Need HELP with lorazepam taper plan, please!

Need some advice. I'm so confused, scared and have no idea how to proceed. Here's my story...

 

I started Ativan the last week of June 2021 at 0.25 mg - 0.75 per day. I took between 0.75 mg - 1 mg once daily between July 1, 2021 and July 19, 2021. So a total of roughly 4 weeks.

 

Started taper with doctor on July 20th. First 10 days of taper was 0.75 mg per day, second 10 days was 0.5 mg, third 10 days was 0.25 mg, final 10 days should have been 0.125 mg. I split each of these daily doses in half to take twice per day to prevent interdose withdrawal, but it still happened due to the short-acting nature of Ativan. I got down to 0.125 mg once per day last week and had to stop. Made it a total of 7 days at this dose before the general withdrawal (and interdose withdrawal) was just too intense. Went back up to 0.25 mg per day, split into 2 doses. Now I'm on the edge of my seat all the time and miserable. Updosing didn't help me stabilize. I'm at a loss for what to do? Doc says I shouldn't have this kind of tolerance to Ativan after only 2 months on it at such a low dose. But I know now there is no such thing as a low dose of a benzo! And the taper he put me on was far too rapid. Any advice for how to continue tapering? I'm not functional now at all, even after updosing to 0.25 mg, and not sure what to do. I thought going back up to it would help but now I'm even worse than before. Don't know if I should try and switch to Valium, water titrate the Ativan, continue cutting dry pills, etc. I'm not sleeping AT ALL so all this is beyond overwhelming. Any help would be greatly appreciated!

RoadtoHealing,

I'm sorry to hear how much you're suffering right now. It sounds like your assessment is accurate: your doctor tapered you too quickly for your nervous system.

 

Lorazepam has a short half-life, so 10 days is usually enough time to eliminate the drug and realize withdrawal symptoms. However, 10 days is not necessarily enough time to recover from the neurological effects of a reduction, but the fact that you only got overwhelmed with symptoms after 7 days at 0.125mg suggest to me that the initial reductions may have been tolerable, and the previous reduction or two just caught up to you as you were trying to stabilize at 0.125mg.

 

I suspect that returning to 0.25mg/day has actually helped, perhaps much more than you realize. There's no control-subject in this experiment, so none of us can say what would have happened had you not updosed, but I imagine it would have been worse. Furthermore I think that a return to neurological stability can take time; I don't think it's just the drugs that are causing all the symptoms and in my experience it can be days to weeks at an updose before feeling a return to stability.

 

I don't agree with your doctor that you "shouldn't have this kind of tolerance to Ativan after only 2 months" or that it was "such a low dose". 2-4 weeks is plenty of time to develop physical dependence to this class of drugs; as far as I know, a suggested jumping (cessation) dose for lorazepam is around 0.05mg, very far from your 1mg/day taper start dose.

 

My suggestion is to hold at 0.25mg/day, and consider that the withdrawal symptom of anxiety can cause poor decision-making until neurological stability is restored. You may be reluctant to wait in your discomfort; this is common, and may be one of the hardest parts about stabilizing after being overwhelmed with withdrawal symptoms. However, it is my opinion that your taper, while rushed, was giving you good feedback along the way and higher doses may not be necessary to stabilize.

 

Keep us posted. Let us know how we can help. 

Thank you so much for your reply. It's REALLY, REALLY hard right now. I don't sleep at ALL and am completely overwhelmed by anxiety and intrusive thoughts. My doctor is useless and I'm having a hard time finding another one. I was prescribed Trazadone for sleep (doesn't help) and Mirtazapine (horrified to take after hearing such terrible stories of people trying to come off it). I tried 7.5 mg of it once and felt really weird, groggy and super hungry. I can't do anything right now other than pace. :-(

I understand you're feeling very dysfunctional right now. It's my suggestion to avoid experimenting with other medications until you have found some relief with your benzo; in my opinion new medications especially can complicate both understanding what is causing what, and sometimes impede recovery (especially if they're GABAa receptor agonists like alcohol, z-drugs, some herbs, etc).

 

It sounds like you're experiencing akathisia. This is a common withdrawal symptom.

https://en.wikipedia.org/wiki/Akathisia

I suggest reaching out on the Withdrawal Support board for commiseration and suggestions on managing your symptoms, and also explore the support boards for specific symptoms, such as the Insomnia board.

 

Were you experiencing withdrawal symptoms before getting to 0.125mg?

