Do not attempt to taper benzodiazepines while unstable
If you are already anxious to the point of not sleeping, or eating, and are constantly in panic, tapering your benzodiazepines could escalate these symptoms. You will likely have to get your stability up in other ways in order to be able to reasonably embark on this journey. You can read some of the content on our benzodiazepine alternative page for natural therapies that might help you get settled. You may consider discussing with your doctor using non-benzodiazepine bridge medications like trazodone or gabapentin to help with the benzodiazepine tapering process. There will be more on this topic below in the section that covers the topic of bridge medications.
Determine if your symptoms are intermittent or constant
Intermittent anxiety that changes throughout the day or week is certainly better than constant unrelenting anxiety. Intermittent anxiety may come on in the morning, and relieve at night, or be better on certain days over others.
Constant Anxiety
Constant type anxiety presentations are like a background roar in your nervous system like you are living in the middle of the freeway. It may get slightly better or worse throughout the day or week, but it is always strongly there. Generally, the anxiety was a slow onset over time building up over many months to years that has now gotten to a place where it is unrelenting. We have found that this is most often due to neurotoxic poisoning. 9 There are poisons that affect the way the nervous system balances itself. Some of the anxiety-driving culprits are mercury,10 lead,11 organophosphates (pesticide)12 accumulation, or problems like Lyme disease.13 Researchers publishing in Psychological Reports in 1994 found that mercury fillings can be an etiological (causative) factor in anxiety, perhaps by altering neurochemicals in the brain.10 We have found this to be especially true in our center, as the correlation between mercury fillings, anxiety, ruminations, and insomnia has been very prevalent. Likely, you will have to figure out where your toxic load is coming from and work toward unburdening this attribute so that you can successfully taper off of the medications and remain stable. Imagine a game of catch, and the pitcher is pitching 100 mph fastballs, so you are wearing the glove of a benzodiazepine. If you just thin down the glove, eventually those pitches are going to start hurting. You would need the pitcher to pitch softer so you can catch it with your bare hand. If you reduce the benzodiazepine while you still have accumulated excitotoxins, you may hit a similar point of pain as you would with the glove analogy. If excitotoxic poisoning is over-ramping your nervous system, that is the issue that needs to be primarily addressed, which in our experience makes the benzodiazepine tapering process ultimately successful. Alternative to Meds Center is specifically designed around dealing with these kinds of stubborn issues in conjunction with benzodiazepine tapering.
Intermittent Anxiety
This type of anxiety will offer the sufferer some relief at certain points of the day, week, or may present seasonally. There are many reasons for this type of anxiety, but they are all almost always easier to confront than the constant type. We list some of the following here:
- Blood sugar swings 7
- Hormonal imbalances 14
- Interdosing withdrawal 42
- Food allergies 15
- Seasonal Affective Disorder
- Mold or mycotoxin sensitivity 16
- EMF influences 17
- Other stimulating medications such as SNRIs 18
- Situational anxiety, workplace anxiety 43
Each one of these factors has strategies to try to alleviate some of the detriments imposed. Regarding interdosing withdrawal, for instance, if someone is taking Xanax only at night, they may be going into withdrawal by the next morning or afternoon. One would be well-advised to speak to their prescriber about breaking the dosing up to be a little in the morning with the majority at night might be a good way to start the benzodiazepine tapering. Or, one could discuss if switching to a longer half-life benzodiazepine like Valium could make it easier. At Alternative to Meds Center, we typically keep the person on the medication they are familiar with as we have supporting mechanisms that make the process easier than what one can expect at home. There are different tapering methods that are described below and also can be viewed on our medication tapering page.
Prior to Tapering Benzodiazepines, Inform Persons Close to You of Your Intentions
It may be truly difficult for your family, friends, employer, and other support people to understand your struggles. It is important that you convey to your loved ones what is occurring with you so that they can attempt to understand your plight. This is often where we suggest that a person does an inpatient stay with us so as to spare loved ones of the emotional ride they will probably be enduring with you in this process. Many mothers come to us having left their children at home so as to get the benzodiazepine tapering successfully accomplished. And while it is difficult to be away from the family, it might be even more traumatic for them to see you go through this at home unsupported. For those trying this at home, letting the people in your close sphere watch videos of others who have struggled might help them to understand and have compassion for your situation.
