Liquid Diazepam

[[Buddie]]

Greetings, [...].  Thank you for letting us know your wife slept ok and is back to a “normal” bad day today.  That’s good news!

I’ve been reflecting on your case and wanted to share three thoughts. First and foremost, I want to recognize and congratulate you both for tapering from 7.5mg to 1.90mg of diazepam in 11 months.  That’s a major accomplishment. 

Second, I’d like to encourage you to consider changing from a fixed amount to a symptom-based percent reduction in dose for the remainder of her taper.

Why? As you have been reducing by a fixed amount (0.15mg every 2-3 weeks), the percent reduction has been steadily increasing. For example:

7.5mg    ->  7.35mg = a 2% reduction in dose
2.05mg  ->  1.90mg = a 7.32% reduction in dose

Your wife’s response to the last reduction suggests she may be approaching a “tipping point” in terms of the percent reduction she can tolerate. Some individuals experience the switch to liquid as a reduction in dose.  This reduction in addition to the planned 7.32% reduction may have been sufficient to tip your wife’s symptom scale from “tolerable” to “intolerable.”

Third and last, am I correct that your wife takes her entire dose at one time in the evening?  If so, I wonder if her “normal” bad symptoms during the day might be due to interdose withdrawal? (See definition below.)

What is Interdose Withdrawal?

Interdose withdrawal occurs when withdrawal symptoms emerge in between scheduled doses. It is common in people who are prescribed benzodiazepines, especially those who become physically dependent by taking them beyond the 2-4 week recommended time frame. While interdose withdrawal typically occurs with short half-life benzodiazepines, like Ativan or Xanax, it can and does occur with longer half life benzodiazepines like Klonopin, Valium, Librium and Tranxene.

Interdose withdrawal is often described as withdrawal symptoms that manifest in between scheduled doses. These symptoms resolve or partially resolve when the next scheduled dose is taken. Some prescribers misdiagnose interdose withdrawal as a worsening anxiety disorder. This can be terrifying for patients as they believe the withdrawal state they experience is now their baseline unmedicated default state. This can lead to a lifelong benzodiazepine prescription—constantly trying to extinguish the interdose withdrawal fire—and the complications that may occur from that.

Source:
Interdose Withdrawal - Benzodiazepine Information Coalition
https://www.benzoinfo.com/interdose-withdrawal/

[[Buddie]]

Thank you, [...].  She has gone to shaving the 2 mg tablet down to 1,9 mg.  It is not the easiest or most accurate thing to do.  The tablets do not split accurately and weight changes from one tablet to another.  Not sure how concerned we should be about a difference of 0.002 mg but we're doing the best we can.  She had very bad days on day 10 and day 12 after dropping to 1.9 mg.
The "tipping point" thought makes sense.
She is extremely anxious about what to do from here on.  We heard about microtapering, but unsure how to do it using the "dry method".  I don't believe it is the same as titration.
She is taking 75 mg of Wellbutrin, but still has anxiety every morning.
She is afraid to make any changes now because of having more severe waves.
We will try your suggestion of a lower percentage when she does her next dropdown.  She also may try the two doses per day idea, but she is afraid she won't be able to sleep at night, which is when she takes her valium.
Are there any schedules for tapering under 2 mg?  What percentage should she drop?
I think I have to change my name to "Helpless Husband"!
Thank you.

[[Buddie]]

Hello again, [...].  If you change your username, might I suggest “Heroic Husband”?  The practical and emotional support you are giving your wife makes you a hero in my book!

Let me see if I can help with the terminology you’ve encountered, specifically titration and microtapering.

The medical definition of “titration” is adjusting the dose of a drug to maximize positive effects while minimizing negative ones. In the context of benzodiazepine withdrawal, titration means making “small enough” reductions in dose to keep withdrawal symptoms tolerable while discontinuing the drug.  Individuals titrate their doses using solid dose formulations, liquid formulations, or a combination thereof.

“Microtapering” means making extremely small dose reductions measured in micrograms (1 microgram equals 0.001 milligram).  Some individuals find this necessary whereas others do not.  The potency of the benzodiazepine being tapered may also be a factor (more potent benzodiazepines may require microtapering whereas less potent ones may not).

The goal of tapering is to make “small enough” reductions in dose on a “gradual enough” interval to keep withdrawal symptoms tolerable for a given individual/benzodiazepine. A caveat is that what is “small enough” and “gradual enough” at one point in a taper may not be at another.  One of the keys to successful discontinuation is flexibility - making adjustments in one’s taper plan as needed in response to withdrawal symptoms.

Given your wife’s recent setback, heightened anxiety, current dose, and taper phase, my inclination would be to err on the side of caution with the next reduction.  Perhaps 5% or 1.81mg (95% of 1.9mg = 1.805mg, rounded up).  If she does ok with that, you could try a slightly higher percent for the next reduction (e.g. 6%).  Note that the percent reduction is calculated using the current dose.  A 6% reduction from 1.81mg would be 1.70mg (94% of 1.81mg = 1.7014mg, rounded down).

Her uptick in symptoms on Days 10 - 12 makes sense given the long half-life of diazepam.  That would be in the range of when the drug reaches a steady state concentration after the latest reduction.

