Clonazepam to Valium tapering plan

[[on...]]

 

Hello everyone, 
 

I’ve been on Clonazepam 1mg (.5mg twice daily) for two years. My psychiatrist and I discussed tapering off and she suggested switching to Valium. I had read about this method so I figured it was good way to go.

I met with her yesterday, the day before the switch, and mentioned doing a crossover taper which I had just read about. She said she doesn’t think it’s necessary and she’s had good success with patients just switching straight from Clonazepam to Valium. To reassure me, she said she conferred with the other psychiatrists at the practice who agreed it was ok. 

Her plan is as follows:

I got straight from 1mg of Clonazepam to 40mg of Valium (20mg, twice daily) and the following is the schedule she laid out:

“Week 1: valium 20mg twice daily

Week 2: take valium 17.5mg twice daily

Week 3: Take valium 15 twice daily

Week 4: take valium 12.5mg twice daily

Week 5: Take valium 10mg twice daily

week 6: take Valium 7.5mg twice daily

Week 7: take valium 5mg twice daily

Week 8: take valium 2.5mg Twice daily

**Week 9: Take vlaium 2.5mg nightly then STOP

(Week 9 is the only exception to the pattern)”

I said I thought this seemed awful fast but she said we can just adjust as needed for up to 18 weeks.

However, after reading a lot of posts today I’m concerned not only at just abruptly stopping the Clonazepam but also that 40mg of Valium seems like a whole lot. I already took my first two doses of Valium and I definitely felt them but now I’m concerned with her plan in general. I can discuss it with her again but I’m not sure how she will respond. If she doesn’t go for reinstating the Clonazepam, I still have about 5mg of of it left and may be able to get a little more from a close friend who takes it only as needed and infrequently. 

I’d really appreciate some feedback her plan, specifically the lack of crossover, the time frame and the seemingly high dosage of Valium. Finally, if the consensus here is to try to get her to go for the crossover instead, I will ask. Yet if she doesn’t go for it, should I even bother trying to mix in the little bit of Clonazepam I have left (and maybe the few more mg’s I can possibly get from my friend) to ease things a bit or given how little it is, might it just do more harm than good?

(Finally, as a side note, I’m not taking any other meds. I really don’t want to in general in addition to having a fear of exacerbating the mild sudden unilateral low frequency hearing loss and ear fullness I got hit with last year and the bilateral tinnitus I was lucky enough to acquire several months later (due to way too much Prednisone to treat the hearing loss) and have been struggling with since. As you can imagine, I’m fearful tapering may make things worse (though I hope not!) but I realize it’s something I might have to deal with it.)

Again, any advice on the tapering method my doctor has laid out for me would be very much appreciated! 

-Michael 

 

[[Co...]]

Hello @[on...]. Welcome to BenzoBuddies.

If you have not read it already, I can recommend the Ashton Manual. Professor Ashton was a GP, a researcher, a pharmacologist, and ran a benzodiazepine withdrawal clinic for several years.

There is disagreement about equivalent doses between different benzodiazepines. Ashton suggested a ratio of 20:1 for Valium/clonazepam. It is worth noting that the ratio Ashton suggested was actually at the high end compared with other authorities. I do not recall coming across a suggested 40:1 ratio by any authoritative source.

Ashton had a wealth of experience in helping tougher cases withdraw from benzodiazepines. I write 'tougher cases' because her patients were mostly referred to her by other doctors after they had already failed to complete a successful taper. I think the distinction is important because, presumably, those who did manage to withdraw, usually did so from their original benzodiazepine without substituting with Valium. Ashton found that here tougher cases usually managed to complete their withdrawal after substitution with Valium.

Ashton gradually switched her patients over to Valium. And for about only half of the dose of Valium suggested by your psychiatrist. Again, Ashton's equivalent tended to be at the high end what was considered an equivalent dose by various medical authorities.

Here are a couple of sample substitution/withdrawal schedules from Prof. Ashton. They should be easily adaptable to your situation:

https://www.benzo.org.uk/manual/bzsched.htm#s5

https://www.benzo.org.uk/manual/bzsched.htm#s6

I think, in your shoes, I would be tempted to ask your psychiatrist to cite the source for the equivalent dose they have decided for you. You might also reference Ashton's Manual and charts. But, depending on the attitude of the psychiatrist, they might either welcome the information, or resent it.

You might be OK with that schedule. It is important to understand that, like with Ashton, our members have usually already experienced problems with withdrawal. So, unless you have personal experience to the contrary, you might be OK. However, substitution of 1mg clonazepam with 40mg Valium seems to be a complete outlier. I think you are right to question that. I am also curious as to why substitution was recommended for you? Have you experienced difficulty withdrawing already?

