An End of Taper Solution

An End of Taper Solution      [september, 2013]

(Aweigh's Wet/Dry Taper)

Intro:

In revising my current taper method I was suddenly struck by how it might have special interest for my friends who are getting near the end of their healing road and can no longer measure doses accurately by dry cutting. Although I’ve been using this method since the beginning of my taper, I started it in part because of problems with accuracy in dry cutting. Even with my jeweler’s balance, I could see things getting harder as my dose got lower. I realized that by measuring just a small amount of the dose in liquid form, I could ride this taper all the way to zero. From what I’ve been reading, it’s precisely at the end of the taper that measurement becomes critical and a small error can have a huge effect. If you can’t procure a liquid form of benzo from your doctor, you’re pretty much on your own. When my doctors refused to Rx the liquid, I decided to make my own. I have a solid background in peparative chemistry. This method allows anyone (except for Klonopin users) to accurately measure as small a dose of benzo as they’d care to. (Unlike other benzos, Klonopin isn’t soluble in alcohol, but necessity is the grandmother of invention. Plenty of people are tapering from Klonopin successfully.)

I'd like to add that this method was designed for people who are or want to be tapering with very small and frequent reductions and people who need to take a smaller dose than they can weigh. It presumes no Rx for a liquid and no access to a compounding pharmacy. The problems I imagine and others I know face do not imply that dry cutting is a dead end or badly flawed. Obviously, many people use it sucessfully. I see it more as a question of choice. "Wet cutting" can provide alternatives.

The Method

The basic idea of this taper is to take most of the dose as uncut pills and use a carefully measured amount of lorazepam in solution to make a small cut in your daily dose. One tablet, of the smallest strength available, is omitted from the daily dose and dissolved. The equivalent amount of lorazepam minus the daily cut is taken in solution (the ‘makeup solution’) over the course of the day. To reiterate, the makeup solution is what you take in addition to your pills to bring your daily dose up to a little less than it was yesterday. The makeup solution, divided into three doses, can be taken at whatever times of the day are best for you. I started out taking it along with my solid dose, then discovered that I could spread the dose out more, to good effect.

Here is a step-by-step description of the four calculations required to do this taper. They are also the four columns of the spreadsheet I use to simplify the math:

1.  Today’s dose. This is yesterdays dose minus the daily cut amount. I’m currently cutting by 0.0125 mg/day. I’ll discuss how I chose that figure a little later. Yesterday’s dose was 4.80 mg, so today’s is 4.80 – 0.0125 = 4.7875 mg.

2.  Today’s make up amount in mg. It’s the difference between what you’ll take in solid form and in liquid form (the “makeup solution”). 4.8 mg/day of lorazepam divided evenly is nine 0.5 mg tablets [= 4.5 mg] + 0.3 mg additional. Today’s dose (from #1) is 4.7875 mg. So, 4.5 mg is taken as solid tablets and the liquid portion (make up dose) is 4.7875 – 4.5 = 0.288 mg. This is the daily make up amount, how much you need to take in addition to the tablets to bring your daily dose up to the full amount. It decreases every day by your cut amount.

3.  Today’s makeup volume in mL. We have it in mg, we need it in mL. This (the volume of the makeup solution) depends on its concentration—how many mg are in each mL. This concentration changes depending on where you are in the taper; it’s a variable that you decide on. More on that later. For now, let’s say the concentration is 0.066 mg/mL; that’s relatively dilute. To get the volume in mL you just divide the make up amount in mg from #2 by the concentration in mg/mL. 0.288 mg / 0.066 mg/mL = 4.363 mL. This is the total daily makeup solution amount.

4.  Today’s individual doses. Divide the total makeup volume from #3 by your number of doses per day. I dose 3X per day, so 4.363 mL / 3 = 1.454 mL. This is the individual dose of makeup solution. It is the amount you remove from the bottle in the refrigerator with the pipette (or syringe) and take.

