Substitution

Crossing Over to Valium

Benzodiazepine substitution is simply the replacement of one benzodiazepine with another. Although benzos have similar actions (though they differ in emphasis of a particular therapeutic effect), one or two benzos in particular have advantages over the others when managing a controlled withdrawal. We tend to advocate Valium as the benzo-of-choice for substitution purposes, as the tablets are relatively large (easier to split), and are of relatively low potency, allowing for a more gentle taper. Importantly, Valium also has a much longer half-life than most other benzodiazepines. This means that consistent blood levels of benzodiazepine are easier to achieve. Some doctors advocate substitution with Clonazepam, but Clonazepam pills are relatively small (tricky to split), and are of high potency. Although Clonazepam does have a reasonably long half-life, it is much shorter than Valium. Valium offers a unique balance of qualities that makes it the better choice for the purposes of substitution.

Switching is not for all though; substitution with Valium is a decision that only you can make. For many it is unnecessary, yet for others it has proved invaluable. Those who have not been able to manage small enough cuts with their particular benzodiazepine may find by switching to Valium they are able to make the small cuts required to proceed. Occasionally people experience great difficulty switching to Valium, and anecdotally, particularly when switching from Clonazepam. However, Clonazepam binds very tightly to GABA receptors, and this might be the cause of problems sometimes associated with withdrawal from this particular benzodiazepine. It appears that when used in substitution, Valium competes to bind with GABA receptors, so helping to dislodge Clonazepam, and may improve the outcome in the medium to long term. Although, this is far from certain.

Substitution should be as carefully considered as the taper itself. Switching is an inexact science, as we need to make assumptions about what is an equivalent dose of Valium to our present benzodiazepine. There is some variance in what is an equivalent dose within individuals, so we need to take things slowly, keep notes of the changes, and make adjustments as needed. By switching just a small proportion of our dose at a time, any error in what is the correct equivalent dose for you will be spread across your total benzo dose, so lessening the impact of the amount in substitution being to large or too small.

As with any taper, stabilising your drug regimen before you start is important. If you take your benzo just once a day, and have been able to taper from this without too many problems, then you should, perhaps, continue your taper off without any other changes. However, if you have been experiencing problems, especially if you feel you cannot wait until the correct time for your next dose, you might benefit by gradually changing your once-a-day dose to two, three (or even more) times a day before you consider the substitution option. As with any change to your dosing regimen, spreading your dose more evenly over the day should be carried out gradually, moving just a small part of your dose at a time (allow at least several days between each change). Once you have made this adjustment, and you feel reasonably stable, you should be better able to manage your taper and/or substitution.

Substitution may be carried out at any stage of your taper. It is perfectly reasonable to attempt to taper off directly from your benzo, but keep substitution as a backup plan should the need arise. Making small cuts (as proportion of our total dose) becomes more difficult the further we proceed with our taper, so substitution might later become necessary for you to taper comfortably.