Benzodiazepine withdrawal schedules

[Micklemouse]

These schedules are I believe based on The Ashton Manual withdrawal regimes, & as such may reflect British prescribing more than anywhere else.

British medicine is a lot more wary of benzodiazepines it seems than American, & maximum prescribed doses may well be lower - lorazepam being a good example: Maximum dose in GB is now 4 mg/24 hours, in 1 mg tablets (BNF 56); I for one have never seen 2.5 mg prescribed or dispensed. Due to the likelihood of paradoxical reactions being high with lorazepam, as well as risking respiratory depression, it is generally felt to be pointless & dangerous going above this, unless treating status epilepticus, although the odd chart from A & E has been seen with doses higher than recommended.

As such the chart stands true, if slightly out of date with current recommended prescribing in Britain.

Can I make clear that the Chlordiazepoxide (Librium) reduction is not the same as an alcohol detox with Chlordiazepoxide, & should only be used to reduce from Chlordiazepoxide where there is no need to detox from alcohol.

[clint]

You're quite right about the prescribing habits of British doctors, which are different even from those in Ireland, with respect to BZDs. However 2mg is not a dosage of lorazepam available in either country, nor, to my knowledge, in any European country, where the normal dosage tablet is 2.5mg. And yes indeed it IS prescribed in that dose quite a lot. Wyeth's ATIVAN 2.5mg tablet is oval and yellow, as opposed to the 1mg which is blue. This is an oddity since most 2.5mg tablets in Europe are blue, which could cause confusion amongst some patients who are changed onto a generic from the Wyeth product. I myself prescribe 2.5mg tablets often; 1mg strength is, for some, too weak a dosage.
I will, however, testify to the fact that it is probably the hardest BZD to withdraw from and certainly has the worst withdrawal symptoms of any BZD I know of, with the possible exception of oxazepam, which is similarly difficult; the 30mg strength has been withdrawn in most countries, leaving the 15mg as the highest strength available for prescription. Oxazepam is only available as a generic in both UK and Ireland - SERENID and SERESTA were withdrawn from the list some time ago.

Yes, those tables are definitely drawn from the Ashton Manual; a most useful tool for calculating the WD schedule for many daily dosages of the most common BZDs, using diazepam substitution. However, one drug that is most difficult to use this substitution method with is alprazolam. That must be handled extremely carefully and the withdrawal should take place over a much longer period than most other benzodiazepines. The period where diazepam and alprazolam are being taken in tandem is a long stretch, but eventually a high-dose alprazolam habit can be broken using a modification of Prof Ashton's recommendations. It may take six months or more - the difficulties inherent in the change from one to the other are very noticeable in the patient. The maximum dose of alprazolam now recommended in the UK BNF is 3mg daily, though many patients are still taking up to 6mg. It has now been removed from NHS prescription, and is only available with a Private Prescription.
Chlordiazepoxide is rarely used now except in cases of acute alcohol withdrawal. The 25mg strength has not been available now for around four years, and the normal six or seven day WD regime starts off with 10mg t.d.s., falling rapidly to one 5mg capsule or tablet on the final day. It is highly unusual to find anybody who would need a withdrawal from high dosage Librium or Tropium now.
I have overseen many withdrawals from benzos, more now than ever before, and can not stress strongly enough that it must be carried out very slowly indeed. The Ashton method is an excellent reference point which can be tailored for the individual patient. I am originally from the USA, and in my time on this side of the water have noticed that diazepam is by far the most commonly abused BZD, probably because clonazepam is not licenced for anxiety and alprazolam is no longer available on the NHS, though many patients still use it on Private Prescription. Alprazolam tends to be used for much longer periods than other benzos, and thus presents problems similar to lorazepam in withdrawal.
An interesting thread here, and anyone who is self-medicating with BZDs, very common here, should read the Ashton Manual from cover to cover. It may not be absolute Gospel, but is certainly the best starting point for any withdrawal scheme.

Reputation Comments on this post:

	Useful post - thank you!
	Informative post, keep it up.

[clint]

A couple more actually, all common BZDs: most importantly FLURAZEPAM, which has the longest of all at 250 hours; PRAZEPAM (Lysanxia, Centrax), and NORDAZEPAM (Calmday, Nordaz). In terms of strength, Lysanxia makes a 40mg tablet, whilst Centrax is only 10mg. Centrax Mono are 20mg. Calmday come in 5 and 10mg, Nordaz in 7.5 and 15mg. Nordazepam is one of the active metabolites of diazepam and several other BZDs with the same kind of half-life.
Flurazepam (Dalmane) is probably best known in the USA, but the other two are popular in Western Europe, and prazepam, in particular the 40mg Lysanxia brand are extremely useful for those with a severe anxiety problem - they are around two thirds of the strength of a 2mg Rivotril tablet but are more sedating in action. Nordazepam is very similar to both medazepam ( Nobrium, Rudotel, which I should have included here) and diazepam in effect and strength.
The surprise packet is flunitrazepam which is an hypnotic, which normally have very short half-lives. I think I have posted before that many people find it unnecessary to use an anxiolytic in the morning after using flunitrazepam as a sleep aid. All are extremely useful and I do not know why they are not available for prescription everywhere. Yes, every person's reaction to a certain drug is different, but the half-life is a definite indication of how long the substance will take to clear from the body, so it is wrong to say that 'all benzos clear in X days/hours'. All depends on the metabolisation of the particular drug and its active metabolite. As well, of course, as the individual patient's metabolism itself.

