Hyperbolic Tapering

[[Ka...]]

On 13/11/2023 at 12:18, [[o...] said:

I was a member before the forum change but I deleted my account after getting off. I recently found out some stuff regarding withdrawal that I might be of interest to the community. For those of you who don't know, there's a psychiatrist called Mark Horowitz who after having been harmed by antidepressants himself decided to specialize in deprescribing. Besides antidepressants he has also done research on neuroleptics and plans on doing the same with benzos. In his papers he advocates for what he calls "hyperbolic tapering". I'm not sure whether he came up with this idea or not but he definitely popularized it. I presume that many of you will have heard the term by now but if you want to find out exactly how it works including the math involved, keep reading.

The name comes from the fact the relationship between dose and receptor occupancy is not linear but hyperbolic. Receptor occupancy is the percentage of the receptors occupied by a drug. This is why it's a very bad idea to taper by a fixed amount based on a percentage of your initial dose. What you can do however is taper by reducing receptor occupancy at a fixed rate. Based on his research on antidepressants and neuroleptics he suggests reducing receptor occupancy by 10% every 1-4 months. As you will see this corresponds to a very big reduction in dose which might be possible with some other drugs but not with benzos. In order to apply his results to benzos we must divide this rate into smaller steps. If you do the math it's approximately equivalent to 1.25% per week. Finally, we need to know the relationship between dose and receptor occupancy. Luckily I managed to find what I believe is the only thing he's written about benzos[2]. From these data one can find the equation of the specific hyperbola which is Y=1/(1 + 22.25/X) where Y is GABA-A occupancy and X is the dose of Diazepam.

I know this all sounds theoretical and complicated, especially during withdrawal, but please bear with me and it's about to become clearer. For example, if you're taking the equivalent of 22.25mg diazepam, it corresponds to a GABA-A receptor occupancy of 1/(1+1)=1/2=50% which means it occupies 50% of your GABA-A receptors. Now let's say you want to make a 1.4% drop in receptor occupancy. The new Y value would be 48.6%=0.486 and you'd need to solve for X. No worries, I've done that for you and it's X=22.25/(1/Y - 1)=21.038mg which you could round to 21mg. All this is just to understand what's happening under the hood. For those of you who aren't comfortable doing the math, I have done all the necessary calculations and rounded everything in terms of doses you can actually achieve by simple pill splitting. As a result, the reduction in receptor occupancy is not fixed but it's always in the range 0.9-1.7% with a mean of about 1.25%

From 160mg   reductions of 15mg    until reaching 130mg   then
from 130mg   reductions of 10mg    until reaching  90mg   then
from  90mg   reductions of  5mg    until reaching  55mg   then
from  55mg   reductions of  2.5mg  until reaching  40mg   then
from  40mg   reductions of  2mg    until reaching  28mg   then
from  28mg   reductions of  1mg    until reaching  13mg   then
from  13mg   reductions of  0.5mg  until reaching   3.5mg then
from   3.5mg reductions of  0.25mg until completely stopped.

Note that all doses are diazepam equivalents. I haven't been able to find any data regarding the GABA-A occupancy of other benzos. As you can see the above rate of hyperbolic tapering is rather close to Ashton's recommendations at medium to high doses but becomes more conservative at lower doses which addresses the main issue people have with the Ashton manual. Last but not least, I'm not a doctor. I'm just good at math. Hope this helps!

References:
1. https://markhorowitz.org/
2. https://www.rcpsych.ac.uk/docs/default-source/events/congress/2021/speaker-presentations-tuesday/horowi-1.pdf?sfvrsn=bb381fba_2

thank you for returning to provide this info/update

[[Ke...]]

On 13/11/2023 at 12:18, [[o...] said:

From 160mg   reductions of 15mg    until reaching 130mg   then
from 130mg   reductions of 10mg    until reaching  90mg   then
from  90mg   reductions of  5mg    until reaching  55mg   then
from  55mg   reductions of  2.5mg  until reaching  40mg   then
from  40mg   reductions of  2mg    until reaching  28mg   then
from  28mg   reductions of  1mg    until reaching  13mg   then
from  13mg   reductions of  0.5mg  until reaching   3.5mg then
from   3.5mg reductions of  0.25mg until completely stopped.