If so, could you tell us what they were and what severity?

Thank you so much for the reply. It truly means the world to me. I feel so desperate and alone right now.

 

Yep, what I'm experiencing does sound like akathisia. I'm avoiding any and all GABA receptor agonists right now as my system is so messed up from the Ativan. I also have OCD (which is largely a GABA issue...not enough gets to the right parts of the brain) so having my GABA going haywire is beyond terrible. Lots of intrusive, repetitive thoughts and inner panic.

 

Yes, I was experiencing withdrawal symptoms before getting to 0.125 mg. Mostly intense rebound anxiety between doses. Hard to concentrate, impossible to distract myself, hard to think of anything else other than the anxiety building up in me. Difficult to meditate. I wanted to complete the taper and thought this was all normal and would subside quickly, per what my doc told me. :-( I began having these symptoms when I got down to 0.5 mg. I also wasn't sleeping much, maybe an hour or 2 per night. I kept going on the taper though, despite them, because I thought they would be go away quickly. I had no idea about benzo withdrawal/rebound anxiety like I do now. :-(

Thank you for sharing more information with us. Your symptoms sound severe; I'm sorry that your taper was so rushed and adjustments weren't made earlier based on symptoms.

 

If you were experiencing intense rebound anxiety between doses (aka interdose withdrawal) at 0.5mg, that's giving me the impression the entire taper has been problematic.

 

I'm sorry that you doctor told you these symptoms would subside quickly; that sounds like a misleading assumption. "Intense rebound anxiety" emerging between doses sounds like a nervous system that is struggling to make the adjustments needed to adapt to being without as much sedative; I believe this is the root of withdrawal symptoms and in my experience they do not improve by taking further reductions without first stabilizing.

 

Unfortunately, it has been my observation that updosing does not immediately fix the problems caused by overly rapid reductions. However, I made my suggestion about holding at 0.25mg based on the limited information we had before. From what you most recently describe a 0.25mg dose does not sound sufficient to treat your severe withdrawal symptoms which you mention began once you got below 0.75mg.

 

The general suggestion I give people who seem to be needing an updose is to return to a daily dose that they were previously stable at. It sounds like this dose was 0.75mg in your case.

 

Will your doctor support a return to 0.75mg/day, a period of stabilization and a slow, symptom-based taper schedule?

 

General information regarding benzo withdrawal practices, written for prescribers...

https://benzoreform.org/wp-content/uploads/2020/11/Pamphlet-3-BZRA-Discontinuation-1-Getting-Started-v1.2.pdf

I will see today if he is agreeable to the 0.75mg/a day dose, period of stabilization and a slow, symptom-based taper schedule.

 

He's eager to start me on Paxil for my anxiety/OCD but, I'm resistant to that idea. And wants me on the Mirtazapine. Your thought still stands that this is not the way to go?

 

My hope is that I can make it through a taper without additional meds for anxiety/OCD without losing my mind. I managed them fairly well without meds before the Ativan. Ironically, I got sucked into the Ativan spiral when I was given it for insomnia after experiencing terrible stomach pain that was keeping me up at night. :-(

 

 

 

In my humble observations, more psyche meds equals more problems. I say that generally, and I'd also be inclined to say, eventually. Meaning that by my observations more psyche meds also equals more problems over time.

 

My experience and opinions diverge from the medical care you are receiving so I am emphasizing this. I don't believe we possess the capacity in medical science to heal any mental illness with medications, and that the profits of the psyche pharmaceutical industry, for which your doctor is an agent, are based on selling fictitious ideas about chemical imbalances designed to support the application of short-sighted chemical augments with long-term and possibly severe health consequences. Again, that's where I'm coming from on all this. I love doctors; I just don't like when they make people sicker.

 

Starting a new medication in the immediate fallout of a failed benzo taper seems very risky and confusing to me, especially if it was my first time tapering the benzo and experiencing this severity of symptoms. I suggest considering that new medications are medication trials. They're literally experiments you are consenting to being done to you, with no guaranteed results. In fact, like the lorazepam, many of the psyche drugs I am aware of that are effective for benzo withdrawal carry physical dependency issues, sometimes described by buddies as being equally difficult to withdraw from as the benzo itself.

 

I've heard it's common to experience increased anxiety starting SSRI antidepressants like Paxil, although I've also heard that Remeron (mirtazapine) helped some buddies, even though I believe it needed to be tapered after the benzo.

