Now Available: Maudsley Deprescribing Guidelines

[[Ka...]]

I think they may be in for a very tough time indeed. 

A doctor actually asked me where I was getting diazepam from? I said from your practice! 
 

[[WU...]]

You are lucky (or not as the case may be) to see an actual doctor.  During the "covid" years I was being prescribed diazepam by the nurse practitioners over email, no questions asked. Then the GP's carried on after that. I feel stupid now for not knowing what these drugs were doing to me but more than one doctor said they acted quickly and were out of the system unlike ssri's which hung around longer. Doctors really ought to know what they are prescribing.

To compare with breaking the law:

In law, ignorantia juris non excusat (Latin for " ignorance of the law excuses not"), or ignorantia legis neminem excusat ("ignorance of law excuses no one"), is a legal principle holding that a person who is unaware of a law may not escape liability for violating that law merely by being unaware of its content.

I think the same should apply to medical practice.

[[Ka...]]

It’s actually against NICE guidance - best practice. It is astonishing to issue meds so casually. 

[[Re...]]

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

" A doctor actually asked me where I was getting diazepam from? I said from your practice" 

@[Ka...] Really? Wow... 😳

@[Li...]

 

The book is outstanding, thorough. It absolutely fulfills what it was created for. There is tapering guide for prescribers, it is easy to understand, and well written. 

@[Ka...]You mentioned the waiting room! My thoughts exactly! Then it crossed my mind how much trash lands on a doctors table or in a waiting room. All these info leaflets from pharma companies about the unproblematic, light nature and easy management of medications... All that rubbish. 
How easy would be our case, if we could just distribute the core guidelines of tapering and add online references or a QR code in the form of a small leaflet for doctors and patients. If we just had those resources.... We could make big publicity for this book and prevent so much suffering. 

It is "not okay" that pharma companies are allowed to distribute their info leaflets in the doctors office about antidepressants,  z-drugs, etc. without even mentioning how to deprescribe and admit the possibility of actual harm.....

I hope, that with time, more publications will follow that are a bit more concise and to the point, especially for GPs and university students. 

All this research Dr. Horowitz and colleagues refer to in the book, these are so wonderfully collected and summarized together. How is it possible it did not reach the medical profession... I was also wondering... 

 

Edited February 29 by [Re...]
Correction

[[WU...]]

"All this research Dr. Horowitz and colleagues refer to in the book, these are so wonderfully collected and summarized together. How is it possible it did not reach the medical profession."

Can I be incredibly cynical and say it is because it is not a profession but a business!  

[[Li...]]

29 minutes ago, [[R...] said:

How easy would be our case, if we could just distribute the corner [core?]  guidelines of tapering and add online references or a QR code in the form of a small leaflet for doctors and patients. If we just had those resources.... We could make big publicity for this book and prevent so much suffering. 

Hello @[Re...].  This is a great idea!  May I have your permission to share it with a few of my contacts who might be interested in implementing something along these lines?

[[Re...]]

@[Li...]I would be most honored if you did!! 🙂

Thank you for correcting corner -> core, will replace it!

Edited February 29 by [Re...]
Wording

[[Li...]]

Thank you @[Re...]! I’ll let you know if I get any takers.

[[Kh...]]

How much does it diverge from Ashton’s guidelines?  I loosely followed Ashton, off for a couple weeks and never felt worse. 

[[Nu...]]

6 hours ago, [[R...] said:

@[Ka...]You mentioned the waiting room! My thoughts exactly! Then it crossed my mind how much trash lands on a doctors table or in a waiting room. All these info leaflets from pharma companies about the unproblematic, light nature and easy management of medications... All that rubbish. 
How easy would be our case, if we could just distribute the core guidelines of tapering and add online references or a QR code in the form of a small leaflet for doctors and patients. If we just had those resources.... We could make big publicity for this book and prevent so much suffering.

I know from experience having marketed to physician offices that it's somewhat a losing battle. Pharma has massive budgets and an already established "in". Bringing food in is the best way, which is hugely expensive. Medical folks will follow free food but throw pamplets straight in the trash, unfortunately. They rarely care about the merits of the information.

Love this idea. Struggle with its implementation. Very interested in brainstorming, though.

[[Li...]]

I agree with @[Nu...] that leaving pamphlets in waiting rooms would not be effective.  What I had in mind was a handout patients could share with their prescribers during appointments … something like a shorter version of the Benzodiazepine Deprescribing Guidance Document (2022) minus the references.   Regrettably, I’m hearing back from my contacts that they don’t have time or resources to commit to this type of project.

 

[[Ko...]]

For anyone who has the book, can you share whether he advocates for microtapering valium vs cut and hold. Just wondering as my prescriber feels there is no need to microtaper valium so it could be useful to show her. 

[[Ko...]]

@[Kh...]I am sorry that you feel so horrid. At least you are off the junk. I think many people in these forums say that Ashton's method was too fast for them, especially under 10 mg. I am decreasing by .25 mg every 2 weeks and at 6.5- seems that this will take forever.

[[Kh...]]

9 minutes ago, [[K...] said:

@[Kh...]I am sorry that you feel so horrid. At least you are off the junk. I think many people in these forums say that Ashton's method was too fast for them, especially under 10 mg. I am decreasing by .25 mg every 2 weeks and at 6.5- seems that this will take forever.

