The recommended way to give up benzodiazepines is to taper from the present dose to nothing in a regular way over a long enough period of time. As outlined earlier, one way to manage this is to have a tapering schedule which is a guide to withdrawal, but is subject to modification at any time, to accommodate changing personal circumstances. Withdrawal is a personal matter and depends both on the person themselves and their domestic circumstances. Flexibility is all important, and with withdrawal the unexpected is normal.
We used a 15 month schedule to take my wife from the equivalent of 10mg Diazepam to 0mg, making one cut a month, gradually reducing towards the end. When she started she was taking Lorazepam, a short acting benzodiazepine, and it soon became apparent that for practical and biochemical reasons she needed to switch to a long acting one, in this case Diazepam. This is the generally recommended route.
The practical reason is that Lorazepam pills are very small, and not made in small doses, so cutting one in half gives a dose of 0.5mg which is a large dose. We tried to cut the pill into 8 (0.125mg) which proved to be virtually impossible. We persuaded our GP to provide us reluctantly with the drug in liquid form, but it has to be made specially, is very expensive and loses its potency quickly. Some people concoct their own liquid solutions by compounding the powdered drug with water or some other liquid, sometimes milk, but then there is always the risk of doses varying in strength.
The biochemical reason is that since Lorazepam is a short acting benzodiazepine, it means that it is effective for less than 24 hours (average half-life 15 hours). Long acting ones such as Diazepam last up to a week (average half-life 60 hours). Since Lorazepam lasts for less than a day, covering the whole 24-hour period needs at least 2 doses, which will eventually become vanishingly small.
For both reasons the recommended approach for anyone on a fast acting drug is to change over to a long acting drug, such as Diazepam. Since the equivalent to 1mg Lorazepam is 10mgs of Diazepam, one dose a day of the latter is practicable and the cutting process is more linear. Pills are available in a range of sizes – the 2mg 5mg and 10mg sizes proved most useful – and it is available in liquid form as standard. This allows you to make the very small cuts needed at the end of the withdrawal accurately. My wife made the change from Lorazepam to Diazepam over a month. She changed a quarter of the dose each week but made no cuts. The changeover is stressful enough without cutting as well.
There is another reason for the changeover. As a person cuts, the nervous system is being deprived of the drug and complains, usually fairly bitterly. The complaints take the form of many different sorts of withdrawal symptom, most of which are very unpleasant. A short-acting drug taken once a day leaves the person substantially without its effect for the remaining hours. The result is that withdrawal symptoms can occur between doses, which is even more unpleasant.
The key to successful tapering is to take it gently. The carer should avoid any pressure on the sufferer to speed up the process. In the event of, say, a family crisis, the sufferer may feel the need to delay the next cut, until the crisis is over. That makes sense. However, temporarily increasing the dose is not such a good idea, because it disturbs the tapering pattern of slowly reducing the level of benzodiazepine in the body. If tapering in conjunction with a GP, make sure they don’t dictate the speed or pattern of the taper. That is the sufferer and carer’s prerogative.
There should be a minimum of 3 weeks between cuts, and the temptation to cut more frequently should be avoided. Too big a gap between cuts should also be avoided, because of the risk of tolerance setting in. We found that a gap of about 4 weeks suited my wife because in the first week after the cut the symptoms were at their most intense. During the following 2 weeks they calmed down a little, and in general by the end of the fourth week she felt able to tolerate another cut. Taking the dose in the evening seems to help people to sleep.
As I mentioned earlier, some times the withdrawal symptoms become intolerable, given the person’s particular circumstances, so they reinstate the drug to a level which allows them to function as satisfactorily as possible. Although not generally recommended, there is nothing to stop the person tapering at a later date, and ultimately enjoying a full recovery.
Finally the closer you get to the end of withdrawal the more pronounced the symptoms can get, presumably because the CNS is being deprived of more and more of the drug.