 

I want to help you in any way that I can to get through a taper without additional meds. Slow, patient-led, symptom-based tapering is how I'm doing it. A supportive doctor, or at least a steady prescription of medication, is typically required for slow tapering.

 

Supportive doctors seems like they're in short supply right now, but myself and others have had luck reaching out to psyche nurse practitioners. For lack of support, a steady prescription of the benzo and an at-home tapering approach is also common around the forum and can lead to a successful slow taper.

 

Sorry for the ramble. I hope some of this was useful. 

Yes, I agree. Adding in psych meds would only further to complicate my current state. I declined all of them at my appt. last week and my doctor no longer wishes to see me as a patient anymore. :-( Fortunately, I have found a new doctor who I believe will be supportive with a slow taper. Fingers crossed!

 

Also, some good news...I've bee back at 0.25 mg per day for 11 days now and I seem to have stabilized. My thinking is a lot clearer and I feel like I haven't lost my marbles like I did for the last 11 days!    Right now I'm doing 0.125 mg in the AM and 0.125 mg in the PM. Sleep is not great but I'm managing 4-5 hours or so with nothing as a sleep aid other than 1 mg of melatonin. Rebound anxiety is there but not as quite as bad. I need to be dosing more than 2x a day with Ativan and I think that would help with the rebound. Which leads me to my next question...

 

My thought is to do a direct taper (dose 4x a day?) instead of going through the hassle and possible issues that a Valium substitution might bring since I'm already pretty low at 0.25 mg daily. And I have existing stomach issues that I don't want to irritate with trying to crossover to Valium. Eager to get your thoughts/insights on this idea? Common to come off Ativan at 0.25 mg?

 

I also need to figure out HOW to continue tapering (safely and carefully!) and make a schedule. Can you help me with this? I can't cut my 0.5 mg any pills smaller than 0.125 mg. Was going to see if I can get a script for liquid Ativan at a local compounding pharmacy. I'm not sure how to instruct my doctor when it comes to writing the order (figuring out how much I'll need, etc.) Thoughts on this? He's never prescribed a liquid taper before and said I needed to figure that part out. How? I've seen people using a scale to measure dry pill crumbs, but not sure how accurate the scales actually are. Seems to be hit or miss for folks using that method. Would water titration be overkill for my situation?

 

Sorry for all the questions! Ready to get started. Staying at 0.25 mg for another few days seems wise, while I gather my taper materials and make a plan. Just not sure how to do it. :-)

 

Thank you so much in advance! Your help is so amazing!

Hello RoadtoHealing,

I'm really glad you stood up for your medical preferences, and to hear that you have a new doctor who you believe will be more supportive of your need for a slow taper. Patient-led, symptom-based tapering really is the best approach I know of for benzo recovery. Formulaic taper plans have low success rates.

 

I'm also relieved to hear that you are stabilizing after 11 days! Stabilizing can be quite an anxious waiting game; I'm relieved that you stuck it out and are seeing improvements. I think it's great that you're getting some sleep, and I think you will get more sleep with further stabilization and slower reduction. Melatonin is something I also use; I take 0.5mg/day. I've found it's a safe way to keep my sleep rhythm steady despite everything.

 

I agree with your risk assessment of a crossover. I think your dose is low enough that a direct taper might be the safest option at this time. I also agree that more doses will likely be needed to improve your neurological stability; lorazepam has an inconvenient half-life in my experience.

 

One quick thing about dosing schedules: changing them can cause withdrawal symptoms IME. I've done very slow rotations of my doses as I went from 4 doses per day to 2, but this is tedious. I suggest planning ahead, making the change on the same day, and then holding for a week or so while expecting a brief uptick in symptoms. The upside is that I expect adjusting to a more frequent dosing schedule will reward you with significantly reduced interdose withdrawal.

 

I suggest 3-5 doses per day. I suggest leaving at least 8 hours between doses at night for sleep. This leaves 16 hours during which to take doses, which makes 5 doses 4 hours apart, or 4 doses 5-6 hours apart, or 3 doses 8 hours apart. What you choose might depend most on your lifestyle (meal schedules etc) and how severe your interdose WD is. I think 5x day or 3x a day are easier to implement, math wise, but 4x could be your happy medium.

 

When to take doses is really easy compared to HOW to take doses, and more specifically how to take reductions. There are so many ways...

