Having Lorazepam Withdrawal Right Now.

Discussion in 'Fibromyalgia Main Forum' started by joeb7th, Apr 9, 2007.

  1. joeb7th

    joeb7th New Member

    I'm fairly certain that's what this is. It is a guess by someone not trained in medicine, but I have experimented with stopping the Lorazepam several times in the last few weeks and it fits the pattern.

    I'll take lorazepam ( trying to cut my doses but not working well and dnagerous I know ) and then not take it for 2 to 3 days and the last few weeks this is what I feel.

    Feeling dizzy, as if I could pass out, insides haywire, feeling nauseous, tremendous anxiety, tremors, breathing is interrupted by incredible tension and tightening up throughout entire body and anxiety to where I just have stunted breathing and I sigh and moan and pray. I blow out big breaths to try to relieve this everything-is-about-to-go feeling.

    If I had the money I would run to a drug rehab center, but no dice there.

    Have used up doctors in my small area. The ones I have and have seen just think I am nuts. The local ER too.

    So right now, just sitting here trembling and so sick and weak and feeling probably as bad as anyone in the middle of a drug withdrawal. This is scary as heck.

    Appetite gone, intestinal tract extremely sore, exhausted, feeling urges for both releases, then they go away for awhile and when I do go it is weak ....legs weak, shakey, fibro pain all over bad, depression to the max.

    But the worst part is knowing there's nothing I can do except stay home and gut this out.
  2. NyroFan

    NyroFan New Member

    jobe:

    All will be well. That med is not as strong as some.
    You might be uncomfortable, but I would imagine it will pass soon.

    I wish you all the best. Some of these doctors just do not listen when it comes to Lyme Disease or Fibromyalgia and what we go through.

    Rest and really good nutrition can be very helpful.

    nyrofan
  3. obrnlc

    obrnlc New Member

    hi joe-
    my sister had same symptoms coming off of paxil, only solution was to titrate down REAL SLOW, while keeping a small dose in your bloodstream, no cold turkey.
    good luck, GO SLOW and hang in there!--L
  4. PHR

    PHR New Member

    and my pain management dr.felt I was having an allergic reaction to the pain meds and gave me Reglan and Zrytec. It took care of all of those symptoms and I can take the pain meds again. It was such a lifesaver!

    Kathy
  5. Waynesrhythm

    Waynesrhythm Member

    Hi Joeb7th,

    The following site is the best I've found regarding benzodiazepine withdrawal. It was my primary guide as I tapered off of clonazepam (which I took over a year to do).

    http://www.benzo.org.uk/manual/contents.htm

    There is so much good information at this site, that I'll not say much more at this time except to paste the following paragraph specifically mentioning Lorazepam.

    Potency. A large number of benzodiazepines are available (Table 1). There are major differences in potency between different benzodiazepines, so that equivalent doses vary as much as 20-fold. For example, 0.5 milligrams (mg) of alprazolam (Xanax) is approximately equivalent to 10mg of diazepam (Valium). Thus a person on 6mg of alprazolam daily, a dose not uncommonly prescribed in the US, is taking the equivalent of about 120mg of diazepam, a very high dose. These differences in strength have not always been fully appreciated by doctors, and some would not agree with the equivalents given here. Nevertheless, people on potent benzodiazepines such as alprazolam, lorazepam (Ativan) or clonazepam (Klonopin) tend to be using relatively large doses. This difference in potency is important when switching from one benzodiazepine to another, for example changing to diazepam during the withdrawal, as described in the next chapter.

    joeb7th, from my experience, patience is a key. Withdrawing slowly and carefully usually means doing it correctly.

    Wishing you the best as you move forward.

    Regards, Wayne

    [This Message was Edited on 04/09/2007]
  6. pat460

    pat460 New Member

    You didn't say if you are out of med. or trying to stop taking it on your own? If you are not out of meds then the key to stopping is not cold turkey. You have to cut your dose slowly, like by 1/3 every few days. Taper yourself off or it will be pure H E double hockey sticks! I have, in a pinch, used Benedryl to help me sleep through some withdrawal symptoms. Your gut might feel better with some probiotics (even yogurt might help some-Activia kind) and Prilosic or Previcid? Remember, I'm not a Dr. and am just telling you things that have helped me. How about a warm soothing bath and soft music or some such things to ease your nerves? Your doctor didn't tell you it's not good to do the take one miss one kinda thing? Just curious cause some don't give a crap and some don't know crap! My mom is totally hooked on Lorazepam, but she doesn't take but 1/2 to 1 a day and without it she's a mess. It doesn't hurt her and makes her feel calmer so I personally don't see anything wrong with her staying on it.

