Tapering Your Benzodiazepine or Z Drug
Tapering is recommended for people who have been dosing these drugs for longer than four weeks. Obviously it should be possible to taper more quickly after a short time but gradual dose reduction is essential, preferably following a taper plan. The plan can be changed in response to uncomfortable symptoms and doses should decrease in a hyperbolic way, that means the decreases are not all the same as this would produce a linear decrease. Each dose should be reduced by a set percentage so that the reduction gets smaller as the dose gets lower. The suggested percentage decrease should fall between 5% to 10% for each dose and the time interval for these decreases should be between 2 to 4 weeks depending on what enables you to keep comfortable in your tapering. David Jones
Withdrawal from Benzos
This is taken from the Ashton Manual. It might help clear up any misunderstandings about tapering.
THE WITHDRAWAL There is absolutely no doubt that anyone withdrawing from long-term benzodiazepines must reduce the dosage slowly. Abrupt or over-rapid withdrawal, especially from high dosage, can give rise to severe symptoms (convulsions, psychotic reactions, acute anxiety states) and may increase the risk of protracted withdrawal symptoms. Slow withdrawal means tapering dosage gradually, usuallyover a period of some months. The aim is to obtain a smooth, steady andslow decline in blood and tissue concentrations of benzodiazepines so that the natural systems in the brain can recover their normal state.
Long-term dosing of benzodiazepines takes over many of the functions of the body's natural tranquilliser system, mediated by the neurotransmitter GABA. As a result, GABA receptors in the brain reducein numbers and GABA function decreases. Sudden withdrawal from benzodiazepines leaves the brain in a state of GABA-underactivity, resulting in hyperexcitability ofthe nervous system. This hyperexcitability is the root cause of most of the withdrawal symptoms. However, a sufficiently slow, and smooth, departure of benzodiazepines from the body permits the natural systems to regain control of the functions which have been damped down by their presence. THERE IS SCIENTIFIC EVIDENCE THAT REINSTATEMENT OF BRAIN FUNCTION TAKES A LONG TIME. Recovery after long-term benzodiazepine use is not unlike the gradual recuperation of the body after a major surgical operation. Healing, of body or mind, is a slow process.
THE PRECISE RATE OF WITHDRAWAL IS AN INDIVIDUAL MATTER. It depends on many factors including the dose and type of benzodiazepine used, duration of use, personality, lifestyle, previous experience, specific vulnerabilities, and the (perhaps genetically determined) speed of your recovery systems. USUALLY THE BEST JUDGE IS YOU, YOURSELF; YOU MUST BE INCONTROL AND MUST PROCEED AT THE PACE THAT IS COMFORTABLE FOR YOU. You may need to resist attempts from outsiders (clinics, doctors) to persuade you into a rapid withdrawal. The classic six weeks withdrawal period adopted by many clinics and doctors is much too fast for many long-term users. Actually, the rate of withdrawal, as long as it is slow enough, is not critical. Whether it takes 6 months, 12 months or 18 months is of little significance if you have taken benzodiazepines for a matter of years.
It is sometimes claimed that very slow withdrawal from benzodiazepines "merely prolongs theagony" and it is better to get it over with as quickly as possible. However, the experience of mostpatients is that slow withdrawal is greatly preferable, especially when the subject dictates thepace. Indeed, many patients find that there is little or no "agony" involved. NEVERTHELESSTHERE IS NO MAGIC RATE OF WITHDRAWAL AND EACH PERSON MUST FIND THE PACE THAT SUITS HIM BEST. People who have been on low doses of benzodiazepine for a relatively short time (less than a year) can usually withdraw fairly rapidly. Those who have been on highdoses of potent benzodiazepines such as X and K are likely to need more time. However, it is important in withdrawal always to go forwards. If you reach a difficult point, you can stop there for a few weeks if necessary, but you should try to avoid going backwards and increasing your dosage again. Some doctors advocate the use of "escape pills" (an extra dose of benzodiazepines) in particularly stressful situations. This is probably not a good idea as it interrupts the smooth decline in benzodiazepine concentrations and also disrupts the process oflearning to cope without drugs which is an essential part of the adaptation to withdrawal. If thewithdrawal is slow enough, "escape pills" should not be necessary. Prof. C. Heather Ashton DM, FRCP
Tapering is Not a Precise Activity!