[H4U2C]

Originally Posted by clint

A couple more actually, all common BZDs: most importantly FLURAZEPAM, which has the longest of all at 250 hours; PRAZEPAM (Lysanxia, Centrax), and NORDAZEPAM (Calmday, Nordaz). In terms of strength, Lysanxia makes a 40mg tablet, whilst Centrax is only 10mg. Centrax Mono are 20mg. Calmday come in 5 and 10mg, Nordaz in 7.5 and 15mg. Nordazepam is one of the active metabolites of diazepam and several other BZDs with the same kind of half-life.
Flurazepam (Dalmane) is probably best known in the USA, but the other two are popular in Western Europe, and prazepam, in particular the 40mg Lysanxia brand are extremely useful for those with a severe anxiety problem - they are around two thirds of the strength of a 2mg Rivotril tablet but are more sedating in action. Nordazepam is very similar to both medazepam ( Nobrium, Rudotel, which I should have included here) and diazepam in effect and strength.
The surprise packet is flunitrazepam which is an hypnotic, which normally have very short half-lives. I think I have posted before that many people find it unnecessary to use an anxiolytic in the morning after using flunitrazepam as a sleep aid. All are extremely useful and I do not know why they are not available for prescription everywhere. Yes, every person's reaction to a certain drug is different, but the half-life is a definite indication of how long the substance will take to clear from the body, so it is wrong to say that 'all benzos clear in X days/hours'. All depends on the metabolisation of the particular drug and its active metabolite. As well, of course, as the individual patient's metabolism itself.

Thats correct Clint nice one, FLURAZEPAM{Dalmane} interestingly is the only BZD with partial antagonist properties.

[clint]

Originally Posted by H4U2C

Thats correct Clint nice one, FLURAZEPAM{Dalmane} interestingly is the only BZD with partial antagonist properties.

And would you believe that my other favorite sleeper has the shortest half-life of all at only TWO hours? Guessed yet?

Triazolam (Halcion, 250mcg, though they do make a 125mcg tablet as well.) I don't have Prof Ashton's table in front of me, but I have an inkling that if you are saying zaleplon has a L/2 of one hour, you're reading a typo. I think it's nearer to five or six hours. Correct me if I'm wrong.

Clint

[Jatelka]

Originally Posted by clint

I don't have Prof Ashton's table in front of me, but I have an inkling that if you are saying zaleplon has a L/2 of one hour, you're reading a typo. I think it's nearer to five or six hours.

Actually, zaleplon DOES have an ultra short half life

Source:

"Benefit-risk assessment of zaleplon in the treatment of insomnia"
Drug Safety 2005;28(4):301-18

(among others)

[clint]

Thanks Jatelka, you beat me to it! I found my equivalence table and was going to post about that.
Having seen so many of your posts may I say that you are most knowledgeable and one of the greatest assets to this board, so far as I can see.
Keep up the good work, as somebody said a few posts back!

[Micklemouse]

Indeed, the normal dosage in England is 1mg, up to 4mg/24hours (from the BNF -

By mouth, anxiety, 1–4 mg daily in divided doses; elderly (or debilitated) half adult dose
Insomnia associated with anxiety, 1–2 mg at bedtime; child not recommended

[lorzapmail]

Swim has not experienced valium withdrawal. With the long half life, it seems to swim it slowly leaves your system. Xanax, Lorazepam,etc. with short half life does merit careful withdrawal. Panic attacks, etc.

[lorzapmail]

Swim sees a newbie totally confused with these taper "guides" Just slowly cut back your doses over a couple weeks. Unless you want to pay thousands to a 'Clinic" to ride horses and look a pretty views. Just use some commom sense. One exception is cutting a legal deal. To stay out of jail. People will believe they need anything if told enough times. Swim thinks most poeple can figure our there own withdrawal sked.

[frankz81]

i think the schedule would work more precisely if they were opiates, as i am certain that benzos store in ur fat, as 3 weeks after my last xanax i showed a positive result for it on about only 2-4 mgs a day...
even now, i havnt had any xanax for 10 days and every day i feel crappy and always very anxious and nervous, i was on around 6-8mgs a day, still not huge but certainly enough to consider withdrawing over a longer period...
swim has been using mj to overcome these symptoms lately and it actually works in regard to the anxiety and rebound insomnia...
if this is the case, is 'one' better off using mj to detox off his benzo of choice? or will it complicate matters worse?

[Synesthesiac]

Never mind, found answer to question by re-reading the OP more carefully!