 

You mentioned liquid compounding. At least in the US, there is a commercially manufactured liquid lorazepam that is available at 2mg/ml; this seems like it would be easy to get prescribed and likely covered by insurance. I think to use this form it would need to be diluted each day, maybe with a daily liquid discard. With a 1ml syringe with 100 gradations you could put 0.15ml (0.3mg) into 100ml-300ml of water, stir well, then a discard quantity removed from the middle of the volume of liquid. The remainder stirred well and divided into separate jars for each dose of the day. The discard quantity of a daily liquid discard is gradually increased, sometimes daily, sometimes weekly or bi-weekly; eventually all the liquid is gone and the taper is over!

https://go.drugbank.com/drugs/DB00186#products-header

 

There's also water suspension (typically also a daily liquid discard), which I generally dislike because the reliability is nebulous but every method has it's risks and water suspensions are extremely simple. Using lots of water, lots of shaking, quick discards or dosing, and a consumed rinse phase seem like tricks that help to improve the odds.

 

We also have research data that proves that pure lorazepam can be dissolved at a maximum of 0.2mg/ml in 20% ethanol. This information could suggest a method where alcohol is used to attempt to dissolve less than 0.2mg/ml in 20% ethanol, either by a compounding pharmacist or at-home using familiar tablets. A 0.1mg/ml solution made this way might be all you need, and the ethanol content is a very small amount per day. Again, a 1ml syringe with 100 gradations is involved.

 

Source: Abolghasem Jouyban, Javad Shokri, Mohammad Barzegar-Jalali, Davoud Hassanzadeh, William E. Acree , Jr., Taravat Ghafourian and Ali Nokhodchi, Solubility of Chlordiazepoxide, Diazepam, and Lorazepam in Ethanol + Water Mixtures at 303.2 K, J. Chem. Eng. Data, 2009, 54 (7), pp 2142–2145, April 22, 2009.

 

There are other ways to do liquid. At-home suspensions, with or without a solvent soak stage (usually alcohol), with or without a proprietary suspension vehicle like Ora-Plus, etc. But I've detailed some of the basics.

 

Lastly, there is dry tapering. And dry tapering can be done, IMO, either with filler and a cheap milligram scale or with an expensive milligram or sub-milligram scale ($500-$700 on Amazon should do it). I think there are a number of important tricks to doing this process reliably and some of them are very fiddly. The cheap scales are garbage for accuracy but as with water suspensions, for some people it's just enough accuracy to get them through their taper. At your dosage and your need for multiple doses per day, I wouldn't use a cheap scale without filler. Bob7 details one way to approach filler on his site benzodrytapermath.com. It's tedious, but I think it goes a long way to get more reliable small doses from tablets.

 

So that's some of the territory. A commercial liquid lorazepam is available by script in the US, and you could dilute some with water each day to make your doses. Liquid is nice because it's easy to measure and really easy to split up into the smaller doses for inter-day dosing.

 

If you haven't seen it already, Jim Hawk's DMT schedule generator takes all the math out of daily micro tapering, whether it's dry, wet, liquid discard, whatever! I wrote an instruction because his online form glitches and people have really struggled with it, but it's a cornerstone of my taper and invaluable for me.

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

 

I'm a little fried at the moment; too much screen time. I hope this was helpful. If I didn't answer all your questions, please ask them again. 

I know you have other people helping you, but your current dose is fairly close to where I began also on Lorazepam. You can see my taper schedule thus far in my signature.

 

I have been doing a liquid micro taper.

 

I wish you the best of luck with your taper and am glad that you are feeling better.

Thank you 3BNN1EE2JG!

 

How did you find syringes that go that low? Lowest I've found is 1 mL syringes.

 

My local compounding pharmacy says they can custom compound lorazepam for me. I need to be dosing 3-4 times a day (right now only 2 and having inter-dose WD's). At 0.25 mg per day currently. I need to figure out how to tell the doc how to write the script for how much I'll need. I want to do a 10% reduction every 14 days. I used Jim Hawk's DMT schedule generator to try and get an idea for how the script should be written (how many mg of Ativan in mL's) and I'm lost. How can I figure this out? It's also not giving me 3 /4  times a day dosing for the duration of the taper on Jim Hawk's generator. Starts at 3 or 4 doses per day, then goes down to 2, then 1. Advice? Meeting with doc tomorrow!

