New here-questions re Ativan to Valium substitution/crossover

Thanks in advance: I am reposting this and have modified it a bit from my intro on the Welcome page. Also thanks to those who responded in the Welcome section.

I am looking for support / help / advice and success stories as I prepare to begin my substitution of Valium for Ativan with the intent of removing this drug from my body forever.

I have taken Ativan for approximately 8 years, with a starting dose of around .5 mg a day, ending up with a routine and steady usage of a total of 1 mg in 24 hours (two .5 pills each day). I finally got up the nerve to ask my p-doctor to consider prescribing Valium so that I may attempt the Ashton method. For me, my body is very, very sensitive to medications, so to say that I would like to do this slooooooooowly is an understatement.

I am scared, but excited as well. I am a single working mother of 2 boys so I need to do this slowly enough that if possible it does not disrupt my normal functioning.....Can I ask you a substitution question? Particularly of anyone who has crosed from Ativan to Valium.

I have only a few Ativan pills left. I have a relatively endless prescription for the Valium (10 mg pills, which I know is said to be equal to the 1 mg I take in a 24 hour period). I have not yet filled it. I am planning on going on a straight crossover to the Valium, I did not consider, until reading here at the forum, that I might need more Ativan to somehow do some kind of "hybrid" crossover. Do you think I will suffer terrible sypmtoms by crossing straight to the Valium 10 mg (splitting it in half and taking the two doses just as I did the Ativan)? And, I know my dose of Ativan seems super low to a lot of folks, but my body is very sensitive. Has anyone had a relatively smooth time going straight from ativan to valium with steady past dose of ativan of approx 1 mg? Or, do you think I will have to ask the doc to prescribe more ativan, which I am hesitant to do, because even though he is definitely a supportive doc, he is likely not fully versed nor wants to hear me educate him about the Ashton method. What do you guys think? I only have barely enough Ativan to last thru Monday at the longest-but could start Valium as soon as I fill it. Finally, what would be a taper schedule once I get onto the Valium? Thanks again, docdaisy.

Hi docdaisy,

 

It's best to cross over in at least a few steps, say a 25% switch out (0.25mg ativan for 2.5mg Valium) every few days. The reason why a direct cross over is not a good idea is because ativan will be pretty much out of your system in a day or so due to it's very short half life, while valium can take up to a week or more to take full effect. So during this in-between period, you may experience withdrawal symptoms. That said, a straight cross-over can and has been done.

 

How much ativan do you have left? Also, 10mg valium pills are difficult to taper from , because realistically they can only be cut and reduced by 2.5mg. Some people find this too large of a cut. 2mg pills are better for directly tapering (dry cutting) all the way down. If you can't get smaller dose pills, a way around that would be the liquid titration method.    

Eljay and others-thanks. Ok, I dropped off the Valium script, but looked at it and checked w pharmacist...they are for 5 mg Valium pills. So, at least I could split those in half. I have maybe 5-6 pills total including cut up quarters. I usually get a standing script that lasts for at least 4 or 5 months, I just happened to be at the very end and when I got caught up discussing switch to Valium 2 days back in doc's office, didn't take need for more Ativan into account. I wonder if I should just eke thru what I have left until Monday (he is closed today) and then call and ask for more Ativan to make switch easier, or should just try to make direct switch? Sorry that I had the script strength wrong. I am assuming (I had this in my orig intro post but got mixed up and thought I had it wrong) that I could take one half of a 5 mg Valium for my one .50 Ativan dose, and take that twice in 24 hour period (that's how I took the Ativan). The pharmacist said it only took 1.5 hrs for Valium to get a "peak blood levels" do you think that she is just trying to help how she can, but maybe is not able to perceive that I may need more days of Valium in system to get full effect? She (pharmacist) thought there would be no prob w crossover-but I bet you guys and gals know better! Thanks for putting up with all of my questions and confusion and a little bit of fright in there too. I have a lot of "fear" that has been built up about this switch since having taken Ativan for 8 plus years and am hoping that most of the fear will blow away once I make the cross over.