    Hope you feel better soon! Pat
  7. MsE

    MsE New Member

    It sounds like I am in the same boat as your mom. One and one-half one mg tablet a day keeps me functioning.

    I think it is social pressure that makes me, periodically, try getting off lorazepam. The best I have been able to do so far is cut back to 1 mg a day. But then something very stressful seems to show up in my life, and I'm back to 1 1/2. It is discouraging.

    Joeb7th, I'll be watching your progress with interest and compassion. I hope you break the chain; it's links are, I know, very tough. Once you are off of it completely, I hope you will let us know how that affects your life--whether you feel a lot better overall, etc.

    By the way, when I do cut back, it is by a quarter of a tablet at a time. The slower I do it, the better it works. However, as I wrote above, I haven't managed to get past the 1 tablet mark.

    Good luck and God bless you.
  8. desertlass

    desertlass New Member

    I don't think you need to go through so much hell to come off of this, but I don't know what all you're dealing with, of course.

    I also don't know all the reasons you want to come off of it, or why so quickly, so of course I can only offer observations.

    If you were taking one pill every day and now are taking one every two to three days, that means you are dropping almost by two-thirds (over half) your dosage all at once.

    However, if it helps to know you might have an alternative to a rehab center, which might not be helpful anyway, depending on the place, here is a suggestion:

    There were sites that people had recommended to you on a previous post about this. So, I will remind you again. :)

    Here is one place that has a schedule with how to come off slowly. The schedule would depend upon how much you are taking to begin with, so you would need to find the one that matches your dosage.

    http://www.benzo.org.uk/manual/bzsched.htm

    I would say to just look at the schedules, and not at all the information on the drug itself which might be upsetting, and not so helpful at this time.

    Are you coming off quickly because your doctor won't prescribe it for you?

    If you're having a hard time with a doctor, you could show him/her the schedule, so that they have some sort of guidance, too.

    I think this would be really hard on your marriage, as you've mentioned. It must be very frightening for your wife to see you go through this, and not know what to do. Seeing the schedule might also help her to feel less bewildered and more hopeful.

    You might also consider staying on it for a while until you feel stable again, if that is an option? At any rate, I wish you significant relief and soon, no matter what way this goes.

    Grace to you,
    Lisette
  9. joeb7th

    joeb7th New Member

    Yes great site for the Benzos. I am not doing this right I can tell. Should go a little slower. And dog gone it, I want those valiums to help me get off this Lorazepam but my psych just keeps fighting me on this. He will prescribe Klonopin but I want to use the Diazepam instead.


    Pat, the Lorazepam does work, but I just would like to not have to depend on this if I can possibly not do this.

    I took a quarter of a 2 mg ( .5 mgs ) pill hours ago and it didn't do much. I should probably go 1 to 1 and 1/2 MG's twice a day to start, and some valium at night.

    I'll probably go back to at least 1 mg or 1 and 1/2 later today. I think going to .5 is just too tough for me right off. And at this higher rate every two weeks I can lower this a third until I just take some valium and then start lowering this on it's own.

    Boy, with everything crashing around us and all the other side pain and symptoms of fibro and immune system problems like my asthma and sinusitis and low B-12 and low testosterone, this is one tough struggle.

    Thanks for sharing with me today everybody.
  10. joeb7th

    joeb7th New Member

    When you say your mom takes 1/2 to 1 a day...does that mean she takes 1/2 to 1 milligrams of Lorazepam a day or a 1/2 to 1 "2" milligram tablet a day?

    I have the 2 mg tabs. Does your mom have 1 milligram tablets?

    My undertstanding is that this is equivalant to 40 mgs of Valium.

    What I don't like about Lorazepam besides it's potency is how fast it leaves your system. In a very short term stress situation this would be great, but I have been taking this stuff on and off for 6 to 8 months!

