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Ativan crossover to Valium


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Hi all, I have a question on crossing over to Valium from Ativan. I have tapered down from 3 mg Ativan starting mid June and am at .5 mg Ativan with .25mg in the morning and .25mg at night. It’s been very hard for me and getting worse as I get lower. My doc wants me to crossover to Valium by just replacing the Ativan with 5 mg of Valium at night without a transition like I’ve seen recommended by Ashton and many other posts. Is this possible since it’s a low dose to no have crossover withdrawl ?
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Hi Joeb,

I understand you are currently taking 1mg of lorazepam per day. Your taper seems to me to be more rapid than many buddies can handle around here which may be cause of your increasing symptoms.

 

I think the best information we current have on crossovers to diazepam is from Dr. Ashton. Her equivalency chart suggests that 1mg lorazepam is equivalent to 10mg diazepam. So I think a crossover to 5mg of diazepam is insufficient, even if this was done slow and step-wise over a month or two.

 

Furthermore, what is not often apparent to doctors or taperers is that Dr. Ashton is talking about the potency of diazepam ONLY after it's had a week or more to layer its doses. A single 10mg dose of diazepam is not going to feel anywhere near equivalent to 1mg of lorazepam. The equivalency chart is based on the fact that each diazepam dose creates a few metabolites, the primary of which has a half-life from 36-200 hours. In other words, diazepam doses layer on top of each other over many days, making the eventual cumulative blood serum levels MUCH higher than a single 10mg dose.

 

So if your doctor suddenly switches you from 1mg lorazepam (which will be largely eliminated from your system in a few days or less, due to it's 10-12 hour half-life), and onto HALF the Ashton equivalent dose of diazepam at 5mg, I suspect you will be experiencing a significant increase in withdrawal symptom severity, not only until the diazepam gets up to strength which can take a week or two, but beyond as your body tries to adapt to what is potentially a 50% reduction in GABAa agonists. This does not sound to me like a safe or comfortable transition.

 

Lastly, by doing a sudden crossover, your doctor is missing the opportunity to help you trial diazepam step-wise and thus give you time to evaluate your compatibility with the new drug before replacing your entire benzo dose. This is a grave oversight in my opinion, as diazepam is not universally tolerated.

 

My suggestion is to hold on your lorazepam dose and try to stabilize there. Crossing over while unstable further complicates the already significant risks mentioned above. You may simply need help adjusting your lorazepam taper to allow stronger neurological stability, and if you seriously want to crossover to diazepam, I strongly suggest doing it gradually and step-wise, ideally over several weeks or longer.

 

I would consider following this crossover timeline but adjusting the doses to your current levels:

https://www.benzoinfo.com/ashtonmanual/chapter2b/#schedule8

 

Sorry for the bad news. We can help you plan a slow, step-wise taper in detail if you'd like.

I hope this saves you from further instability and suffering.  :thumbsup:

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Thank you very much slownsteady for the replying think you misread my dosage it is a total of .5 per day. Would that change anything in your reply?
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Joeb, I'm going to chime in here because I was once in a similar position to the one in which you find yourself.  I was taking 1.5 mgs of Ativan (dosing 3 x a day) and the interdose w/ds were unbearable.

 

So I decided to follow Ashton's schedule and cross over stepwise to 15 mgs of valium. I had to make some math adjustments, of course, but in general I followed her blueprint.

 

Let me tell you that what slow is inferring is quite accurate: the valium you "substitute" for Ativan is not a physiologically similar substitution. You will not feel the same "ah" relief from a long-acting benzo that must build up in your system (valium = three metabolites) as you do from the instant relief of, say, Ativan. Consequently, the crossover for me was a little rocky. I understand why now. At the time, I didn't. Anyhow, I persisted, and by the time the rocky crossover was finished, my discomfort had settled down. Once I was completely on valium things went very smoothly.

 

I urge you not to let your doc simply make a substitution of valium (make sure it's a correct substitution) for Ativan. I think the potential for distress is great. There's no downside to following Ashton's schedule imo.

 

Anyhow, that was my experience. Hope this helps,

 

Katz

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Thanks Katz, I’m overwhelmed, my total daily dose is .5mg Ativan slow misread that part of my post

I don’t see any schedule in the Ashton manual for this low a dose,

Why was your transition so difficult, I have been struggling with doing it

 

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Thank you so much Katz for sharing your personal experience, and such an meaningful insight into the subjective effects of changing between short-acting and long-acting benzos.  :thumbsup:

 

Thank you very much slownsteady for the replying think you misread my dosage it is a total of .5 per day. Would that change anything in your reply?

