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A random person's sub experience...well written by the author I thought

Dec 09, 2008 - 5 comments

suboxone can be the worst mistake you ever make. or maybe it can be the answer for you. i think it all depends on your dosage, how long you use them, and how serious you are about getting clean.

i started using suboxone about one year ago. throughout my life ive used heroin, sometimes frequently enough to get a habit, sometimes not. before the suboxone i was not using heroin at all, and hadnt used for probably a year. what caused me to start the suboxone is pretty stupid. i got a bottle of painkillers from the dentist after some root canals. they were only 7.5s, not very strong. but to an ex opiate addict, they felt great. it had been so long since i had steady opiate in me, that little bit made me feel like superman. i used them not at all for the pain in my mouth, but to give me energy and euphoric feeling before work. as soon as they ran out, i went into withdrawl. i was amazed. i couldnt believe i was sick from using 20 7.5 oxycodones. but that is how my body is now. when it feels opiates, it goes crazy. so when the painkillers ran out, i had a pretty substantial physical and mental withdrawl going on. i was very, very weak. i was very depressed and sad. like a fool, i went to a clinic and got suboxone. i started one 8mg a day, breaking it in half and talking half in the morning, half at night. after some months, i moved down to 4 mg a day, then some months later 2 mgs a day. to be honest, going from 8 to 4 to 2mgs/day wasnt hard at all for me. so i was very optimistic about being able to quit totally. guess what. NOT HAPPENING. ive been taking 2mg (sometimes even less) of suboxone a day for about 4 months now, and cant f*cking get off them. ONLY 2MGs!!!! this is the smallest dose made, where do i go from here? its awful. i have to have half a 2mg pill right when i wake up. every morning when i wake up, im feeling WD symptoms. anxiety, depression, weakness, tingling extremities, everything. its unreal. ive tried taking litte tiny pieces, tapering down like that, and its torture. like someone said previously, even if you break it down into little tiny crumbs and taper with that, its just like an extended withdrawl rather than a healthy, successful detox.

i desperately want to be clean. i havent had desire to use opiates in two years now. that part of my life is over, ive moved past it. if you didnt know me, youd think i was an athlete or personal trainer in amazing shape. im 5'11 185lbs of muscle. i workout every day. i do martial arts, running, etc. but i cant get off this evil drug.

i think the thing that got me so hooked is how long i stayed on the suboxone, and the fact i didnt take it seriously enough. i believe that if you start at a modest dose of 8mg MAXIMUM or preferably less, like 6mg a day, and taper quickly down to 2, then break that in half to 1 mg a day, you can use suboxone successfully. but you have to do this over a short period of time. if you use the suboxone to catch any buzz, or use it to substitute one drug for another, youre really screwing yourself. if i wouldve just used it for lets say, 3 months maximum, i think id be fine today.

i used methadone successfully twice in my life. people who say methadone is worse are misinformed. methadone was 10xs easier to get off for me than suboxone is. im even considering using a very low dose methadone taper to get off the suboxone, as backwards as that sounds.

i should share this experience also. suboxone blocks most of the effect of other opioids. so if youre on suboxone, and take say a 40mg oxy, you shouldnt really feel much. i accidentally did this once. i was given a 40mg oxy. instead of throwing it out like i should have, i accepted it and put it in my clonipin bottle. during the night, not thinking of course, i took what i thought was a clonipin out of the bottle and swallowed it. WRONG. it was the oxy i took. when i realized it about an hour later, i started to panic. i was afraid i might get sick or something. what actually happened was strange. while i didnt feel a high from the oxy at all, i also didnt feel the need to take my suboxone at the normal time. i think i was able to go almost 6-8 hours longer than usual without feeling i needed the suboxone. it almost felt like i could kick suboxone using a broad spectrum opiate.