    And when it leaves your system it brings about the most powerful symptom of depression I have ever experienced. So deep and profound with me I feel like my head is going to blow and I lose all appetite and can't even smile. The last time this happened to me I curled up in a ball and layed on my bed with a pilow over my face and just prayed.

    It only left when I took more Lorazepam.


    Sp personally I think this makes me more depressed than I already am...and no way can I afford to stay on something like this.
  11. pat460

    pat460 New Member

    Called my mom to make sure--she said she was taking 1/2 of a 1 mg. tablet and did this for years. She recently broke her hip and was sent to a rehab center for physical therapy where they started giving her one whole 1 mg. tab each night at bedtime. It helped her more this way so she has stayed on that dosage. When something traumatic happens in the family, she will take an extra one to help her handle it. Sometimes we don't like being dependent on our meds, but if they are making us feel better and handle the symptoms of all the crap (physical and mental)then I personally don't think we should worry about it so much. I'm glad you are going to do a slower taper. By the way, my Mom said this stuff is really hard to come off of so I guess she's had the same feelings as you in the past and tried to stop taking them. My family has always encouraged her to not worry about taking meds unless she is trying to get high--that makes her laugh because she is a very christian woman who's never even tasted alcohol! lol!

    Feel Better, Pat
    By the way, did you tell your doctor that you think you would do better on a longer acting less potent drug? I too have very bad depression but can't handle those kind of meds. They knock me out and make me feel drunk. Antidepressents, particularly Celexa, was the answer to my prayers. I don't like having to take it but, I hated crying all the time and making my children wonder if it was their fault even more. I need it and know I can't be without it more than a couple days at a time. Have you tried anything like that before?[This Message was Edited on 04/09/2007]
  12. joeb7th

    joeb7th New Member

    Gee, thats a low dose of Lorazepam your mom takes. .5 milligrams doesn't seem to do anything for me.

    Yes, I tried the anti-depressant Lexipro for about 3+ months. I gained 40 lbs in that time without trying, ( haven't lost a pound off this in 6 months!) also lost my sex drive completely and had insomnia.

    It "did" help with anxiety though. And it didn't make me sick feeling or anything. I think Lexipro is the mildest of anti-depressants but funny how doctors act like "so what's the big deal" when you lose your sex drive, gain 40 lbs and lose your self image and you can't sleep.

    Like this is nothing?

    I disagree with our medical society in their down-playing a patients concerns about these side effects. These side effects are hugely affecting of your life. And they shouldn't be down-played. They are clearly major losses...not gains.

    I wanted to say, " hey, as of right now your sex drive is gone, you will have 40 paunchy pounds on by tomorrow and you won't sleep but two hour stretches at a time...see how long they put up with this.

    Never, has even one doctor ever told me he or she has ever took any of these anti-depressants and even anti-anxiety meds...yet they act so cocky about knowing everything about them and how we shouldn't complain about losing these natural healthy body things like sex drive, weight loss and sleep.

    Sorry, but until you perfect these to stop doing these three things to people which effects them in so many ways, I would never brag about how good these anti-depressants are.
  13. obrnlc

    obrnlc New Member

    hi joe--about these side effects you just mentioned--that is 3 more meds they can give you now to combat the 3 new side effects you just mentioned, thus making the drug reps happy as a lark and willing to shell out all kinds of perks!
    sure, maybe joe is miserable with these 3 side effects, but for a small fortune and a whole slew of other side effects--we can fix him!!

    the relationship between the medical. field (many--not all-- i can't generalize ALL of them) and the pharm. comp. is a bond glued together with cold hard cash and who cares about us who are stuck in the middle!

    had to throw in that rant--hope you are tapering down slow and starting to feel better. from what i saw w/ my sis and paxil--it was worse than my duragesic "cold turkey", at least i knew i was going to live thru that!

    good luck--L
  14. pat460

    pat460 New Member

    to everything you said about the anti-depressants. I am battling the insomnia and decreased sex drive. I can't blame my extra 50lbs. on them because I gained that during my 2nd pregnancy, then got sick, and never recovered enough to exercise. Recently, I've started researching natural alternatives. Also, I'm playing with the time I take the Celexa to see if I can get my insomnia under control. I would like to find a different alternative because of all the side effects but when you have such bad depression, taking nothing would be the end for me I know. You know, suicide starts looking too good and I definitely don't want to go there again. How does your spouse feel about you taking the Lorazepam? Sorry I couldn't help you out but don't give up. Do try the slower taper and keep searching for a doctor who will help you find the right alternative. I'll be thinking of you and watching for your posts to see how it's going. Please don't forget to let us all know.

