Starting Diazepam Titration with Tinnitus Issues - Unsure About Titration Rate

Hello all.

 

Thank you for coming to my post and accepting me into this forum; I'll try to keep this short and simple.

 

Mid-March 2021, I began taking between 0.5 and 1.5mg of Ativan daily. After three months (June 10th), I stopped cold-turkey and was fine until two days later, when on the morning of June 12th, I awoke with raging tinnitus (note: I had suffered very mild tinnitus 12 years prior, but it resolved completely after two years). I started taking Ativan again immediately because of the stress of the tinnitus, having no idea it was the abrupt stopping of the Ativan in the first place that was its cause. Unfortunately my GP (family doctor) was of no help.

 

During the next couple of weeks, I began to realize I could control how bad the tinnitus was based on the dosage of Ativan I was taking; I could keep the tinnitus mostly at bay by taking 0.25mg of Ativan three times a day.  It wasn't perfect, but it was good enough to keep the tinnitus tolerable.

 

Last month, I found a sympathetic psychiatrist/psychopharmacologist who is willing to help me get off benzos, but recommended I first switch to Diazepam/Valium as it would be easier to control. He said I would “suffer less from inter-dosage withdrawal symptoms during the day.”  He was absolutely right, and after trial and error, we found that taking 10mg of Valium (5mg at 10am and then 5mg at 8pm) has kept the tinnitus extremely low and easily tolerable/manageable. Although I feel the sedative effects, I can deal, and know those effects will decrease as the titration begins.

 

So, at this point, I have been on benzos for a total of 5 months; first 4 months on Ativan (avg. 1mg/day) and now currently the last month on Valium (10mg/day).

 

I am ready to start titration and my psychiatrist is willing to support whatever reasonable titration schedule I feel comfortable with. He supports the research I'm doing on this benzo forum because he does not have much direct experience dealing with patients who are also dealing with benzo withdrawal-induced tinnitus. I am very lucky to have his support as well as the support of you all.

 

I've been using this calculator (http://benzo.alwaysdata.net/direct/directForm.php) to come up with a titration schedule that would reduce my daily 10mg of Valium by 1mg (10%) every 10 days (which seems to the maximum rate that I should not be exceeded according to my research and a couple of recommendations). The total titration would take 95 days to take me down to my final daily dose of 0.5mg of Valium.

 

I have a PDF showing the data I input into the titration calculator and the resulting titration schedule output. I thought there was a way to upload an attachment with messages on this forum, but that does not seem to be the case. You can view my PDF using this private Microsoft OneDrive Link: https://1drv.ms/b/s!AthhheIudAlMg759cc6Cw68M0lo0tw?e=q3t5R1 (I give you my word this is not spam. It only links to a PDF showing my proposed titration schedule).

 

Can anyone help me to determine if this schedule seems reasonable or at least a good starting point? If my tinnitus starts to flare, should I slow the taper or stop the taper for a week until the tinnitus subsides or are tinnitus flare-ups going to be part of the the price I'll need to pay as the titration continues?

 

I have a digital milligram scale, so I am confident I'll be able to do a dry titration.

 

Any input would greatly be appreciated. Thanks so very much for any/all advise or tales of experience.

 

All my best,

RoyRand

 

Hello RoyRand,

 

Thanks for the very detailed post. I do not have experience with titration but I know you'll receive good support and shared experiences from those who are versed in this method.

 

You asked me about tinnitus in a PM since I have had it and it did increase during my withdrawal. My tinnitus was at it's 'normal' low level throughout my taper but increased dramatically after completion, especially during the early days of recovery. It is a very common withdrawal symptom.

 

Should you expect it? Try not to assume you'll have any one symptom, as you mentioned, everyone is different.  The best plan in terms of withdrawal is to be patient and practice acceptance.  There will likely be withdrawal symptoms but if you plan to follow a symptom based titration plan, this would be a way to minimize them.

 

If the tinnitus increases during the taper it might be a sign to go slower. Benzo withdrawal is not a race, slow and controlled is the way to go. You are in charge, it's your taper, do whatever you need to make it work for you. It will.

 

PG

Hello all.

 

Thank you for coming to my post and accepting me into this forum; I'll try to keep this short and simple.

 

Mid-March 2021, I began taking between 0.5 and 1.5mg of Ativan daily. After three months (June 10th), I stopped cold-turkey and was fine until two days later, when on the morning of June 12th, I awoke with raging tinnitus (note: I had suffered very mild tinnitus 12 years prior, but it resolved completely after two years). I started taking Ativan again immediately because of the stress of the tinnitus, having no idea it was the abrupt stopping of the Ativan in the first place that was its cause. Unfortunately my GP (family doctor) was of no help.