Get a prescriber to help you
We know this might be difficult, but searching “holistic psychiatrist” or “integrative doctor” in your local area may help you get started. Benzodiazepine tapering is truly difficult to manage for an outpatient doctor and a residential stay is certainly preferred. But if you are limited to outpatient, you still absolutely need to have someone monitoring your medications and medical care.
Avoid caffeine, MSG, glutamate, and Aspartame
We probably don’t need to mention this to most anxiety sufferers but we cannot really overemphasize the importance of making discerning food and beverage choices. Caffeine is definitely not going to be well tolerated during the benzodiazepine tapering process.19 MSG and glutamate are highly stimulating. Glutamate is the most excitatory neurochemical of the central nervous system and can contribute to heightened anxiety.20 Aspartame breaks down into aspartate and phenylalanine, both of which can be stimulating.21
Balance blood sugar
Blood sugar spikes and crashes can cause anxiety and other symptoms. Creating a lifestyle to avoid these can make tapering benzodiazepines a lot easier.7 To alleviate blood sugar crashes, eat a healthy portioned protein-based breakfast. Try to limit excess sugars and simple carbohydrates like rice, wheat, and other starches. Consuming snack-like meals ongoing throughout the day can help balance blood sugar.5 A bag of carrots with nut butter is a viable snack, so is raw green beans or avocado. You want to avoid going on a blood sugar roller-coaster during the benzodiazepine tapering period. If you find it hard to eat, still try by eating small portions. Your gut is a muscle and might need to exercise a bit if you have been food restricting due to anxiety.
Exercise
Getting your body moving can help with the overall detoxification of the body by assisting your immune system, kidneys, liver, and respiratory system to work more efficiently.22 Stagnation is not helpful, especially when you are stewing in your own anxiety and ruminating thoughts. Getting your body moving may not have an immediate effect on anxiety, but can make an impact in the long term.8 It is good to have an exercise routine established before attempting to taper benzodiazepines. Again, we know this might be a tall order, but this is a place you might want to lean into and push yourself within reasonable limits.
Get the lowest dose version of your medication prescribed to you
If you are planning the direct tapering route using your existing medication, you will want your doctor to have the lowest dose version of it on hand for the benzodiazepine tapering process. For instance, someone is taking Klonopin 3 mg (three 1 mg tablets) and they want to drop down to 2.75 mg. Klonopin comes in a 0.5 mg dose. So in this cut, the person would take two of the 1 mg, one of the 0.5 mg, and half of 0.5 mg for a total of 2.75 mg. Speak to your doctor who will likely be able and willing to assist you, once informed of your intentions.
Lowest dose benzodiazepines include:
- Ativan (lorazepam) 0.5 mg
- Klonopin (clonazepam) 0.5 mg
- Librium 5.0 mg
- Valium (diazepam) 2.0 mg
- Xanax (alprazolam) 0.5 mg
- Ambien (zolpidem) 5.0 mg (not technically a benzodiazepine)
Speak to your prescribing physician about how these medications can be cut into smaller fractions. Many people choose tapering steps to be smaller than the lowest dose pill. Librium comes in a capsule, and can only be cut by opening the capsule. Know that if you are using a timed-release version of your medication such as Xanax XR or Ambien CR, it will lose the extended-release aspect if you cut the pill. If you are on extended-release versions, one approach would be to keep the extended-release for the larger milligram portions of the total dosing and use the non-time-release lowest dose pills if you have to cut one of the pills. For instance, you are on Xanax XR 3.0 mg and want to taper to 2.75 mg. Consider getting a combination from your prescriber of 1.0 mg and 0.5 mg Xanax XR, and also get the 0.5 mg Xanax non-XR. So you could get to your target taper amount of 2.75 mg taking two of the 1.0 mg Xanax XR, one of the 0.5 mg Xanax XR and the 1/2 of the 0.5 mg normal Xanax (0.25 mg).