 

Also, you mentioned that in another post that the compounded route didn't go well for you? How was it different from the pills for you as far as how you felt?  If my doc isn't comfortable with the compounded route, I may have to do water titration with pills. What's your process and has it been smooth?

Hi slownsteady,

 

THANK YOU for such an amazing, thoughtful, detailed reply! Your explanations are superb and so very much appreciated. <3  You're like my guardian angel and give me so much hope for the future! From the bottom of my heart, thank you for all your wonderful help!!!

 

My local compounding pharmacy says they can custom compound lorazepam for me and I want to give this option a go. Seems like it would be theoretically easier than the commercially prepared solution (no diluting). I need to be dosing 3-4 times a day (right now only 2 and having inter-dose WD's). At 0.25 mg per day currently. I need to figure out how to tell the doc how to write the script for how much I'll need. I want to do 10% reduction every 14 days. I used Jim Hawk's DMT schedule generator to try and get an idea for how the script should be written (how many mg of lorazepam in mL's) and I'm lost. How can I figure this out? It's also not giving me 3 or 4 times a day dosing for the duration of the taper. Starts at 3 times per day, then goes down to 2, then 1. Any advice? Meeting with doc tomorrow! Sorry for all the questions...this inter-dose WD is awful and puts me off my game. :-(

 

Also, lowest syringe I'm finding is 1 mL. Where do you find them lower?

 

Hello RoadtoHealing,

I'm glad that post was helpful for you! It's hard to summarize the options; tapering is a live-and-learn type of experience, for me anyways. I tried pill splitting only, I tried compounded suspensions, I tried dry tapering, I tried homemade liquid, and I tried a compounded solution. I'm actually making my homemade liquid clonazepam from tablets as I type; I'm switching back to this after a few months with a compounded solution. I'm still learning!

 

For using the generator: choose "Across Doses" in the "Planned reduction" section (right before the Submit button). The default is "First dose first" but that's not appropriate if you want to keep your number of doses. Let me know if that fixes it!

 

Could you tell us more about what it is your compounding pharmacy is offering to make? Is it a suspension in something like Ora-Plus? If so, did they tell you what ingredients are in the suspension vehicle they're using? Are they making it with crushed tablets or pure lorazepam? What concentrations are they offering to make?

Thanks for the tip on the generator! Yes, that fixed it! 

 

https://www.amazon.com/1ml-Syringes-Caps-Pack-25/dp/B06ZZ4BZ15 - are these the best type of syringes to use? I think these will be the most accurate out there. 0.01 mL.

 

Not sure how the pharmacy will do it, but I'll find out. Should have asked for more details over the phone!

 

Are crushed tablets better than pure lorazepam? And are certain suspension vehicles better than others? I'll go in with this info. tomorrow to discuss with the pharmacist (if you happen to see this tonight or tomorrow morning and have a chance to get back to me, if not no worries). Not sure what concentration they will be willing to make but it's gotta be something like 20 mg/200 mL or something like that for the syringe, I think.

 

THANK YOU!!!

https://www.amazon.com/1ml-Syringes-Caps-Pack-25/dp/B06ZZ4BZ15 - are these the best type of syringes to use? I think these will be the most accurate out there. 0.01 mL.

 

Are crushed tablets better than pure lorazepam? And are certain suspension vehicles better than others? I'll go in with this info. tomorrow to discuss with the pharmacist (if you happen to see this tonight or tomorrow morning). Not sure what concentration they will be willing to make but it's gotta be something like 20 mg/200 mL or something like that for the syringe, I think.

 

I have purchased the syringes that you linked to, but I did not like them and tossed them. In my experience the pharmacy gives an appropriate oral syringe with every order. These are very similar to the syringes I get from the pharmacy:

https://www.amazon.com/gp/product/B01628CDEE

 

If you're going to switch over to liquid entirely, I think pure lorazepam might be the better option. I am actually going back to liquid made from tablets personally, but my taper technique is liquid/tablet so I need the liquid to be bioequivalent to the tablets since I use both concurrently.

 

Going with pure lorazepam in your case is probably better because then you won't have to worry about your compounding pharmacist switching tablet manufacturers on you; I've heard this does happen, they don't have to warn you about it, and many buddies report issues with changing between generic tablet manufacturers.

 

Yes, not all suspension vehicles are created equal. They're a very complex topic, and often contain a complex of ingredients, some of which are intolerable for some people. There are preservatives, pH buffers, anti-foaming agents, sweeteners, etc, all of which seem like a liability to me. You can read more about them here:

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

 

Also I don't recommend oil-base suspensions; these did not work for me, and I think it's because of involving digestion in the process of absorbing the medicine.

