A Different Kind of Substitution Regimen - just for discssion and fun

I was about to post this response to a post on the Titration board, but thought it probably deserved its own thread, and this is the better board for this discussion anyway. As per the title, it is just for discussional purposes. The figures I have used are purely illustrative (made up by me).

 

thank you for this!

 

it backs up what i already suspected, but on another board was told my taper off of all 3 psych meds was supposed to take about 7 years for each med, one at a time consecutively. i was punished for agreeing wth a person who successfully poly-tapered from polydrugs by doing a very very slow microtaper. personally 21 years of DLMT is unreasonable for me, and i would be elderly and unable to secure work at the finish!! having been polydrugged for 24 years, i know that my taper is likely to last up to ten years, which i'm not excited about but am prepared to do. i think expecting people to spend over a decade to come off of a drug is unrealistic...of course there are exceptions. but the vast majority can come off in much less time if doing a DLMT at a slow but steady rate i do believe!

 

you stated that "1mg K-pin = 15mgs Valium."

since the Ashton Manual says 1mg K=20mg V, where did you get your numbers?

 

Hi nomoredrugsforme,

 

This response is not really aimed at you - I am just taking the opportunity to explain a few things, and post a highly speculative substitution regimen which is probably overkill for the situation (even if we assume my methodology is correct - I make no such solid claim)

 

Ashton states that 1mg Klonopin is equivalent to 20mg Valium, but only for the purposes of substitution*. She does not state that they are therapeutic equivalents**. The distinction is important, because if the discussion is not about substitution, it can be misleading. Additionally, equivalent doses are always approximate - the true equivalent dose can and will vary (sometimes very significantly) between individuals. There is much greater accumulation involved with long half-life benzodiazepines, where accumulated blood levels are roughly proportional to the half-life value (within the individual). Conversely, with short half-life benzodiazepines, blood levels are roughly proportional to the dose taken. Medium half-life benzos will result in blood levels which are a geater combination of the two forces. So, how fast an individual metabolises these meds affects what is true equivalent dose, as this greatly affects blood levels of the long half-life benzo (because it greatly affects accumulation), but has relatively little effect upon short(er) half-life benzodiazepines. So, when people try to get you hung up on exactitudes in this process, it is almost certainly nonsense.

 

* I am not certain why Ashton claims there is this difference, but it might be to do with a shortfall in blood levels because a reduction in a short half-life benzo will rapidly result in an equivalent reduction in blood levels. Whereas the substitute benzodiazepine (Valium) will take time to accumulate. So, there will be shortfall in blood levels in the shorter term and likely withdrawal symptoms (until Valium builds up in your system). The precise reasons for Ashton's advice is speculation from me. As far as I know, she has not stated the reasons, and it could be as simple as her advice comes from empirical observation rather than theory. If my speculation and theory is correct, there is a way around this: use a single 'loading dose' with each new (additional) substitution, and use a true® equivalent therapeutic dose as the base figure. So, it might look something like this:

 

Assume that a true® substitution dose (for the individual) is 1mg Klonopin = 10mg Valium; starting dose is 2mg Klonopin; loading dose is 40mg Valium (this is a completely made up figure for demonstration purposes) to circumvent the short-term short fall, so as to get closer accumulated blood levels after a single dose.

 

So:

 

Step 1) 2mg Klonopin

Step 2a) 1.75mg Klonopin + 10mg Valium (first dose only)

Step 2b) 1.75mg Klonopin + 2.5mg Valium (every dose until step 3a)

Step 3a) 1.5mg Klonopin + 2.5mg Valium + 10mmg Valium = 1.5mg Klonopin + 12.5mg Valium (first dose only)

Step 3b) 1.5mg K + 2.5mg V + 2.5mg V = 1.5K + 5V (every dose until 4a)

Step 4a) 1.25mg K + 2.5mg V + 2.5mg V + 10mg V = 1.25mg K + 15mg V (first dose only)

Step 4b) 1.25mg K + 2.5mg V + 2.5mg V + 2.5mg V = 1.25mg K + 7.5mg V (every dose until 5a)

Step 5a) 1mg K + 2.5mg V + 2.5mg V + 2.5mg V + 10mg V = 1mg K + 17.5mg V (first does only)

Step 5b) 1mg K + 2.5mg V + 2.5mg V + 2.5mg V + 2.5mg V = 1mg K + 10mg V (every dose until step 6a)

 

Hopefully you all now understand the process and where this is going:

 

