How to taper off high potency and or short acting benzodiazepines
Most people in the U.K., who are addicted to benzodiazepines and who wish to undertake a withdrawal programme do so by tapering by using diazepam. Diazepam is recommended for tapering because of its extremely long half life (its active benzodiazepine metabolite has a half life of up to 200 hours). This allows for a smooth slow gradual decline in blood plasma levels with each cut in dosage which helps the body gradually adapt to decreasing blood levels of benzodiazepine and therefore reduce the intensity of withdrawal symptoms. Diazepam also comes in "low dose" 2 mg tablets which can easily be broken in half or in quater in the final stages of withdrawal. Sometimes a taper with a long half life benzodiazepine such as diazepam is not always possible.
For the most part this paper is not necessary for U.K. residents because the standard treatment for benzodiazepine addiction is to use diazepam for tapering. Occasionally residents of the U.K. dependent on benzodiazepines find difficulty in obtaining diazepam from their prescribing physician for tapering purposes or they found diazepam was unsuitable for them and some U.K. residents may therefore still benefit from this paper. Unfortunately in other parts of the world obtaining diazepam for tapering is more difficult due to prescribing trends and other reasons explained below. Many of these people are using high potency benzodiazepines such as clonazepam or alprazolam which are notorously difficult to withdraw from due to reasons explained below.. This paper is aimed at these mainly international web visitors who fall into this category.
Why High Potency or Short Acting Tranquillisers Are Unsuitable For Tapering
A slow gradual dose reduction is not possible by cutting high potency benzodiazepines e.g. clonazepam (klonopin, Rivotril) or alprazolam (Xanax) tablets in half or quarter as the smallest available tablets are 0.5 mg which are equivalent to 10 mg of diazepam. Often these high potency benzodiazepines have a short half life requiring dosing of 3 or 4 times daily or more to keep blood plasma levels relatively stable. With regular dosing there are still peaks and troughs in blood levels which often cause inter-dose withdrawal symptoms. Even quartering these tablets and taking a quarter of a tablet 3 or 4 times a day leaves a patient trying to jump off the equivalent of 7.5 mg or 10 mg of diazepam which many workers in the benzodiazepine addiction field would regard quite correctly as still a cold turkey or over rapid withdrawal. This scenario would likely provoke severe withdrawal symptoms. The shorter half life of some benzodiazepine drugs cause sharp drops in blood levels which typically provoke stronger withdrawal reactions even with gradual reduction.
Reasons for not being able to use the Standard Diazepam Taper
The following gives some of the reasons for patients not being able to do the cross over from their high potency and or short half life benzodiazepine drug onto an equivalent dose of diazepam :-
Not being able to tolerate diazepam
(1) Abrupt transfer across
The inability to tolerate diazepam is often but not always due to too abrupt a transfer across to diazepam. Abrupt transfer e.g. dropping 4 mg of lorazepam over night and putting a person straight onto diazepam would likely provoke a withdrawal syndrome in most people. The reason for a gradual cross over is because diazepam is a long acting benzo and the long acting drugs take time to accumulate and plateau at a constant level in the blood usually between 4 and 6 weeks with most accumulation occuring in the 1st 1 - 2 weeks therefore leaving a patient in a withdrawal state for at least the first week of abrupt transfer to diazepam. The gradual cross over period should be no less than a month but if necessary can take 2 or 3 months or so. After complete cross over it is advised to allow a stabalising period usually of 4 weeks or so before a tapering schedule is started. Diazepam should therefore always be transfered in a step wise fashion. Gradually dropping say a quarter of their short acting benzo each week or 2 and substituting it for an equivalent dose of a long acting benzodiazepine preferably diazepam. Transfer to diazepam can be done in smaller amounts each week if necessary.
(2) Metabolic differences
These include subtle metabolism differences between different people and different benzodiazepines. Half lives can vary from drug to drug and person to person and therefore there can be usually relatively small degrees of difference in equivalency's of the different benzo's between different people which may account for some reports of intolerance of diazepam.
(3) Psychological reasons
Also psychologically people who have been used to taking a particular drug for years may fear adding a "new" drug to the equation. Often these people can loose this fear with some basic pharmacological information given in layman's terms about diazepam and benzodiazepines in general and related drugs (e.g. the 'Z' drugs) i.e. all benzo's work the same way on the brain by binding to the same cells / receptors in the body and the only difference is how long the drug stays in the body etc. Sometimes reassurance is not enough. It is best that a patient with this fear is encouraged but not forced into transferring to diazepam as a forced routine change may produce anxiety and panic and make the withdrawal process harder and less successful.