The pills are mass produced and the pill weight and the drug weight can possibly vary by up to 5%. Who knows as big pharma will not tell you any answers! We have to accept that the drug is evenly distributed through the filler material. I have asked this from Accord in the U.K. and they replied that it was to the best of their knowledge. When removing daily reductions by water tapering how much drug is in the reduction? When you cut and weigh how much drug do you eliminate? As long as there is some reduction and no problems, keep going, you are heading in the right direction!
Preparing for Your Taper
Starting Out
Once you’ve determined that you’d like to taper your benzo and improve your health it really helps to break down those changes into do able steps. This not only makes it easier; it also gives you a sense of control and confidence. An important provison in this is to trust yourself because you may have been raised to believe that only medical professionals are qualified to tell you what to do for your health like most of us. But the best expert on you is yourself! Arming yourself with knowledge at the outset should help you gain that trust in you and in the process of recovery from benzos.
Simple Ways to help you start your recovery….
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Try and start eating a healthy diet with less or no sugar, caffeine and processed foods to give your body the best possible boost to health.
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Forgive yourself any past failures to get off these drugs and concentrate on ‘now’ as these won’t prevent your healing. Learn from these failures to help yourself.
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If at all possible get a medical professional on board so you can get reassurance or tests for any symptoms that may crop up.
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Don’t give up easily if things get rough. Remember this can happen and through no fault of your own. Members in the groups will support you through any difficult patches and these are part of healing for most of us as the body and brain read just.
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Learn coping skills that will help deal with the initial problem that led you to take a benzo and also help you to manage symptoms without further drugs.
Let your journey unfold as it will for you after you’ve taken that first step.
Love and Support today for those just starting out and remember you are an amazing person,strong and resilient and can recover so trust in yourself.
More Simple Rules for Successful Tapering and Holding
The advice is mostly to start slowest end of a 5-10% reduction, or possibly even slower than that, for at least the first couple of months. The thinking goes that this can allow people who might be feeling eager to taper “quickly” to first become familiar with how their bodies respond to cuts before they then carefully work their way up to their own tolerable reduction rate.
Holding
When new, troublesome symptoms appear, holding a dose steady without making further reductions until those symptoms resolve themselves can help the central nervous system to settle back down. This can then return the withdrawal experience to a more manageable place. Heather Ashton doesn’t recommend long holds as this doesn’t always allow for stabilisation but holding for a few days, even weeks can help and prevent any increase in major symptoms. This is an area where there is no definitive solution for any one person so the choice must be yours and what you can tolerate.
Slowing the Taper Rate
If holding isn’t successful then slowing down the taper rate may help. What is important is that what any one person can stand is very individual so it’s not the actual percentage rate of each cut but finding a speed that is personally tolerable. So, if withdrawal problems are worsening, holding isn’t helping or withdrawal symptoms appear straight after cuts slowing the taper rate may help.
Regular Breaks
A few people find that giving the nervous system regular breaks through long holds allows for alonger healing time before the next cut. Also, sometimes an approaching event such as travelling, family wedding or dealing with operations or dental procedures, may make a long hold preferable until the event has passed. These allow for a planned hold.
It’s Not always the Taper
Sometimes other, sudden outside events may cause symptoms to increase momentarily. These may take the form of added family stress, eating the wrong food, taking another drug or supplement or suffering a virus. Such bad times will pass but can make withdrawal symptoms worse and again it’s personal choice whether to hold or continue your taper in these circumstances. These are unplanned holds that can’t be predicted in advance.