Let’s look at this in a tabular form, more like a spread sheet:

    column A              column B                column C                column D

(4.80-0.0125)      (4.788 – 4.50)        (0.288 / 0.066)            (4.363 / 3)                                   

    4.788 mg              0.288 mg                4.363 mg                1.454 mL

For practice, you could calculate tomorrow’s single makeup dose: 1.391 mL.

The cut is done by simply measuring a little less make up solution each day. Your total daily dose = the portion of your dose in tablets (most) + the the portion of your dose in makeup solution (a little). The portion in tablets stays the same for a while, the volume of makeup solution changes a little bit every day. The whole point is that you can measure lorazepam much more accurately in solution than you can with any dry technique (basically, weighing). Say, 1,000 times more accurately. I have not done it, but I believe this method could easily be adapted for cutting less often than once/day.

Solubility:

People use a variety of liquids in tapering, in order to put solid drugs into liquid form for accurate measuring. Water and milk are the probably the most common. Lorazepam is not soluble in water, and I do not know if it is soluble in milk. I would guess that the fat globules in milk help to keep the lorazepam particles in suspension, but I don’t know. I prefer to work with solutions, as I am familiar with their properties but know very little about handling suspensions. The main difference is that solutions are homogenous by their nature, while suspensions are not, though they can be made so. In a homogeneous solution, every mL contains the same amount of drug as every other mL. This is the prerequisite for accurate measurement.

Lorazepam is soluble in ethyl alcohol, with maximum solubility at about 160 proof (80%) and reduced solubility at higher and lower concentrations. Don’t go below 120 proof. I use 151 proof Everclear, which is purely alcohol and water. 151 proof rum would probably work in a pinch, but I would prefer not to have smelly, unknown compounds in my solvent, if possible. Vodka would be a better substitute, if you can find it at 140 proof. Anyway, 1 mL of 75% alcohol will dissolve 18 mg of lorazepam—Jordan Journal of Pharmaceutical Sciences, Volume 5, No. 2, 2012. That’s plenty soluble!

Solution preparation:

I’ll use my own figures for an example. Carefully measure 15 mL 75% alcohol into a clean, alcohol-rinsed brown glass bottle. This bottle should have an airtight cap with (ideally) a silicon or Teflon sealing ring. Place two 0.5 mg lorazepam tablets in the bottle, close tightly and shake gently by inversion for 30 sec. Let stand at room temperature with occasional shaking for 5 min. Open the bottle and crush the tablets gently with the round end of a glass stirring rod. Let it sit. Stir and crush some more. Shake and examine to see that all the pills are now powder. Keep at room temperature for 1 hour with occasional shaking (this is important), then refrigerate.

Storage: I prepare enough make up solution to last 3-4 days, kept in the refrigerator. Once in solution, it’s not that stable. Keep all lorazepam solutions at 40 deg. F. Do not freeze. Protect from light by wrapping in foil. Solution concentration is 2 X 0.5 mg / 15 mL = 0.0667 mg/mL. Discard after 3-4 days. I believe >99% of the lorazepam is in solution, so you could filter or (better) centrifuge it to separate the phases, but I haven’t found the solid to be a problem other than that it’ll plug up the pipette if you jam the tip into it. Remember, it’s in a 75% alcohol solution at 40 deg F. in the dark for good reasons. Lorazepam, like most drugs, is much less stable in solution than as a dry solid. Water decomposes it. Heat and light accelerate this process. Once you put it into dilute water solution at room temperature for drinking, use within ½ hour max. If you have to transport it, keep it undiluted until use and pack it in an ice chest.

