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BENZODIAZEPINE DEPENDENCY AND WITHDRAWAL

Frequently Asked Questions (FAQ) file

DISCLAIMER: THIS FAQ WAS NOT WRITTEN BY A DOCTOR OR SOMEONE WITH ANY FORM OF MEDICAL TRAINING. THE ADVICE CONTAINED HEREIN SHOULD NOT BE SUBSTITUTED FOR THE ADVICE OF A PHYSICIAN WHO IS WELL-INFORMED IN THIS SUBJECT MATTER. BECAUSE THIS FAQ IS NOT WRITTEN BY A DOCTOR, ALL ADVICE IN THIS DOCUMENT IS TO BE FOLLOWED AT YOUR OWN RISK.

This FAQ is expressly placed into the public domain and may be freely disseminated by any who come into its possession. The identity of its authors is irrelevant. It is a gift to anyone in the world whose life has been touched by benzodiazepine dependency.

Any proposed corrections or revisions should be stated on the forum known as the benzo.org.uk forum. When the authors have accumulated sufficient revision material to justify creating a new version, one will be issued. Legitimate revisions include spelling, grammar, and punctuation errors; scientific and/or medical inaccuracies; new questions; and information newly discovered through scientific research or empirical observation, e.g. some new form of adjunct medication or herbal therapy that is discovered to be helpful in withdrawal. Differences of opinion with the authors are warmly accepted, but are unlikely to alter the contents of the FAQ unless supported by solid factual data.

TABLE OF CONTENTS:

1. WHAT IS A BENZODIAZEPINE?

Benzodiazepines are a large class of commonly prescribed tranquillisers, otherwise referred to as central nervous system (CNS) depressants, anxiolytics and sedative-hypnotics. They include alprazolam (Xanax), bromazepam (Lexotan, Lexomil), chlordiazepoxide (Librium, Nova-Pam), clobazam (Frisium), clonazepam (Klonopin, Rivotril), clorazepate (Tranxene), diazepam (Valium, D-Pam, Pro-Pam), estazolam (ProSom), flunitrazepam (Rohypnol), flurazepam (Dalmane), halazepam (Paxipam), ketazolam (Anxon), loprazolam (Dormonoct), lorazepam (Ativan), lormetazepam (Noctamid), medazepam (Nobrium), midazolam, (Versed, Hypnovel, Dormicum), nitrazepam (Mogadon, Insoma, Nitrados), oxazepam (Serax, Serapax, Serenid, Benzotran), prazepam (Centrax), quazepam (Doral), temazepam (Restoril, Euhypnos, Normison, Sompam), triazolam (Halcion, Hypam, Tricam). See: Benzodiazepine Drug Index for links to monograph and drug information sites.

Some lesser known benzodiazepines: brotizolam, camazepam, clotiazepam, cloxazolam, delorazepam, etizolam, fludiazepam, haloxazolam, oxazolam, nimetazepam, nordazepam, pinazepam, tetrazepam, tofisopam.

All benzodiazepines have five primary effects. They are:

Hypnotic (tending to make you sleepy); Anxiolytic (tending to reduce anxiety/produce relaxation); Anti-seizure (tending to reduce the probability of having seizures and convulsions); Muscle relaxant (tending to reduce muscle tension and associated pain); Amnesic (amnestic) (tending to disrupt both long and short term memory).

There may be secondary effects as well. Different benzodiazepines exhibit these primary effects to varying degrees. For example, diazepam (Valium) is a relatively powerful hypnotic (sleep inducer), whereas the more modern benzodiazepines such as alprazolam (Xanax), lorazepam (Ativan), and clonazepam (Klonopin) are less powerful hypnotics, but are very powerful anxiolytics. Do not assume that because one benzodiazepine makes you sleepier than another that this benzodiazepine is more potent than those which do not produce sleepiness to the same degree. Often, the reverse is true.

Benzodiazepines have been referred to as being part of a larger class of drugs known as "minor tranquillisers". As applied to benzodiazepines, this is almost certainly a misnomer, and the label has fallen into relative disuse in the past ten years. However, you may encounter this term from time to time.