Other medications you are taking
If you are on a stimulant, such as Wellbutrin, Effexor, Cymbalta, Provigil, or an SNRI type of antidepressant, talk with your doctor about eliminating these first. These drugs could be fueling anxiety or sleep problems.18
Other drugs like Seroquel, Trazodone, gabapentin, SSRI antidepressants, mood-stabilizers like Lamictal will likely assist the benzodiazepine tapering process. If you are already on those medications, have your doctor consider keeping you on those medications until after you are stably off of the benzodiazepine.
At Alternative to Meds, we generally do the most challenging drug first. That is after we remove conflicting drugs like the stimulants listed above. So let’s say someone is one Wellbutrin, Seroquel, Ativan, Lamictal, and gabapentin. And anxiety and sleep issues are the diagnosis. We would remove the Wellbutrin first. Then, we would attend the Ativan. The remaining would involve more investigation into the individual presentation but might look like Seroquel, then Lamictal, and saving gabapentin for last. Removing the stimulants and attending to the benzodiazepine first is the most common strategy. Removing the easier drugs first might paint someone into a corner where they have no medication support for the benzodiazepine withdrawal.
How Long Will My Benzodiazepine Taper Take?
If you have the constant anxiety presentation, and it is only marginally helped by the drugs, then your case might take longer. If you started taking benzos because of a traumatic life event that has now passed, or because you were having intermittent sleep issues, then you can likely get through this rather quickly. There are a lot of details to consider when answering this question. At Alternative to Meds Center, most people can accomplish benzodiazepine cessation and be stable within an eight-week period. Most people attend to a whole host of other medications in that time frame as well. Those with multiple medications combined with decade-plus consistently long use of benzos may take more time. Outpatient, for those with the intermittent type of anxiety, you might want to set the broad expectation to be 10-25% every two weeks, which adds up to anywhere from 8 weeks to 20 weeks.
During benzodiazepine tapering how much dose reduction and how often?
There is no one size fits all answer for this. For inpatients at Alternative to Meds Center, we build people up with nutraceutical agents, use IVs, and begin the process of removing excitatory neurotoxins prior to making medication cuts. When the cause of the anxiety is being alleviated, the tapering can go substantially quicker with fewer complications. For outpatient populations and guidance for the doctors handling these situations, we would recommend the initial cut to be 10%. And the time till the next re-evaluation would be 2 weeks. If that is easily tolerated, then the person can step it up by either cutting 10% every week or going up to 20-25% every two weeks. Other outpatient people may find this is too much and do better with 5% cuts. We do not prefer the type of liquid titration methods where someone frequently cuts a small percentage, like 2.5% every day, as that can lead to confusion from overlapping dosages during the withdrawal. In this method, there is not time between the cuts to get a good sense of the withdrawal syndrome. Liquid titration to get good accurate milligram dosing levels is a great method for tapering certain water-soluble medications, but we like to leave time between each cut for the person to rebalance and get ready for the next step-down.
Benzodiazepine Tapering and Interdosing Withdrawal
If a person is only taking a benzodiazepine one time a day, especially short half-life drugs like Xanax or Ativan and to some degree Klonopin, there can be a withdrawal between dosing. This is a common phenomenon associated with many classes of drugs, including opiates as well as benzodiazepines.44 We find it better to split up the dosing so that there is at least some of the medication active in the body throughout the day. So if a person is taking 1 mg Xanax at night, the first medication change might be to move 0.25 mg to the morning and leave the 0.75 mg at night. For example, after this has been adjusted then the person’s physician might suggest going to 0.625 mg at night and 0.25 mg AM. As they get down below 0.5 mg PM, then they might drop the AM to .125 mg. Each person will have a unique strategy regarding this. Another method to discuss with your prescribing physician is switching to Valium, which has a longer half-life, as described in the next section.
Valium Crossover for Benzodiazepine Tapering
We have tried many, many ways of approaching benzodiazepine withdrawal inpatient over our now 16 years at the date of this writing. We do not use the Valium crossover method very often for our inpatient population. Our detoxification processes, supplement infusions, and tapering adjunctive therapies make benzodiazepine tapering a much different experience in relation to those doing tapering without those mechanisms of support. We have found it best to do a direct taper on the drug the patient is familiar with. Changing to a new drug is not always that well-tolerated, and the crossover period itself can take one to two weeks even in our inpatient setting, which loses valuable time.
