12. IF I DISCONTINUE MY BENZODIAZEPINE, WON'T THE UNDERLYING CONDITION
THAT MY DOCTOR PRESCRIBED THE BENZODIAZEPINE FOR RETURN?
It may or may not. It depends on what your underlying problem was, and
what post-withdrawal measures you take to manage the condition, if
necessary. Sometimes, the underlying problem is simply "gone" by the
time you have detoxified yourself from a benzodiazepine. Many physical
and psychological conditions are a transitory response to a temporary
condition in your life, such as a traumatic event. Often, people take
habit forming drugs such as benzodiazepines to alleviate the symptoms
of these transitory conditions, and continue taking them long after the
condition would have gone away on its own.
Other conditions are less transitory, such as chronic, long term panic
disorder (PD). However, it is important to bear in mind that there are
other treatments for these conditions, both of a pharmacological and a
non-pharmacological nature. Anxiety and stress can be managed in a
variety of different ways that are not as harmful to your body as
benzodiazepines.
There is an ongoing debate in the medical profession as to whether there
is a narrow class of individuals with long-term, chronic panic disorder
(PD) who are justified in taking benzodiazepines for life. This F.A.Q is
for informative purposes only, and will not take a position on this
controversial issue.
Often, when people complete their benzodiazepine detoxification, they
find an emergence of an underlying psychological problem that was masked
by the benzodiazepine use for many years. People also often feel the
resurfacing of emotions that may have been suppressed for a long time.
Thus, there is sometimes a period of difficult adjustment even after the
withdrawal symptoms subside. However, people often find the end result
of this period of adjustment to be very rewarding.
13. I HAVE DECIDED TO DISCONTINUE THE USE OF MY BENZODIAZEPINE.
WHAT ARE THE FIRST STEPS I SHOULD TAKE?
Your first step is to educate yourself. That means reading this F.A.Q.
and seeking out many of the resources referred to herein. Your second
step is to see a doctor who understands the seriousness of benzodiazepine
dependency, and be as well armed with information as possible going into
that visit. Your third step is to approach your detoxification with a
clear plan in mind, to set goals for yourself, and to begin the
withdrawal process with confidence. Do not listen to horror stories
from others who have had unusually bad experiences in withdrawal.
Everyone's experience is different, and many people are able to withdraw
with very manageable symptoms.
14. IS COLD TURKEY (ABRUPT, TOTAL DISCONTINUANCE OF THE DRUG) AN
ACCEPTABLE METHOD FOR DETOXING FROM A BENZODIAZEPINE?
No. There is nearly complete uniformity of opinion both in the medical
profession and in the benzodiazepine recovery community that cold turkey
is a dangerous and unacceptable method of detoxification. Cold turkey
withdrawal may cause seizures, and is also associated with a higher
probability of withdrawal psychosis. Seizures are almost non-existent
in those employing a taper method, with the limited exception of people
who have taken a benzodiazepine for a seizure disorder. Furthermore,
psychosis is rare in those who taper their benzodiazepine slowly.
There is a misconception that cold turkey withdrawal, though it may
cause more severe symptoms, will bring about a faster remission of
symptoms. This is the idea that a slow taper "prolongs the agony of
withdrawal". This notion is almost certainly false. In fact, there is
some anecdotal evidence that cold turkey withdrawal may lengthen the
course of the withdrawal syndrome, and may even cause Protracted
Withdrawal Syndrome (see below).
15. OK, IF I AM GOING TO TAPER MY BENZODIAZEPINE, HOW SHOULD I STRUCTURE
THE TAPER?
There are two very general rules, and one exception to the rule that is
discussed below. The first rule is, the slower the taper, the milder
the withdrawal symptoms. The second rule is, the smaller the cuts you
are able to make, the milder the withdrawal symptoms. These are
related, though separate, issues.
For example, you might decide to cut your dose by 1/4 mg. every month,
or in the alternative, cut your dose by 1/8 mg. every two weeks. Either
way, you are tapering at the same rate. In this author's opinion, the
second option is a far superior method of tapering. Any cut is a shock
to your brain and body. Cold turkey is the largest cut of all. It is a
spontaneous, total deprivation of your dependent substance. The shock
caused by cold turkey withdrawal is such that even after resumption of
your drug at the previous dose, it may take weeks or months to
"stabilize", and in some cases, you may never stabilize from a cold
turkey withdrawal until after you have completed your taper.