Benzodiazepines are most commonly prescribed for anxiety conditions, especially panic disorder (PD) and generalised anxiety disorder (GAD). They are also sometimes prescribed for seizure disorders. Klonopin, for example, is often prescribed for epilepsy. Benzodiazepines are also prescribed for insomnia and other sleep problems, such as restless leg syndrome (RLS). Benzodiazepines are also frequently prescribed as muscle relaxants.

By far the most common benzodiazepines prescribed today are Valium, Xanax, Ativan and Klonopin. Valium (diazepam) is particularly common in the UK. Valium has become less common in the United States over the past 15 years, while Xanax and Klonopin have experienced increased popularity in the United States over this time. In certain Latin American countries, it appears that the drug Lexotan (bromazepam) is very popular.

All benzodiazepines can cause physical dependency, otherwise commonly known as addiction.

2. HOW DO BENZODIAZEPINES AFFECT YOUR BODY?

Benzodiazepines are general central nervous system (CNS) depressants. They are all very similar chemically. All benzodiazepines act by enhancing the actions of a natural brain chemical, GABA (gamma-aminobutyric acid). GABA is a neurotransmitter, an agent which transmits messages from one brain cell (neuron) to another. The message that GABA transmits is an inhibitory one: it tells the neurons that it contacts to slow down or stop firing. Since about 40% of the millions of neurons all over the brain respond to GABA, this means that GABA has a general quietening influence on the brain: it is in some ways the body's natural hypnotic and tranquilliser. This natural action of GABA is augmented by benzodiazepines which thus exert an extra (often excessive) inhibitory influence on neurons.

The way in which GABA sends its inhibitory message is by a clever electronic device. Its reaction with special sites (GABA-receptors) on the outside of the receiving neuron opens a channel, allowing negatively charged particles (chloride ions) to pass to the inside of the neuron. These negative ions "supercharge" the neuron making it less responsive to other neurotransmitters which would normally excite it. Benzodiazepines also react at their own special sites (benzodiazepine receptors), situated actually on the GABA-receptor. Combination of a benzodiazepine at this site acts as a booster to the actions of GABA, allowing more chloride ions to enter the neuron, making it even more resistant to excitation. Various subtypes of benzodiazepine receptors have slightly different actions. One subtype (alpha 1) is responsible for sedative effects, another (alpha 2) for anti-anxiety effects, and both alpha 1 and alpha 2, as well as alpha 5, for anticonvulsant effects. All benzodiazepines combine, to a greater or lesser extent, with all these subtypes and all enhance GABA activity in the brain.

As a consequence of the enhancement of GABA's inhibitory activity caused by benzodiazepines, the brain's output of excitatory neurotransmitters, including norepinephrine (noradrenaline), serotonin, acetyl choline and dopamine, is reduced. Such excitatory neurotransmitters are necessary for normal alertness, memory, muscle tone and co-ordination, emotional responses, endocrine gland secretions, heart rate and blood pressure control and a host of other functions, all of which may be impaired by benzodiazepines. Other benzodiazepine receptors, not linked to GABA, are present in the kidney, colon, blood cells and adrenal cortex and these may also be affected by some benzodiazepines. These direct and indirect actions are responsible for the well-known adverse effects of dosage with benzodiazepines.

Contrary to a popular misconception, benzodiazepines do not actually increase the organic synthesis of GABA. As stated, they enhance the action of existing GABA. Actually, benzodiazepines can, over time, decrease the synthesis of GABA in certain areas of the brain. This is one of numerous theories attempting to explain the occurrence of "paradoxical" symptoms (see below).

3. HOW QUICKLY CAN I BECOME ADDICTED TO A BENZODIAZEPINE?

The time it takes to form a physical dependency on a given benzodiazepine varies widely. The following variables may play a role: the size of your dose, the regularity with which you consume your dose, and most importantly, your personal body chemistry. People have been known to form dependencies in as little as 14 days of regular use at therapeutic dose levels. Your probability of forming some degree of dependency is significant, probably at least 50%, by the time you have been using them daily for 6 months. After a year of continuous use, it is highly likely that you have formed a dependency. It is unclear whether certain benzodiazepines are associated with a more rapid onset of dependency than others.