The Final Stage
When following a taper rate of 5-10% this involves recalculating on the basis of the current dose. For bigger doses this means bigger decreases but as the dose decreases so should the size ofthe decrease. Thus tapering from 10mg at 10% means you decrease by 1 mg but at 5mg you should decrease by 0.5mg. Eventually you arrive at a much lower dose and the decrease will become very small. There’s a limit and you can’t go on forever getting smaller and smaller! You therefore need to decrease by more than 10% of the dose taken. With cut and weigh the decrease can be a percentage of the cut; with water taper you can add more water to the pull/water mixture. Monitor symptoms and proceed with care, jumping off when you feel ready.
Heather Ashton in the manual comments that...
‘With slow tapering, some long-term users have virtually lost all their symptoms by the time they take their last tablet, and in the majority symptoms disappear within a few months. Vulnerability to extra stress may last somewhat longer and a severe stress may - temporarily - bring back some symptoms.’
Tapering Options
For many people wishing to get off these drugs, there are several different ways of doing so. The option that you chose should be one that you can understand and you are able to carry out the practicalities. Pharmaceutical companies do not make the task easy for you. Tapering requires small reductions. How can you achieve them when the pill doses are limited to a few different amounts?
Dr Ashton shows in her manual that she did cross overs, changing over to diazepam because the doses were suitable for tapering and the pills were big enough to break in half to give smaller doses. The other bonus was the long elimination time (half life) of the diazepam which meant that the blood concentration of the drug decreased slowly and smoothly. Some benzodiazepines are available as oral solutions. The drug has been dissolved in a solvent and is available at a particular concentration, for example, 1mg in 1ml of solution. This allows a reduction in dose based on volume and there may be a dropper with the oral solution or it many possible to use a 1ml syringe to administer the doses. For some countries in the World there are ‘compounding pharmacies’. These can prepare specific oral solutions for you, usually using propylene glycol as the solvent. They prepare a variety of concentrations on request but this may at cost.
Option 1
Based on the Ashton Manual, changing the drug that you are dosing to diazepam.The change over happens according to the Ashton Equivalence Table. For example, if the total daily dose was 1mg of clonazepam then the equivalent dose of diazepam would be 20mg to maintain the same potency. Usually recommended for high potency, short acting drugs like alprazolam and lorazepam. The cross over is done in steps over several weeks as each benzodiazepine has a slightly different action and the slower cross over enables the CNS to process the change. The diazepam is tapered. Pill cutter needed.
Option 2
Liquid tapering with oral solution. Let us suppose that you have two doses of lorazepam daily, both 0.5mg. I would suggest that the concentration of the oral solution is 0.1mg per 1ml. So each dose would be 5ml to begin with. You would then reduce the volume at a planned rate to get you down to a point when you could stop and recover. Suitable syringes would be needed.
Option 3
Water tapering involves mixing the pills with a suitable volume of water and removing the decrease on a daily basis. Most benzodiazepines and z drugs do not dissolve very much in water! But don’t worry, you can create a cloudy mixture of the pill bits and water that will enable you to reduce the daily dose by a very small amount. This adds up over 15 or 30 days so that the taper progresses steadily. The amount of water used depends on the amount of drug being decreased and the speed that you wish to decrease at. You would require a small glass jar with a lid in which to mix the pills and water and the use of two syringes, 50ml size and either 10ml or 20ml size.
Option 4
Cut and weigh requires a jewellers scales like the AWS Gemini 20 scales available from Amazon. Each pill has a pill weight and a drug weight. The pills are a mixture of drug and filler materials which contribute to a much bigger pill weight than drug weight, for example, one 1mg pill of clonazepam could weigh as much as 170mg so the filler weighs 169mg!! The scales weigh down to 0.001g which is 1mg. You would need some implements to reduce the weight of the pills such as anail file and a sharp blade. The pills from different Pharmaceutical companies may have different pill weights so it is best to keep to the same supply. Even pills from the same supplier can have a small range of weight. Since most of the weight of a pill is due to the filler material I am not worried by this variance. You cannot weigh every single pill, calculate the decrease required and then execute the pruning!!