[[on...]]

Hi @[Co...]. Thank you for the extremely informative reply. 

Regarding you questions, my psychiatrist suggested I switch to Valium because, as she put it, "it's standard practice to switch from Klonopin to an equivalent dose of Valium as opposed to doing a cross over taper".

As for your other question, I have nit made much of an attempt to taper from the Clonazepam. A few months back I did start reducing my dose very slightly. I did this for about 10 days but without a real plan or a way to measure things accurately. I began feeling "off" and decided I wasn't prepared or ready to continue so I just went back to my 1mg daily dose. Again, I would not really consider this a serious attempt.  

I wrote my psychiatrist this morning to bring some things to her attention that you mentioned and that I've read on here in other posts. I asked her about 1) why she switched me as opposed to trying to taper from the Clonazepam and that I've learned that this usually is done if someone fails at their attempt to taper from their current med 2) why she didn't do a cross taper and about a possible "coverage gap" I read about on here, and, 3) the ratio she prescribed, the reason for such a large dosage and informed her that the first two doses I took hit me like a ton of bricks (although I only took 12.5mg for the second dose due to my reaction to the first). Her reply was as follows:

"1. Either way is an acceptable way to taper. Using Valium allows for more control in that you make increments that are smaller than Klonopin equivalent. It also has such a long half-life that it's less likely to cause any withdrawals.

2. No need to worry about a coverage gap as Klonopin and Valium are analogous medications. Additionally, the Valium has such a long half-life, it won't be exiting your system at any point of the taper (until after the very last week when we stop it altogether).

3. You are correct that this is the most generous conversion rate. 0.25mg of Klonopin equates to 5-10mg of Valium. I used the higher rate to provide peace of mind, but this is acutally great news if you need less Valium as a starting dose. I'd suggest just stepping down to 10-15mg for your next dose and see how you tolerate it. You can continue with the taper from this point on."

She then added, "while I certainly want you to be informed, I also worry that of this researching is exacerbating the anxiety at play."

I haven't had a chance to reply to here yet but I will do so tonight. It appears though that this is her plan so I guess I will just have to hope for the best. I will ask her  to either do a cross taper or switch me back to the Clonazepam but I don't believe she will. As I mentioned in my original post I still have 5mg of Clonazepam left but it's so little that I assume it's best I continue with the switch as planned? Albeit from a lower starting dose. 

If you (or anyone else) has any further insight or advice I'd of course be grateful. Either way, I very much appreciate your help already.

 

 

  

[[on...]]

Hi all,  

After my conversation with @[Co...], and realizing the Valium dose I was prescribed (40mg daily from 1mg Clonazepam) was very high I dropped my Valium dose. The first 20mg I took on Wednesday night hit me very hard so as I mentioned above, I took 12.5mg on both Thursday morning and Thursday night.
 

Still feeling like this was a high starting point given our conversation, the resources you provided and that my psychiatrist said I can start stepping to a lower dose, I dropped down to about 11.5mg on both Friday morning and Friday night, then to 10mg yesterday morning (Saturday) and last night to establish baseline 20mg (10mg twice daily) to establish a lower starting point. I figured since I only been been on the higher doses for a few days I would go down to 20mg daily and stay there for 2 weeks before beginning to slowly taper. 
 

I was feeling just fine until this morning when I woke up with a bad headache, my ears ringing again, feeling a bit achy overall as if withdrawals are beginning.
 

I have a few questions which I really hope any of the knowledgeable people would address. They are as follows:

1. Would it be advisable to stay at 20mg daily for two weeks from here or maybe go back up to 25mg daily and sort of restart from there for a few weeks?
 

2. As I mentioned, I still have 5mg of Clonazepam (and might be able to get a little more - about 3-4mg) so would there be a good way to use that in to do a very brief cross taper?

3. If my psychiatrist would prescribe me Clonazepam as well, would it be wise at this point to fully jump back on it and either taper straight from the Clonazepam or institute do a cross taper? Or at this point would it be better to just stay solely on the Valium and taper from here? 
 

I realize this is not an exact science. I know that no method will be perfect and that everyone will react differently but I’m just trying to get some advice from people that are more knowledgeable than my psychiatrist who I’m getting little guidance from. Thank you. 
 

Michael 

 

 

[[Co...]]

In medicine, there is something called 'a loading dose'. It is sometimes used for medicines with longer half-life values. Medicines with long half-life values have strong accumulation effects when taken regularly. For a medicine like Valium, this means that it will take a few weeks for blood levels of the medicine to level out. The increase in blood levels is more rapid at first, and accumulation slows from there. Loading doses (a single higher dose, or several higher doses) are used when it is important get the effect soon, raising blood levels sharply, whereas waiting for blood levels to rise to a therapeutic level would be detrimental to the health of patient. It is a shortcut.