Step 6a) 0.75mg K + 20mg V (first step only)

Step 6b) 0.75mg K + 12.5mg V (every dose until step 7a)

Step 7a) 0.5mg K + 22.5mg V (first step only)

Step 7b) 0.5mg K + 15mg V (every dose until step 8a)

Step 8a) 0.25mg K + 25mg V (first step only)

Step 8b) 0.25mg K + 17.5mg V (every dose until step 9a)

Step 9a) 0mg K + 27.5mg V (first step only)

Step 9b) 0mg K + 20mg V (stabilise and then taper from here)

 

There probably would be a week or two between each full step. And, the above table is based upon a single dose per day of Klonopin and Valium.

 

A regular substitution regimen, following a 1:20 ratio (as per Ashton), would end up at 40mg Valium. Utilisation of a loading dose might allow for a reduction from that headline figure. But it would require a proper trial by a doctor/researcher. Again, my equivalent and loading doses in the above are purely illustrative - I've pulled the figures out of my ass. In any case, the precise figures would vary between individuals, because metabolisation rates vary between individuals (thus, affecting accumulation and steady state blood levels for a given chronically administered dose).

 

** Therapeutic differences will also vary for the condition/symptoms under treatment, and different benzos have differing therapeutic profiles according to the condition being treated. Though this effect/variance might not be as marked as pharmaceutical companies might claim, as they might wish to inflate differences for marketing purposes.

 

Anyway, those of you interested in or have knowledge of pharmacokinetics, please have at my idea, dissect it, and see if there are any true merits to it. But in the final analysis, I suspect that it would be too complicated as even if it could work, it would probably require tailoring to fit the individual's specific rate of metabolisation of benzodiazepines.

I edited my post, above, to add that there probably would be a week or two between each new (full) step.

Brilliant!   

I've also edited my post to add that the regimen I described is based upon a single dose of Klonopin and Valium per day.

 

Ashton states that 1mg Klonopin is equivalent to 20mg Valium, but only for the purposes of substitution*. She does not state that they are therapeutic equivalents**. The distinction is important, because if the discussion is not about substation, it can be misleading. Additionally, equivalent does are always approximate - the true equivalent does and and will vary (sometime very significantly) between individuals.

 

20 mg of Valium worked fantastically for me for the purpose of substituting for 1 mg of Klonopin.

 

I was taking .5 mg of Klonopin twice a day and started to rather suddenly get interdose withdrawal or tolerance withdrawal.  I had been on the .5 mg Klonopin twice a day for a bit over 2 years.  Before that I was taking one to three .5 mg xanax a day for anxiety attacks.  Switching to the longer acting Klonopin completely stopped it for the next 2+ years.  But one night I got an anxiety attack a few hours after taking my nightly dose of Klonopin.  The next day the Klonopin did not seem to be working well.  And the day after that I got an anxiety attack a few hours after my nightly dose of Klonopin.

 

I had some 10 mg valium around and was familiar with the Ashton plan.  So the following day I took 10 mg of valium for my early dose and did not experience an anxiety attack.  That evening I took a .5 mg dose of Klonopin and felt a good deal of anxiety a few hours later.  After that I switched straight to two 10 mg valiums per day, and other than being shaken up by the whole thing felt fine.  Since I was suddenly having a bad reaction from the Klonopin I made my complete switchover in two days and did fine after that.  After two weeks or so on the 20 mg of valium per day I began to taper.

 

Maybe 20 mg of valium is a bit more than the equivalent to 1 mg of Klonopin.  I don't care.  What is important is that it allowed me to switch over comfortably at a time when I was quite shaken up by the Klonopin not working.

 

 

Ashton states that 1mg Klonopin is equivalent to 20mg Valium, but only for the purposes of substitution*. She does not state that they are therapeutic equivalents**. 

 

And they are NOT.  That's a point I have made on many posts.

I was about to post this response to a post on the Titration board, but thought it probably deserved its own thread, and this is the better board for this discussion anyway. As per the title, it is just for discussional purposes. The figures I have used are purely illustrative (made up by me).

 

thank you for this!

 

it backs up what i already suspected, but on another board was told my taper off of all 3 psych meds was supposed to take about 7 years for each med, one at a time consecutively. i was punished for agreeing wth a person who successfully poly-tapered from polydrugs by doing a very very slow microtaper. personally 21 years of DLMT is unreasonable for me, and i would be elderly and unable to secure work at the finish!! having been polydrugged for 24 years, i know that my taper is likely to last up to ten years, which i'm not excited about but am prepared to do. i think expecting people to spend over a decade to come off of a drug is unrealistic...of course there are exceptions. but the vast majority can come off in much less time if doing a DLMT at a slow but steady rate i do believe!

