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October 7, 2002
I am occasionally asked why I always advise people, who are on one of the more potent benzos, to switch first to Valium (diazepam) before tapering and whether it is possible taper such drugs as Xanax, Ativan and Klonopin directly.
I agree that it is possible for people to taper one of the more potent benzos directly but it presents many difficulties and from my observations people who choose such a method have greater problems, more severe withdrawal symptoms, and they may even invite the protracted withdrawal syndrome. There is also a high failure rate. People simply give up because of the severity of the withdrawal or relapse within a few weeks after cessation.
I would therefore urge anyone contemplating withdrawal to give themselves the best possible chance of success.
Tapering with Valium is the only tried and tested method and has the greatest number of successes. Professor Ashton employed this method at her Benzodiazepine Withdrawal Clinic which she ran in Newcastle in the UK from 1982-1994. The BNF / British National Formulary (equivalent to the PDR in the USA) also recommends Valium (diazepam) substitution and gradual reduction. See this page for details of the BNF's advice on benzo withdrawal. You can visit the BNF site online but it requires registration to view the latest information.
I appreciate that Valium is sometimes difficult to get hold of in North America. It is just not fashionable for doctors to prescribe it any more (except perhaps as a muscle relaxant). I think this is because of the bad press Valium got in the 1970s and, at the risk of sounding cynical, because there's simply no money to be made from prescribing it. One person told me that her doctor wouldn't prescribe Valium because it was too addictive. The doctor had no such qualms about prescribing one of the more potent benzos however! IMO any doctor who refuses to be sympathetic to his/her patient's clinical needs is not acting that patient's best interests so it may be a wise move to find one who is at least prepared to examine the evidence.
Switching to Valium can be daunting for many people. It is a step into the unknown and I do appreciate that. Difficulties do arise when people cross over too quickly or use an inadequate equivalence. When this happens very often the cry goes up: "This doesn't work!" or "I can't tolerate Valium!"
Of course making this switch is very hard to do when we are so cut off and isolated, and doctors just don't have really much idea about how best to help. People attending Ashton's clinic had the benefit of her hands-on advice and encouragement of course and that would have made the whole process much easier to manage.
What about other drugs?
Detox Centers in North America regularly use Phenobarbital to "detox" patients from benzodiazepines. This is a brutal method IMO and one which was outlawed long ago in the UK - and with good reason. People forced to endure a quickie detox with this drug invariably end up in a mess with intolerable symptoms and most just go back on the drugs.
The question of whether the use of adjunctive meds is helpful in benzodiazepine withdrawal comes up quite frequently and although a number of candidate drugs are regularly suggested such as: Tegretol (carbamazepine), Neurontin (gabapentin), Gabitril (tiagabine) but there is no published evidence that any of these (or any other drugs for that matter!) actually facilitate withdrawal from benzodiazepines.
Ashton notes this as follows in the Manual: "There have been some reports that gabapentin (Neurontin), tiagabine (Gabitril) and possibly pregabalin (yet to be licensed) help with sleep and anxiety in withdrawal. However, there have been no controlled trials and it is not clear whether these drugs themselves cause withdrawal effects. In practice additional drugs are seldom needed with very slow benzodiazepine tapering."
What about Liquid Valium?
This method is occasionally spoken about and one that is sometimes employed by one of the Bristol Support Groups. It is supposed to ensure a smoother taper but personally I don't see that it has any advantages over using tablets and Professor Ashton always used tablets with her withdrawal patients. AFAIK it is not available in North America so rarely even becomes an option. I do know that people experiment (with varying degrees of success!) with their own homemade solutions but I really am not sure how anyone can guarantee any accuracy or consistency.
If I switch won't I get just get addicted to Valium?
This question used to surprise me but after being asked it a dozen times or so I began to see that it really is a genuine concern for some people. Switching to Valium is not about further addiction; it is about employing a safe method of withdrawal and recovering from addiction. Some people are surprised when I tell them that if they have been on another benzo for any length of time then they are addicted to benzodiazepines and switching to Valium won't change that.
People on high doses of Xanax, Klonopin, Ativan etc.
Question: I am currently on 8mg Xanax (alprazolam) daily. The equivalence table indicates this is the equivalent of 160mg (Valium) diazepam. Am I seriously expected to switch to 160mg Valium before tapering?
Answer: No. I would never advise this and I don't know of anyone else who would. I always suggest that people on high doses of high potency benzodiazepines [eg. Xanax (alprazolam), Klonopin (clonazepam), Ativan (lorazepam)] taper those drugs directly as far as they can before attempting the Valium (diazepam) substitution. The further you can reduce the dose of the drug you're on (cutting at the rate of, say, 10% every 2-4 weeks) the better, in my opinion.