The pharmacist said it only took 1.5 hrs for Valium to get a "peak blood levels" do you think that she is just trying to help how she can,

 

Yes, this is true, but they will also drop again everyday. But with each new dose, you will reach higher peak levels until you reach steady state, which is where you want to be. Here is a great post Colin made about this effect  http://www.benzobuddies.org/forum/index.php?topic=18902.msg289157#msg289157

 

5mg Valium pills are better. You should be able to cut those in quarters, giving you 1.25mg doses. For some, this size cut can still be a bit large, but it's doable. I tapered by 0.125mg klonopin, and that is roughly equivalent to 2.5mg Valium.

 

As for the ativan, It would probably be best to try and get a few more pills to do a cross over, but if you can't get them, just do the best with what you have left. If you let us know exactly the dose size and amount, including the quarters, we can come up with a quicky cross over for you.    

Hi Eljay. Boy, you guys are great. I am so uplited just by knowing that you are all here. Thanks for the link from Colin. In regards to the quicky crossover, yes I could really use some help. Here is what I have:

 

A total of 6-7 AT MOST pills of .5 Ativan (and we are talking 2 whole pills and a lot of "crumbs"/not really quarters but they add up-I divvied them out and counted hard)

I am picking up my prescription for Valium in a little while so haven't read the bottle, but they are 5 mg pills (30 in bottle) with 5 refills and he has said I can take as long as I want, he will refill, etc.

 

My dose all of this time for Ativan has been .5 2X a day (total of 1 mg) for 8 plus years.

 

So, I can either stick it out this weekend and make it to Monday morning (hope doc is open) and make the case for short course of Ativan to help w switch (but am not sure he will understand...), or go ahead and cross over--either way, what is your reccomended schedule for crossing over (know you are not doctors but I trust your experiences and knowledge and really appreciate your suggestions and ideas!!!), and then tapering? You folks are soooo wise, there is so much knowledge here. Again, I am so grateful in advance! Blessings, docdaisy

Hi Daisy,

 

There are two main considerations when switching benzodiazepines: the relative differences in how long one benzo leaves your system and how long it takes for the new benzo to build up (already mentioned by eljay); and, what constitutes an equivalent dose in an individual. Both these factors are related to the half-life values for different benzos (and the relative potencies of each benzo for a given dose, which is very difficult to measure). The upshot is that it is better to switch gradually, switching-out just a small proportion of your dose at a time, allowing your body time to adjust to any differences in blood levels (of the different benzos) and their relative potencies.

 

In your situation, where you have a very limited supply of your original benzodiazepine (Ativan), you have little choice but to switch over a few days. Here's my suggestion:

 

Because Valium will be very slow to build up in your system (and the Ativan will leave pretty quickly), you could use a loading dose. When taking a long half-life drug (such as Valium), it will be slow to build up to "steady state". This is where your blood levels stop rising with additional doses. How long it takes to reach steady state depends upon how long it takes for you metabolise Valium. How long it takes you to metabolise Valium (and to reach steady state) also determines blood levels of Valium in an individual for a given dosing regimen. I am explaining this so that you realise that there is no way for us to know what your steady steady blood levels will be, since we do not know how long it takes you to metabolise Valium. So, if you do take a "loading dose", you should take a conservative approach, one where we assume you metabolise benzodiazepines relatively rapidly (a half-life value for Valium of 36 hours - the extreme fast end).

 

What does this all mean? If you take Valium once per day, and you metabolise it at half-life value of 36 hours, your "steady state" blood levels will be about 2.7 times your peak value after your first dose*. Steady state occurs gradually (slowly, for long half-life drugs), so it would take five days for you reach 90% of the steady state blood levels if taking Valium once a day (half-life 36 hours). However, if you take a double dose of Valium (just the first time), you would instantly jump to 74% of the steady state value (it would normally take 3 days for a half-life value of 36 hours, taking one dose per day, to reach 74%).