 

During the next couple of weeks, I began to realize I could control how bad the tinnitus was based on the dosage of Ativan I was taking; I could keep the tinnitus mostly at bay by taking 0.25mg of Ativan three times a day.  It wasn't perfect, but it was good enough to keep the tinnitus tolerable.

 

Last month, I found a sympathetic psychiatrist/psychopharmacologist who is willing to help me get off benzos, but recommended I first switch to Diazepam/Valium as it would be easier to control. He said I would “suffer less from inter-dosage withdrawal symptoms during the day.”  He was absolutely right, and after trial and error, we found that taking 10mg of Valium (5mg at 10am and then 5mg at 8pm) has kept the tinnitus extremely low and easily tolerable/manageable. Although I feel the sedative effects, I can deal, and know those effects will decrease as the titration begins.

 

So, at this point, I have been on benzos for a total of 5 months; first 4 months on Ativan (avg. 1mg/day) and now currently the last month on Valium (10mg/day).

 

I am ready to start titration and my psychiatrist is willing to support whatever reasonable titration schedule I feel comfortable with. He supports the research I'm doing on this benzo forum because he does not have much direct experience dealing with patients who are also dealing with benzo withdrawal-induced tinnitus. I am very lucky to have his support as well as the support of you all.

 

I've been using this calculator (http://benzo.alwaysdata.net/direct/directForm.php) to come up with a titration schedule that would reduce my daily 10mg of Valium by 1mg (10%) every 10 days (which seems to the maximum rate that I should not be exceeded according to my research and a couple of recommendations). The total titration would take 95 days to take me down to my final daily dose of 0.5mg of Valium.

 

I have a PDF showing the data I input into the titration calculator and the resulting titration schedule output. I thought there was a way to upload an attachment with messages on this forum, but that does not seem to be the case. You can view my PDF using this private Microsoft OneDrive Link: https://1drv.ms/b/s!AthhheIudAlMg759cc6Cw68M0lo0tw?e=q3t5R1 (I give you my word this is not spam. It only links to a PDF showing my proposed titration schedule).

 

Can anyone help me to determine if this schedule seems reasonable or at least a good starting point? If my tinnitus starts to flare, should I slow the taper or stop the taper for a week until the tinnitus subsides or are tinnitus flare-ups going to be part of the the price I'll need to pay as the titration continues?

 

I have a digital milligram scale, so I am confident I'll be able to do a dry titration.

 

Any input would greatly be appreciated. Thanks so very much for any/all advise or tales of experience.

 

All my best,

RoyRand

 

I took a look at your link to your taper rate and I would recommend one thing that could really smooth out your taper at lower doses. In the planned reductions section deleat the 0.5 and the percentage taper field will turn from grey to allow you to enter the 5%. This will give a taper of 5% as the decreaseing mg get lower it will stay constant creating a curve rather then a straight line. Here's a link to explain what I'm talking about, it's critical to a smooth jump. The ten days will stay the same. http://www.benzobuddies.org/forum/index.php?topic=254653.5#post_generator

Your tapering plan looks ok, but it would be better to have a percentage-based reduction. Each tapering plan has to take into account the way you feel and what your body is telling you. If you are struggling, you could stay at a dosage. If you are feeling really well, you could reduce your dosage. Both options are acceptable. If you are functional and stable, and your symptoms are manageable, then keep plugging away. The key is to keep moving forward while listening to your body.

 

When I was tapering, I listened to my body. Things went really well my last 3 weeks of tapering, so I actually sped up the tapering, and I was still feeling good.

 

I had an excel spreadsheet with the tapering plan on one side, and my actual dosage in another column. Some days I would be on par with it, some days I would be slower than the tapering plan. It did not matter. The goal is to keep moving forward while still being able to function and manage life/family/friends/work, etc.

Hello RoyRand!

 

It's great to hear how well supported and well prepared you are to do this taper. I'm glad you're able to make use of Jim Hawk's DMT schedule generator, it is a powerful tool. I'm also reassured that you now, unfortunately, are familiar with the range of symptom severity that happens as a result of dosage and reduction rates; your plan to adapt your taper according to symptom severity is just perfect, IMO. 

 

I have two suggestions for your consideration.