The sound clinical reasons why Valium is the preferred method have been posted regularly here so I make no excuse for including them again:
REASONS FOR A DIAZEPAM (VALIUM) TAPER by Professor C Heather Ashton DM, FRCP, April 2001. Diazepam [Valium] is one of the most slowly eliminated benzodiazepines. It has a half-life of up to 200 hours, which means that the blood level for each dose falls by only one half in about 8.3 days. The only other benzodiazepines with similar half lives are chlordiazepoxide [Librium], flunitrazepam [Rohypnol] and flurazepam [Dalmane] all of which are converted to a diazepam metabolite in the body. The slow elimination of diazepam allows a smooth, gradual fall in blood level, allowing your body to adjust slowly to a decreasing concentration of the benzodiazepine. With more rapidly eliminated benzodiazepine e.g. lorazepam, (Ativan) (which has a half-life of 10-20 hours) the blood concentration drops rapidly and withdrawal symptoms can occur between doses, because your body has little time to adjust to low concentrations.
Diazepam comes in the smallest dosage levels of all benzodiazepines - 2mg tablets which can be halved to give 1mg doses. This means you can reduce in stages of 1mg every 1-4 weeks or more. It is difficult to obtain such low doses of other benzodiazepines. For example the lowest dose of lorazepam in the UK is 1mg, equivalent to 10mg of diazepam. (In the US 0.5mg lorazepam are available, but these are equivalent to 5mg diazepam).
Many other benzodiazepines are more potent than diazepam. For example lorazepam (Ativan) is 10 times stronger and it is difficult to reduce from this gradually. Temazepam [Restoril], though less potent than diazepam, has a shorter half-life and the smallest tablet is 10 mg (equivalent to 5mg diazepam).
Because of the slow elimination and small available dosage strengths of diazepam, it is often advisable to switch to diazepam when withdrawing from other stronger or more rapidly eliminated benzodiazepines. This switch allows you to tail off your benzodiazepine dosage smoothly and gradually and minimises withdrawal symptoms.
When making the switch it is important to do it gradually, replacing one dose at a time and at approximately weekly intervals and making allowance for the difference in potency. For example, if you are taking lorazepam 1mg three times daily, first change the night dose to 10mg diazepam. (This can be done in two stages if necessary e.g. lorazepam 0.5mg (half a 1mg tablet) plus diazepam 5mg; then drop the lorazepam and go on to diazepam 10mg). A week or two later change one of the day-time doses, and two weeks later change the other day-time dose.
See also Benzodiazepine Equivalence Table.
The Ashton Manual gives more details about switching to Valium and tapering and has excellent general advice and information about benzodiazepines.
GABA - DISPELLING MYTHS
June 28, 2003
For those either on benzos or withdrawing from them ingestion of GABA in any form is a waste of time and money. There is absolutely no evidence to suggest that GABA is missing from your brain and body. Depletion or deficiency of GABA (and also of vitamins, minerals and other amino acids) caused by benzo use and withdrawal is an erroneous and unscientific proposition promoted by quacksalvers and peddlers of snake oil cures and remedies. Their sole interest is in separating you from your money. Ingesting GABA will no more help you to recover from benzo withdrawal any more than eating fish will help you to swim.
Withdrawal symptoms from benzodiazepines (and this includes tolerance withdrawal symptoms while still on the drug) are caused by disruption to and hyperexcitability of the brain and nervous system. Because the nervous system is in a state of shock, recovery from this slow-to-reverse functional damage may take many many months, and in some cases years. Although perfectly understandable, succumbing to the temptation to medicate the wide range of distressing, perplexing and often bizarre symptoms of benzodiazepine withdrawal with prescription or over-the-counter medications, potions and supplements, may actually impede or delay that recovery; it may even precipitate new problems.
The following quotations explain further and are drawn from Professor Heather Ashton's statements:
"In benzodiazepine withdrawal almost all the excitatory mechanisms in the nervous system go into overdrive and, until new adaptations to the drug-free state develop, the brain and peripheral nervous system are in a hyperexcitable state, and extremely vulnerable to stress."
"Compensatory changes occur in the GABA and benzodiazepine receptors which become less responsive, so that the inhibitory actions of GABA are decreased. Withdrawal symptoms occur if the benzodiazepine is reduced or stopped because the GABA receptors remain down-regulated (relatively unresponsive to GABA) for a long time."
"There is no evidence that nutritional supplements such as vitamins, minerals, amino acids etc. are helpful in benzodiazepine withdrawal. Excessive doses of some can be toxic and others may even contain benzo-like substances that have the same adverse effects as benzodiazepines themselves. Nor is there any evidence that suggests benzodiazepine withdrawal causes vitamin, mineral or other deficiencies. No-one should take supplements without clear evidence of a specific deficiency. Those who advocate multiple supplements should first show evidence of any deficiency and then conduct proper controlled trials. In particular, taking GABA precursors does not increase GABA concentrations in the brain. Benzodiazepines do not decrease GABA concentrations; instead they alter GABA-receptor affinity. This slowly reverses without the need for supplements and there is no evidence that supplements speed the process. People taking or withdrawing from benzodiazepines should eat a normal healthy diet - which, after all, consists of "natural" substances and contains all the ingredients necessary for the body."