 

If you metabolise Valium much more slowly, you will experience greater accumulation, and your steady state blood levels will be greater. Assuming a half-life value for Valium of 100 hours, again taken just once per day, steady state blood levels will be about 6.5 times that after the initial dose (there is greater accumulation). Your blood levels will be about 15% of steady state after the initial dose, and it would take 14 days to reach 90% of steady state. If you instead took a double dose (just your first dose), you would again experience a boost to blood levels, but only to bout 30% of steady state. Still, this is an improvement, and blood levels will continue to rise afterwards. If we knew how quickly you metabolise benzos, we would have a better idea of a suitable loading dose for you. Because we cannot know this, you should assume the more extreme scenario (36 hours half-life), and use a more conservative loading dose.

 

In more usual crossovers to Valium (more usual for our members), a loading dose is not worth worrying about. Because they are switching just a small proportion of their dose, any inaccuracies in the equivalent dose, and slowness to reach a steady state, are proportionally smaller because it is only the proportion of the dose being switched that's being affected. So, if they are initially underdosed by 80%, but they are switching only one-tenth of their total dose, they are being underdosed by just 8% (which would slowly diminish as they approach steady state). Now, you have a few doses of Ativan available, so you might as well switch as gradually as possible. It seems that you have 6 pills, and you take 2 pills per day. This is enough for three days. If, instead, you take 1.5 pills for two days (3 pills), 1 pill for two days (2 pills), and 1 pill for two days (1 pill) - a total of six days - this too will total 6 pills.

 

It appears that your doctor has agreed that 5mg Valium is equivalent to 0.5mg Ativan (this only can be an approximation because of the accumulative effects which are dependent upon the specific half-life within the individual, as I have described above), but this is an equivalent that works for most people (when switching gradually).

 

When you reduce your dose of Ativan to 1.5 pills per day (0.75mg), you would take 2.5mg Valium (half-a-pill) in substitution for the 0.25mg Ativan you have dropped.

 

When you reduce your dose of Ativan to 1 pill per day (0.5mg), you would take 5mg Valium (one pill) in substitution for the 1mg Ativan you have dropped.

 

When you reduce your dose of Ativan to 0.5 pills per day (0.25mg), you would take 7.5mg Valium (one-and-a-half pills) in substitution for the 0.75mg Ativan you have dropped.

 

When you reduce your dose of Ativan to zero pills per day (0mg), you would take 10mg Valium (two pills) in substitution for the 1mg Ativan you have dropped.

 

I am sorry for all these complications, but because I am suggesting a temporary increase in dose (with each substitution), I feel duty bound to fully explain my rationale. So, here's my suggested schedule:

 

AM | PM

 

Day1: 0.5mg Ativan | 0.25mg Ativan + 5mg Valium (this includes a loading dose);

Day2: 0.5mg Ativan | 0.25mg Ativan + 2.5mg Valium (the loading dose has ceased);

Day3: 0.25mg Ativan + 5mg Valium | 0.25mg Ativan + 2.5mg Valium (this includes a loading dose in the morning);

Day4: 0.25mg Ativan + 2.5mg Valium | 0.25mg Ativan + 2.5mg Valium (again, the loading dose has ceased);

Day5: 0.25mg Ativan + 2.5mg Valium | 7.5mg Valium (this includes a loading dose in the PM);

Day6: 0.25mg Ativan + 2.5mg Valium | 5mg Valium (the loading dose in the PM has ceased);

Day7: 7.5mg Valium | 5mg Valium (this includes a loading dose in the morning);

Day8: 5mg Valium | 5mg Valium (the loading dose has ceased).

