fine-tuning an Ativan => Valium crossover and the notion of "equivalent dose"

[Guest [ch...]]

My situation is, after a failed attempt at a direct taper all by myself off Ativan, I re-instated and am now trying again. The new plan will be a standard Ashton taper consisting of a crossover to Valium and then taper the Valium. This time I am doing it under the guidance of a prescribing psychiatrist. She is learning this as she goes (she just read the Ashton manual for the first time about a week ago!). Mostly her function is to sign off on my crossover + taper plan and write the needed prescriptions.

 

After my re-instatement in December my Ativan dose was bouncing around a bit, but let's say I wound up more or less stable at a dose of 1.5mg/night by Jan 5. So I'm using that as my starting point.

 

The standard equivalency formula is 10-to-1 so that would dictate a crossover to 15mg of Valium. However I question this formula. Let's dig a little deeper into what it really means. My motivation here is if I can get away with crossing over to a smaller dose of Valium (e.g. something in the range of 8 to 10 mg instead of 15), and start my taper from there, I'd save months off my next taper. I'm impatient to get to the endgame...

 

So here's my thinking. Valium has a long half life, like 1 week. That means if I take 10mg Valium today, then by tomorrow most of that 10mg is *still in my system*. So if I take another 10mg tomorrow, then the total in my system will be something like 18mg. Similarly, on day 3 the total will go up again... i.e. some of the day 1 & day 2 dose has been eliminated but most remains, so after day 3 the Valium in my system will be something like 25-26mg. Eventually if you keep taking 10mg/day, you'll reach a steady state amount in your system somewhere up around 70mg or so, because of the long half-life and the amount remaining in your system from the prior week. I hope this makes some sense. (I realize in reality the situation is even more complex than that because the Valium is being converted to other active benzos rather than simply "staying in your system", but the gist of my argument is the same).

 

Because of the above, the following 2 questions will yield very different answers for X and Y:

 

Single-dose 1.5mg Ativan = Single-dose Xmg Valium

Steady-state 1.5mg Ativan/day = Steady-state Ymg Valium/day

 

E.g. if the answer for X is 15, then the answer for Y is a much lower number like maybe 8.

 

Yeah, the above is very technical. I hope it made sense to at least one reader. :-)

 

Anyway, with these considerations in mind, I am trying to fine-tune my crossover with a goal of winding up stable on as-low-as-possible-while-remaining-stable dose of Valium. Here's how it's going so far:

 

...

Jan 5  1.5mg A  0mg V  - pre-crossover - stable (meaning slept fine, fine next day)... start crossover...

Jan 6  1.5mg A  5mg V  - stable (I know, temporarily going up but I want to give the V a chance to build)

Jan 7  1.0mg A  5mg V  - big drop in A, some next-day anxiety but not too bad...

Jan 8  .9mg A  6mg V  - stable. V is building up in my system, doing its job

Jan 9  .8mg A  6mg V    - stable.. starting to "fine-tune" the crossover by holding the V at 6...

Jan 10 .7mg A  7mg V    - stable but don't want to push my luck so added 1mg V...

Jan 11 .6mg A  7mg V    - more fine-tuning... trying to hold the line on amount of V... still stable

Jan 12 .5mg A  8mg V    - continuing crossover, stable

Jan 13 .4mg A  8mg V    - again reduced A but held V, still stable

 

At this point I'm not only not having anxiety/insomnia (my main withdrawal symptoms during my previous taper); I'm relaxed to the point of even feeling sleepy all day. I find Valium is very sedating once it builds up in your system. So I might even risk the following plan with the goal of winding up at 8mg V as the starting point of my new taper:

 

Jan 14 .3mg A  8mg V

Jan 15  .2mg A 8mg V

Jan 16 .1mg A 8mg V

Jan 17  0mg A 8mg V

 

If I do start experiencing any anxiety/insomnia I will adjust the Valium up 1 or 2 mg but I don't want to go higher than 10. From there I'll start a standard Ashton taper, i.e. cut 10% and hold for at least a week, rinse and repeat ... with the plan of getting to 0 in maybe 6 to 8 months ... and *succeed* in staying off this time.

 

My prescribing psychiatrist thinks I am trying to fine-tune too much, but she's OK with this plan. She's kind of learning from me. Which is weird when you think about it (imagine if you went to a heart surgeon and he said "well I know nothing about heart surgery and have never done it, but let's learn it together"). But, it is what it is. Psychiatry is still in the stone ages compared to other branches of medicine.

 

What do you guys think?

 

Chessplayer

 

 

 

[[...]]

I think when equivalency is stated between benzos it takes into account the total effect, i.e., the effect of metabolites and half lives as well as the amount of time the drug binds to the receptor.  Potency seems to be the result of these three things.  I'd make a guess that the metabolites formed and the binding time are fixed and do not vary from one person to the next, but we know that different people metabolize drugs at different rates and I think this may be what accounts for potency differences between people.

 

Ashton used 10 to 1 for V and A.  This is an "on average" number that will vary between people depending on how fast or slow they metabolize the two drugs.  If you are a fast metabolizer of A and/or a slow metabolizer of V it stands to reason the ratio will be lower than 10 to 1 (since fast metabolizing does not let as much A accumulate and makes A less potent and slow metabolizing lets more V accumulate and makes V more potent).  For slow A and/or fast V the ratio would be higher than 10 to 1.  Of coarse, if you are a fast metabolizer of one you may also be a fast metabolizer of the other so the rates can have a cancelling effect.  It would be the same for the slow/slow case.

 

Ashton's numbers always seem to be enough when people cross to V, so that makes me think she was generous to make sure those who used her values to cross to V would not get shortchanged.  You may be able to find a lower crossing amount.  I don't recommend trying, but if you do I would be careful.  Also, of concern is the rate you are crossing at.  Typically it takes a month or more to cross when the half lives are so different as they are with A and V.  Symptoms have lag times that can range quite a few days out - up to 10 or so.  It is possible you could be short of benzo and just have not felt it yet.  I'd slow down the crossing rate.

[Guest [ch...]]

Thanks for your feedback SG! I will take your advice into account and adjust my plans.

 

Chessplayer

[[Ra...]]

Hi chessplayer,

 

Good luck, i'm coming off A at the moment but in a slightly different way but have substituted A for V the same as you. I think perhaps you are over engineering the switchover, I went from 1.5 A to 5 V and 0.5 A. I was a bit uptight for a few days, perhaps a little snappy, increased heartbeat but not much else. I've failed loads of times when I haven't substituted A for V but have had very mild s/e with a 1mg drop.

 

I started xmas eve and for the last two days I've had no A at all and am fine on the 5mg V. I also take 225mg Effexor a day so don't know if this is making it easier.

 

I guess what i'm trying to say is all the very best to you. Don't pay these drugs too much respect, they're not as badass as they think they are and if you want to get off them quickly then don't be scared to drop 0.5mg in one go. I did it and am feeling good, the Valium truly makes it easier.

 

Bon Courage mon ami.

[[sp...]]

im opposite, coming from V to Ativan. At first i was on xanax but the interdose withdrawls had me so i swiched to valium. All was great but there the thing folks you can camp out too loon on any of this crap....do your conversion and get on with it. Cut every 7-10 days and cut a miligram and be done with it . What i did was stop at 5MG and camped out there and what happ is i caused myself interdose withdrals and felt horrible all day on 5mG of valium. So i had a doc swich me back over to ativan. Now i have to get off that starting togight. Its going to be no more than a 3 month taper and ill be cutting every night so never holding still.