This logic further extends to the size of your cuts. The smaller the
cuts you make, the less the shock to your system, and the less
pronounced the withdrawal symptoms triggered by the cut. It is not
recommended that any individual cut represent more than 10% of your
total dose at a given time. Thus, it is preferable to make smaller and
smaller cuts as you go, though this can be very difficult as you
approach the end of your taper.
Always make the smallest cuts possible. That means taking the smallest
dose size available and splitting it into 4 pieces, which can be done
easily with or without a razor blade. For example, with Valium, you can
split the smallest (2 mg.) tablet into 4 .5 mg. pieces. With Klonopin,
you can split the smallest (.5 mg.) tablet into 4 pieces of .125 or
1/8th mg. If you are on a high dose and feel that you are able to taper
rapidly at first because you are above your tolerance point (see above),
space your cuts close together (no closer than 1 cut every 3 days), but
make the smallest cuts possible. If or when you begin to feel
withdrawal symptoms, you can start to space your cuts further apart (up
to about 4 weeks). Generally, the higher potency benzodiazepines such
as Xanax, Klonopin, and Ativan force you to make larger cuts (see
below), and therefore you must space your cuts at least 3 weeks apart
toward the end of your taper. Of course, even where you are able to make
very small cuts with lower potency benzodiazepines such as Valium, you can
make these small cuts relatively far apart if this is your most comfortable
method of detoxification.
There is a method of tapering that involves mixing the drug with either
water or a dry carrier like sugar to produce a "titration" which allows
for very minute reductions, such as 1% every other day. This method has
been employed with success by some people. In England, doctors have
created a liquid titration kit to assist users in withdrawing
comfortably. There is some promise that this method can substantially
diminish, if not eliminate, the withdrawal syndrome. Unfortunately,
these titration kits are not available in North America.
If you are unable to use a titration method, you may wish to consider
switching to Valium, assuming, of course, that you are not already using
that particular benzodiazepine. (See below) This method has been used
with success, particularly in England, for many years.
Dr. Heather Ashton has detailed taper schedules available that are based
on switching to Valium. (Also see below.)
There seems to be a limited exception to the slow taper rule where
people find that they have a "toxic" reaction to taking the
benzodiazepine (see "paradoxical symptoms" above). There is a tricky
distinction between toxic symptoms and withdrawal symptoms. The usual
way to tell the difference is to try increasing your dose. If the
symptoms reduce or stay the same, your symptoms are likely attributable
to withdrawal. If your symptoms increase, you may be experiencing
toxicity, and should probably consider a faster taper (6 to 8 weeks).
However, do not make a hasty decision to taper fast. Make certain that
you are experiencing toxicity first. Generally speaking, your symptoms
are far more likely to be related to withdrawal than toxicity.
One cause of toxicity may be the taking of more than one psychoactive
drug simultaneously. For example, taking a benzodiazepine with an
anti-depressant and a narcotic (pain killer).
16. SHOULD I SWITCH TO ANOTHER BENZODIAZEPINE SUCH AS VALIUM BEFORE
TAPERING?
Keep in mind that some people feel that switching to Valium is not for
everyone; and many have tapered their drug of dependency and have
recovered very well. However, if you are considering this alternative,
there are three reasons that are often cited for switching to Valium for
purposes of detoxification.
First, Valium has a far longer half-life than most other
benzodiazepines. (See above). This allows for a steady, smooth
reduction in dose over time. It also permits you to take your dose less
often. In some cases, you can take your entire daily dosage before
bedtime. This reduces problems of micro-managing your dose by taking
another pill every few hours. It also can aid in sleep, which can be a
large issue during withdrawal.
Second, Valium is low in potency relative to most other benzodiazepines
and comes in tablets of 2 mg., 5 mg. and 10 mg. As a practical matter,
you can make cuts as small as .5 mg. This is the equivalent of somewhere
between 1/20th and 1/40th mg. of Xanax or Klonopin. Given the importance
of making the smallest cuts possible, particularly as you approach the end
of your taper, this is a very large benefit.
Finally, Dr. Ashton and some others believe that the more modern, high
potency benzodiazepines such as Xanax, Klonopin, and Ativan tend to
produce more difficult withdrawal syndromes. So far the evidence of
this is anecdotal, meaning that it is based on clinical observation and
patient self-reports. There do not appear to be any studies that
conclusively correlate severity of withdrawal with type of
benzodiazepine.