    Pat
  15. joeb7th

    joeb7th New Member

    My wife is so exhausted from all my suffering and being the main person I have turned to 50 times at 2 in the morning with crying out pains and fear and ER drives, she just wants me to stabilize on the lorazepam. I can't blame her one bit.

    Add on my not working for 15 months with no disability or anything and all the debt we've accrued....I am surprised she hasn't lost it by now too.
  16. BobinGermany

    BobinGermany New Member

    Hi Joeb,

    I have detoxed off of xanax a couple of times (doctor I was seeing at that time didn't think I needed it) and the valium route was the best way to go in my opinion. It's effects don't drop off quickly like xanax or lorazepam so it is easier to to keep a constant amount in your system as you cut down. I detoxed once with out the valium and did well also. If you are taking say 2 mg now, cut back to 1,5 mg for at least one week or a little longer. This will give your body time to adjust and not produce such a bad withdrawal. Then after one week or so at 1,5mg, cut down to 1mg. And so forth until you are down to none. This worked super for me and I had little or no side affects. The benzo.org site is really good also.

    Good luck as you continue to detox and I will be praying for you...

    God Bless,
    Bob

    I am not a doctor so please check with your doctor or medical professional before trying anything I have suggested.
  17. jmq

    jmq New Member

    You are so brave to be trying this. It is amazing how hard we all try and work to get better. I do not know if I would be as brave as you. I am pretty strong with pain..but not panic and the psychological aspects of this dd. I just wanted to send you some words of encouragement...as well as to your wife. I have a feeling you will get out of this hell you are in and start organizing our rally soon. I love your spirit.


    I will check on you tomorrow.
    jmq
  18. Didoe

    Didoe New Member

    May i suggest something not harmful that may soothe your stomach and intestinals...please try to get the best yogurt you can find, without the gunky fruit junk on the bottom
    get vanilla or plain and then put uncooked buckwheat honey on it, buckwheat honey is dark, strong flavored--if you cant find buckwheat, get any uncooked honey--uncooked honey is amazing stuff, a few days supply of both would be less than $10. (& that's NY prices:)
    Prayers are with you and your amazing wife.
  19. SusanEU

    SusanEU New Member

    I am interested in your post too, cause I have been taking 0.5 to 1 mg to help with sleep and once in a while if I feel anxious, but I thought this was too small a dose to have withdrawal from. (been taking for about 1 1/2 years)

    I hope you are feeling better and have gone down slowly. I don't know if I will ever get off of it, cause it is the only thing that helps me get a half decent sleep.

    The thing is, the longer I am on it, the less it works, so I need to go up another another 1/2, but that worries me.

    Again, hope you feel better soon, and thanks for posting. It's good to get the real info on meds from someone whose been there.

    Sue in Ontario
  20. PVLady

    PVLady New Member

    I don't know if it might help but here is a excellent site about benzo withdrawals etc. Look at "The Ashton Manual" on the left side.

    http://www.benzo.org.uk/index.htm

    You may need to call a drug rehab and see what they can do to get you admitted. Based on the little I read below, it looks like you need to be in the hands of a professional.

    I think one recommendation was when stopping Ativan, to first switch to a long acting benzo like Valium that has half life of 200 hrs. Below is a (long) exerpt. Too bad this doc is in England.

    THE WITHDRAWAL

    (1) Dosage tapering. 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 (see Chapter III).

    Slow withdrawal means tapering dosage gradually, usually over a period of some months. The aim is to obtain a smooth, steady and slow decline in blood and tissue concentrations of benzodiazepines so that the natural systems in the brain can recover their normal state. As explained in Chapter I, long-term benzodiazepines take 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 reduce in numbers and GABA function decreases. Sudden withdrawal from benzodiazepines leaves the brain in a state of GABA-underactivity, resulting in hyperexcitability of the nervous system.