It has been some time since I've ran some estimates, but for Valium, blood levels will rise several-fold their level after the first dose. It will vary depending upon how regularly it is taken, and the half-life value within the individual (because is does vary quite considerably).

I should stress that I have not heard of a loading dose being used for benzodiazepines. But, since you have effectively double-dosed your first dose, and took some moderately higher doses for a few days after this, this will have acted like a loading dose. Even though your dose is now halved, it is possible that your blood levels continue to rise (albeit, far more slowly now). It is impossible to say for sure where you are at. Since we do not know the half-life value of Valium for you, it is not possible to even model where you might be. But, since you took just one 'double-dose', my seat-of-my-pants guess is that your blood levels are not dropping since you cut your dose, because your double-dose probably was not enough to get you near 'steady state' (where blood levels stop rising for a given dose).

If all of that sounds like gobbledygook, you only need to understand that just because you halved your dose, and since you had just started this long half-life medicine, this does not mean there was a corresponding halving of your blood levels of Valium. My guess is that there was no drop at all.

I suspect that your symptoms are due to the rapid change from one benzodiazepine to another. They have slightly different therapeutic profiles, and quite different half-life values. Typically, it will take some time to adjust. Even if the cut to 20mg after the one-off 40mg dose of Valium (I know, and a few subsequent moderately larger doses than 20mg) means that your blood levels of Valium have actually dropped, the drop will be small. Further, you were not taking the higher dose of Valium for long enough for you to experience withdrawal. The only other issue is if 20mg Valium is large enough to cover 1mg clonazepam - the literature seems to suggest that it is.

What might be happening is that your blood levels of Valium remain significantly below the 'steady state' value. So, you are in withdrawal because the clonazepam left your system faster than the Valium could build up to replace it. If so, this should correct itself over the next week or two as you approach steady state.

Sorry if the above is about as clear as mud. Give it some time is my suggestion.

[[je...]]

Hi @[on...]

If I understand correctly this is your first attempt at tapering and you did a direct crossover. It is natural that at some stage you'll start experiencing withdrawal symptoms, in this case probably due to the direct crossover. It's highly unlikely to go through a taper without any type of symptoms. 

I would've done exactly the same as you and reduce the Valium to 20mg. I'm not sure if it's a good idea going back and forth between benzo's. Maybe it will be better to give the Valium a chance especially since it seems as if it's your doctor's preferred choice. I'm also not sure if attempting a cross taper at this point will make much of a difference. 

I do think if you can hold your Valium dose for a couple of weeks before you make any reductions it will set you up to be stable for the rest of your taper.

I also hope your doctor is open to slowing down your taper beyond 18 weeks. You were a long-term user. To give you an idea, it took me about 20 months to taper 1mg Clonazepam at an average taper speed of 7.5% reductions every 2 weeks. 

[[on...]]

Thank you so much @[Co...] and @[je...]. Everything both you of said makes a lot sense and was extremely informative.
 

Although it’s impossible to know for certain, I do have a feeling that the way I felt earlier today was due more to the Clonazepam leaving my system than from dropping my dose of Valium - which as you both noted, wasn’t really established yet. 
 

On a positive note, I took my 10mg dose of Valium of few hours after I posted and within a fairly short time I felt better for the rest of the day. Given that, I’m going to stick with it and assume/hope that 20mg daily is enough to cover the switch from 1mg Clonazepam. I plan on staying at 20mg daily for a few weeks to adjust to it and reach a ‘steady state’ before beginning to attempt taper. I’m also going to leave the little Clonazepam I have remaining alone and won’t be asking my doctor to cross taper at this point. Beside the fact I don’t think she’ll agree to it, I really don’t want to be jumping back and forth between two different medications if it’s not necessary. 

Finally, I realize there will almost certainly be more withdrawal symptoms along the way but today was the first I’ve experienced so I guess I freaked out a little, especially given that my doctor’s chosen method/dose/time frame doesn’t seem to line up well with the information you both provided and from most of what I’ve read on here. Basically, I was confused about what to do. Specifically, I didn’t know if I should take a Clonazepam or just stay the course with the Valium. My intuition was telling me to just stay the course with the Valium but my body was telling me to take a Clonazepam, if that makes sense.
 