 

First, I understand you've plotted a linear reduction schedule of 0.5mg/10 days. I'm going to disagree with TMH and darkarchon and instead support your decision to use a linear reduction schedule with diazepam. Since you'll be doing a symptom-based taper, I think keeping it linear will make things much simpler dosage wise (especially to my second point which will be about avoiding a DMT). I'm glad you have a scale and are comfortable taking smaller reductions in the future but I think to start I'd be looking to reduce by tablet splitting and linear works well for this.

 

I don't put much faith in any taper plan applying, as written, all the way through a taper. So if you plot a linear reduction and are willing to adjust the reduction rate as necessary, then I wouldn't bother fussing with planning the ending just yet. Better, in my opinion, to start with what's easy, keep detailed daily notes on your dosage and conditions, and make adjustments as you go.

 

Which brings me to my second suggestions, which is not doing a DMT for diazepam. Diazepam already has a very long half-life, and a DMT only artificially stretches this out even further. There are some disadvantages to a long half-life, including making it more difficult to correct overly rapid reductions. By doing a DMT of diazepam, this problem of symptom lag becomes even more severe as dysfunction may only become apparent after taking several weeks of small reductions that then take another several very uncomfortable weeks of holding to correct. Furthermore, a DMT is just more work. More work for more difficulty managing symptoms is not an arrangement that interests me.

 

As an alternative, I suggest using the DMT generator for getting a sense of the timelines involved at various rates, but doing a weekly or bi-weekly cut-and-hold of your diazepam instead. If you can get 2mg tablets, 0.5mg is 1/4 tablet which can be removed with a good aluminum tablet splitter (I like the EqualSplit brand on Amazon).

 

Here's why I love the aluminum splitters...

 

I suggest starting your taper by taking a 0.5mg reduction and holding for two weeks; you may not actually fully realize and recover from your reduction within 10 days, which is why I say holding 2 weeks minimum to start. I think you will learn a lot about your unique neurology, especially your elimination rate (i.e. when your symptoms peak), by doing a cut-and-hold in this way.

 

I hope these suggestions help you. Let me know if you have questions! 

First, thank you all very much for your kind and helpful suggestions. And sorry for the delay in responding. My partner and I left Wednesday for a last minute half-week trip to our favorite sea-side bed & breakfast when we found out they had availability. Living in a big city, nothing fuels calm like spending time next to the ocean listening to the crashing waves.

 

TMH; thanks for the advice to switch from a linear taper to a percentage-based one, which makes sense since the same size cut each time ends up being a larger percentage than the previous cut. That's something I will keep in mind as my dosage continues to be lowered.

 

pianogirl, darkarchon and slownsteady; although your specific tapering techniques may differ slightly, I agree with you all that ultimately it's about quality of life and a cut-and-hold technique taken slowly and listening to my body and symptoms before doing the next cut-and-hold would be a better technique than following a fixed daily microtapering (DMT) plan (especially for the reasons you've specified, slownsteady, about the likelihood of symptom lag when taking Diazepam/Valium as I am).

 

After discussing this feedback with my psychiatrist, we've decided on the cut-and-hold method with no hard-fixed timeline other than perhaps aiming for a three to four month tapering plan, but with the flexibility of making any necessary adjustments if/when needed. My first cut has just been made as of yesterday (which I'm both very excited and a bit nervous to have finally begun) and a 10% cut from 10mg Diazepam/Valium down to 9mg daily has been made. I know some may feel that 10% might be too high to start, but my psychiatrist felt pretty confident that I should be able to tolerate this initial cut. We will see how the next 10 to 14 days go.

 

I know a lot of people who are in similar situations like to read and keep up to date on the progress of others, especially if their circumstances are similar. So, I will continue to post updates to let you know my progress, especially if there are any notable developments, good or bad.

 

Thank you all so very much for your informative, thoughtful, and encouraging feedback. It's truly appreciated more than you know as this been a very trying and frightening time for me, as I'm sure you all are very aware having gone through this difficult journey yourselves.

 

All my best to you all,

RoyRand

Hello,

 

I hope you enjoyed your get away, true, there is nothing more calming then the sound of ocean waves!

 

It sounds like you have a good plan in place and a supportive provider.  Thanks for updating and we look forward to hearing more about the progress with your taper.

 

PG 

Thanks for the update! Sounds like a great start.

Looking forward to updates. 