 

I personally would try the commercially manufactured solution first because dilution offers some significant benefits; benefits like consuming a very small amount of the additional ingredients and being able to take small regular reductions (such as daily) from a large volume but then divide it up evenly throughout the day. Not to mention insurance coverage, and easy prescriptions. Not to make you doubt yourself, but just to be clear where I'm coming from. Dilution isn't perfect, but I just like the options it offers.

 

FYI 20mg/200ml is 0.1mg/ml. I think the reduced form of the fraction might be easier to communicate about with doctors and pharmacists. I think that's about the range you'll want to use if you get compounding. And yes, if you go with that concentration, you might be limited to bi-weekly reductions.

 

I hope this helps! Good luck tomorrow. 

Hello, RoadtoHealing.

 

Tip of the hat for reaching out to a compounding pharmacist for information and support. A qualified and experienced compounding pharmacist can be a valuable ally during benzodiazepine discontinuation.  For example, s/he can tell you exactly what your doctor needs to write on the prescription for your compound.  Compounding pharmacists can also supply you with high-quality oral syringes and adapter caps, teach you how to use a syringe to measure your dose, and help you with calculations.

 

Please be sure to ask the compounding pharmacist for specifics about the formulation s/he plans to use. Who developed the formulation?  Has it been stability-tested?  What does it use for the drug source (pure active drug substance or regular tablets)? Is it a solution or a suspension?  What ingredients does it contain in addition to the drug? What is its shelf-life?  What are the storage requirements?

 

I’ve included references below to stability-tested formulations for a 1mg/mL oral lorazepam solution as well as a 1mg/mL oral lorazepam suspension you may wish to share with the pharmacist.  (I also can provide contact information for a compounding pharmacy that has a formulation for a 0.1mg/mL lorazepam oral solution if your pharmacist is interested.)

 

Stability-Tested Formulations:

 

Vossen, A.C. & Velde, I. & Smeets, O.S.N.M. & Postma, D.J. & Eckhardt, M. & Vermes, A. & Koch, Birgit & Vulto, Arnold & Hanff, L.M.. (2017). Formulating a poorly water soluble drug into an oral solution suitable for paediatric patients; lorazepam as a model drug. European Journal of Pharmaceutical Sciences, pp. 205-210. Accessed online at: https://www.sciencedirect.com/science/article/pii/S0928098717300490

 

Wan-Man Ellaria Lee, Ralph A. Lugo, William J. Rusho, Mark MacKay, and John Sweeley. (2004). Chemical Stability of Extemporaneously Prepared Lorazepam Suspension at Two Temperatures. The Journal of Pediatric Pharmacology and Therapeutics: October 2004, Vol. 9, No. 4, pp. 254-258. Accessed online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3469120/pdf/i1551-6776-9-4-254.pdf

 

Thanks Libertas! 

Hi Libertas,

 

Thank you so unbelievably much for all the helpful info. I appreciate it so, so, so much! The contact information for the compounding pharmacy that has a formulation for a 0.1 mg/mL lorazepam oral solution would be amazing!!! As I discovered yesterday, it is not very well known how to do this among pharmacists.

 

My pharmacist wanted to put crushed lorazepam tablets into PCCA Suspendit.

My pharmacist wanted to put crushed lorazepam tablets into PCCA Suspendit.

Hi RoadtoHealing,

 

Suspendit seems like a decent suspension vehicle at first glance, but I think a solution per the first method Libertas provided could be a much better option. Using pure lorazepam makes the most sense to me given your goal of a total switch to liquid.

 

Both of Libertas' suggestions are for 1mg/ml concentrations; I wonder if the first could be made into a 0.1mg/ml solution instead for easier dosing given your current daily dosage. The alternative, mentioned before, is a daily dilution which may be necessary anyways to get your dose easily divided throughout the day.

 

How did your doctors appointment go?

Do you intend to do a step-wise transition to liquid?

Hi slowandsteady,

 

I asked about the commercially manufactured liquid lorazepam that is available at 2mg/ml. Apparently it's for IV use and the pharmacy won't prescribe me a bottle and let me dilute at home. :-( I agree that would have been the better option! The dilution ability would have made for some really nice customization.