4. WHAT ARE THE DOSE EQUIVALENCIES AMONGST VARIOUS BENZODIAZEPINES?

There are no clearly definitive equivalencies for various benzodiazepines. This author has personally seen at least a dozen different benzodiazepine equivalency charts and no two are alike. The table below has been chosen because it reflects the clinical experience of Professor Ashton in having helped over 300 people to withdraw from benzodiazepines by use of a Valium substitution method (see below).

Alprazolam 0.5 Bromazepam 6 Chlordiazepoxide 25 Clonazepam 0.5 Clorazepate 15 Diazepam 10 Estazolam 1-2 Flunitrazepam 1 Flurazepam 15 Halazepam 20 Ketazolam 15-30 Lorazepam 1 Lormetazepam 1-2 Nitrazepam 10 Oxazepam 20 Prazepam 10-20 Quazepam 20 Temazepam 20 Triazolam 0.5

Thus, 1mg of alprazolam (Xanax) or clonazepam (Klonopin) is the equivalent of 20mg of Valium; 1mg of lorazepam (Ativan) is the equivalent of 10mg of Valium.

These dose equivalencies are important for a number of reasons, the most significant of which is the issue of switching to a different benzodiazepine such as Valium prior to tapering (see below). These figures are taken from Professor Ashton's Manual (see below) and several other sources. See for example the Benzo Equivalence Table on this site.

You may find a doctor who will want to switch you from Xanax to Valium at a 1mg to 10mg equivalency. This is a recipe for a very difficult cross-over. Whatever the precise therapeutic dose equivalencies, the above equivalencies should be observed in switching from one benzodiazepine to another for purposes of withdrawal (see below).

5. WHAT IS A "HALF-LIFE", AND HOW IS THE CONCEPT IMPORTANT TO BENZODIAZEPINE DEPENDENCE?

Half-life is a numerical expression of how long it takes for a drug to leave your body. Technically, the "half-life," expressed as a range, is the time it takes for half of the amount consumed to be eliminated from your body, and so on. There is some controversy as to how long benzodiazepines may actually remain in your body after you have discontinued them entirely. Benzodiazepines are fat soluble and can persist in fatty tissues. However, benzodiazepines no longer show up in blood screenings beyond 30 days after discontinuance. This either means they are totally eliminated by that time, or that they persist in amounts too small to have any long term effect.

The importance of half-life is that a longer half-life generally makes for an easier withdrawal because your blood levels remain relatively constant, as opposed to the up and down roller coaster that you experience with short half life benzodiazepines. Furthermore, longer half-life benzodiazepines require less dose micro-management. For example, Valium can be taken once every 12 hours, or in some cases, once every 24 hours. Xanax, however, must be taken once every 4-6 hours to maintain constant blood levels. This is a practical impossibility for some people.

The following is a list of benzodiazepines with their corresponding half-lives, expressed as a range in hours:

Alprazolam 9 - 20 Bromazepam 8 - 30 Chlordiazepoxide 24 - 100 Clonazepam 19 - 60 Clorazepate 1.3 - 120 Diazepam 30 - 200 Estazolam 8 - 24 Flunitrazepam 18 - 26 Flurazepam 40 - 250 Halazepam 30 - 96 Ketazolam 30 - 200 Lorazepam 8 - 24 Lormetazepam 10 - 12 Nitrazepam 15 - 48 Oxazepam 3 - 25 Prazepam 30 - 100 Quazepam 39 - 120 Temazepam 3 - 25 Triazolam 1.5 - 5

There is a misconception that longer half-life benzodiazepines prolong the withdrawal recovery process by remaining in your body tissues for longer. However, there is no evidence that longer half-life benzodiazepines represent any greater risk for Protracted Benzodiazepine Withdrawal Syndrome (see below) than shorter half-life benzodiazepines. This method of using a longer half-life equivalent is well understood in addiction medicine circles, and is employed with other classes of drugs as well. For example, people who are experiencing withdrawal symptoms from an antidepressant such as Paxil (Seroxat, paroxetine) are often given Prozac (fluoxetine) as a substitute for purposes of withdrawal, because Prozac has a longer half-life. Perhaps a more typical example is the use of the drug Methadone in heroin detoxification, which is employed in part because of its relatively long half-life.