Measuring:

You can use a plastic syringe and it’ll work. For a while. I recommend buying and using good quality lab glassware. $45 gets all you need from Amazon. Learn how to use it from a book or the net if you need to. I think there are decent videos on YouTube. I'd get a pipette bulb or plastic "pipette aid" and practice with water until you get the knack. I have written a description of how to pipette by mouth, but it's rather hard to describe and I'm not happy with it. If it comes together, I'll post it. Plastic syringes aren’t well made and soon become unreliable. However, not everyone can afford $45. So, many people use ½ cc syringes (diabetes syringes, not the TB) which are also marked in 100ths of a mL for small volumes. They read better than the 1mL TB syringes, which also do work, and they’re cheap. Clean off the lubricant on the plunger and barrel with alcohol or soap and water before you use it for the first time. Rinse off the soap very thoroughly. Soap films can stay on your equipment forever, which is why I prefer alcohol. Lab equipment is one area where you won’t save money by purchasing the cheap stuff. If I’d have  planned ahead, I’d have bought 1, 2, and 5 mL class B Mohr pipettes, 10 mL and 25 mL class A volumetric flasks, a 25 mL graduated cylinder, a stirring rod, and a medicine dropper. That’s about the only stuff I use all the time. All from Amazon.

In measuring your daily makeup doses, it really doesn’t matter if you foul one up. Think about it. Your cut is ~15 micrograms. If you took 50% more, would you even notice it? If you took 100% less, you just had a hold day and will be back to work tomorrow. An error would likely have to be in the same direction for several days running to make any noticeable difference. What matters isn’t how accurate a single measurement is, it’s more in using the same technique, the same equipment, and the same “head” every day. On a day trip, I just measure my individual makeup doses with an eyedropper with a mark on the side. OTOH, the makeup solution itself needs to be measured very carefully indeed, as any mistake here will propagate into all doses from that batch. That’s why I use a volumetric flask—they only measure one amount, but they measure it real accurately.

So, now that you’ve gone through all this work to get the correctly calculated, accurately measured, real-deal makeup dose, what do you do with it? I take it out of the ‘fridge, warm the bottle in my hands for a couple of minutes, shake it gently and pipette it immediately into about 20 times its volume of water and drink it down. Apple juice is OK if you hate the taste. Yum! Better than Mg sulfate...

I know this method works for at least one person. I have to assume that it will work for others, but not for everyone. I just hope that I've been able to communicate it clearly enough so that people don't throw up their hands (as I think a lot of folks did with the first version of this taper) and say: "There's no way I could do this; I can't even understand it!" I'll answer any questions I can.

May you find what you never lost. 

Aweigh

Notes:

I chose my starting cut rate by converting a Valium rate from someone whose taper started well and had a similar drug history to mine. I’d also heard that ~0.3%/day was a reasonable starting point. 0.3% of 6 mg/day = 0.018 mg/d, which turned out to be a little fast for me. A week’s hold and restart at 0.0125 seemed much better. One refinement, which I have found unnecessary so far, would be to use less than the smallest tab for the makeup solution by cutting a tab and weighing the fragment with a jeweler’s balance.

The cited paper examines lorazepam’s solubility in propylene glycol (PG) and various surfactants. PG is used commercially to prepare pharmaceutical solutions for oral use, as is alcohol. PG could probably be used in place of alcohol here, with some method modifications. I prefer to use alcohol.

A book worth knowing: Handbook of Solubility Data for Pharmaceuticals

Abolghasem Jouyban, CRC Press 2009

Print ISBN: 978-1-4398-0485-8

Hi, folks:

68 views ('tho some of them are mine) and 0 replies . Well, I always wanted to write something that would leave people absolutely speechless, and I appear to have succeeded. 

I'm beginning to realize that no matter how much I simplify this method, it's still going to be too technical and difficult for a lot of people who are going through wd. A buddie suggested doing a "condensed version", containing only what's needed to actually do the taper. I'm not so sure. There really isn't much interest in this method, and I don't know that another revision would make it any clearer. I can make it shorter, but I can't make the math go away. I'm inclined to leave it as is for now.

Aweigh

Great and detailed explanation Aweigh! 

I used vodka for my last little bit of Valium, but I didnt know all these great facts. Mine was by the seat of my pants and it went ok for me. Wish I had known these things back then.

Good stuff. 

Flip

Thank you for this. I am going to see if I can use this to taper gabapentin! Much appreciated!

Hopeful Girl

I'll have a read. I'm interested and it looks like some good maths there

The only thing that makes me think I'd use it only as a last resort is chucking another type of benzo in there just because they aren't all created equal.