i might try this. i dont know what else to do, except go to inpatient rehab or outpatient methadone clinic. i might actually go without the suboxone until i get sick, then take a small amount of a painkiller and see how long that gets me through. if it gets me through a long time, i might try to taper with that instead, because tapering with the suboxones JUST ISNT WORKING. like i said, ive had heroin habits before and used methadone successfully to get clean. all i had to do was a slow taper, down to even 1mg of methadone which might as well be nothing, some people start at 120mg. i was able to get clean. but not with suboxone. this stuff is killing me.

i know i just wrote a novel. but i had to get it out. this stuff is running my life right now, and im by no means abusing it, or over doing it. yet still i cant go without it, and when i do the WDs are AWFUL. i feel terribly alone, depressed and sad. i feel almost hopeless. im very scared. ive never wanted to be clean so badly and just not able to do it! i dont know who to talk to or where to go with this. im just going to try to taper again. if it doesnt work, im gonna have to go inpatient rehab because i dont want to be on this drug for another day, let alone a year.

oh one more thing, my doctor once said that some people take low dose suboxone for depression. he actually suggested that like it was a good idea, to take 2mg of suboxone a day for depression. holy sh*t, i almost passed out when i heard him suggest that. its absolutely true that probably more than half of these doctors either dont know or dont care what theyre getting their patients into.


*** Again..this is not me and I just found it at the hosptial and thought it was a good story and well written...there was a post about mehadone verses sub earlier here on medhelp...this showed how some many make different choices..if they must to get clean...

Tapering schedules from benzos

Nov 13, 2008 - 0 comments

CHAPTER II

SLOW WITHDRAWAL SCHEDULES

A variety of withdrawal schedules from several benzodiazepines are illustrated below. Schedules such as these have worked on real people, but you may need to adapt them for your own needs. Reference to Table 1, Chapter I, which shows the equivalent strengths of different benzodiazepines, should enable you to work out your own programme and to devise an appropriate schedule for benzodiazepines such as prazepam (Centrax) and quazepam (Doral) and others which are not illustrated.

In my experience, the only exception to the general rule of slow reduction is triazolam (Halcion). This benzodiazepine is eliminated so quickly (half-life 2 hours) that you are practically withdrawn each day, after a dose the night before. For this reason, triazolam can be stopped abruptly without substitution of a long-acting benzodiazepine. If withdrawal symptoms occur, you could take a short course of diazepam starting at about 10mg, decreasing the dosage as shown on Schedule 2. The same approach applies to the non-benzodiazepines zolpidem and zaleplon which both have half-lives of 2 hours.

1. Withdrawal from high dose (6mg) alprazolam (Xanax) daily with diazepam (Valium) substitution

2. Simple withdrawal from diazepam (Valium) 40mg daily
3. Withdrawal from lorazepam (Ativan) 6mg daily with diazepam (Valium) substitution
4. Withdrawal from nitrazepam (Mogadon) 10mg at night with diazepam (Valium) substitution
5. Withdrawal from clonazepam (Klonopin) 1.5mg daily with substitution of diazepam (Valium)
6. Withdrawal from clonazepam (Klonopin) 3mg daily with substitution of diazepam (Valium)
7. Withdrawal from alprazolam (Xanax) 4mg daily with diazepam (Valium) substitution
8. Withdrawal from lorazepam (Ativan) 3mg daily with diazepam (Valium) substitution
9. Withdrawal from temazepam (Restoril) 30mg nightly with diazepam (Valium) substitution
10. Withdrawal from oxazepam (Serax) 20mg three times daily (60mg) with diazepam (Valium) substitution
11. Withdrawal from chlordiazepoxide (Librium) 25mg three times daily (75mg)
12. Withdrawal from zopiclone (Zimovane) 15mg with diazepam (Valium) substitution
13. Antidepressant Withdrawal Table

Schedule 1. Withdrawal from high dose (6mg) alprazolam (Xanax
daily with diazepam (Valium) substitution. (6mg alprazolam
is approximately equivalent to 120mg diazepam)

