Need advice on Ativan to Valium crossover

I am currently on .375 Ativan and have seen some forum info that this dose is low enough to directly cross over. If not, would appreciate perspectives on how to go about it

I am dosing 3 times a day.

Hi Joeb!

 

Short to long-acting benzo crossovers are notoriously uncomfortable. The short-acting benzo typically loses it's blood serum levels before the long-acting benzo is up to equivalent potency. The goal of a step-wise crossover is to make this lapse in benzo dosage into smaller chunks taken weekly or bi-weekly, so as to be more tolerable.

 

I don't know of a therapeutic dosage of benzo where this effect wouldn't occur, so I don't agree with the opinion that your dosage is "low enough" for a sudden crossover. Anyone can do a sudden crossover; it's just the most uncomfortable method of crossing.

 

Generally the buddies around here need the slow approach and appreciate the results of step-wise transitions, even just between different forms of the same drug.

 

Since you are dosing 3x/day, I suggest considering a 3-step crossover schedule, each step replacing one of your daily doses with the equivalent in diazepam, with 1 week between steps (or longer if you need to stabilize). I suggest replacing your last dose first, per Ashton's usual guidelines. 1mg lorazepam = 10mg diazepam per Ashton, so the equivalency math is pretty easy. If you want help putting together a step-wise crossover schedule, please let us know the exact dosage of each of your three daily doses.

 

Let us know how we can help. 

Thanks slow they are .125 morning .125 midday .125 night

Also I started by replacing the night dose 1.25valium

For the last 4 nights but not sure o want to continue

I feel ok but having second thoughts

Wud I get slot of withdrawl if I went back?

If I continue what approach wud you recommend

 

Wud I get slot of withdrawl if I went back?

 

Yes-and-no; or rather no, and then likely yes. The problem I see with going from a long-acting benzo to a short-acting benzo, especially between drugs like diazepam and lorazepam which have wildly different half-lives, is that the diazepam stays in the blood for a long time. During this time, if you go back to lorazepam, you're essentially dosing BOTH diazepam and lorazepam while you wait for the diazepam to be eliminated from your blood, so your overall benzo blood serum levels can become significantly higher for a time, equating to an initial and sometimes significant.

 

In simplest terms, if you'd gotten the diazepam up to potency before switching back to lorazepam for that dose it's like doubling your last dose of the day on the first day back on lorazepam, and then automatically tapering 50% of that dose over the next 1-2 weeks as the diazepam is eliminated; as this 50% dose reduction is 25% of your total daily dose at the time of crossing back, I would expect both the updose and later withdrawal symptoms to be noticeable. If you go this route, I suggest a 2-3 week hold time on lorazepam to notice any withdrawal symptoms from the diazepam elimination, and then if you are symptomatic holding as long as you need to recover stability.

 

As for going forward, it sounds like you already are started on my suggested schedule. I suggest holding with 1.25mg diazepam as your last dose of the day for 1 week or longer if unstable, then replacing another dose with 1.25mg diazepam and holding 1 week again or longer if unstable, and then a final substitution of your remaining dose with 1.25mg diazepam, for a total of 3.75mg/day of diazepam, and again holding after this last step 1 week or longer if unstable. Pretty simple.

 

After crossing over you could at some point aggregate the diazepam doses, but I suggest waiting until you're stable to do this as IME sometimes just moving doses can cause noticeable instability and require a period of recovery.

 

This is your taper so whatever you decide to explore I support. These are just suggestions.

 

If you don't mind me asking...

When did you take your first crossover step?

Why do you have second thoughts about this crossover?

Thanks slow, I started Wednesday night, I was suffering a lot that day it was 12 days since my drop to .375. I had I doctors appt that day and had a weak moment to go with the Valium

He wanted me to just start taking the Valium and doesn’t know I am still taking Ativan and doing the crossover. The pain has really messed me up and the last 4 days since I am feeling better has put me in a quandary. I’m thinking the reason I’m feeling better is the valium ratio is up dosed from where I was

The reason for the second thoughts is the risk of having issues with the Valium later after suffering so hard to get to .375

I keep taking myself into these rabbit holes and not thinking things thru since this experience has taken its toll on me.

I hear you Joeb. Decision-making during benzo tapering can be very difficult, especially when we aren't medical experts and our providers aren't doing enough to help plot a safe course.

 

I don't think you've updosed significantly by substituting with an Ashton equivalent; some buddies argue she's a little heavy on the diazepam side of her chart but if so, I think this improves the chance for success with the crossover and is a small price to pay for a successful taper.

 

In my opinion diazepam has MANY benefits over lorazepam, pharmacokenetically. It can dramatically reduce interdose withdrawal, it can radically simplify dosing, and it comes in low potency tablets and a commercially manufactured liquid solution which both can make tapering easier and safer.

 

In my humble experience, this journey of tapering really rewards both self-awareness and patience. If you can keep an eye on your symptoms but allow things to play out for long enough to gain the hindsight to understand what's happening, I think you will feel more confident in your decisions.