Note that all doses are diazepam equivalents.

References:
1. https://markhorowitz.org/
2. https://www.rcpsych.ac.uk/docs/default-source/events/congress/2021/speaker-presentations-tuesday/horowi-1.pdf?sfvrsn=bb381fba_2

Can you calculate a tapering reduction schedule starting from 20mg Diazepam?  I have a pill cutter which results in partial clean cuts and making a lots of crumbs at other times. Imprecise, even though it is a 'pill cutter', and that the 5mg tabs of valium are scored. Still get those crumbs.  At the lower doses where fine tuning of the tapering process is suggested, that 'small crumb' might be the dose of that time.  Observed topics on liquid taper for reductions under the 1mg range. (Jack Dobson Benzo Book) Problem here in Florida valium is highly controlled as the infamous pain pill saga and is dispensed on a 30 day cycle only.  Dobson used a solution made up for him for a 60 day reduction plan. I do not have the luxury of that here.

Would like to use the simple pill cutter - (crumbs and all), but if I do go with a liquid taper under the 1mg mark (still using the 5mg size tabs and 30 day supply) that would make for an interesting calculation in the amount of 5mg pills to mix with a bottle of water and put into the fridge (prevent spoilage), pulling out XmL amounts per day via dropper, and replacing the same amount with plain water. 

Whatever - I am already confusing myself already thinking about all this. I also take baclofen for cervical stenosis (bones in my neck pinching into my spinal cord).  trying to stop the baclofen which is also a problematic GABA drug - GABA-b I think. Almost the same as the benzo GABA-a.  Has all kinds of warning on it to not stop abruptly for risk or organ damage and death.

Been using valium since about 2002 when I almost died from prostate cancer. Surgery felt like the aftermath of being in a combat firefight. Rare fingers of the tumor extended to within 1mm of the edge of the lab slide according to the pathology report. That was my margin of life/death = 1mm. Had those tumor fingers went further, some of the cancer would have been left to grow back and I would not be typing this. 

I have been reading solid pill dose reductions postulating within the ranges of 5-10% per 1 to 2 weeks, your hypothesis is intriguing. What do your math equations suggest for a 20mg/day tapering regimen?

Mike

 

[[ou...]]

7 hours ago, [[K...] said:

Can you calculate a tapering reduction schedule starting from 20mg Diazepam?  I have a pill cutter which results in partial clean cuts and making a lots of crumbs at other times. Imprecise, even though it is a 'pill cutter', and that the 5mg tabs of valium are scored. Still get those crumbs.  At the lower doses where fine tuning of the tapering process is suggested, that 'small crumb' might be the dose of that time.  Observed topics on liquid taper for reductions under the 1mg range. (Jack Dobson Benzo Book) Problem here in Florida valium is highly controlled as the infamous pain pill saga and is dispensed on a 30 day cycle only.  Dobson used a solution made up for him for a 60 day reduction plan. I do not have the luxury of that here.

Would like to use the simple pill cutter - (crumbs and all), but if I do go with a liquid taper under the 1mg mark (still using the 5mg size tabs and 30 day supply) that would make for an interesting calculation in the amount of 5mg pills to mix with a bottle of water and put into the fridge (prevent spoilage), pulling out XmL amounts per day via dropper, and replacing the same amount with plain water. 

Whatever - I am already confusing myself already thinking about all this. I also take baclofen for cervical stenosis (bones in my neck pinching into my spinal cord).  trying to stop the baclofen which is also a problematic GABA drug - GABA-b I think. Almost the same as the benzo GABA-a.  Has all kinds of warning on it to not stop abruptly for risk or organ damage and death.

Been using valium since about 2002 when I almost died from prostate cancer. Surgery felt like the aftermath of being in a combat firefight. Rare fingers of the tumor extended to within 1mm of the edge of the lab slide according to the pathology report. That was my margin of life/death = 1mm. Had those tumor fingers went further, some of the cancer would have been left to grow back and I would not be typing this. 

I have been reading solid pill dose reductions postulating within the ranges of 5-10% per 1 to 2 weeks, your hypothesis is intriguing. What do your math equations suggest for a 20mg/day tapering regimen?

Mike

What you quoted is an example of such a schedule. You simply start at your current dose.