Compounding pharmacies may also make up doses of pills for you but it is not available everywhere and you may have to give them directions regarding the taper decreases.
Tapering Strips
are another alternative method and although they are made in the Netherlands, the company will send them worldwide. The idea is a blister strip for 28 doses of the drug. Eachstrip will reduce your dose over 28 days and you will need as many strips as necessary to taperdown safely.
https://www.taperingstrip.com
Visit the website for information
Combination tapering is the use of a cut and weigh taper followed by a water taper. If you were dosing 4mg of alprazolam daily as four doses, then it would be possible to cut and weigh the doses first to reduce them down to a lower amount. As the pills get smaller and more difficult to handle, the change to a water taper would enable an easier reduction and opportunity to reduceto a much lower dose before stopping.
As an alternative you could take ‘mixed doses’, part as pills and part as water taper before finishing with a water taper only. So using our previous 4mg of alprazolam, you could water taper 2mg and dose with 2mg. When the water taper is finished and you only have 2mg of pills, then you would repeat the water taper. The reason for this is to avoid using a bigger volume of water for the whole 4mg. So each dose would be 0.5mg as pill plus 0.5mg as water taper in first taper followed by just 0.5mg as water taper the second time around.
There is no “better” taper. It is whatever suits you!! As a taper depends on how much drug you are reducing then all tapers for say 4mg of alprazolam should take the same length of time.
Maths. Alert!
From dealing with taper plans over several years I have engaged with members who have issues with understanding basic maths. including where to put the decimal point! My worry is that you will jump off the drug at a higher dose than you thought you were on. People seem to relate to percentages, the usual being 5% to 10%, without realising how a percentage converts into real numbers. This is why I type out plans to follow. The spreadsheets available on line are useful but you have to put in the correct numbers otherwise you will get the wrong plan for you!
1mg quite a small amount if you were making a cake but in drug terms it can have a profound effect. 1mg is about thirty times smaller than 1 oz.
If you cut a 1mg pill into two halves, each half is 0.5mg
If you cut one 0.5mg piece in half again you have two pieces, each 0.25mg
Split in half again gives 0.125mg
If I write down 0.05mg that is NOT half of 1mg. That is one twentieth of 1mg
Half of this is 0.025mg.
Where you use zeros in your number is very important.
001 is 1 BUT 100 is one hundred.
The numbers before the decimal point are whole numbers
25.123 shows 25 as a whole number and .123 as a decimal fraction
When using a scales the display might show 0.100,0.010 or 0.001
0.100g is 100mg 0.010g is 10mg 0.001g is 1mg
Don’t get anxiety over it. Always ask someone to confirm what you understand the number to be.
A Successful Water Taper
Water taper!
Let’s clear things up a bit. The water taper is the most gentle way to withdraw. My taper has beenvery complicated.
I switched to water from dry cut. It is very accurate. A controlled water micro taper will allow youto gently remove the chemicals from your system. It is less trauma to the central nervous system,as you are shocking it less than you would with cut and hold.
I have been healing all the way through my taper. I had a huge break through last year this time. Idrive again and do my own grocery shopping!! I see people!! Today I’m hosting a tiny belated birthday celebration for my precious grand niece!! I’m living and healing. Last summer I joined a gym!! I could go on and on about my recovery!!
I was completely bed bound and shut in for several years. My dose was 5 and 6 mgs Xanax a year.I’m 59. I’ve been on it for 23 years.
I am getting better and better. I still have bad days and symptoms. BUT I AM HEALING!!
So choose your own route and journey. I’ve been cold turkey, rapid detox… floxed, dry cut and hold… so I’ve the experience sadly. Water taper is completely safe and the most gentle. I highly recommend the water taper.
-Mary