 

I suggest staying the course with your crossover. I think you're lucky that your doctor is comfortable writing a diazepam script, and I'm sorry that he's not able to understand or support your need for a step-wise crossover. It sounds like you already have the step-wise part of the crossover in-hand, so your situation looks really promising to me.

 

Feel free to keep us updated on this thread! It sounds like your next crossover step will be middle of this week at the earliest. Whatever you decide, we're here to support you.

Thanks Slow I greatly appreciate your perspective and understanding ....making decisions on this has really added to the pain. This is not the real me; and not feeling in control of the situation is frustrating g. Making the wrong decision and adding more suffering is what really scares me.

You're welcome Joeb.

 

You might benefit from labeling your fear of not being in control and fear of making decisions as symptoms of your mental health situation. You also might want to share your symptoms on the Withdrawal Support board.

 

The fear you're going through is very common around here. We all can relate with this fear of suffering. Sometimes it helps me to stay the course by just knowing I'm not alone. We're here for you.

 

 

Hey slow, thank you again

I notice I feel worse when I take the Ativan and good when I take the morning Valium

I really hate not doing what my doctor told me to do so do you think based on that I may have a shot of being ok by just replacing my doses with Valium

Also, I notice the night Valium dose lasts from about 930pm til about 2pm the next day before I feel some very slight w/d symptoms.

I suggest staying the course with your crossover. I think you're lucky that your doctor is comfortable writing a diazepam script, and I'm sorry that he's not able to understand or support your need for a step-wise crossover. It sounds like you already have the step-wise part of the crossover in-hand, so your situation looks really promising to me.

 

You know my suggestion; it looks promising from here Joeb. But of course, you'll be the best judge of your unique circumstances.

Thank you Slow for all your help

I said this on my other string but my doc finally agreed to support my crossover!!

 

I’m in my second week of crossover having replaced my evening dose with 1.25V and now on this week replaced my morning dose with 1.25V. So far symptoms are mainly depression with some anxiety here and there. So it’s rough but nothing compared to the Ativan inter-dose w/d. Next week I’m planning to replacing midday dose.  Very nervous hope all goes well.

Hi Joeb,

I'm glad to hear that you're making progress on your crossover. It sounds like you are already noticing overall improvements compared to just dosing lorazepam. What sort of improvements have you noticed?

 

Have you waited to experience stability and functionality improvements before taking steps, or are you just following your crossover schedule?

 

Great job hanging in there! 

Hi Slow, I’m noticing more of a hung over feeling in the mornings along with depression. Less than with the Ativan but still bad enough that I don’t want to do much along with that feeling of hopelessness None of the other symptoms like intense anxiety or burning face.

I proceeded into the second step this week. Taking that one remaining Ativan dose makes me feel worse so not sure whether to hold another week or not. It feels like the Valium is improving but still feel depressed, just getting worn out from all of this. Also, in order to do the crossover I am splitting 5mg pills into 1.25 mg per dose, which I don’t have many. I was thinking for my third week next week that I could resize my doses to 1.5 mg morning, .5mg mid-day, and 1.5mg night and be only off by .25 on the Ashton manual.

Thinking ahead I really want to stabilize and be able to function better before starting to make cuts. I am concerned about the dry cutting seeing that the most accurate smallest you can get is a .5 cut on the 2 mg pills which I have plenty. Compared to Ativan it’s a much smaller cut but I don’t know how I will respond to it. I am going to ask my doctor about the 5mg/5ml liquid solution next week. I’ve read on bb about diluting and small dosing but this all is getting overwhelming to me. Appreciate your perspective on this

 

 

 

Hi Joeb,

It sounds like you are plotting a good course through this nebulous business of crossing and stabilizing.

 

I like what you're thinking about adjusting your doses to the tablets on hand. If you don't already have one, I suggest considering an aluminum pill splitter as they make very clean and accurate splits in my experience if tablets are stood on end between the blades; they also never seem to go dull.

 

I suggest stabilizing on diazepam by tablets before considering liquid. Once your stable, I suggest trialing a tablet reduction of 0.5mg (1/4 of your 2mg tablets), to find out if this is tolerable. I think diazepam will be a very different reduction experience to what you've felt on lorazepam, due to it's incredibly long half-life. But yes, if after trialing these reductions you need a slower pace, a gradual transition to a tolerated liquid form of diazepam could be a good option for progressing.

 

That seems like getting ahead of things though! For now it sounds like your focus needs to be on symptom-monitoring and slow, careful crossing. Depression is common when beginning diazepam; buddies have reported that this usually improves significantly with regular dosing.

 

Keep us posted! You can do this. 

Thanks Slow, had a good window today, first in a very long time. I really hope the Valium is easier to taper, so tired of feeling so bad.  Very much appreciate all your perspectives I did get the pill splitter you recommended some time ago it does work better than the other one I had. Not looking forward to the delay on the w/d symptoms, any thoughts on how to handle this? Sounds like it could be a few days before it happens.

Going to see what the next couple days bring before doing the final dose swap. Wondering if I can go a bit lower than the 1.25mg since it seems a bit higher based on my initial swap out

Wud like to start lower if I can but also don’t want to underdose the crossover.