 

Of course, you could use a loading dose for two days instead, and the likelihood is that this would be fine, but there is small chance that your blood levels will be higher than they need be (but they will drop again). This explanation is becoming too involved, but if you did metabolise benzodiazepines very quickly, you would require a higher equivalent dose switching from Ativan to Valium anyway (1mg to 10 ratio is about average, and will be fine for those that metabolise benzos more in the middle range).

 

So, that's it, except that if you instead decided to use a loading dose for two days with each substitution, it would look like this:

 

AM | PM

 

Day1: 0.5mg Ativan | 0.25mg Ativan + 5mg Valium (this includes a loading dose);

Day2: 0.5mg Ativan | 0.25mg Ativan + 5mg Valium (this includes a loading dose);

Day3: 0.25mg Ativan + 5mg Valium | 0.25mg Ativan + 2.5mg Valium (this includes a loading dose in the morning | the evening loading dose has ceased);

Day4: 0.25mg Ativan + 5mg Valium | 0.25mg Ativan + 2.5mg Valium (this includes a loading dose in the morning);

Day5: 0.25mg Ativan + 2.5mg Valium | 7.5mg Valium (the morning loading dose has ceased | this includes a loading dose in the PM);

Day6: 0.25mg Ativan + 2.5mg Valium | 7.5mg Valium (this includes a loading dose in the PM);

Day7: 7.5mg Valium | 5mg Valium (this includes a loading dose in the morning | the loading dose in the PM has ceased);

Day8: 7.5mg Valium | 5mg Valium (this includes a loading dose in the morning);

Day9: 5mg Valium | 5mg Valium (all loading doses have ceased).

 

If following the second suggested regimen, my calculations suggest that your blood levels will be a maximum of about 20% higher than they need be if you metabolise Valium exceptionally quickly. However, because these loading doses are temporary, your blood levels will sink again quite quickly to steady state for your given dose. At the same time though, as I have already mentioned, if you metabolise benzodiazepines very quickly, you probably would require a higher equivalent dose of Valium anyway (because there is less accumulation), so, this peak in blood levels may not be a peak for you anyway, because you would require more to account for the loss of Ativan.

 

I realise that this is all very technical, but a large reason for me posting this is for me to work out a few ideas. I guess all you need to understand is my two suggested crossover schedules. I recommend that you start straight away, given your very short supply of Ativan.

 

Good luck.

 

*I'm using a simplified metabolisation model - it does not take into account absorption times. However, since absoption times are relatively short compared to half-life values, my figures should be very close to a model that includes absorption rates/times.

Colin-

 

You are an amazingly intelligent and incredibly generous human to take the time to provide such a well-thought out analysis of my situation. I cannot tell you how grateful I am for your help (understatement of the year) on this. I am going to sit down once the kids are in bed and read your post very thoroughly. I did find 2 additional Ativan in one of my purses (gosh it sounds so demeaning....) so I feel a little more comforted to get to the next "doctor business day"-Monday.

 

I will, again, read through your suggestions and analysis very thoroughly. I hope it is okay for me to bring my faith into this, sorry to be so "drama", but I do have a strong faith and I look for daily experiences which show the wonderful people that our Creator puts us in touch with. You, and this group, are an unbelievable example of running smack into a heaping helping of God's grace when needed most. Again, hope it's ok to mention my faith briefly (move or delete if you need to!) just wanted to explain how grateful I am for all of your help. Thanks so much and be in touch, docdaisy

Hi Daisy,

 

I have only just realised that you take two 0.5mg tablets of Ativan per day - I thought you took two 1mg tablets per day (2mg in total). I will need to edit my previous post.

 

Thank you so much for your kind words.

 

We have a specific board for faith-based posts, but the odd small religious comment here and there on the other boards is fine.

 

Take care.

Thanks again Colin. I would like to start tomorrow or Sunday, I think. Did you have a chance to edit the plan like you had mentioned? Thank you again, docdaisy.

Hi,

 

Yes, I made the edits shortly after my post last night.

 

If you are going use one of the accelerated crossover schedules, you will need to start straightaway because of your very limited supply of Ativan.