(4) Binding Affinity's and Penetration of the Blood Brain Barrier
There has been some debate in the benzo community in particular but also by some medical researchers about certain benzodiazepines having a higher 'binding affinity' or 'tighter binding' to the benzodiazepine receptors and also a quicker penetration of the blood brain barrier e.g. lorazepam and alprazolam have often been termed by some in the medical community as the cocaine / heroin benzodiazepines because of their rapid penetration of the blood brain barrier and therefore their instant "hit" they give. These fast acting benzo's are often favoured by those seeking to abuse benzo's for their instant 'chillout' effect. Professor Heather Ashton states that different binding effinities between the different benzodiazepines can usually be ameliorated by the correct equivalent dose of diazepam and a gradual cross over. It may however very well be that a small sub group of people cannot tolerate a cross over to diazepam due to subtle pharmacological differences between the various benzodiazepines. For such people this tutorial should be of use.
(5) Ignorance on the part of the prescribing physician
Unfortunately the most common reason for not being able to use a diazepam taper is a lack of basic pharmacological knowledge about benzodiazepines on the part of the prescribing physician or an unwillingness to support their patient in their attempt to free themselves from the grip of physical addiction of benzodiazepines.
Also another reason is sometimes due to the patient being on an exceedingly large dose of benzodiazepine e.g. 6 mg of clonazepam (klonopin, rivotril) which would be equivalent to 120 mg of diazepam which is well above the recommended dose of diazepam. A physician will often not be willing to prescribe above the recommended dose of diazepam. In such cases the patient can taper down their high potency benzodiazepine to the equivalent dose of 30 - 40 mg of diazepam and then request a transfer across to 30 or 40 mg of diazepam and often the prescribing physician is more co-operative. Another reason is the reputation of valium being a household name for causing addiction. This is largely due to the news media, music and film industry and ignorance of the prescriber. Some physicians therefore assume because of the media focus on valium that it is the most addictive benzo. All benzo's are physically addictive and diazepam aka valium is generally the best for tapering for reasons explained above.
Other Methods of Benzo Tapering
(1) Liquid Raw Suspension Method
- What you need for this method:-
- Raw suspension kit (available in local drug store, pharmacy, chemist) known under the brand name "keltrol" in the U.K.
- Measuring device (syringe or graudated cylinder)
- Storage container e.g. sealable bottle (available in local drug store, pharmacy, chemist)
- Mortal and pestel
This is probably the best method for tapering off high potency benzodiazepines. How it works is obtaining a raw suspension kit from a pharmacist / chemist / drug store. Some pharmacists may be more helpful than others and you may have to do some "shopping around" to find a co-operative pharmacist. The raw suspension usually comes in a sachet and pharmacists use it for creating their own suspensions of drugs. Once you have the raw suspension powder you can crush your tablet or tablets (a mortal and pestle works well for this) and grind it into a fine powder. You then follow the instructions on the sachet of raw suspension powder which usually includes adding water to the suspension powder and then you add the finely ground powder to the suspension mix and giving it a stir for several minutes. You can then pour it into a container. Your pharmacist should be able to provide you with a container for storing the suspension in. A brown bottle often is best and storage in a fridge is also recommended.Your pharmacist may be able to also provide you with a bottle with a built in measuring 'dropper' or a syringe without the needle can also be obtained at most pharmacist stores and works just as well for measuring out doses.
If you are lucky you may even be able to establish a working relationship with your pharmacist and they may me willing to crush the tablet and make the suspension for you. Some preparations of high potency benzodiazepines are produced in suspension form by their manufacturers. I believe there is a suspension form of clonazepam (klonopin). If this is the case with your benzodiazepine your doctor may be willing to write a prescription specifically for the suspension form.
How long the drug can remain viable in a solution will largely be determined by the solution you use. I spoke to a pharmacist about this and he said that he would say it should remain usable for at least a week if not longer. Remember to store solution in the refrigerator.
An example of reducing using this method
If you mix for example 2 mg of clonazepam (equal to 40 mg of diazepam) in 100 ml of suspension solution you could remove say 10 ml and take 90 ml per day for four weeks or so and then down to 80 ml and so on. This would be a reduction of about 10 % per month. The rate of reduction can be done slower if necessary depending on what your body tells you. Some people even prefer to make very tiny reductions every day or every other day or each week rather than per month. They are all different routes to the same destination. Take note that as the dose gets lower the milligram size of the cuts will have to be smaller as well to avoid unpleasant withdrawal symptoms. It is probably better to reduce using at least small weekly cuts rather than larger monthly cuts if cutting from short half life benzodiazepines to achieve a smoother decline in blood levels. See notes below.
(2) Water Titration Method
To carry out out this type of tapering then the following should be available:-
- Sugar (optional)
- Blender (optional)
- Measuring device (syringe and or graudated cylinder)
- Storage container e.g. sealable bottle (available in local drug store, pharmacy, chemist)
- Mortal and pestel
It involves as said above crushing the benzodiazepine up in a mortel and pestel. The crushed up powder is then added to a measurement of water usually between 100 ml and 250 ml. Vigorous stirring or shaking should be done for several minutes to ensure the drug is well absorbed. Some people prefer to do this with a blender. If using a blender use it for about 30 seconds. The solution is then poured into a container e.g. a bottle. There may be some settling of the drug so it is best to stir or shake the mixture for several minutes before each dose. As in the above example using a syringe or dropper 10 ml or so can be removed from say 100 ml solution to achieve a 10% reduction. Again as said above some people prefer to make very small reductions on a daily or weekly basis to achieve a very gradual decline in blood levels similar to what would happen with long half life benzo's naturally. It is probably best to make a new solution each day with the water titration method. Remember to stir well before each use.