Hello, all. This is my first update since I started my first cut-and-hold taper of Diazepam/Valium 5 days ago. I went from 10mg daily (2 x 5mg doses @ 10am and 8pm) down 10% to 9mg daily (2 x 4.5mg). The first four days I didn't really notice much difference - some days better than others in terms of the tinnitus but it was like that even before this first taper. However today on day 5 I'm noticing a slightly different than usual pattern. I woke up with a higher level of tinnitus and my usual 60 minute morning walk didn't bring the level back down that it usually does. Also, I typically get a mid-afternoon flare-up with tinnitus and it's a much more noticeable flare-up today than usual.

 

I'm assuming that when a taper occurs there likely must be some resulting effects, and that is what I'm now experiencing. Would this slightly increased tinnitus be considered normal shortly after a taper?

 

And if so, what the typical protocol for determining what the next step is? If I'm able to tolerate the increased tinnitus, do I just stay at this new dosage level for as long at it takes for my tinnitus levels to return to about the same levels as they were before this first cut, hopefully within a total of 10 to 14 days? Or does the fact that I am already noticing an increase indicate that the 10% cut may have been too aggressive to begin with?

 

If my tinnitus does not improve or if the levels continue to get worse over the next day or two should I increase my dosage to back up slightly to perhaps up 9.5mg (5% cut) instead of staying on the 9mg (10% cut)?

 

I'm just not sure what the typical protocol is when starting tapering and how long to wait to judge whether a cut-and-hold taper was too aggressive because of a slight increase in symptoms or if it's just a normal part of the tapering process and not be too concerned if it's just a temporary increase that only lasts a few days.

 

I just wanted to say that this is tinnitus increase, although annoying, is tolerable so far and if it's in my best interest to not move back to a higher dose and instead just wait out this adjustment period I'm fine with doing that. I know tinnitus is one of, if not the most persistent withdrawal side effects to deal with, so if elevated tinnitus is going to be the "new normal" for me and expecting it to remain low throughout the taper is just not going to be realistic then I'm better to just accept it as the price I have to pay to get off of benzos and learn coping techniques for the tinnitus rather than have an overly-long tapering period. I guess the challenge is finding the right balance of symptom management vs tapering length which is what I'm trying to learn about now.

 

As always, your feedback is greatly appreciated.

 

Best,

RoyRand

 

Hi RoyRand,

I understand that you're wondering what to do when you've taken a cut-and-hold reduction and you're feeling an increase in withdrawal symptoms, in your case tinnitus. The simple answer is to hold as long as you need to until your symptom severity returns to where it was before you took your reduction; this is called stabilizing.

 

A reduction of diazepam can take four or more days to be felt. I think sometimes it's over a week for taperers to feel their diazepam cut. With a cut-and-hold strategy there will be a pattern of symptoms emerging at some point after the reduction, building for a couple days or longer, peaking, and then symptom severity will reduce as your nervous system recovers and you stabilize. The timeline for this is unique to the medication and especially to the individual which is why your first cut-and-hold is going to feel so mysterious!

 

But everything you describe sounds perfectly normal. Symptoms may get worse before they get better. I suggest doing what you can to keep good notes in a daily tapering journal so you can map out your symptom severity timeline. I suggest also being on the look-out for how well you can function during this 2+ week hold period. If the symptoms are too severe to meet your functionality goals, that's a sign to lower your reductions in the future. In the meantime, I think cut-and-holds are all about holding on, trying to stay calm, and doing your best to learn about yourself from the experience.

 

Yes, it's all about finding that balance. I suggest letting this 2+ week hold period play itself out, and then make a decision about the next reduction once you've stabilized. I suggest only considering an updose if things have gone HORRIBLY wrong; for now discomfort is probably unavoidable, and may be made worse by the newness of everything. Prayer might help; you are walking a well-tread pilgrimage of benzo recovery after all.

 

You're doing awesome! Hang in there. Keep us posted.

slownsteady, thank you so much for your kind and supportive response. You are spot on about where my head is right now, especially as you put it so well,  with this being all so new and mysterious to me being my first cut. It started to feel a bit overwhelming, raising my anxiety, and then of course which raises the tinnitus/other withdrawal effects - that old vicious circle.

 

Everything you said makes perfect sense and has given me a great sense of calm and relief now that I know what to expect and how to handle it. Perhaps that's the reason that so far today, it's been an excellent day of extremely low T since I no longer feel so anxious at the first sign up a rising level of T.

 

Thank you again so much. You really have no idea how calming and supportive your response was and how much it helped. Thanks for your kindness.

 

All my best,

RoyRand

I've been there, so I'm happy to help. And I'm so glad to hear that you were able to put your mind at ease! Keep up the great work.