 

My mistake, I did misread your post and yes I would change some things in my earlier reply. Namely that 5mg diazepam is an Ashton equivalent crossover dose for 0.5mg lorazepam, so at least your dosage is not being cut in half by an insufficient equivalency. I'm sorry for any confusion I caused.

 

Everything else I wrote suggesting step-wise substitutions and sufficient adjustment periods between steps are all the same, and the pharmacokenetics of diazepam and lorazepam haven't changed even though you're on a lower dose than I realized. I agree with Katz that a sudden crossover will carry a risk of significant distress.

 

I still suggest stabilizing if at all possible before attempting a crossover, and using the step-wise, slow crossover approach to trial and hopefully adapt to your equivalency in diazepam.

 

Let us know if you need help planning a step-wise crossover. You could consider doing this privately at-home if you have sufficient lorazepam tablets remaining and are collecting your diazepam script.

 

Do you think you could get your doctor on-board with a step-wise crossover?

If not, would you consider doing a step-wise crossover without your doctors support?

How can we help?

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I really appreciate the support on this I al having a lot of difficulty and stress trying to make decisions on this stuff. I have a zoom apt with her at 4 today. Been really struggling since doctors don’t seem to understand.

I will ask and see if she wud support me but as you know it can be touchy.

I wud appreciate any recommendations, but since Ashton doesn’t have a schedule for this low a dose how is one developed

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Slow/Katz

Do you think crossing over at my low dose is worth the hassle and potential misery in adjusting to the Valium?

 

I think this is a SUPERB question to ask Joeb at this time, considering your situation with your doctor and your dosage.  :thumbsup:

 

My opinion is no, I don't think it's worth the risk at this time. From what little I know, I think your symptoms are likely to be caused by tapering too quickly and I think a hold, possibly combined with a broader distribution of your daily dose across the day, would go much farther in offering you symptom improvements than a switch of drugs.

 

Would you consider holding for a few weeks or until stable?

Would you consider tapering at a slower rate? If so, what is your current reduction method?

Would you consider taking more doses during the day, but the same total daily dose?

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Hmm,

Early on I was tapering .25mg every 5-7 days

Then went to 7-14 days .125mg since it got harder

Instead of stabilizing for longer periods I would taper when I had a decent day which I know is bad, but getting worn out and want it to be over,

I started with 3 doses now am at 2.

So I agree with the changes your recommending

 

Another concern is the pill sizes, that was another reason I considered changing

As I get lower it’s hard to get to the smaller doses

I have a Gemini 20 scale but it gets hard to get accurate weights consistently

 

 

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Slow

I would like to take you up on your offer for a crossover plan for Ativan to Valium

Honestly not sure what I’m going to do but wud appreciate it if you have the time

Thank you for all the advice

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I thought difficulties taking reductions might be part of the reason you were pushing yourself.

 

Yes, cutting on a good day seems likely to be problematic. In my experience, neurological repairs aren't linear; I might have a good day, then a bad day, then a good day, even in the middle of the peak of my withdrawal symptoms during a cut-and-hold. I dislike cut-and-holds for this reason. I do a daily micro taper, using tablets combined with liquid clonazepam; my current-use tapering methods are described in the link in my signature. Different medicine, but many aspects overlap.

 

For a medication like lorazepam, I suggest maintaining at least 3 daily doses until very late in your taper. This is possible to do with a scale, but I agree, it can get very difficult on the cheap ones. I think it's much easier to dose with liquid, but there are problems with that approach as well such as finding a reliable and tolerable liquid option, which I assume given your doctor situation will need to be homemade.

 

I'll be honest, it's my experience that the Gem 20 and similar inexpensive scales are wildly inaccurate when measuring milligrams. I own the same scale as Bob7, and it has a feature that hides the ongoing fluctuations in weight, but it's never giving me the same weight twice and often by as much as 10mg difference. For some people and some drugs, this isn't enough to cause a problem; for my sensitivity and especially for lorazepam, I wouldn't be comfortable with this approach.

 

Bob7 and others have explored methods to make these cheap scales more reliable, namely by combining crushed pills with micro-crystalline cellulose to make the pill weight per milligram of medicine much higher. This is a tedious but effective solution in my opinion.