That said, I’ve lost confidence in my doctor’s knowledge and communication. My sister has a close friend who is a ‘mental health and outreach consultant’ and she gave me a few doctors to reach out to and told me to mention to them that she referred me. I’m going to call them tomorrow and hopefully I can find someone who I have more confidence in and will realize that I may need significantly more time to taper than what my current doctor laid out for me. 
 

I feel much more informed, prepared and better in general than I did earlier today and I thank you both sincerely. 
 

Michael 

[[Co...]]

Hi @[on...] Sound like you have a plan. The schedule your doctor outlined might be manageable, or it might not. So, yes, some flexibility would be very advantageous. Good luck with your search for another doctor.

[[je...]]

Good luck @[on...]. I hope you find a doctor you feel comfortable with. I understand once you feel disillusioned it can be difficult to continue to work with the provider.

Just a heads up. In my experience doctors don't need to be benzo wise or understand tapering. They just need to allow you flexibility in your taper. My first doctor cut me off and wanted me to taper in 6 weeks. My second doctor was lovely. She knew nothing about tapering and I was teaching her about withdrawal and tapering as I went along. Everything I know about tapering I learned here. I was functional throughout my taper.

Let us know how it goes.

[[on...]]

That’s very good advice @[je...]. 
 

From reading many posts on here it appears there are a lot of doctors that aren’t very well versed in tapering. I will definitely discuss things in detail with any new doctor before potentially switching. I’ll also reach out to my current doctor and if she agrees to allow me taper at a pace that is working for me, not cut me off until I get through this, I would consider staying with her. I’m not taking any other medications so her agreeing to this is the only thing I would need from her.
 

With all the information on here and people such as yourself and @[Co...], I feel much more comfortable moving forward than I did just a few days ago. 
I can’t thank you both enough and l’ll definitely let you know how things are going. 

 

[[Co...]]

You are very welcome, @[on...]. Please keep us updated of your progress.

[[je...]]

@[on...] you sound like a very pragmatic person to me in how you're approaching this, which is really good. I do want to say, I think your doctor's response to your questions was very reasonable. I don't necessarily agree with everything she said, but she certainly seem to know more about benzo's than the doctor who prescribed to me for tapering. Usually I try to place myself in their shoes. How would I react if I studied medicine for 6+ years and have many many years of experience with thousands of patients, only to have a patient come to me and present information from non-medically educated strangers on an internet forum. I probably would not react very favourably. I think your doctor handled your enquiry pretty well. 

[[on...]]

Point taken @[je...]. Fwiw, I did tell my psychiatrist that I’m not trying to play doctor and that I respect her knowledge and experience. 
 

One thing I didn’t go into detail about on my original posts was that all of this was brought about very abruptly. I won’t bore you with the details but the suddenness of her decision game me little time, less than 24hrs to be exact, to prepare questions for her that likely would’ve made me more comfortable from the outset. It was this and the very high dose she prescribed (which at the time I didn’t realize was so unusually high) that were my main issues. As I mentioned earlier, when I questioned her later as to the reason for such a high dose, her reply was that it was ‘to give me peace of mind’. That’s a nice sentiment but not what I need when my long term health is potentially at stake. And after acquiring potentially chronic tinnitus last year when my ENT prescribed my multiple very high-dose courses of Prednisone over a short period of time which two other ENT’s I later saw confirmed was an outrageous amount, you can color me a bit jaded.

I’ve been extremely fortunate to have not had any major health issues throughout my life, that is until my ear issues which came about last year. That said, after my recent experiences and after reading many “horror stories” on here, tinnitus forums, Meniere’s forums and others as well, my impression of doctors and medicine in general has changed to a degree. I know there are many, many knowledgeable, caring and overall great doctors out there but unfortunately, I’ve  also learned the hard way the importance of being an informed patient.  
 

Lastly, on a personal note, I thoroughly enjoyed being referred to as ‘pragmatic’. Admittedly, that’s probably not been my most defining quality over the years but I guess I do have my moments 😉

[[je...]]

I hope you don't feel I've criticized your decision to question your doctor @[on...]. On the contrary, most of us are here because we just accepted what they told us. You had every right to ask about these issues, and I'm sure you did it very respectfully. The reason I made that comment was to give you peace of mind that should your quest for another prescriber not work out and you're stuck with your psychiatrist, then it might not be the end of the world, so to speak - she comes across as a reasonable person. (Well, at least more reasonable than I probably would've been ).

[[on...]]

@[je...] I didn’t take that way at all 😁. I feel you made a fair and valid point.
 

I’m still a bit concerned about some of her decisions and her reasoning behind them, I agree that she handled me questioning her both calmly and professionally.

Once again, I sincerely appreciate all your help and I’ll be sure to keep you posted. Have a nice weekend! 
 

Michael