    This hyperexcitability is the root cause of most of the withdrawal symptoms discussed in the next chapter. 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 in control 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 the agony" and it is better to get it over with as quickly as possible. However, the experience of most patients is that slow withdrawal is greatly preferable, especially when the subject dictates the pace. Indeed, many patients find that there is little or no "agony" involved.

    Nevertheless there 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 high doses of potent benzodiazepines such as Xanax and Klonopin are likely to need more time.

    Examples of slow withdrawal schedules are given at the end of this chapter. As a very rough guide, a person taking 40mg diazepam a day (or its equivalent) might be able to reduce the daily dosage by 2mg every 1-2 weeks until a dose of 20mg diazepam a day is reached. This would take 10-20 weeks. From 20mg diazepam a day, reductions of 1 mg in daily dosage every week or two might be preferable. This would take a further 20-40 weeks, so the total withdrawal might last 30-60 weeks.

    Yet some people might prefer to reduce faster and some might go even slower. (See next section for further details).

    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 of learning to cope without drugs which is an essential part of the adaptation to withdrawal. If the withdrawal is slow enough, "escape pills" should not be necessary.



    (2) Switching to a long-acting benzodiazepine. With relatively short-acting benzodiazepines such as alprazolam (Xanax) and lorazepam (Ativan) (Table 1, Chapter I), it is not possible to achieve a smooth decline in blood and tissue concentrations. These drugs are eliminated fairly rapidly with the result that concentrations fluctuate with peaks and troughs between each dose. It is necessary to take the tablets several times a day and many people experience a "mini-withdrawal", sometimes a craving, between each dose.

    For people withdrawing from these potent, short-acting drugs it is advisable to switch to a long-acting, slowly metabolised benzodiazepine such as diazepam. 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 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 the body to adjust slowly to a decreasing concentration of the benzodiazepines.

    The switch-over process needs to be carried out gradually, usually in stepwise fashion, substituting one dose at a time. There are several factors to consider. One is the difference in potency between different benzodiazepines. Many people have suffered because they have been switched suddenly to a different, less potent drug in inadequate dosage because the doctor has not adequately considered this factor. Equivalent potencies of benzodiazepines are shown in Table 1 (Chapter I), but these are only approximate and differ between individuals.

    A second factor to bear in mind is that the various benzodiazepines, though broadly similar, have slightly different profiles of action. For example, lorazepam (Ativan) seems to have less hypnotic activity than diazepam (probably because it is shorter acting). Thus if someone on, say, 2mg Ativan three times a day is directly switched to 60mg diazepam (the equivalent dose for anxiety) he is liable to become extremely sleepy, but if he is switched suddenly onto a much smaller dose of diazepam, he will probably get withdrawal symptoms.

    Making the changeover one dose (or part of dose) at a time avoids this difficulty and also helps to find the equivalent dosage for that individual. It is also helpful to make the first substitution in the night-time dose, and the substitution may not always need to be complete. For example, if the evening dose was 2mg Ativan, this could in some cases be changed to 1 mg Ativan plus 8mg diazepam. A full substitution for the dropped 1 mg of Ativan would have been 10mg diazepam.

    However, the patient may actually sleep well on this combination and he will have already made a dosage reduction - a first step in withdrawal. (Examples of step-wise substitutions are given in the schedules at the end of this chapter.)

    A third important practical factor is the available dosage formulations of the various benzodiazepines. In withdrawal you need a long-acting drug which can be reduced in very small steps. Diazepam (Valium) is the only benzodiazepine that is ideal for this purpose since it comes in 2mg tablets, which are scored down the middle and easily halved into 1 mg doses.

    By contrast, the smallest available tablet of lorazepam (Ativan) is 0.5mg (equivalent to 5mg diazepam) [in the UK the lowest available dosage form for lorazepam is 1mg]; the smallest tablet of alprazolam (Xanax) is 0.25mg (also equivalent to 5mg diazepam). Even by halving these tablets the smallest reduction one could easily make is the equivalent of 2.5mg diazepam. (Some patients become very adept at shaving small portions off their tablets). Because of limited dose formulations, it may be necessary to switch to diazepam even if you are on a fairly long-acting benzodiazepine of relatively low potency (e.g. flurazepam [Dalmane]).