6. WHAT DOES "TOLERANCE" MEAN?

Tolerance is the process by which the receptors in your brain become habituated to the action of a drug. When tolerance is reached, more of the drug is required to achieve the same effect. With benzodiazepines, and probably with many other classes of drugs as well, tolerance is virtually always associated with some degree of physical dependence. If you find that you are experiencing tolerance, this is a clear warning sign that you may have formed a dependency.

7. IF MY DOCTOR HAS PRESCRIBED A BENZODIAZEPINE AND INSTRUCTED ME TO TAKE IT FOR A MEDICAL AND/OR PSYCHOLOGICAL REASON, IS THERE ANY REASON I SHOULD DISREGARD MY DOCTOR'S ADVICE AND DISCONTINUE THE BENZODIAZEPINE?

Yes, there may be. Unfortunately, there are many well-intended physicians who simply do not understand the seriousness of long-term benzodiazepine use.

Regular benzodiazepine use almost always causes some degree of deterioration in cognitive functioning, which progresses with continued use.

Long term benzodiazepine use also causes lethargy and decreased energy levels that result in impairment in work productivity and disinclination towards exercise.

Furthermore, benzodiazepines, and all other classes of sedatives, frequently cause and/or worsen depression. This is why people are often given antidepressants after being given a benzodiazepine for anxiety. Antidepressants have their own complications and potential for dependency (see below).

Benzodiazepines can also cause what is sometimes referred to as a "emotional anaesthesia", or "emotional blunting," in which the user's ability to experience powerful emotions is impaired. This has been described as "the inability to feel pleasure or pain" in the medical literature (e.g. Ashton C H, Toxicity and Adverse Consequences of Benzodiazepine Use, 1995). Long-term benzodiazepine users often describe their experience as "sleepwalking through life".

Benzodiazepine use can also cause what are referred to as "paradoxical" symptoms in a minority of users. Paradoxical symptoms are contrary to the intended therapeutic purpose, including outbursts of rage, increased anxiety, and sleeplessness. Paradoxical symptoms can be caused by the drug's interaction with the psychological makeup of the user, or may be a biological reaction to use of the drug that people sometimes refer to as "toxicity". Paradoxical symptoms are sometimes mistaken for withdrawal, and vice versa. See: Benzodiazepines: Paradoxical Reactions & Long-Term Side-Effects. For further discussion on the long-term effects of benzodiazepines see: Benzodiazepines and their effects by Professor Ian Hindmarch.

The above effects occur to varying degrees, depending on the individual. Some individuals may not experience many of the effects at all. However, one effect is common to virtually all users: a physical dependency will eventually form. Benzodiazepine dependency is particularly serious as the withdrawal syndrome (see below) can be extremely difficult and protracted. Furthermore, the development of tolerance often makes long term use non-feasible, and withdrawal becomes a necessary eventuality.

Benzodiazepines are often misprescribed for conditions to which they are not appropriate, such as depression. Furthermore, they are often prescribed for anxiety conditions for which the individual could be treated effectively with other therapeutic techniques.

There are, however, legitimate therapeutic benefits for benzodiazepines, particularly if they are used in the short term (no more than 2 weeks of continuous use), or for situational anxiety/panic (for example, one dose of Xanax per month as the need arises.) Furthermore, many users of benzodiazepines, including some who have used them regularly for more than a year, are able to discontinue them with little difficulty.

