Substitution

~ Crossing over to Valium

Benzodiazepine substitution is simply the replacement of one benzodiazepine with another. Although benzos have similar actions (although 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 benzos. This means that consistent blood levels of benzo are easier to achieve. Some advocate substitution with Clonazepam, but Clonazepam pills are relatively small, and are of high potency. Though 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 benzo of choice for substitution purposes.

Switching is not for all though; this 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 that switching to Valium allows them to make the small cuts they need to proceed. Occasionally people experience great difficulty switching to Valium, and anecdotally, particularly when switching from Clonazepam. At the same time though, Clonazepam binds very tightly to GABA receptors, and may be the cause of particular problems sometimes associated with withdrawal from this benzo. It appears that Valium competes to bind with the GABA receptors, so helping to dislodge Clonazepam, and may improve the outcome in the medium to long term.

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 benzo. There is some variance in what is an equivalent dose in the individual, 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 the whole of your benzo dose, so lessening any impact of the equivalent being to large or too small.

As with any taper, first stabilising your drug regimen 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, then you will probably benefit from gradually changing your once-a-day dose to two, three (or even more) times a day. 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. Once you have made this adjustment, and you feel reasonably stabile, you should then 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 technique if the need should arise. Making small cuts to our dose becomes more difficult the further we proceed with our taper, so substitution might later become necessary for us to manage a smooth withdrawal.

Titration of our benzos is another option to mange small cuts to our benzos. Titration takes very little time to carry out once we are used to it, but can be a little restrictive. The method we advocate utilises milk, and we need to make up doses for the day, so storage of the titrated liquid may be an issue outside of the home. However, titration may also be used with Valium after substitution, allowing for super-small cuts for those who find benzodiazepine withdrawal particularly difficult.