  Morning Midday/Afternoon Evening/Night Daily Diazepam
Equivalent
Starting dosage alprazolam 2mg alprazolam 2mg alprazolam 2mg 120mg
Stage 1
(one week) alprazolam 2mg alprazolam 2mg alprazolam 1.5mg
diazepam 10mg 120mg
Stage 2
(one week) alprazolam 2mg alprazolam 2mg alprazolam 1mg
diazepam 20mg 120mg
Stage 3
(one week) alprazolam 1.5mg
diazepam 10mg alprazolam 2mg alprazolam 1mg
diazepam 20mg 120mg
Stage 4
(one week) alprazolam 1mg
diazepam 20mg alprazolam 2mg alprazolam 1mg
diazepam 20mg 120mg
Stage 5
(1-2 weeks) alprazolam 1mg
diazepam 20mg alprazolam 1mg
diazepam 10mg alprazolam 1mg
diazepam 20mg 110mg
Stage 6
(1-2 weeks) alprazolam 1mg
diazepam 20mg alprazolam 1mg
diazepam 10mg alprazolam 0.5mg
diazepam 20mg 100mg
Stage 7
(1-2 weeks) alprazolam 1mg
diazepam 20mg alprazolam 1mg
diazepam 10mg Stop alprazolam
diazepam 20mg 90mg
Stage 8
(1-2 weeks) alprazolam 0.5mg
diazepam 20mg alprazolam 1mg
diazepam 10mg diazepam 20mg 80mg
Stage 9
(1-2 weeks) alprazolam 0.5mg
diazepam 20mg alprazolam 0.5mg
diazepam 10mg diazepam 20mg 80mg
Stage 10
(1-2 weeks) alprazolam 0.5mg
diazepam 20mg Stop alprazolam
diazepam 10mg diazepam 20mg 60mg
Stage 11
(1-2 weeks) Stop alprazolam
diazepam 20mg diazepam 10mg diazepam 20mg 50mg
Stage 12
(1-2 weeks) diazepam 25mg Stop midday dose;
divert 5mg each
to morning and
night doses  diazepam 25mg 50mg
Stage 13
(1-2 weeks) diazepam 20mg -- diazepam 25mg 45mg
Stage 14
(1-2 weeks) diazepam 20mg -- diazepam 20mg 40mg

Continue as on Schedule 2, reducing from diazepam 40mg


Schedule 1 Notes:


There is no actual withdrawal (only diazepam substitution) in Stages 1-4, so these could be undertaken at weekly intervals (but you could take 2 weeks for each stage if preferred).

The evening dose of diazepam could be taken at bed-time, rather than with the alprazolam if that is usually taken earlier. (Do not take any other sleeping tablet).

Some dosage reduction occurs in later stages of the diazepam switchover (Stages 5-11), so these stages could be undertaken at two week intervals. Even at reducing doses, the diazepam should cover withdrawal from alprazolam, because by this time it has had time to work through the body and will be acting smoothly both day and night. The aim is to obtain a dose of diazepam which avoids withdrawal symptoms but is not so great as to make you sleepy.

At Stage 12 it would be sensible to move to twice daily dosage. Diazepam is long-acting and there is no need to take it more than twice a day. There is no reduction in dosage while you make this change (Stages 11 and 12).


--------------------------------------------------------------------------------

Schedule 2. Simple withdrawal from diazepam (Valium) 40mg daily
(follow this schedule to complete Schedule 1)