Nothing in this FAQ is to be construed as advising any individual to ignore the advice of his or her physician. Decisions regarding the use or discontinuation of any benzodiazepine should be made in consultation with a physician. However, in this area you must also undertake considerable self-education in addition to listening carefully to your doctor's advice. Fortunately, there are many available resources to accomplish that (see below). Where a doctor does not appear to be up to date with current medical literature regarding benzodiazepine dependency and the withdrawal syndrome, seeking a second and third medical opinion can be a desirable option.

8. WHAT IS THE BENZODIAZEPINE WITHDRAWAL SYNDROME?

The Benzodiazepine Withdrawal Syndrome is believed to be caused by a dampening of the action of GABA as neuroadaptivity causes GABA to become dependent on stimulation from the benzodiazepine to initiate its primary action. In other words, when you have become dependent upon a benzodiazepine, your GABA is unable to perform its natural action without the presence of the benzodiazepine. This results in a wide variety of over-activity in different areas of your brain, causing a vast and diffuse array of symptoms. These symptoms are believed to be various manifestations of neurological over-excitation as the cells in your brain become especially sensitive to the action of excitatory neurotransmitters. The most extreme manifestation of this over-excitation is a seizure event.

The Benzodiazepine Withdrawal Syndrome is noted both for its relative severity and, in some cases, its lengthy duration, as compared to withdrawal from other classes of drugs.

Withdrawal either occurs through the development of tolerance without an attendant increase in dose, or through a decrease in dosage below your "tolerance point". Your tolerance point is the dose point below which the functioning of your receptors becomes impaired due to a deficiency in stimulation from the drug. Your tolerance point may be lower than your actual dosage, such that you can sometimes cut your dose by some amount without experiencing withdrawal symptoms.

Generally, a drug's withdrawal syndrome is the mirror of its primary effects. Thus, for benzodiazepines, you can expect sleeplessness (the mirror of its hypnotic effect), anxiety (the mirror of its anxiolytic effect), muscle tension/pain (the mirror of its muscle relaxant effect), and seizures in rare cases (the mirror of its anti-seizure effect). The only exception is that the Benzodiazepine Withdrawal Syndrome does not "mirror" the amnesic effect. On the contrary the Withdrawal Syndrome often results in increased impairment of memory and cognitive functioning. However, in all cases, after the withdrawal is complete and in total remission, cognitive functioning will gradually return to the level that it was at before you began using the drug.

For a more complete list of symptoms, see below.

9. WHAT ARE THE SYMPTOMS OF BENZODIAZEPINE WITHDRAWAL?

The following is a list of symptoms. As they have been reported by enough individuals they are statistically likely to be legitimate withdrawal symptoms. Keep in mind that there are a wide variety of other symptoms that have been reported that may be legitimate withdrawal symptoms as well, but have not been reported by enough individuals to be statistically significant. The determination of statistical significance is not based on hard data, but on the observations of this author in reading through thousands of posts from people in withdrawal, as well as several books and articles on the subject.

This list is broken down into psychological and physical symptoms. The double asterisk (**) indicates symptoms that occur to some degree or another, at one time or another, in virtually every person experiencing benzodiazepine withdrawal. Single asterisk (*) are symptoms that are common, and occur in most people. Others are symptoms that are common enough to be verifiable withdrawal symptoms, but probably occur in a minority of cases.

Psychological symptoms: anxiety** (including panic attacks), depression**, insomnia*, derealisation/depersonalisation* (feelings of unreality/detachment from self), obsessive negative thoughts*, (particularly of a violent and/or sexual nature) rapid mood changes* (especially including outbursts of anger or rage), phobias* (especially agoraphobia and fear of insanity), dysphoria* (loss of capacity to enjoy life; possibility a combination of depression, anxiety, and derealisation/depersonalisation), impairment of cognitive functioning*, suicidal thoughts*, nightmares, hallucinations, psychosis, pill cravings. Note that it is far more common to fear psychosis than it is to actually experience it.