Tough making theses decisions

On a separate note hope your doing well, sorry, so hard not to be self centered in all this nightmare

Hi Joeb,

It's okay to focus on your needs on this thread. It's your taper support thread!

 

It's up to you if you want to try to lower your diazepam dose as you cross. I think it's not worth the added complexity and significant potential for prolonged instability but it's your cross. I think you will feel better dosing diazepam once you've had more time to adjust the medication.

 

The delay in withdrawal symptoms from diazepam is actually a really good thing. This special benzo gives most people a very gradual reduction in blood serum levels, without having to do a daily micro taper. A delayed peak in withdrawal symptom intensity may seem inconvenient, but the intensity of that peak can be controlled by lowering the size of reductions. If you transition to liquid, I think it's possible to do weekly reductions (instead of every 2-3 weeks) and smooth out symptom intensity peaks even more.

 

I'm glad you have a good pill splitter.

I suggest letting time do the heavy lifting for you.

Slow is smooth and smooth is fast.

Thanks Slow, just an update, my symptoms after Monday added some depression and anxiety but still not as bad as Ativan and somewhat manageable. Now in my third week and have taken the last step to all Valium. As of today I’m at 1.25V 9am 1.0V 5pm. 1.25V 930pm. I took the midday a bit later because I was hedging on doing it today. Will change to 3pm tomorrow to even it out. I did the 1mg because I’m getting low on the 5mg so figured I’d try it out and see how it goes. I can go another week then change to dosing twice a day. Hope this all works out. I almost did .5 in the midday dose but didn’t want to risk instability being that I was having w/d before cutting midday dose.

Meeting with my doc tomorrow to see if he will order me liquid since it takes about 4 weeks to get according to my pharmacy. Could use some help on how to dilute and use since it’s all new to me.

 

 

Hi Joeb,

Thanks for the update! I'm glad to hear that you're still seeing improvements during your cross. I've probably mentioned this already, but I think the last step of a crossover is an important final stabilization period, 1-2 weeks by Ashton averages but really until you feel fully stable and adjusted to the new medication. It sounds like you'll have this time while waiting for liquid, if that option is available.

 

I'm seeing at DrugBank Onlinethat the commercial liquid diazepam solution, at least in the US, is at a concentration of 5mg/ml. With a 1ml syringe with 100 gradations, you can reduce this liquid directly (no dilution) by 0.05mg intervals. This seems more than sufficient for weekly diazepam reductions.

 

You may eventually want to consolidate your doses into twice daily, and then once daily, as you get lower in dosage. For now I think it makes the most sense to stick with the dosing routine that you're familiar with as you're stabilizing and the diazepam is getting up to potency. I understand that you're planning to make small adjustments to your dosing schedule to better accommodate your new 2mg tablets; this makes sense to me, and I just suggest making these adjustments slowly whenever possible.

 

I hope this helps. Congrats on all your progress thus far.

Thanks slow trying to push thru just getting worn out from feeling so crappy most days like everyone else. Wish I cud just quit all the meds but I know that wud b worse. So tempting, though.

 

 

Thanks slow trying to push thru just getting worn out from feeling so crappy most days like everyone else. Wish I cud just quit all the meds but I know that wud b worse. So tempting, though.

 

I don't think CT would be very tempting once you'd had a taste of that nightmare! But I completely understand, the end of this journey can seem so attractive (and elusive). I hope that once you get a hang of it, you'll find that tapering is manageable and you're getting to focus on other things in life. 

Hi Slow, wed was my transfer to complete Valium I’m feeling fairly stable so you think starting to taper next week is too soon? It still feels like I’ve updosed a bit, not sure what to do but really want to get the tapering started.

Hi Slow, wed was my transfer to complete Valium I’m feeling fairly stable so you think starting to taper next week is too soon? It still feels like I’ve updosed a bit, not sure what to do but really want to get the tapering started.

 

I suggest giving yourself at least a week, but beyond that I think your symptoms will be the best judge of when to start cutting. I think a number of buddies have reported on the forum that the Ashton equivalent diazepam dose felt too strong for them once they crossed. If you're fully functional a week after your last lorazepam dose, I don't see any reason not to take your first diazepam reduction.

 

Could you update your signature with your new dosage? My memory is fuzzy...

When you start cutting, what reduction amount are you thinking of taking, and how?

Hi Slow I updated profile, feeling somewhat stable but also feel sedated and somewhat depressed, I am also taking 30mg mirt at night which really sucks since it adds to the sedation. Want to get off of it but worried about more w/d

Hi Slow I updated profile, feeling somewhat stable but also feel sedated and somewhat depressed which sucks. I don’t know if waiting will stop the depression or not. I am also taking 30mg mirt at night which really sucks since it adds to the sedation. Want to get off of it but worried about more w/d

Also not sure what to cut yet, i hope when cutting it lessens the sedation and depression. I was initially thinking .25 off the night and morning doses or cutting mid day dose by .5 and combining the remainder of the mid day dose of .5 into the morning dose so I would have 1.5mg night and 2.5mg day. So tired of all this

Also my psych wants to reduce mirt and welbutrin and add some other anti-dep to help with the withdrawl. To me I don’t think Ad’s work and add more potential for side effects and wd.