Hope it goes well for you 

All of you: Thanks so much for taking the time to plunge in and read the whole thing; and then reply!    Having received a bit of "it's well done, but too long and technical for most people to use", I was thinking of having a try at moving the content that isn't hands-on how to do it into a separate section, so that there's a shorter version.

Do you think it would be worth it, in the sense of making the document more useable? I don't know if I can make the method descriptions any clearer, but I could certainly move fascinating but extraneous  material into the basement.

Watcha think?

Aweigh

I think a condensed version may be helpful for many. I think you've done an excellent job but I love this stuff and it doesn't overwhelm me...plenty does  and certainly during acute w/d the simpler the better. I think many are scared of microtapering just because it can be intimidating at first.

Thanks for doing this!

Hopeful Girl

Hi:

I've been recovering from a "medical procedure" and so haven't had much time or energy for writing, but that is changing. I hope to begin work on a condensed version of this taper next week. Whether it'll be any easier to use is anybody's guess, but it will be shorter 

Aweigh

Hello 

I've been reading this with much interest. I like the idea of a solution rather than a suspension. It just seems "truer" to me, knowing that I would doubt my abilities to make a trustworthy suspension. 

I have read where others use a combination of a wet/dry taper. Could you help me understand the reasoning behind this? What are the advantages?  Also, what are the advantages of taking the wet portion along with the dry portion? I've not seen that anywhere before.

You've probably explained this somewhere I haven't found yet, and I apologize ahead of time if you have. Please just point me where to look!

Thank you!

Hi, leanek:

25 years and you never went over 3 mg. Good fo you! I'm not familiar with others' use of the wet/dry idea--if you could point me to them, I'd greatly appreciate it. I use it because I want to taper daily and that requires measurement of a very small cut--the 'wet' part. I take whatever I don't need for measuring the cut as dry tablets, if only to minimize my alcohol intake.

I no longer think there are any advantages to taking the wet and dry doses at the same time; quite the opposite, in fact  . Better to spread them out. Which is why I'm doing the transition to 4X day dosing as soon as my taper hits the next "inflection point". That's the day on which the total daily dose can be taken dry. In this case, I'm coming up on 4.5 mg/day, which is 3 0.5 mg tabs 3X day and the easiest point at which to switch.

You might consider going to 4X/day yourself. Every 6 hour dosing could get rid of a lot of those nasty ol' IW sx.

            The condensed version has weighed anchor and is coming about to course 270 degrees.

Aweigh

Thank you for your reply. I don't have any examples from a forum of people using this method. There is a spreadsheet at benzo.org that calculates partial dry and partial wet doses for those who take a large dose. When calculated that way, the toss amount is taken from the one daily wet dose, with all remaining doses taken dry.  This doesn't seem good to me, as it makes for uneven doses throughout the day.

It also calculates an all wet dose reduction. The spreadsheet calculates daily micro taper amounts, valium equivalents, different dilution amounts, etc. I will PM you the link if you'd like.

I have started spreading my doses to 4x a day. It makes sense.

I see my dr tomorrow, and need to have my ducks in a row before then. My plan is to taper directly off lorazepam, with a goal of dropping 1 mg per 12 months, adjusting as needed. I do have some questions for you, if I may impose? (Please answer as if speaking to a child...between benzo brain and terrible math skills, I estimate my approximate "age" to be 10. 

1. If lorazepam is soluble in the alcohol @ 18 mg per ml, I could dissolve my entire 3 mg daily dose in 1 teaspoon of alcohol, couldn't I?

2. If so, and assuming a total daily dilution amount of 300 ml, (just an example to simplify.) I would:

a) Dissolve one 1 mg tablet in 1/4 tsp alcohol. Top it off to 100 ml with water. Discard taily toss amount.

b) Dissolve the remaining two 1 mg tablets in 3/4 tsp alcohol, top it off to 200 ml with water.

c) Combine all to make a total of 300 ml solution.

d) Divide 300 ml solution into 4 equal doses.

Is that correct?