Physical Symptoms: abnormal sensitivity to sensory stimuli* (such as loud noise or bright light), muscle tension/pain**, joint pain*, tinnitus*, headaches*, shaking/tremors*, blurred vision* (and other complications related to the eyes), itchy skin* (including formication, ie sensations of insects crawling on skin), gastrointestinal discomfort*, electric shock sensations*, paraesthesiae* (numbness and pins and needles, especially in extremities), fatigue*, weakness in the extremities* (particularly the legs), feelings of inner vibrations* (especially in the torso), sweating, fluctuations in body temperature, difficulty in swallowing, loss of appetite, "flu like" symptoms, fasciculations (muscle twitching), metallic taste in mouth, nausea, extreme thirst (including dry mouth and increased frequency of urination), sexual dysfunction (or occasional increase in libido), heart palpitations, dizziness, vertigo, breathlessness.

Here, I have cited only the most commonly reported withdrawal symptoms. For more comprehensive lists of withdrawal symptoms see the Symptoms Index on this site.

10. I AM EXPERIENCING ONE OR MORE OF THE SYMPTOMS LISTED ABOVE, BUT I HAVE NOT BEGUN TAPERING MY BENZODIAZEPINE. IS IT POSSIBLE THAT THE SYMPTOMS ARE NOT RELATED TO BENZODIAZEPINE USE, OR COULD I ALREADY HAVE STARTED WITHDRAWAL WITHOUT EVEN TAPERING?

You are probably experiencing tolerance withdrawal. When you reach tolerance, your brain needs more of the drug to stimulate the activity of GABA, and you begin to experience withdrawal symptoms. Some people find that no matter how much they increase their dose, they are unable to obtain complete relief. This may be caused by a fast, upward tolerance spiral, or by toxicity (see above). Complete withdrawal is necessary where this occurs.

Some people mistakenly form a belief that the drug has stopped working, and no longer alleviates their anxiety disorder when in fact they are experiencing anxiety brought on by tolerance withdrawal. Unfortunately, physicians will usually reinforce this misperception and advise you to increase your dose as a result or prescribe an additional benzodiazepine and/or antidepressants.

11. WHAT FACTORS DETERMINE HOW SEVERE MY WITHDRAWAL WILL BE?

It is impossible to predict how severe your particular withdrawal will be, or which of the 30 or so common symptoms you are likely to experience. Duration of use, dosage, type of benzodiazepine, age, your personal body chemistry, and your method of withdrawal may all play a part. It is unclear which, if any, of these factors relate to the duration of your withdrawal syndrome as opposed to the severity.

There is some evidence that the newer, high potency benzodiazepines, especially Xanax, Klonopin, and Ativan may be associated with more severe withdrawal syndromes. However, this evidence remains anecdotal.

Bear in mind that there is wide variation in people's withdrawal experiences. For example, one person may take a low dose of a benzodiazepine for a short period of time, and suffer a very severe withdrawal. Another individual may take a high dose of the same drug for much longer, and experience very manageable withdrawal symptoms. Furthermore, an individual Valium user may have a harder time than an individual Xanax user.

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 withdrawan 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.

Often, when people complete their benzodiazepine withdrawal, 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 FAQ 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 withdrawal 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 OF WITHDRAWING 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 withdrawal. 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 based on the idea that a slow taper "prolongs the agony of withdrawal." This notion is erroneous. In fact, there is some anecdotal evidence that cold turkey withdrawal may lengthen the course of the withdrawal syndrome, and may even cause the 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 1/4mg every month, or alternatively, cut your dose by 1/8mg 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 and the shock caused by such an abrupt withdrawal is so severe that even after resumption of your drug at the previous dose, it may take weeks or months to "stabilise", and in some cases, you may never stabilise 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 or pill-cutter. For example, with Valium, you can split the smallest (2mg) tablet into 4x0.5 mg pieces. With Klonopin, you can split the smallest (0.5mg) tablet into 4 pieces of 0.125 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 withdrawal.

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 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. Professor Heather Ashton has detailed taper schedules available that are based on switching to Valium (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 toxicity 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 antidepressant and a narcotic or 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 recommended method, there are three reasons that are often cited for switching to Valium for purposes of withdrawal.