    Liquid preparations of some benzodiazepines are available and if desired slow reduction from these can be accomplished by decreasing the volume of each dose, using a graduated syringe.

    Some doctors in the US switch patients onto clonazepam (Klonopin, [Rivotril in Canada]), believing that it will be easier to withdraw from than say alprazolam (Xanax) or lorazepam (Ativan) because it is more slowly eliminated. However, Klonopin is far from ideal for this purpose.

    It is an extremely potent drug, is eliminated much faster than diazepam (See Table 1, Chapter I), and the smallest available tablet in the US is 0.5mg (equivalent to 10mg diazepam) and 0.25mg in Canada (equivalent to 5mg Valium). It is difficult with this drug to achieve a smooth, slow fall in blood concentration, and there is some evidence that withdrawal is particularly difficult from high potency benzodiazepines, including Klonopin. Some people, however, appear to have particular difficulty in switching from Klonopin to diazepam.

    In such cases it is possible to have special capsules made up containing small doses, e.g. an eighth or a sixteenth of a milligram or less, which can be used to make gradual dosage reductions straight from Klonopin. These capsules require a doctor's prescription and can be made up by hospital pharmacists and some chemists in the UK, and by compounding pharmacists in North America.

    A similar technique can be used for those on other benzodiazepines who find it hard to substitute diazepam. To locate a compounding pharmacist in the USA or Canada this web site may be useful: www.iacprx.org. Care must be taken to ensure that the compounding pharmacist can guarantee the same formula on each prescription renewal. It should be noted, however, that this approach to benzodiazepine withdrawal can be troublesome and is not recommended for general use.

    (3) Designing and following the withdrawal schedule. Some examples of withdrawal schedules are given on later pages. Most of them are actual schedules which have been used and found to work by real people who withdrew successfully. But each schedule must be tailored to individual needs; no two schedules are necessarily the same. Below is a summary of points to consider when drawing up your own schedule.

    Design the schedule around your own symptoms. For example, if insomnia is a major problem, take most of your dosage at bedtime; if getting out of the house in the morning is a difficulty, take some of the dose first thing (but not a large enough dose to make you sleepy or incompetent at driving!).

    When switching over to diazepam, substitute one dose at a time, usually starting with the evening or night-time dose, then replace the other doses, one by one, at intervals of a few days or a week. Unless you are starting from very large doses, there is no need to aim for a reduction at this stage; simply aim for an approximately equivalent dosage. When you have done this, you can start reducing the diazepam slowly.

    If, however, you are on a high dose, such as 6mg alprazolam (equivalent to 120mg diazepam), you may need to undertake some reduction while switching over, and may need to switch only part of the dosage at a time (see Schedule 1). The aim is to find a dose of diazepam which largely prevents withdrawal symptoms but is not so excessive as to make you sleepy.

    Diazepam is very slowly eliminated and needs only, at most, twice daily administration to achieve smooth blood concentrations. If you are taking benzodiazepines three or four times a day it is advisable to space out your dosage to twice daily once you are on diazepam. The less often you take tablets the less your day will revolve around your medication.

    The larger the dose you are taking initially, the greater the size of each dose reduction can be. You could aim at reducing dosage by up to one tenth at each decrement. For example, if you are taking 40mg diazepam equivalent you could reduce at first by 2-4mg every week or two. When you are down to 20mg, reductions could be 1-2mg weekly or fortnightly. When you are down to 10mg, 1mg reductions are probably indicated. From 5mg diazepam some people prefer to reduce by 0.5mg every week or two.

    There is no need to draw up your withdrawal schedule right up to the end. It is usually sensible to plan the first few weeks and then review and if necessary amend your schedule according to your progress. Prepare your doctor to be flexible and to be ready for your schedule to be adjusted to a slower (or faster) pace at any time.

    As far as possible, never go backwards. You can stand still at a certain stage in your schedule and have a vacation from further withdrawal for a few weeks if circumstances change (if for instance there is a family crisis), but try to avoid ever increasing the dosage again. You don't want to back over ground you have already covered.

    Avoid taking extra tablets in times of stress. Learn to gain control over your symptoms. This will give you extra confidence that you can cope without benzodiazepines (see Chapter III, Withdrawal Symptoms).