While you and your wife are waiting for her to stabilize ... if you have not already done so, might I suggest you explore resources aimed at helping your wife (and you) cope during withdrawal and recovery?  I’ve included one such resource below.  Learning about and practicing good sleep hygiene is also important.

Lastly, you might find it helpful to read through some of the posts in the Support Group named “3,2,1: Under 3 mg Valium people” at http://www.benzobuddies.org/forum/index.php?topic=151673.msg2035496#msg2035496

Resource:

Cope, Take Care of Yourself, and Heal | The Withdrawal Project
https://withdrawal.theinnercompass.org/page/cope-take-care-yourself-and-heal

[[Buddie]]

Thank you so much, [...].  You are so helpful to my wife, Ingrid.  You set her mind at ease (to a point).  She will go to 5% next drop and see how it goes.  The time you take to help us is greatly appreciated.
She is also looking far ahead by wondering when it will be safe to jump off Valium altogether.  We have seen a lot of different answers on this from 1 mg to o.o1 mg.
Thank you.

[[Buddie]]

You are most welcome, [...]. I am glad your wife’s mind is more at ease. Re: a jump dose for Valium ... it depends on the individual. Professor Ashton suggested a jump dose of 0.5mg (see quote below).  However, as you’ve discovered, we have members who taper lower than this for a variety of reasons. If you would like more input on this topic, you could post to the “3,2,1” Support Group I referenced earlier and/or the Valium/Diazepam Support Group at:
http://www.benzobuddies.org/forum/index.php?topic=96753.msg1238323#msg1238323

Getting off the last tablet: Stopping the last few milligrams is often viewed as particularly difficult. This is mainly due to fear of how you will cope without any drug at all. In fact, the final parting is surprisingly easy. People are usually delighted by the new sense of freedom gained. In any case the 1mg or 0.5mg diazepam per day which you are taking at the end of your schedule is having little effect apart from keeping the dependence going. Do not be tempted to spin out the withdrawal to a ridiculously slow rate towards the end (such as 0.25mg each month). Take the plunge when you reach 0.5mg daily; full recovery cannot begin until you have got off your tablets completely. Some people after completing withdrawal like to carry around a few tablets with them for security "just in case", but find that they rarely if ever use them.

Source:
Benzodiazepines: How They Work & How to Withdraw, Prof C H Ashton DM, FRCP, 2002
https://www.benzo.org.uk/manual/bzcha02.htm

[[Buddie]]

[...]: I just read the following post to the “3,2,1: Under 3 mg Valium people” support group and thought of you and your wife:

Just a quickie to say I took my last diazepam on Saturday. Good luck to all!
I feel great! The fear I had of jumping was unjustified. If I did it again, I would jump at .25, not .07.

If you want to ask JimmyT (or other members who follow the “1,2,3” thread) about a jump dose for Valium/diazepam, click the header directly above the quote — Quote from: JimmyT on February 22, 2021, 04:19:00 am. You will be taken to JimmyT’s post in the thread. Click the Reply button at the top or bottom of the page to add a post of your own.

[[Buddie]]

[...],
Sorry about the PM.  That was an error.  Still trying to figure out this website procedure.
Our question was about accuracy when splitting tablets and possible crossover to liquid Valium.

[[Buddie]]

Hello, [...]. Good to hear from you.

I don’t have experience with pill-splitting, pill-shaving, or the grind-into-powder-then-weigh approaches so will defer to other members as to their accuracy.

In my opinion, if accuracy in dose is a primary concern, using the commercially manufactured 5mg/5mL (1mg/mL) oral solution of diazepam is the best option. Many members have tapered successfully using the oral solution “as is” or diluting it to 0.1mg/mL using water (so they can make smaller reductions in dose).

If I were in your wife’s shoes, I would definitely consider giving the oral solution another try.  It may well be that the issues she experienced earlier were due to the “too large” reduction in dose that was made at the same time she switched her entire dose to the solution. (I also wonder if anxiety about changing dose formats may have been a factor.)

It is not uncommon to encounter members who make two changes simultaneously — a change in dose format from solid to liquid and a reduction in dose. When they experience issues, they attribute it to the change in dose format when in fact the issues were due primarily to a too-large reduction in dose.

Below is one strategy your wife could use to “test the waters” again with the oral solution.  Let’s assume she has 2mg tablets and is taking 1mg in the evening and 1mg in the morning.

Split the 2mg tablet into quarters; each quarter will contain about 0.5mg of the drug.
Take two of the quarters at night.
The next morning, take one of the quarters (0.5mg) plus the equivalent of 0.5mg in the oral solution. 
Repeat the above for a few days to gauge reaction.
If all goes well, replace one of the quarters with another 0.5mg of the solution.
Continue the above until the entire dose is being ingested as solution.

[[Buddie]]

[...],
Thank you again.
Your suggestion makes sense.  I will suggest it to her.  She will be concerned, again, about the accuracy of the tablet cuts.  I am still not sure how much difference a small variation makes as long as she still gets her total of 1.9 mg each day.  We will try to do the math with each morning dose in measuring the liquid,
Thank you.

[[Buddie]]

You are welcome, [...].  Please keep us posted.