 

By making the tablets weigh 10x more than they did previously, taperers can get out of the milligram measurements and into the centigrams. This could allow you to keep tapering by weight, but you'd have the challenges of learning the math, mixing crushed tablets with filler accurately, and then filling gelatin capsules by weight with the new tablet powder mix. At 3 capsules per day, this can be a fair bit of work.

 

My suggestion is to consider liquid. The easiest at-home liquid that I know of is to suspend tablets in a proprietary suspension vehicle; there are a few brands online, Versa Free, Ora-Plus, etc, and they're pretty inexpensive. These do not dissolve the medicine, but instead deconstruct the tablet and float the particles so that the tablet contents can be dosed by volume with a syringe. I like dosing with a 1ml syringe with 100 gradations because this has decent accuracy and minimizes the amount of liquid ingredients I need to consume.

 

Also, I suggest considering a daily micro taper (DMT). There is an online tool to generate a liquid or dry DMT schedule and while it takes some practice to use, it's a very powerful resource. I wrote an instructional on how to use it here:

http://www.benzobuddies.org/forum/index.php?topic=254653.5#post_generator

 

I hope Katz and others will weigh in on your situation regarding crossing or not. But I think their suggestions will be similar to my own. It's risky.

 

Let us know how we can help.

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Slow

I would like to take you up on your offer for a crossover plan for Ativan to Valium

Honestly not sure what I’m going to do but wud appreciate it if you have the time

Thank you for all the advice

 

Sure, it's pretty simple; I'm basing this off of Dr. Ashton's 6-step crossover for 3mg of lorazepam, dosed 3x per day. Since you have 2 doses, I suggest 4 steps each 1-2 weeks apart.

Here's a suggested schedule...

 

Step 1 - 0.25mg A AM, 0.1mg A 1.5mg V PM

Step 2 - 0.1mg A 1.5mg V AM, 0.1mg A 1.5mg V PM

Step 3 - 0.1mg A 1.5mg V AM, 2.5mg V PM

Step 4 - 2.5mg V AM, 2.5mg V PM

 

I suggest keeping in mind that step 4 is not stability, but a full 1-2 week adjustment period on the full 5mg diazepam dose, with 1mg of that dose still working its way up to potency. I suggest tapering again only after giving this last stage a full 2 weeks to adjust, or longer if you're still struggling to stabilize.

 

You may find you prefer more or all the diazepam in the evening; it has a 12-24 hour active duration so a single dose may be all that's needed per day. I think fine-tuning will be easier once you make it to step 4 of the suggested schedule.

 

I know tapering with lorazepam is complicated and difficult. So my earlier message hopefully addresses those options in basic, and this gives you a crossover to consider.

 

I hope this helps!  :thumbsup:

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Slow I read both of your replies thank you very much for the info

I wud like to do DMT but the methods seem rather complicated for me

Seems like it wud be hard to get the right amount in a siring and converting mg to ml

All seems overwhelming

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I understand how complicated it can seem at first. If you crossover to diazepam, I don't think you'll have want or need of a DMT. If you stay on lorazepam, the DMT schedule generator I linked to will do all the dosage calculations you'd need. We can help you get that started if you decide to stay with lorazepam. Otherwise, I'm wishing you luck and patience on your crossover.

 

If you get the chance, please let us know what next step you decide to pursue.

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Hey Slow doc insists no crossover is needed stressed over 30 yrs exp and director of substance abuse for the state. I am baffled by that. There is nothing on the net that says you can do this
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Are you abusing your medication? If not, maybe the state director of substance abuse isn't going to be the best support for you.

 

From what little I know about it, substance abuse carries a strong stigma akin to criminality. I've heard this can lead to some rough handling and insensitive treatment from doctors and recovery centers who think their patients are not worth listening to because they're "addicts".

 

If I was getting this treatment from my doctor, I would be looking for a new one.

 

There is nothing on the net that says you can do this

What does this mean?

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Sorry it wasn’t clear I meant to say there isn’t any drug information that says you can just substitute benzos, on the contrary all information I’ve seen describes a crossover transition

Which is why I was surprised by her answer and justification based on her experience

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Sorry it wasn’t clear I meant to say there isn’t any drug information that says you can just substitute benzos, on the contrary all information I’ve seen describes a crossover transition

Which is why I was surprised by her answer and justification based on her experience

 

Thanks for clarifying. I understand your concern. What are you thinking of doing next?