Plan B: Liquid Ativan--2mg per ml concentrated suspension, which comes in a 30 ml bottle.

IF my dr would prescribe this, how on earth would I figure out how to dilute it and @ what dilution, and how much to toss?  At first it seemed like it would be easier, but now I realize that I couldn't use the spreadsheet and have no idea how to do the math. Would it simplify things enough to even bother going there with the dr?

So now I've imposed greatly and written a book, as well. Thank you ahead of time for your help and patience!

Lea

I have a fundamental question.  Why are microscopic cuts necessary at the end of taper? After being off for four months I still have symptoms. I made microscopic cuts at the end and it didn't help. I had symptoms throughout my taper, and after my taper.

Because no scientist has studied this topic, I don't think we know if a microscopic taper works. If it doesn't work, then why bother?

I know there are people who swear by a microscopic taper, but they don't know what would have happened if they did their taper another way. It seems to work for some people. It does not seem to work for others. I don't think we know enough to make any general conclusions.

Hi, Preston:

I'm not sure what you consider "a microscopic cut"; your sig does not specify. I don't think it's valid to generalize from one case--I'm genuinely sorry microscopic cuts didn't work for you. Perhaps the method was at fault, or a particular application of it, and not the concept. IMO, it has been studied enough to make some pretty useful general conculusions.

aweigh

leanak:

I agree about unbalanced doses. Also, 4X/day dosing, for most people, including me. I don't think in terms of a daily toss. I suggest you read my method, which is linked at the end of my sig. It's thick reading, but not that long. I plan to condense it. I think it will answer a lot of your questions.

Diluting a concentrated alcoholic solution of A with water will make the A come right back out of solution, although as tiny, pretty crystals that may be easier to measure. If you can get the liquid  A, believe me the dilution is no problem. Google "serial dilution" for the technique.

aweigh

Preston,

I think that this is an individual decision. I also think that if we were to wait for a scientist to study, conclude & publish any findings before we decided how or even whether to taper, we'd never get off this stuff! 

Speaking for myself, I know that if I didn't have the option of taking tiny, microscopic cuts, along with the real world experiences of those who have successfully done just that, I might never have the courage to even make an attempt to be free from this drug.  :'(

Hi Preston

I would think your taper from 1.5mg of Klonopin to 0 would require dose cuts a lot higher than what I would consider microscopic. Even if you went really low at the end. It just plain takes a long time to recover from benzo damage. You will eventually heal. Every day is one day closer to complete healing.

Bart

I have read your method many times. I'm brand new to all of this, and I'm afraid it would have to be severely dumbed-down for me to completely grasp it.  Googled serial dilutions. Seriously?  I got anxiety just trying to figure that out!

Looks like I'll be taking my chances with milk. 

Thank you kindly for your time! 

leanek:

I'm sorry this method is proving so hard to understand [and therefore useless] to so many people. I will do a condensed version, but I don't think I can dumb it down much, although I can simplify the language.

A serial dilution: you make a 1:10 dilution and then make a 1:10 diluiton of that dilution. You've just made a 1:100 serial dilution. Dilute the 1:100 by 10X and you've got a 1:1000 dilution, a solution that is 1/1000th as concentrated as the original solution. Maybe not so hard.

You're welcome,

Aweigh

leanek:

I'm sorry this method is proving so hard to understand [and therefore useless] to so many people. I will do a condensed version, but I don't think I can dumb it down much, although I can simplify the language.

A serial dilution: you make a 1:10 dilution and then make a 1:10 diluiton of that dilution. You've just made a 1:100 serial dilution. Dilute the 1:100 by 10X and you've got a 1:1000 dilution, a solution that is 1/1000th as concentrated as the original solution. Maybe not so hard.

 

You're welcome,

 

Aweigh

I have no problem with the math or with understanding the method. If it works, then great. But if it's the only method tried a person will never know if it was necessary.

I started with cuts that that were larger than at the end. I made my cuts smaller at several places during my taper. I had fewer problems at the start, and reduced the size of my cuts as I progressed. My taper got worse as it progressed so I made smaller and smaller cuts. After stopping, I still had symptoms. In my case the smaller and smaller cuts did not help.