If you do decide to switch to Valium, it is important that you have an
idea of what to expect. First of all, because each benzodiazepine has a
unique chemical composition, one benzodiazepine will not completely
cover the withdrawal syndrome of another. Medical literature
indicates that lower potency benzodiazepines cover fewer subclasses of
GABA-A receptors (see above) than the modern, high potency
benzodiazepines such as Xanax and Klonopin. This is why it is important
to observe the proper dose equivalencies. (See above.) These are
special equivalencies for purposes of switching to Valium, and are
sometimes called "loading doses" or "suppression doses." The consequence
of taking a loading dose is that although your withdrawal symptoms may be
suppressed very well, you might also experience the side effect of over
sedation. This is particularly so as Valium is a more potent sleep
agent than most high potency benzodiazepines even at the equivalent
therapeutic dose, and these equivalencies are probably well above the
therapeutic dose equivalencies. However, most benzodiazepine users
rapidly develop a tolerance to the sleep inducing (hypnotic) effects of
benzodiazepines, so that it is likely that this over-sedation will
recede within the first few weeks.
Because it is important to manage this problem of over sedation and to
avoid cross-over withdrawal symptoms, it is a very good practice to use
a gradual dose substitution method rather than simply discontinue your
drug of dependency and begin taking Valium at the full equivalency dose.
Depending on the size of your dose, the period of dose substitution may
be anywhere from 3 weeks to about 3 months.
During this period of dose substitution, sometimes cuts to your total
dose are made, and other times, slight increases are made. If you
experience extreme over-sedation and no withdrawal symptoms, that is a
sign that the equivalency dose is too high for you, and you may wish
make a small cut in your total dose as you cross-over. If, on the other
hand, you begin to experience heightened withdrawal symptoms during
cross-over, you may wish to make a small increase in your dose during
cross-over. Because the proper equivalencies vary from person to
person, the cross-over process can be a matter of trial and error.
However, it is important to understand that the end result of switching
to Valium should be that you are relatively stable after the switch is
complete, meaning that you are experiencing either no withdrawal or very
mild withdrawal symptoms.
Dr. Ashton has circulated detailed protocols based upon switching to
Valium and explaining the method in detail. (See above and below.)
Librium is another long acting benzodiazepine that is sometimes (but
rarely) used as a substitute. This author has insufficient information
regarding the effectiveness of Librium substitution to provide a
meaningful comment at this time. It is not necessary to switch from
Librium to Valium. Librium should be tapered directly, although there
is a problem in that it comes only in 5 mg. capsules in North America.
Ideally, for Librium detoxification, the capsule should be opened and
the contents halved to make 2.5 mg. cuts. Of course, if it possible
to make even smaller cuts, that is most preferable.
17. MY DOCTOR HAS ASKED ME TO SWITCH TO A DRUG CALLED "PHENOBARBITOL"
FOR DETOX? IS THIS A GOOD IDEA?
Some doctors, particularly in the United States, use a detoxification
method of switching the patient to phenobarbitol, then tapering the
phenobarbitol, usually over a period of 2 to 6 weeks. Phenobarbitol is
a long acting barbiturate (another class of sedatives). It acts upon
many of the same GABA-A receptors as benzodiazepines, but binds to the
receptors at a different location. Phenobarbitol is very cross-tolerant
with the benzodiazepine class, and if taken in a proper "loading dose"
(see above) will probably suppress withdrawal symptoms fairly well.
Phenobarbitol detoxification is "medically safe," in that Phenobarbitol
is a potent anti-seizure agent so that you will likely not have any risk
of seizures with this method.
Phenobarbitol also has a very long half-life, similar to that of Valium,
and can be broken down into very small cuts. The equivalency is 3 mg.
of Phenobarbitol to 1 mg. of Valium.
Reported results from Phenobarbitol substitution are mixed but
inconclusive due to the small number of people at
benzo@egroups.com who
have experienced this method. Doctors using this method generally
observe the practice of using a heavy "loading dose," but they usually
do not employ a gradual dose substitution method. More importantly,
when this method is used, the detoxification is usually done very
rapidly (e.g. 4-6 weeks). The problem with Phenobarbitol detoxification
may not be so much the use of Phenobarbitol itself as the rapidity of the
taper that is usually employed. Where information is discovered related
to the effectiveness of Phenobarbitol using a slow taper method, this F.A.Q.
will be revised to reflect that information.