However, for people working with an outpatient doctor, this is a very viable approach, especially for those who are having a rough time making even the smallest of cuts.
One crossover approach would be some version of converting half or less of the medication to Valium, and then waiting to see how well that was tolerated before switching over the rest. Some people may want to switch over a smaller portion of medication first, especially those who have truly struggled and need to play it extra safe. An example might be, a person is taking 1.5 mg a day of Ativan split up into 3 dosings of 0.5 mg at different times of the day. Switching over one of the 0.5 mg Ativan to 5.0 mg of Valium might be a good test. If well-tolerated, the rest can be converted over possibly a two-week period in two steps.
Another crossover approach would be converting one-half of the medication over to Valium in one or more steps. But then instead of converting the other half, cutting only the other benzodiazepine (Ativan, Xanax, Klonopin, etc) in 10-25% increments until to are only left with Valium. Then you would proceed in a similar fashion with the Valium. These are points you can discuss with your doctor.
Benzodiazepine to Valium Equivalency Chart
When converting a benzodiazepine like Xanax over to Valium (diazepam), the milligram levels are not equivalent, and the dosing level will have to be adjusted. Every person tolerates medications differently, and so the below is simply a guide to share with your prescriber.
1.0 mg Ativan ~ 7.5 mg diazepam (range 2.5 to 10 mg)
1.0 mg Klonopin ~ 12.5 mg (range 2.5 to 20 mg)
5.0 mg Librium ~ 1.5 mg diazepam ( range 1.0 to 4.0 mg)
1.0 mg Xanax ~ 12.5 mg (range 5.0 to 20 mg)
The above calculations were gathered by our in-house observations and a combination of conversion ranges found on both clinicalc.com and mdcalc.com.23,24
Extended-release Benzodiazepine Tapering
Some people might find they want to stick with the medication they are prescribed but move to an extended-release version of their medication for benzodiazepine tapering purposes. This may help with interdosing withdrawal intensity, but realistically, the half-lives of the extended-release versions are very similar to the non-extended release versions. It also generally requires that you have multiple extended-release milligram strength levels prescribed to you as well as the lowest dose non-extended release version. If you “cut” the extended-release tablet, it is no longer extended-release. But a process for this method could be, for instance, you are on Xanax XR 3.0 mg and want to taper to 2.75 mg. This could be achieved with a combination of 1.0 mg and 0.5 mg Xanax XR and also using half of the 0.5 mg Xanax non-XR. So you could get to your target taper amount of 2.75 mg by taking two of the 1.0 mg Xanax XR, one of the 0.5 mg Xanax XR and the 1/2 of the 0.5 mg normal Xanax (0.25 mg). Discuss these strategies with your medical support person if you believe they would be helpful.
Benzodiazepine Tapering: Symptoms to Expect During Withdrawal
Benzodiazepine tapering symptoms will generally occur starting about the half-life of the drug. Depending on the person, the withdrawal can last days, weeks, or even longer in some people. The people that have an unresolved toxic body burden of accumulated environmental poisons, or other situations such as Lyme disease, in our experience, can have a long and potentially protracted withdrawal period. The longer the half-life, generally the easier the withdrawal experience. Each person’s elimination time is going to be dependent on age, genetics, liver and kidney health, and other lifestyle factors.25
Half-lives chart for benzodiazepines and Ambien
- Ativan ~ 12 hours 26
- Klonopin ~ 20-30 hours 27
- Librium ~ 24-48 hours 28
- Valium ~ 100 hours or more 29
- Xanax ~11.2 hours 30
- Ambien CR ~ 2.8 hours 31
Tapering benzodiazepines can result in a benzodiazepine withdrawal syndrome. Some of the features of this withdrawal syndrome can include some of the following.