 

Pure lorazepam compounded was going to be at least $75 for a 2 week supply! Yikes!  $35 every 2 weeks for crushed tablets compounded (and they are a different manufacturer than my current ones). Ugh.

 

Doc appt. went well. He's good about letting me try out these various options.

 

Hadn't considered going step-wise to liquid? Was just going to go straight to it but not advisable?

 

None of this is easy and I'm so tired, I can't see straight. Have got to get these inter-dose WD's under control. Talk about quality of life down the tubes.

 

Finding a way to stick to my familiar tablets is starting to look better and better from a $$$ and safety standpoint. My body won't reject them the way they may a liquid.

 

You mentioned this several posts ago....."We also have research data that proves that pure lorazepam can be dissolved at a maximum of 0.2mg/ml in 20% ethanol. This information could suggest a method where alcohol is used to attempt to dissolve less than 0.2mg/ml in 20% ethanol, either by a compounding pharmacist or at-home using familiar tablets. A 0.1mg/ml solution made this way might be all you need, and the ethanol content is a very small amount per day. Again, a 1ml syringe with 100 gradations is involved." I could use my tablets and make at home. Hmmm.......

 

As always, thank you by the way. I would be so lost without you. Sending over a big virtual hug! When this is all over for both of us, we should totally celebrate! 

 

RoadtoHealing,

I know how complicated this can be, and frustrating when we're already struggling with withdrawal symptoms. Your virtual hug is reciprocated.  Let's celebrate today together! I like small milestones; we've made it this far. One step at a time.

 

Speaking of steps, step-wise to liquid is just a suggestion; it's not necessary, but if it's easy I'd suggest doing it. It could be only two steps, each with a 1-2 week hold. The idea is just to make whatever adjustment is necessary for your body to use the liquid into a smaller adjustment done in stages; or you could just switch entirely to liquid and hold for 1-2 weeks or until stable again.

 

Whomever told you that 2mg/ml lorazepam oral concentrate was for IV use was confused. Here's a list of oral concentrates available in the US according to DailyMed:

https://dailymed.nlm.nih.gov/dailymed/search.cfm?adv=1&labeltype=all&query=NAME%3A%28lorazepam%29+AND+34068-7%3A%28liquid%29

 

Here are the instructions from the manufacturer of one such concentrate...

Lorazepam oral concentrate is a concentrated oral solution as compared to standard oral liquid medications. It is recommended that Lorazepam Oral Concentrate be mixed with liquid or semi-solid food such as water, juices, soda or soda-like beverages, applesauce and puddings.

 

Use only the calibrated dropper provided with this product. Draw into the dropper the amount prescribed for a single dose. Then squeeze the dropper contents into a liquid or semi-solid food. Stir the liquid or food gently for a few seconds. The Lorazepam Oral Concentrate formulation blends quickly and completely. The entire amount of the mixture, of drug and liquid or drug and food, should be consumed immediately. Do not store for future use.

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=bf265c2e-ab2f-42e5-96cf-3998eb5a644d

 

The manufacturer is recommending that you to dilute it. How much you dilute it and what you do with that dilution (daily liquid discard, etc), is not something I expect the pharmacist would know about or be able to help with. But clearly dilution is expected, so again, someone was confused.

 

I made sure to include the instructions to consume immediately and not store for future use, even though I think these last details are overly cautious.

 

I would guess that in the refrigerator a dilution would still be viable within 24 hours, especially if agitated before consumption. There is a risk of the medicine precipitating out during this time and at these temperatures, but I think this isn't so much of a problem once it's been reduced and divided into individual doses. I suggest considering making a dilution in the morning at room temp, at that time taking the discard amount and dividing it into glass individual dose jars, and storing the rest of the days doses in the fridge until use. I'd also do a little rinse of the dose jars after consuming each one and drinking the rinse water, for good measure.

 

Lastly, yes, I think you could make small-batch non-stability-tested homebrew of lorazepam at-home from familiar tablets. We have data that defines the maximum solubility of pure lorazepam in various ethanol and water mixtures, so erring on the side of caution I think it can be done if generous ethanol is used (still a tiny amount per dose), and the resulting intended-solution is treated like a water suspension from a handling and dosing standpoint for safety. This is what I'm doing currently with clonazepam.

 

I think your compounding pharmacy is offering to charge an arm and a leg! I suggest following up with a pharmacist at an ordinary drug-store pharmacy with the info from DailyMed and see if they can supply a liquid lorazepam oral concentrate like one of the seven commonly available. One brand that I've heard people use is Intensol, but there are others as seen from the search linked above.