Thanks Kozmo.  It’s just Groundhog Day.  Feeling bad every morning when waking up just trying to survive the day.  It’s rough and I don’t know what to do.  

Edited March 2 by [Kh...]

[[Ko...]]

@[Kh...]I am so sorry. People say it will get better with time. I am trying to go slowly enough to maybe avoid some of the pain but who knows how possible this is.  I pray that I can keep my job through this process if I go slowly enough. 

[[Kh...]]

6 minutes ago, [[K...] said:

Thanks Kozmo.  It’s just Groundhog Day.  Feeling bad every morning when waking up just trying to survive the day.  It’s rough and I don’t know what to do.  

 

1 minute ago, [[K...] said:

@[Kh...]I am so sorry. People say it will get better with time. I am trying to go slowly enough to maybe avoid some of the pain but who knows how possible this is.  I pray that I can keep my job through this process if I go slowly enough. 

Yes it is supposed to get better with time, but right now, after 3 weeks off, it just keeps getting worse.  I hope ur taper goes smoothly.  I never imagined it would end up this way.  We all fear permanent issues and that’s all I can think about.  

[[Ko...]]

@[Kh...]Getting worse? Oh no...I read the first 3 months off of valium can be the toughest.  I am sure this is not permanent though. 

Thank you for your well wishes, I hope mine goes smoothly too.  Seems it's all I can think about....

[[Re...]]

@[Ko...], 
Dr. Horowitz mentions different taper speeds in the book - it has microtapering regimens, too . But, the only really specific suggestion I came across was the patient led aspect of tapering - as you probably know already, following your symptoms and their severity and adjusting your taper rate and speed accordingly.
If you need more specific information from its contents (sample regimens, drug kinetics, references, etc.), you might want to invest in this book. I did buy my version online in digital form, because it would have taken quite a good while to receive the shipment. I use a Kindle reader.

I think it is pretty understandable for everyone.

I truly hope you can solve this problem with your provider and taper at your own pace. 

 

[[Ko...]]

@[Re...]Thanks for your response.  My provider is actually letting me dictate the pace of the cuts and would let me hold as long as I wanted if I needed to. She is willing to use valium liquid too. Its really the daily microtapering piece that she took issue with.

I don't know if I will need to go that route or not but if I did, I would likely need to show her the reference.

 

[[Ko...]]

@[Re...]Are you still tapering or off?

[[Re...]]

I am very happy you have such a cooperative prescriber!  It is so good to hear this! 

As for me, I am not tapering anymore.

@[Ko...] This book seems to have information on this subject. The Maudsley Guidelines is a well known series of books and source of knowledge in the medical community as far as I know. 

You might try posting in the Taper Strategies section of the forum if you have questions or issues with purchasing the book, but I understand that is not something your prescriber would consider as a valid source.  

[[Ko...]]

@[Re...] She is better than most as far as not rushing and willingness to use the liquid. I found her through the BIC website. She didn't even know what the BIC was ....she's an NP in an addictions cash only practice.  

But, she still doesn't totally get it and thinks benzobuddies and the facebook groups are for people who are overly anxious and obsessed. 

[[Li...]]

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

For anyone who has the book, can you share whether he advocates for microtapering valium vs cut and hold. Just wondering as my prescriber feels there is no need to microtaper valium so it could be useful to show her. 

@[Ko...]

Here’s what the Maudsley Deprescribing Guidelines (MDGs) have to say about micro-tapering:

Although the major approach outlined in the drug-specific sections involves making reductions every 1-4 weeks (sometimes called ‘cut and hold’) an alternative approach is called micro-tapering, whereby a smaller change in dose is made each day. Theoretically making smaller reductions should produce smaller disruptions of the homeostatic equilibrium leading to less intense withdrawal symptoms.

The taper schedule you have described (decreasing 0.25mg every 2 weeks) is a linear taper.  If you begin to experience issues, you may wish to consider a hyperbolic taper as presented in the MDGs.  

Given your current total daily dose of 6.5mg diazepam, you could use the slower taper schedule on pages 409 - 410.  This schedule uses a liquid formulation for total daily doses below 10mg so it’s good your provider is willing to prescribe the liquid if needed.

Fyi Micro-tapering rates can be calculated from the MDGs taper schedules by dividing the change in dose for each step by 14 or 28 days. If you get the liquid, you could trial this.

Edited March 3 by [Li...]
Clarification

[[Ko...]]

@[Li...]

thank you.

I recall Dr Horowitz's slower taper for valium schedule from a  relatively recent youtube video presentation and he had proposed decreasing .4 mg every 2 weeks from 10 mg to 4 mg and then decreasing .2 mg every 2 weeks from 4 mg until off.  So, I am going a little slower than he had proposed right now and if I can continue this until I get to 4 mg I will change to liquid and try the decreasing by .2 every 2 weeks schedule.

 

 

[[Li...]]

You’re welcome @[Ko...].  I double-checked the slow taper schedule in the book and you are correct, starting at a total daily dose of 4mg, the reductions are 0.2mg per step down to 0. 

Just checking … if you are in the US, are you aware that diazepam oral solutions are available in two different concentrations?  You’ll want to get the one with the lower concentration.  Here’s a link to the FDA drug label from one of the manufacturers (Hikma):

DailyMed - DIAZEPAM solution - 5mg/5mL (1mg/1mL)
https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9e85abed-1a8b-4762-a31f-f2c7f196b8af