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Thanks slow ....Staying with Ativan for now and try to find a doc that understands. I’m on my 7th day of my last taper and still feeling depressed anxious etc appetite gone

Do you know if it’s possible to get liquid Ativan

I see it on online pharmacy’s but my primary doc insists he can’t get it

I suspect you wud have liquid K if it was possible

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Yes of course Ativan comes in a liquid:

 

This medication is a high-strength concentrated liquid. Use the provided medicine dropper to carefully measure the exact amount of medication prescribed by your doctor. You may mix the measured dose with a small amount of juice, water, soda, applesauce or pudding.

 

As for your doc asserting that no crossover is needed, my doc at the time would not cross me over, either. Indeed she wanted me to cut my Ativan in half for a week, then in half again, then in ??? and be done. I tried the cutting in half drill, got terribly anxious and a bit psychotic, and looked for another doc. During the cutting-in-half week, I found a Nurse Practitioner who helped me cross over and prescribed valium for the rest of my taper. Sometimes, ya just gotta change horses. I believe slow agrees.  ;)

 

So, just a thought.

 

Katz

 

 

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Thanks for sharing more of your experiences here Katz! I agree entirely, and psyche nurse practitioners, IMO, are an undervalued resource for taperers.

 

IME psyche NPs can be younger, better informed, and more available. I called so many psychiatrists unable to get any appointments and was waiting over a month for an initial visit with someone who must have been in his 80s (graduated med school in the 60s), but literally the first NP I called was available to meet within the week. The NP was really supportive as well and while not a tapering wizard or anything, he did not ever try to rush me. His goal was a "downward trend in medication dosage", same as myself.  :thumbsup:

 

Yes, commercially manufactured liquid clonazepam is not available by prescription in the US at this time. To be entirely honest though, I'm not sure I'd trust the ingredients if it was. I'd be sticking with my liquid/tablet hybrid taper to minimize the impact of any liquid I used.

 

I don't mean to put you off of liquid lorazepam at all; it could be a great option for you and convenient. I'm wary of going all-liquid on something with so many ingredients, but if and when you get to that bridge, I do believe it could be crossed. Ideally with a gradual transition from tablets or a liquid/hybrid approach, IMO.

 

Joeb, it sounds like you have options, and maybe better options if you change care providers.

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His goal was a "downward trend in medication dosage", same as myself.

 

So odd you would say that, slow. My NP said virtually the same thing. She never balked when I had to  make infinitesimally small reductions. She willingly kept my valium prescription coming, as long as, in her words, "the general direction was down". Your NP and mine mustthave attended the same School of Common Sense and Compassion.

 

Joeb, it seems you have several options here. I just want to add another one. I couldn't tolerate liquid valium -- the artificial sweetener, the artificial taste, the color . . . nope. But as I needed to make tiny reductions, I needed a liquid. So I made my own. I know this is not a popular topic on here, but it's possible to dissolve your benzo in say, Everclear or us PG to make a suspension, add water, and get something that will let you make small reductions. So . . . just a thought.

 

Wishing us all well,

 

Katz

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Your NP and mine must have attended the same School of Common Sense and Compassion.

:laugh:

 

In addition to trying to make a solution/suspension of a benzo using a solvent as Katz mentioned, there's also the option of making a pure suspension from tablets. Suspensions are when tablets deconstruct but the particles do not necessarily dissolve, and instead are floated in something with enough viscosity to allow a good window of time during which to take a reliable liquid dose. An easy at-home option in my opinion is Ora-Plus (the regular stuff, without sweeteners).

 

Here's more information on proprietary suspension vehicles...

https://fisherpub.sjfc.edu/cgi/viewcontent.cgi?article=1189&context=pharmacy_facpub

 

The beauty of a liquid from tablets is being able to divide a tablet into smaller pieces than a pill cutter could; it does this by distributing the same medicine across a volume of liquid and taking a tiny "tablet piece" with a measuring tool like an oral syringe.

Options options options.  :smitten:

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Greatly appreciate all the replies

I was originally considering water but I see the inaccuracy in it

How exactly would I use the suspension vehicle. Is it fairly simple like adding a measured amount of water and pills. Sorry I’m a bit overwhelmed and not myself

 

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