Some people add sugar to the water preparation to decrease the settling effect or they use milk instead of water. This may allow for more accurate dose reductions due to decreased settling of the drug. The preparation may go "off" or "bad" more quickly using sugar or milk especially if it is not kept cool in a fridge.
I am unsure of the distribution of benzodiazepine's in water. They are not water soluble as such they are fat soluble drugs so whether they accumulate at the top or sink to the bottom I am unsure. I did make enquiries with pharmacists but unfortunately they could not provide this kind of information relating to benzodiazepines and their solubility in water.
(3) Yogurt as the suspension medium
Another idea is to use yogurt as the suspension medium. The thick nature of yogurt should prevent settling of the drug. Vigorous stirring for at least 3 minutes may be necessary to disperse the drug thoroughly. The problem however with yogurt may be that due to its thick nature it may produce problems in measuring off say 10% of the yogurt when reducing etc. Perhaps adding a small amount of water may help.
(4) Crushing up the tablets
Another method is just to simply crush up the tablets with a mortel and pestel and then put the crushed powder onto a flat and smooth surface and devide the powder into even lines using a credit card or similar and omit a small line each week or so and gradually reduce. As tablets often taste quite foul it may be worth while stirring the powder into a yogurt or some other food or drink to disguise the taste.
An electronic scale could be purchased to more accurately measure the crushed up powder.
If using a short half life benzodiazepine it is important to remember to take the dose in at least 3 to 4 or sometimes more divided doses each day equally spaced out as best is possible in a 24 hour period.
When tapering short half life drugs it is probably better to make at the most weekly cuts rather than monthly cuts but at the same time it is recommended that the reduction is not more than 10% every 4 weeks at least initially and then dose reduction is titrated according to symptom severity.
Some people decide to reduce quicker than 10% per month. Such people should pay close attention to their body and mind because as the dose starts to decrease and they get towards the lower dosage ranges withdrawal symptoms can become more difficult or catch up with them and they may not be able to handle the fast rate they previously could tolerate. If severe withdrawal symptoms provoke suicidal thoughts or aggression SLOW DOWN. It is better to take longer coming off than to end up in a psychiatric ward or worse.
When reducing short half life drugs it is probably best to reduce every week and these cuts are best done in 2.5% cuts per week. Anyone who has difficulty with monthly cutting can try cutting to smaller weekly cutting. Some people prefer to do very small daily cuts. I have provided a link below to a support group which advocate and provide reduction regimes and instructions on daily cutting using the water titration method.
- It has been pointed out that when cutting in percentages that the dose can become undoable because of rediculous decimal points etc. Obviously in such situations you would round the dose to the nearest managable cut. For example if 10% of a dose took you to a strange dose like 17.452 of diazepam you would round that up to 17.5 mg of diazepam. All common sense really.
If the drug has an unpleasant taste having a sweet or yogurt nearby can be useful to get rid of any after taste.
Although a small amount of people cannot tolerate diazepam for reasons explained above it should be bore in mind that most people can tolerate a transfer across to diazepam if it is done correctly and diazepam should be tried before determining whether it is suitable or not.
Capsules obviously negate the need for crushing up unless the contents are tightly bound together.
If you have trouble understanding reductions we can recommend visiting non-benzodiazepines forum or or perhaps try and get a friend or family member to assist you. Benzo brain fog can play a number on peoples mathmatical skills.
Useful links and References
benzo yahoo support group
This group is the largest benzo support group. It has lots of detailed information on water titration which may supplement the information on this page. It also includes detailed withdrawal schedules for some of the common benzodiazepine drugs e.g. lorazepam (ativan), clonazepam (klonopin, rivotril) and alprazolam (xanax). You will need to request to join this group and usually your account will be activated within 24 hours. Once your account is activated you can log into the group with your web browser and navigate to their 'files' section and read the information regarding water titration. On their file section they have more precise information for people who would prefer to make precise tiny daily cuts each day.
Benzodiazepine Equivalents and Half Life Table by Professor Heather Ashton
Professor C Heather Ashton, DM, FRCP, Emeritus Professor of Clinical Psychopharmacology has extensive clinical experience with benzodiazepine addiction and her equivalencies are regarded by the majority of experts to be the most accurate.
Valium versus Klonopin by Dr Reg Peart
This article by Reg Peart discusses similar issues raised in this article. It may be of supplementary use to this article.
The Clinicopharmacotherapeutics of Benzodiazepine and Z drug dose Tapering Using Diazepam
Dr JG McConnell explains the benefits of a diazepam dose taper when weaning off of benzodiazepines or the nonbenzodiazepine "Z Drugs".
BCNC suggested Rate of withdrawal
See what BCNC suggests regarding the rate of reduction.
Forum Disclaimer SiteMap Home Contact us The Ashton Manual