Common Benzodiazepine Tapering Symptoms 32
- Rebound Sleep issues
- Rebound Anxiety
- Panic
- Increased excitability
- Heart palpitations
- Muscular pain and stiffness
- Changes in perception such as dizziness, visual disturbances, skin pain, etc
Serious symptoms from an abrupt benzodiazepine withdrawal may include: 32
The most common symptoms are certainly rebound anxiety and insomnia usually occurring 1-4 days after a tapering step. Going too fast on a benzodiazepine taper, especially when higher doses are involved, may result in seizures or psychosis. Slower tapering is advised to avoid extreme symptoms. 33
NOTE: The last benzodiazepine tapering cuts may be the most difficult
As you do each cut, starting with the first, the symptoms you go through, and the time it takes to restabilize are generally a guide for each benzodiazepine taper that is to follow. This information will help your doctor and you to get a more predictive picture of the way your body will respond to each cut. Tapering of the upper milligram levels of benzodiazepines may be somewhat uncomplicated in many, but when getting down below the halfway point, things might get more difficult. Tapering at the lower dosing levels may require elongating the time frame between tapering steps and reducing by smaller amounts each step. It has been our observation at the center that this is especially true when a person gets to the last few steps.
Gabapentin used as a bridge medication
Gabapentin is a medication that actually has the capacity to raise intracerebral GABA levels.34 Benzodiazepines act by making GABA, an inhibitory neurochemical, more potent at the receptor.35 This then creates a sedating effect. But the benzodiazepine tends to exhaust this mechanism and tolerance occurs.36 While coming off of the benzodiazepine, gabapentin can be extremely useful in mitigating the withdrawal. And then after the withdrawal, we have observed that it can generally be discontinued in a comparatively expedited taper. Each person is different, and there are a small few who have difficulty tapering off of the gabapentin, but even in those cases, it is almost certainly easier than benzodiazepine tapering. Even though gabapentin is moving toward being a scheduled drug at the time of this writing, we feel it is a much better drug than benzodiazepines and far less addictive. It has virtually no impact on the liver and is excreted by the kidneys as an unchanged substance.37 Many persons feel guarded around introducing another drug, and that is okay. We present it as an option. GABA has a short half-life of 5 to 7 hours,37 and to mitigate the withdrawal, it may have to be taken 3-4 times during the day during the benzodiazepine tapering process. To be effective. the dosing can range between 100 and 600mg 3-4 times a day depending on the severity of the withdrawal and how well tolerated the gabapentin is. If you are considering this option, ask your doctor to integrate it slowly so that you can ease into it.
There are certain people that have the opposite effect from gabapentin than most people in that it stimulates them as opposed to sedating them. We suspect that this may be due to a genetic polymorphism type called GAD1 and GAD2. While these polymorphisms are somewhat uncommon in the general population, it does show up in people with chronic anxiety.38,40 GAD has a lot to do with how the synthesis gating of GABA and glutamate occurs. Strangely, GABA, the most inhibitory neurochemical, and glutamate, the most excitatory neurochemical, share a common glutamic acid precursor.39 Those with the GAD polymorphism tend to produce less GABA and may be possible that even GABA products such as gabapentin can get shunted toward excitatory glutamate. For these people, they may have to take Trileptal or Trazodone if they are considering a temporary bridge medication. Speak to your prescribing physician to address these issues.
More help for benzodiazepine tapering: benzodiazepine alternatives and benzodiazepine Withdrawal Links for more information.
We have pages on our site that address benzodiazepine alternatives that can be used during the benzodiazepine tapering process. We strongly recommend you review these pages.
Quick links are: benzodiazepine alternatives, Ativan alternatives, Klonopin alternatives, Valium alternatives, Xanax alternatives, Ambien alternatives, and Librium alternatives. There is also a page that covers different types of medication tapering strategies. You may also want to consider reading the benzodiazepine withdrawal page.
At Alternative to Meds Center, we provide the space and time allowed to properly orchestrate benzodiazepine tapering, weaning, and titration. We are not a rapid benzo detox, which we consider largely inappropriate for this class of medication. Let us be clear — weaning off benzo drugs just cannot be treated like any other class of drugs. To do so may add additional injury and heightened distress while attempting benzodiazepine tapering.
Do Your Symptoms Require Benzodiazepines?
Alternative to Meds has delivered expert benzodiazepine tapering programs for a decade and a half. Our published evidence demonstrates our clients’ successes. While some can come off these invasive drugs more easily than others, a significant number of people we see have become neurotoxic. We have found that clearing out the burden of toxicity first gives the best method to regulate neurochemistry. Alternative to Meds Center knows that every individual needs a personalized benzodiazepine titration and weaning program that is uniquely tailored to their real-time needs and situation. 