I can't generalize my taper to apply to anybody else. There are some people who make large cuts and get away with it, Others make very small cuts throughout and still have many symptoms. I don't see many who say they made very small cuts and had an easy taper. Those who did have no way to know if larger cuts would have also been easier from them.

Perhaps those who have it easy would have been OK no matter how they tapered. Ditto those who had it hard. We just don't know.

Perhaps it makes sense to try both ways to see what works. I feel that I tried both ways and nothing worked for me.

Because we are all guessing and trying things, it makes sense to ask if going very slow just prolongs the agony. Perhaps it is going to be hard no matter how a person does it. We just don't know.

I don't think we have enough science to make the statement that one way is better than another. It seems logical that a very slow taper is the best, but we really don't know except in a few reported cases.

If I had it to do over, I would probably do the same thing. I would not make tiny cuts from the very start because that would just prolong the whole thing. I would probably reduce the size of my cuts in an attempt to find that illusive "symptom free" taper.

Hi, Preston:

I certainly agree with what you say about generalizing--benzos and human bodies are too varied for that. You say "I don't see many who say they made very small cuts and had an easy taper. Those who did have no way to know if larger cuts would have also been easier from them." I do see quite a few who say their taper got easier and sx less severe after they began using smaller, more frequent cuts. I started with the std. BB milk suspension taper and went through a couple of others before I found/devised one that works well for me, so I do have some other methods to compare with.

aweigh

WOOT! The dr gave me the liquid ativan with no problem! He also tried to switch me to Buspar, of all things,  and thoroughly cautioned me to not believe everything I read on the internet. LOL!

The pharmacy had to order it, so won't have it in my hot little hands until tomorrow, but that's fine.

Your explanation of serial dilutions actually penetrated my fog, so thank you. It gives me hope that I may be able to figure out how to use this stuff to daily microtaper off this drug.

I hate math & it hates me back! 

leanek:

Getting the Rx was the delicate part. Now it's just measuring and dispensing. The pharmacist should be able to help you with that; some of them seem to have forgotton the hands-on basics right after the exam. You probably don't have the proper tool that would allow you to measure a very small amount of a very concentrated solution in order to make the dilution for daily use. I can give you a hint, but I can't give you the tool. If I were a pharmacist, I would not want to dispense the 2 mg/mL solution directly (safety issues), but would dilute it in the same solvent it came in to a convenient concentration for use. Wouldn't you rather be measuring 2 mL to get your daily dose than 0.05 mL.

Math is your friend; it allows you to calculate the proper dose. Wrong dose = bad taper experience 

aweigh

The commercial solution from the manufacturers use either alcohol or propylene glycol as the solvent. Both solutions are 2 mg/mL in Ativan, quite concentrated. Since you're starting from a very concentrated solution, it's just a matter of diluiton. You set it up as a ratio.

The pharmacist was unable to help, and can only dispense the bottle as it comes. Her conclusion: There's no way to measure out such a small quantity.

I'm a little confused. From what you said, it seems that there is such a tool to measure teeny amounts, but you can't tell me what it is? I don't understand, but I would surely like to know what it is, so if you can, and are willing, to help me, please do!

I have PG USP on hand from making creams and lotions, and can get the ETOH easily enough. The first thing I'm planning to do is to immediately dilute the 30 ml bottle of 2mg per ml into another 30 ml of appropriate substance to get it to 1 mg per ml. (Correct?) (The last thing I want to do is accidentally increase my dosage on a bad day.)  Diluting past that with either ETOH or PG would'nt be good, I think,  since I'd be ingesting too much ETOH or PG on a daily basis.

If I'm unable to get a tool to measure the tiny dosage, I guess the thing to do would be to just take the 1mg per ml suspension and add it to 500 ml of water, withdraw the daily toss amount and divide into 4 daily doses.  Is there any reason you can think of why this wouldn't work? Although I'd much rather be able to take the doses directly without wasting the "toss", I'll do what I need to do.

Thank you!