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 2mg, 5mg and 10mg. As a practical matter, you can make cuts as small as 0.5mg. 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, some people, including some experts believe that the newer, high potency benzodiazepines such as Xanax, Klonopin, and Ativan tend to produce more severe withdrawal syndromes. So far the evidence of this is purely anecdotal. There do not appear to be any studies that conclusively correlate severity of withdrawal with benzodiazepine type.

If you do decide to switch to Valium it is important to observe the proper dose equivalencies. These are special equivalencies for purposes of switching to Valium. (see table above)

The cross-over process also needs to be carried out gradually, usually in stepwise fashion, substituting one dose at a time. Many people have suffered because they have been switched too quickly. Making the changeover one dose (or part of dose) at a time avoids this difficulty. Depending on the size of your dose, the period of dose substitution may be anywhere from 3 weeks to about 3 months.

Valium is a more potent sleep agent than most high potency benzodiazepines even at the equivalent therapeutic dose and many people may find it initially more sedating. However, most benzodiazepine users rapidly develop a tolerance to the sleep inducing (hypnotic) effects of benzodiazepines, so that it is likely that this oversedation will recede within the first few weeks.

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 oversedation 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.

Professor 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 may be tapered directly, although there is a problem in that it comes only in 5mg capsules in North America. Ideally, for Librium withdrawal, the capsule should be opened and the contents halved to make 2.5mg cuts. Of course, if it is possible to make even smaller cuts, that is most preferable.

17. MY DOCTOR HAS ASKED ME TO SWITCH TO A DRUG CALLED "PHENOBARBITAL" FOR DETOXIFICATION. IS THIS A GOOD IDEA?

No. Although this method of "detoxification" is commonly practised in the USA, it has long been abandoned in the UK and is even regarded by some authorities as barbaric. It is best avoided.

18. SHOULD I CONSIDER GOING INTO AN IN-PATIENT DRUG REHABILITATION FACILITY OR DETOX CENTER TO GET OFF MY BENZODIAZEPINE?

Only in a relatively small percentage of cases do people have successful experiences withdrawing from benzodiazepines on an in-patient basis. The problems with detoxification centers are multi-fold. First and foremost, detox facilities are geared towards treating drug abuse behaviours, not providing support for withdrawal. The facilities often do not understand the necessity of tapering benzodiazepines slowly. Often, they will require you to taper over a 3-6 week period. Some will even take you off your benzodiazepine over a one week period with a Valium or Phenobarbital substitute. These facilities usually will not keep you as an in-patient for more than about 6 weeks. The result is that you may end up coming off the drug in an overly rapid fashion, while receiving classes on drug abuse but no specific support for managing withdrawal. The experience after leaving the facility can often be very rough, as you may be left in a state of fairly intense withdrawal that can persist for a long while. In short, people with benzodiazepine dependencies often feel worse after they leave these facilities than before they entered.

Clinical experience suggests that benzodiazepine withdrawal works best where the patient controls his or her own taper schedule in conjunction with the advice of a physician knowledgeable about benzodiazepine dependency. Detoxification centers, even where they might permit a relatively slow taper, will usually take the control of the process away from the patient and force the patient into a rigid protocol.

However, detox centers should be considered in two circumstances. First, if you have a problem abusing benzodiazepines either alone or in combination with other drugs, an in-patient setting is often appropriate to enforce the discipline of tapering the drug, and to educate you on how to avoid drug abuse. (But see the discussion on 12 step programs below.) If you feel that you lack the necessary self-discipline to taper yourself slowly and gradually and have no spouse or other caregiver who will manage your taper for you, you may wish to consider going in to a facility.

Second, in the rare circumstance where your withdrawal syndrome is so severe that you are unable to take care of yourself and you have no live-in spouse or other caregiver, you may wish to consider the in-patient option.

Before choosing a detox facility, you should call at least five different facilities and make, at a minimum, the following enquiries: