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Crossover Schedules

A note of explanation goes with Dr. Reg Peart’s sample schedules and suggestions.  Dr. Peart is head coordinator of VOT (Victim of Tranquilizers).  He has in-depth knowledge of benzodiazepine withdrawal and years of experience helping people taper off benzos.  He believes that a more rapid crossover will ‘cover’ tolerance w/d more quickly, allowing for less distress during the process.

Dr. Peart is not suggesting a new ‘method’ of tapering that contradicts Dr. Heather Ashton.  Roche’s drug literature advises a more rapid crossover.   And Dr. Ashton has always said that each person should adjust the sample schedules as tolerated. 

Many lay people advise slowing down the crossover when one feels worse.  Dr. Peart does not agree with this and in fact believes that it keeps the person in high tolerance w/d even longer and for no medical reason.   

Sample Schedules by Dr. Reg Peart

 Table for Transition from 0.75 mg Clonazepam (Klonopin) to 15 mg Diazepam (Valium):

 Approximate equivalence for crossover 1 mg K = 20 mg V – Prof. C. H. Ashton

Day

9am

3.pm

Bedtime

Day 0

0.25mg K

0.25mg K

0.25mg K

Day 1

0.25mg K

0.25mg K

 5mg of V

Day 2

Same as Day 1

 

 

Day 3

5mg of V

0.25mg K

 5mg of V

Day 4

Same as Day 3

 

 

Day 5

5mg of V

5mg of V

5mg of V

Day 6

Same as Day 5

 

 

 If sleep is a problem, try: 

Day 7

4mg of V

4mg of V

7mg of V

 (Alternately, in the above schedule, the person can split their Clonazepam into parts as small as 0.125 mg and substitute each of those parts with 2.5mg Diazepam every other day.  The crossover would then take 16 days.)

 Subject to change depending on response.

 Table for Transition from 1.5 mg Xanax to 30 mg Valium

 Approximate equivalence for 1 mg (X) = 10 – 20 mg (D) – Roche values

Approximate equivalence for withdrawals 1 mg (X) = 20 mg (D) – Prof. C. H. Ashton 

Day

7.00am

3.00pm

11.00pm

Day 0

0.5mg of X

0.5mg of X

0.5mg of X

Day 1

0.5mg of X

0.5mg of X

0.25mg X & 5mg of V

Day 2

Same as Day 1

 

 

Day 3

0.5mg of X

0.5mg of X

10 mg of V

Day 4

Same as Day 3

 

 

Day 5

0.25mg X & 5mg of V

0.5mg of X

10 mg of V

Day 6

Same as Day 5

 

 

Day 7

10 mg of V

0.5mg of X

10 mg of V

Day 8

Same as Day 7

 

 

Day 9

10 mg of V

0.25mg X & 5mg of V

10 mg of V

Day 10

Same as Day 9

 

 

Day 11

10 mg of V

10 mg of V

10 mg of V

Day 12

Same as Day 11

 

 

 If sleep is a problem, try: 

Day 13

7mg of V

8mg of V

15mg of V

 Subject to change depending on response.

 Table for Transition from 1.0 mg Lorazepam & 10 mg Ambien to 15 mg Valium

 Approximate equivalence for crossover 1 mg Lorazepam = 10 mg V and 10 mg Ambien = 5 mg V – Prof. C. H. Ashton                       

Day

AM

Afternoon

PM

Day 0

0.5mg of L

0.5mg of L

10mg of  A

Day 1

0.5mg of L

0.5mg of L

5mg of A & 2.5mg of V

Day 2

Same as Day 1

 

 

Day 3

0.5mg of L

0.5mg of L

5 mg of V

Day 4

Same as Day 3

 

 

Day 5

0.25mg of L & 2.5mg of V

0.5mg of L

5 mg of V

Day 6

Same as Day 5

 

 

Day 7

5 mg of V

0.5mg of L

5 mg of V

Day 8

Same as Day 7

 

 

Day 9

5 mg of V

0.25mg of L & 2.5mg of V

5 mg of V

Day 10

Same as Day 9

 

 

Day 11

5 mg of V

5 mg of V

5 mg of V

Day 12

Same as Day 11

 

 

 If sleep is a problem, try: 

Day 13

4mg of V

4mg of V

7mg of V

 Subject to change depending on response.

 If during the transition period you begin to feel more tired than normal, this generally indicates that the diazepam is "kicking in" - proceed with no additional increases (above those planned). 

It would be anticipated that a patient who is working and has family commitments could take a minimum of 18 months for the taper to be complete. Often the dose taper is not linear. The last one-third dose reduction can be as long as the first two thirds. 

The process of withdrawing from other benzos under the cover of diazepam is a trial and error procedure. About 95% achieve it with a 1-week approximate change over period. This change over period is Phase I. 

Phase II is the steady state accumulation period. Diazepam metabolizes into the active metabolites: desmethyldiazepam, oxazepam and temazepam with an overall half-life of about 9 days. Ninety percent of steady state accumulation is achieved in 3.3 half lives i.e., about 30 days which should be the approximate length of Phase II and results in an accumulation of about 5 times the daily dose level. The long half-life (about 200 hours) ensures a constant level in the body and blood and prevents interdose withdrawals as long as severe tolerance effects are not in operation. Tolerance to long half-life benzo anxiolytic effects start after 2 to 6 months. 

Phase II is a stabilization period and if the previous drug has effectively been eliminated (6 half lives leaves about 1 to 2% in the body i.e., 12 days maximum for Klonopin) the patient is usually in a state of only minor physical and mental discomfort. As the individual sensitivity can vary a lot, it may require an upward adjustment of the dose to achieve it. Try not to do this until the end of the accumulation period of 30 days. 

Phase III is the stepwise reduction of the diazepam. This is seldom achieved without some level of discomfort and therefore must be controlled by the patient. Only the patient can determine what is tolerable. 

The dose reduction should not be more than 10% for each step, e.g., 5 mg from 90 to 50 mg, 4 mg from 50 mg to 40 mg, 3 mg from 40 mg to 30 mg, 2 mg from 30 mg to 20 mg, 1 mg from 20 mg to 10 mg, 0.5 mg from 10 mg to about 4 mg. Below 4 mg some patients can tolerate 0.5 mg steps, ending up with 0.5 mg every 2 and then every 3 days. Others are more sensitive and require smaller steps which can be achieved by using diazepam in liquid form (manufactured by Roche) for steps of 0 to 1 mg. 

The length of each step is usually 2 to 4 weeks, some as short as 1 week or as long as 2 months. From a pharmacological point of view, there is no value in greater than 2 months, the level of diazepam has reached a constant value and tolerance effects could become evident. 

Notes: 

(1)        This is a trial and error procedure. Ninety-five percent successfully achieve it with a transition period of 7 to 12 days.

(2)        Sudden change over is not advisable.

(3)        After the changeover, wait about 4 weeks before attempting to reduce the dose slowly. If you feel very comfortable after 2 to 3 weeks, go ahead with the next step.

(4)        During tapering and at least one year after, the patient should enlist the help and support of family, friends and those who have successfully come off these drugs. Knowledge and support helps to remove fear. 

Anyone using these guidelines and information should get the agreement and support of their prescribing physician. 

Micellaneous Notes:  

In dealing with problematic tapers, there is often a problem with interdose withdrawal in some people, even when using Valium but especially in the faster-acting benzos like Xanax and Ativan.  Dr. Peart suggests people change to 3 doses per day by splitting their one dose into thirds.  Doing this and leaving these 3 doses in place as long as possible will often stop the interdose w/d symptoms. 

In situations where high tolerance withdrawal has occurred i.e., someone has stayed on the same dose for several months or simply ‘hit the wall’ as we sometimes call it, these people can consider updosing.  How much and how fast is going to be very variable but a very general rule would be to updose 1-2 mg per day for 2-3 days and see how one feels at that point.  (This is speaking to the person on Valium only.) 

One of the biggest problems with updosing is when it doesn’t help.  This is usually seen in the person who is creeping the dose up too slowly in the hopes they will feel better without having to increase too much.  This is often a mistake and actually allows the tolerance w/d to literally follow the person up as they increase the dose; thus pretty much insuring a failed updose situation. 

Post Withdrawal Syndrome: 

The dose required and length of taper to cover the post withdrawal syndrome (PWS) (long term side effects – see toxicity paper by R. F. Peart ) is not predictable. The higher the dose and longer the period of ingestion, the greater the probability of PWS problems. Others with sensitivity to these drugs, even with short ingestion periods and low doses, can still have significant PSW problems.  

Those who have ingested higher than therapeutic levels need flexibility built into the transition period to ensure that the minimum dose to cover the PWS is used, ensuring the maximum accumulation of diazepam is important, e.g., continuing the Phase II period for 30 days after withdrawal. It takes about 3 days and 12 days for Xanax and Klonopin respectively to be eliminated from the body. These are average values as the half-lives can vary significantly from person to person.

 

 

Disclaimer:  The information contained in this website was not compiled by a doctor or anyone with medical training. The advice contained herein should not be substituted for the advice of a physician who is well-informed in the subject matter discussed. Before making any decisions about your health or treatment you should always confer with your physician and it is always assumed that you will do so.

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Last updated 22 July 2015