  Morning Night Total
Daily Dosage
Starting dosage diazepam 20mg diazepam 20mg 40mg
Stage 1 (1-2 weeks) diazepam 18mg diazepam 20mg 38mg
Stage 2 (1-2 weeks) diazepam 18mg diazepam 18mg 36mg
Stage 3 (1-2 weeks) diazepam 16mg diazepam 18mg 34mg
Stage 4 (1-2 weeks) diazepam 16mg diazepam 16mg 32mg
Stage 5 (1-2 weeks) diazepam 14mg diazepam 16mg 30mg
Stage 6 (1-2 weeks) diazepam 14mg diazepam 14mg 28mg
Stage 7 (1-2 weeks) diazepam 12mg diazepam 14mg 26mg
Stage 8 (1-2 weeks) diazepam 12mg diazepam 12mg 24mg
Stage 9 (1-2 weeks) diazepam 10mg diazepam 12mg 22mg
Stage 10 (1-2 weeks) diazepam 10mg diazepam 10mg 20mg
Stage 11 (1-2 weeks) diazepam 8mg diazepam 10mg 18mg
Stage 12 (1-2 weeks) diazepam 8mg diazepam 8mg 16mg
Stage 13 (1-2 weeks) diazepam 6mg diazepam 8mg 14mg
Stage 14 (1-2 weeks) diazepam 5mg diazepam 8mg 13mg
Stage 15 (1-2 weeks) diazepam 4mg diazepam 8mg 12mg
Stage 16 (1-2 weeks) diazepam 3mg diazepam 8mg 11mg
Stage 17 (1-2 weeks) diazepam 2mg diazepam 8mg 10mg
Stage 18 (1-2 weeks) diazepam 1mg diazepam 8mg 9mg
Stage 19 (1-2 weeks) -- diazepam 8mg 8mg
Stage 20 (1-2 weeks) -- diazepam 7mg 7mg
Stage 21 (1-2 weeks) -- diazepam 6mg 6mg
Stage 22 (1-2 weeks) -- diazepam 5mg 5mg
Stage 23 (1-2 weeks) -- diazepam 4mg 4mg
Stage 24 (1-2 weeks) -- diazepam 3mg 3mg
Stage 25 (1-2 weeks) -- diazepam 2mg 2mg
Stage 26 (1-2 weeks) -- diazepam 1mg 1mg

Schedule 2 Notes:


You could probably manage Stages 1-5 (or even Stages 1-10) in weekly intervals (but take 2 weeks between stages if you prefer).

The later stages are probably better taken in 2 week intervals.

When you get down to a dose of 5mg daily, you could begin to decrease in 0.5mg doses, but most people manage with 1mg reductions.

You will need to utilise a mixture of 10mg, 5mg, and 2mg diazepam tablets to obtain the required dosages. Halve the (scored) 2mg tablet to obtain 1mg doses.

If your starting dose is 20mg diazepam daily, you could begin at Stage 10, but in this case you could reduce by 1mg every 2 weeks.

If starting from Schedule 1 (alprazolam 6mg daily) continue your reduction using this schedule.


--------------------------------------------------------------------------------

Schedule 3. Withdrawal from lorazepam (Ativan) 6mg daily
with diazepam (Valium) substitution. (6mg lorazepam is
approximately equivalent to 60mg diazepam)