 

you stated that "1mg K-pin = 15mgs Valium."

since the Ashton Manual says 1mg K=20mg V, where did you get your numbers?

 

Hi nomoredrugsforme,

 

This response is not really aimed at you - I am just taking the opportunity to explain a few things, and post a highly speculative substitution regimen which is probably overkill for the situation (even if we assume my methodology is correct - I make no such solid claim)

 

"... But in the final analysis, I suspect that it would be too complicated as even if it could work, it would probably require tailoring to fit the individual's specific rate of metabolisation of benzodiazepines.

 

hey Colin 

thanks for taking part of our discussion and finding it important enough to turn into it's own topic..it makes me feel good that it might help others, even if it is rather complicated to explain lol!

 

and yes i do think it's complicating things beyond need for my personal purposes but i'm just one out of however many thousands of benzo quitters out there so i still am glad for this you started here!

 

for myself, i am keeping the benzo i'm currently on clonazepam and NOT switching over to V because my body is accustomed to clon and been thru enough changes already, so for me, i'm going to taper my other 2 meds and then clon using liquid and taper down the same way but at different rates as each drug dictates at the time of tapering. i just use Ashton as my starting point and have tweaked and tailored the tapers from there extensively to suit me.

 

i have been on over 45 prescribed psych meds in 24 years, so my situation and metabolism is unique (as is everyone's!) many times the dr's yanked me on and off meds with no tapering at all, cold frikkin turkey and no explanation that i was going thru wd's just "oh you're having___________sx's? here try this pill..."  so i was in actuality in wd many times and kindled because of that and the fact they never spaced my doses out by their halflives or anything, so i woke up already in wd for the next dose, never knowing why i felt bad every day for years. anyhoo

 

...i started my taper off the antipsychotic in 0ct of 2017, with NO GUIDANCE at all, then discovered Ashton, tried to loosely adapt a taper based on that but learned it didn't work for my particular antipsychotic (duh not a benzo!) and so have slowed it way down and taken a few extended HOLD's for stressful holidays and trips, etc, and just use a 2.5% reduction per week with a HOLD following 4 weeks, based on my sx's...and continue on. i use a HUMCO suspension vehicle and slip tip oral syringe to measure my doses.

 

on July 14 next month i will begin my gabapentin liquid solution (just distilled H2O since gabapentin is almost 100% soluble in H2O) taper, using almost the same schedule as the one i currently follow for my antipsychotic taper, but the rate will be different. i'm at a high dose, so knocking off the first 100mg in 47 days won't be as harsh/noticeable as the remaining 800mg to go after that. i will adjust my rate per sx's dictate after that. i need to get the total daily dose reduced to an amount which forces insurance to allow the dr to write my RX in 100mg pill amounts. so that's my reason for the faster taper of the first 100mg of gabapentin.

 

then, after i've gotten on a taper schedule for the gabapentin that i can live with, and am still stable on my current clon taper, i will make my date to begin the benzo taper. probably after the holidays, around jan 2020.

 

i print all my taper schedules out on spreadsheets and keep daily notes on everything i eat, drink, meds, sx's etc in a large daily planner. that has helped me see where and when what i ate or meds i took or my sleep hygeine etc affected my sx's. i also use my cellphone alarms to go off for every med dose time, plus a reminder 5 minutes later on the 2 dose alarms that i tend to forget which include clonazepam doses and will noticably mess me up if i forget to take them, so the 5 minute reminders have saved my butt lotsa times.

 

i have read all the Ashton manual and lotsa other people's views on it including yours Colin, and have made the determination that, for me, it is not best to switch to Valium to do the taper. hah...unless they make clonazepam unobtainable! in that case i will most certainly reconsider but for me, i plan to stay on clonazepam and dissolve it using Builder's formula with a tiny amount of alcohol for solvent plus a greater amount of H2O plus the clon to make my solution. perhaps i will end up making a suspension so i dont have to mix it up every single day? i do like the freedom the quetiapine suspension gives me. less stress. and that's why i don't want the switch to V because of the added stress on my cns and the possibility of having a bad reaction and having to switch back, the extra time required to make the crossover to V, just stress, stress and more stress. for me, less stress is best.

Interesting.