    Avoid compensating for benzodiazepines by increasing your intake of alcohol, cannabis or non-prescription drugs. Occasionally your doctor may suggest other drugs for particular symptoms (see Chapter III, Withdrawal Symptoms), but do not take the sleeping tablets zolpidem (Ambien), zopiclone (Zimovane, Imovane) or zaleplon (Sonata) as they have the same actions as benzodiazepines.

    Getting off the last tablet: Stopping the last few milligrams is often viewed as particularly difficult. This is mainly due to fear of how you will cope without any drug at all. In fact, the final parting is surprisingly easy. People are usually delighted by the new sense of freedom gained. In any case the 1mg or 0.5mg diazepam per day which you are taking at the end of your schedule is having little effect apart from keeping the dependence going.

    Do not be tempted to spin out the withdrawal to a ridiculously slow rate towards the end (such as 0.25mg each month). Take the plunge when you reach 0.5mg daily; full recovery cannot begin until you have got off your tablets completely. Some people after completing withdrawal like to carry around a few tablets with them for security "just in case", but find that they rarely if ever use them.

    Do not become obsessed with your withdrawal schedule. Let it just become a normal way of life for the next few months. Okay, you are withdrawing from your benzodiazepines; so are many others. It's no big deal.

    If for any reason you do not (or did not) succeed at your first attempt at benzodiazepine withdrawal, you can always try again. They say that most smokers make 7 or 8 attempts before they finally give up cigarettes. The good news is that most long-term benzodiazepine users are successful after the first attempt. Those who need a second try have usually been withdrawn too quickly the first time. A slow and steady benzodiazepine withdrawal, with you in control, is nearly always successful.

    (4) Withdrawal in older people. Older people can withdraw from benzodiazepines as successfully as younger people, even if they have taken the drugs for years. A recent trial with an elderly population of 273 general practice patients on long-term (mean 15 years) benzodiazepines showed that voluntary dosage reduction and total withdrawal of benzodiazepines was accompanied by better sleep, improvement in psychological and physical health and fewer visits to doctors. These findings have been repeated in several other studies of elderly patients taking benzodiazepines long-term.

    There are particularly compelling reasons why older people should withdraw from benzodiazepines since, as age advances, they become more prone to falls and fractures, confusion, memory loss and psychiatric problems (see Chapter 1).

    Methods of benzodiazepine withdrawal in older people are similar to those recommended above for younger adults. A slow tapering regimen, in my experience, is easily tolerated, even by people in their 80s who have taken benzodiazepines for 20 or more years. The schedule may include the use of liquid preparations if available and judicious stepwise substitution with diazepam (Valium) if necessary. There is, of course, a great deal of variation in the age at which individuals become "older" - perhaps 65-70 years would fit the definition in most cases.

    (5) Antidepressants. Many people taking benzodiazepines long-term have also been prescribed antidepressant drugs because of developing depression, either during chronic use or during withdrawal. Antidepressant drugs should also be tapered slowly since they too can cause a withdrawal reaction (euphemistically labelled "antidepressant discontinuation reaction" by psychiatrists).

    If you are taking an antidepressant drug as well as a benzodiazepine it is best to complete the benzodiazepine withdrawal before starting to taper the antidepressant. A list of antidepressant drugs and brief advice on how to taper them is given in Schedule 13 of this chapter. Some antidepressant withdrawal ("discontinuation") symptoms are shown in Chapter III (Table 2).

    The above summary applies to people who are planning to manage their own withdrawal - probably the majority of readers. Those who have the help of a knowledgeable and understanding doctor or counsellor may wish to share the burden somewhat. In my withdrawal clinic I used usually to draw up a draft schedule which I discussed with each patient. Most patients took a close interest in the schedule and suggested amendments from time to time. However, there were some who preferred not to think about the details too much but simply to follow the schedule rigidly to the end.

    This group was equally successful. A very few (probably about 20 patients out of 300) wished to know nothing about the schedule, but just to follow instructions; some of these also entered a clinical trial of withdrawal. For this group (with their consent or by their own request), dummy tablets were gradually substituted for the benzodiazepines. This method was also successful and at the end of the process the patients were amazed and delighted when they found they had been off benzodiazepines and taking only dummy tablets for the last 4 weeks. There are more ways than one of killing a cat, as they say!



    [This Message was Edited on 04/09/2007]