 

It sounds like the gears are turning for you!

I know good things will come from all your hard work and planning.

Hello again, RoadtoHealing.

 

If I were in your shoes, I would find a different compounding pharmacy.  The pharmacist you talked to gave you incorrect information and imo is over-charging. As is true of all businesses/service providers, there are good compounding pharmacies and not-so-good ones; due diligence is required to find the former.

 

In the US, lorazepam is indeed available as a 2mg per mL oral solution.  You can verify this at DailyMed (see link below) or at:

 

https://www.goodrx.com/lorazepam

 

Locate the Prescriptions Settings menus at the top of the page.  Leave the Brand menu as is (it’s set to “generic”). Select “dropper” from the Select Form menu.  The Dosage menu will change to “30mL of 2mg/mL solution.” Leave the Select Quantity menu as is (it’s set to 1 dropper). A list of popular pharmacies will appear along with the cost of 30mL of the 2mg/mL solution.  As you’ll see, prices are quite reasonable — in the $17 to $22 range without insurance.

 

PS The compounding pharmacy I mentioned upthread is Drug Crafters (DC) in Frisco, TX.  According to its website, DC serves 19 states (it may or may not be licensed to ship controlled substances such as lorazepam interstate — you would need to ask).

 

DailyMed Link:

https://dailymed.nlm.nih.gov/dailymed/

 

Search first for lorazepam, then look for “LORAZEPAM concentrate” or “LORAZEPAM solution, concentrate.” If given a choice, I would select Lorazepam Intensol™ Oral Concentrate USP, NDC 0054-3532-44, packager: West-Ward Pharmaceuticals. You would need to find a pharmacy that can obtain this particular generic from its distributor/supplier and your doctor would need to specify the packager and NDC — National Drug Code — on the Rx. Two final points: (1) we have several members who have used/are using the oral lorazepam concentrate to taper and (2) note that the instructions on how to use the concentrate state that the entire amount of the drug/water/food mixture should be consumed immediately, not stored for future use.

Hi Libertas,

 

Thank you for all the wonderful information! Your help and insight is beyond amazing and I really, really appreciate it. <3

 

Yes, the first pharmacy was indeed mistaken about the 2mg per mL oral solution of lorazepam. Thank you for the links!

 

I did go to 2 other compounding pharmacies after visiting that first one and took along your stability-tested formulations articles with me, along with a list of questions (many of which you mentioned to be sure and ask...thank you!) They said Suspendit would work just as well and they are familiar with it. I couldn't find any research to support the use of lorazepam in Suspendit so it would be new territory.

 

Both want to put pure or crushed lorazepam into PCCA Suspendit if I go the compounded route. No flavorings or other ingredients. It would be a 0.1 mg/1 mL suspension supplied in a plastic bottle containing 140 mL of the suspension along with 1 mL syringes that measures to .02 gradations, so not perfect but I can get pretty close on dosing. Both pharmacists are assuring me that by using fresh Suspendit and fresh lorazepam, the suspension will last in the fridge for weeks. 140 mL would get me through a chunk of my taper. Cost would be roughly $25-$30. No diluting would be required. I would take my 4 daily doses right from the bottle with a syringe after a good few shakes. What are the red flags you see with this approach?

 

Otherwise, the Intensol oral lorazepam concentrate looks like a good bet and should be easy to get. Thank you for the info! Diluting each day wouldn't be bad once I got the hang of it, I think. I'm so worried I'm going to make a mistake with it for some reason. Making a small-batch homebrew of lorazepam at-home from dry pills with ethanol and then doing a water suspension is also a great idea from slowandsteady. So many options!

 

 

New to the thread here. I am currently tapering off of Ativan from 2 failed tapers and kindling. I managed to stabilize and through slowandsteadys help have been totally successful so far during this taper. There have been some terrible days/nights but I’ve fought through them and never upped my dose.

 

First and foremost once you find a dose you can get steady on you need to work on your mental health through a professional. Benzos are a bandaid, you’ve got to work hard on the real underlying issues as you will need the CBT coping skills to fight through the mental aspect and withdrawal. It’s not easy but it always can be done. I’ve had to retrain how I think and not resist the withdrawals but invite them in.

 

I’ve mixing a daily water alcohol titration and am down from 1mg to 0.35 in 4 months. If you have any questions please reach out