain tested (effect size 0.74) [barker-2004], which sits beside the label’s own statement that little tolerance develops to the cognitive effects. the side-effect figures have no placebo comparison [label, adverse reactions].

the warnings, measured. the opioid warning’s size is in the three studies above: twice the odds of an overdose visit with concurrent prescriptions [sun-2017], a benzodiazepine present in one in three prescription-opioid deaths [tori-2020], and nearly two thirds of opioid deaths involving another drug [gladden-2019]. the dependence warning’s timescale is in the uk guideline [nice-2022] and in the cochrane finding that no medicine makes stopping reliably easier [baandrup-2018]. on dementia, the two best class studies point in opposite directions and neither is lorazepam-specific: a case-control study of 1,796 older adults with alzheimer’s disease found past benzodiazepine use beyond three months associated with about 1.5 times the odds [billioti-2014], while a prospective cohort of 3,434 adults aged 65 and over followed for 7.3 years found no increased dementia risk in the heaviest users and no dose-response [gray-2016].

questions people ask

what does the ativan (lorazepam) black box warning mean?

it has three parts, rewritten by the fda for every benzodiazepine in september 2020. first, taking a benzodiazepine with an opioid can cause profound sedation, slowed breathing, coma and death, so the two should be combined only when alternatives are inadequate, at the lowest doses for the shortest time. second, benzodiazepines carry risks of abuse, misuse and addiction that can lead to overdose or death, and prescribers should assess that risk before and during treatment. third, continued use can cause physical dependence, and stopping abruptly or cutting the dose quickly can cause withdrawal reactions that can be life-threatening, so the dose should come down by a gradual taper. it is a warning about how the drug is used, not an instruction to stop it.

is lorazepam addictive?

the label says benzodiazepines expose users to risks of abuse, misuse and addiction, that even taking them as prescribed may put people at risk of misuse, and that physical dependence, which the label distinguishes from addiction, can develop with continued use, with the risk rising with higher doses and longer treatment. dependence means withdrawal symptoms on stopping, which the label says can be life-threatening and in some people last more than a year. lorazepam is a schedule iv controlled substance. that is why the label says to taper rather than stop.

what are the most common lorazepam side effects?

the label reports four rates from a sample of about 3,500 people treated for anxiety, with no placebo comparison: sedation 15.9%, dizziness 6.9%, weakness 4.2% and unsteadiness 3.4%, with sedation and unsteadiness increasing with age. the rest of its list has no rates: memory impairment, confusion, depression, disinhibition, slurred speech, blurred vision, changes in libido, and the paradoxical reactions of agitation, aggression, rage and hallucinations. the label says little tolerance develops to the memory and cognitive effects.

what happens if you stop lorazepam suddenly?

the label says abrupt stopping or a rapid dose cut after continued use can cause acute withdrawal reactions that can be life-threatening, including seizures, catatonia, delirium tremens, hallucinations, mania, psychosis and suicidality, and that a protracted syndrome of anxiety, cognitive impairment, depression, insomnia, crawling-skin sensations, tremor, tingling and tinnitus can last weeks to more than 12 months. its instruction is a gradual taper, pausing or returning to the previous step if withdrawal appears and then going more slowly; it gives no schedule. a taper plan belongs with a prescriber.

can you take lorazepam with opioids or alcohol?

the boxed warning says benzodiazepines with opioids may cause profound sedation, respiratory depression, coma and death, and that the combination should be reserved for people with no adequate alternative, at the lowest doses for the shortest time. the label says tolerance for alcohol will be diminished and lists alcohol first among the drugs that add to lorazepam’s sedation. in the studies behind the warning, people filling both prescriptions had about twice the odds of an overdose emergency visit, and a benzodiazepine was present in one in three prescription-opioid overdose deaths in 2017. the person who can make sure both prescribers know is the patient.

is lorazepam approved for sleep?

not as an indication. the label approves it for anxiety disorders and the short-term relief of anxiety symptoms. its dosing section does include one sleep line, a single bedtime dose of 2 to 4 mg "for insomnia due to anxiety or transient situational stress", so sleep appears on the label only as a symptom of anxiety. the label describes no sleep trial, and its four-month limit on assessed effectiveness applies to every use.

does lorazepam cause dementia?

unsettled, and nothing in the library is lorazepam-specific. a 2014 case-control study of 1,796 older adults with alzheimer’s disease found past benzodiazepine use beyond three months associated with about 1.5 times the odds, rising with longer use. a 2016 prospective cohort of 3,434 adults aged 65 and over, followed for 7.3 years, found no increased dementia risk in the heaviest users and no dose-response, which argues against causation; anxiety and insomnia can be early symptoms of dementia that lead to a prescription years before diagnosis. what is better established is that long-term users score worse on cognitive tests while taking the drug, and the label says tolerance to those effects is limited.

how is lorazepam different from xanax (alprazolam) or klonopin (clonazepam)?

all three carry the same 2020 boxed warning and the same dependence and withdrawal language, and all three are schedule iv. the label facts that differ: lorazepam has a mean half-life of about 12 hours, is cleared by conjugation rather than cytochrome enzymes so fewer drugs change its level, and its tablet label approves anxiety only, with no clinical studies section and no taper schedule. the alprazolam and clonazepam labels each have their own explainer on this site [alprazolam-explainer; clonazepam-explainer], and alprazolam and lorazepam are compared side by side on the comparison page [compare]. nothing in any of the labels is a reason to prefer one drug; that is a prescriber’s decision.

sources for this section

the library rows link to our one-page summary of each study, with the original paper, its funding and our evidence grade on that page.

1. lorazepam tablets prescribing information, fda label on dailymed (set id 6c5356b1-c199-49ad-bb00-fd67c6691f74, version 10, effective august 7, 2026; remedyrepack, anda 072927): boxed warning; indications and usage; contraindications; warnings; precautions, including information for patients, essential laboratory tests, drug interactions, pregnancy, nursing mothers and geriatric use; adverse reactions; drug abuse and dependence; overdosage; dosage and administration; clinical pharmacology
2. drugs@fda, nda 017794 (ativan), approved september 30, 1977; no fda review of the original application is published, as for most approvals of that era, and the tablet label has no clinical studies section
3. ahrq medical expenditure panel survey, prescribed medicines public-use files 2014 (hc-168a) and 2024 (hc-254a): people with at least one lorazepam purchase and prescriptions, weighted; the 2014 to 2024 prescription fall is larger than the survey’s margin of error; computed by veisund, method on the usage section of this page
4. fda drug safety communication, september 2020: fda requiring boxed warning updated to improve safe use of benzodiazepine drug class (library row)
5. the lorazepam label’s interaction list, read for the library: alcohol, antidepressants and antipsychotics named together as drugs that add to its sedation (ativan prescribing information, bausch health, november 2025, a different labeler’s copy of the same text) (library row)
6. sun ec, et al. association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. bmj 2017 (library row)
7. tori me, larochelle mr, naimi ts. alcohol or benzodiazepine co-involvement with opioid overdose deaths in the united states, 1999 to 2017. jama network open 2020 (library row)
8. gladden rm, et al. changes in opioid-involved overdose deaths by opioid type and presence of benzodiazepines, cocaine, and methamphetamine, 25 states, 2017 to 2018. mmwr 2019 (library row)
9. national institute for health and care excellence. medicines associated with dependence or withdrawal symptoms (ng215), 2022 (library row)
10. baandrup l, et al. pharmacological interventions for benzodiazepine discontinuation in chronic benzodiazepine users. cochrane database of systematic reviews 2018 (library row)
11. barker mj, et al. cognitive effects of long-term benzodiazepine use: a meta-analysis. cns drugs 2004 (library row)
12. treiman dm, et al. a comparison of four treatments for generalized convulsive status epilepticus. new england journal of medicine 1998 (intravenous lorazepam, 518 patients) (library row)
13. alldredge bk, et al. a comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus. new england journal of medicine 2001 (intravenous lorazepam, 205 patients) (library row)
14. zaman h, et al. benzodiazepines for psychosis-induced aggression or agitation. cochrane database of systematic reviews 2017 (20 trials, 695 participants) (library row)
15. billioti de gage s, et al. benzodiazepine use and risk of alzheimer’s disease: case-control study. bmj 2014 (a benzodiazepine class study, not lorazepam-specific) (library row)
16. gray sl, et al. benzodiazepine use and risk of incident dementia or cognitive decline: prospective population based study. bmj 2016 (a benzodiazepine class study, not lorazepam-specific) (library row)
17. what the alprazolam (xanax) warnings mean, the companion explainer on this site: the same 2020 boxed warning, that label’s taper wording and side-effect tables
18. what the clonazepam (klonopin) warnings mean, the companion explainer on this site, with the one benzodiazepine label on this site that prints a taper schedule
19. alprazolam vs lorazepam, the side-by-side comparison page on this site

Most-reported reactions

• Fatigue13,822
• Nausea13,647
• Drug ineffective12,491
• Diarrhoea10,647
• Off label use10,585
• Dyspnoea9,489
• Anxiety9,034
• Headache8,908
• Pain8,868
• Vomiting8,797