  Morning Midday/Afternoon Evening/Night Daily Diazepam
Equivalent
Starting dosage lorazepam 2mg lorazepam 2mg lorazepam 2mg 60mg
Stage 1
(one week) lorazepam 2mg lorazepam 2mg lorazepam 1mg
diazepam 10mg 60mg
Stage 2
(one week) lorazepam 1.5mg
diazepam 5mg lorazepam 2mg lorazepam 1mg
diazepam 10mg 60mg
Stage 3
(one week) lorazepam 1.5mg
diazepam 5mg lorazepam 2mg lorazepam 0.5mg
diazepam 15mg 60mg
Stage 4
(one week) lorazepam 1.5mg
diazepam 5mg lorazepam 1.5mg
diazepam 5mg lorazepam 0.5mg
diazepam 15mg 60mg
Stage 5
(1-2 weeks) lorazepam 1.5mg
diazepam 5mg lorazepam 1.5mg
diazepam 5mg Stop lorazepam
diazepam 20mg 60mg
Stage 6
(1-2 weeks) lorazepam 1mg
diazepam 5mg lorazepam 1.5mg
diazepam 5mg diazepam 20mg 55mg
Stage 7
(1-2 weeks) lorazepam 1mg
diazepam 5mg lorazepam 1mg
diazepam 5mg diazepam 20mg 50mg
Stage 8
(1-2 weeks) lorazepam 0.5mg
diazepam 5mg lorazepam 1mg
diazepam 5mg diazepam 20mg 45mg
Stage 9
(1-2 weeks) lorazepam 0.5mg
diazepam 5mg lorazepam 0.5mg
diazepam 5mg diazepam 20mg 40mg
Stage 10
(1-2 weeks) Stop lorazepam
diazepam 5mg lorazepam 0.5mg
diazepam 5mg diazepam 20mg 35mg
Stage 11
(1-2 weeks) diazepam 5mg Stop lorazepam
diazepam 5mg diazepam 20mg 30mg
Stage 12
(1-2 weeks) diazepam 5mg diazepam 5mg diazepam 18mg 28mg
Stage 13
(1-2 weeks) diazepam 5mg diazepam 5mg diazepam 16mg 26mg
Stage 14
(1-2 weeks) diazepam 5mg diazepam 5mg diazepam 14mg 24mg
Stage 15
(1-2 weeks) diazepam 5mg diazepam 5mg diazepam 12mg 22mg
Stage 16
(1-2 weeks) diazepam 5mg diazepam 5mg diazepam 10mg 20mg
Stage 17
(1-2 weeks) diazepam 5mg diazepam 4mg diazepam 10mg 19mg
Stage 18
(1-2 weeks) diazepam 4mg diazepam 4mg diazepam 10mg 18mg
Stage 19
(1-2 weeks) diazepam 4mg diazepam 3mg diazepam 10mg 17mg
Stage 20
(1-2 weeks) diazepam 3mg diazepam 3mg diazepam 10mg 16mg
Stage 21
(1-2 weeks) diazepam 3mg diazepam 2mg diazepam 10mg 15mg
Stage 22
(1-2 weeks) diazepam 2mg diazepam 2mg diazepam 10mg 14mg
Stage 23
(1-2 weeks) diazepam 2mg diazepam 1mg diazepam 10mg 13mg
Stage 24
(1-2 weeks) diazepam 1mg diazepam 1mg diazepam 10mg 12mg
Stage 25
(1-2 weeks) diazepam 1mg Stop diazepam diazepam 10mg 11mg
Stage 26
(1-2 weeks) Stop diazepam -- diazepam 10mg 10mg
Stage 27
(1-2 weeks) -- -- diazepam 9mg 9mg
Stage 28
(1-2 weeks) -- -- diazepam 8mg 8mg
Stage 29
(1-2 weeks) -- -- diazepam 7mg 7mg
Stage 30
(1-2 weeks) -- -- diazepam 6mg 6mg
Stage 31
(1-2 weeks) -- -- diazepam 5mg 5mg
Stage 32
(1-2 weeks) -- -- diazepam 4mg 4mg
Stage 33
(1-2 weeks) -- -- diazepam 3mg 3mg
Stage 34
(1-2 weeks) -- -- diazepam 2mg 2mg
Stage 35
(1-2 weeks) -- -- diazepam 1mg 1mg
Stage 36 -- -- Stop diazepam --

Schedule 3 Notes:


There is no actual withdrawal (only diazepam substitution) in Stages 1-5, so these could be undertaken at weekly intervals (but you could take 2 weeks if preferred).

The evening dose of diazepam could be taken at bed-time, rather than with the lorazepam if that is usually taken earlier. (Do not take any other sleeping tablet).

Some dosage reduction occurs during the later stages of the diazepam switchover (Stages 6-11), so these stages could be undertaken at two week intervals. Even at reducing doses, the diazepam should cover withdrawal from lorazepam, because by this time it has had time to work through the body and will be acting smoothly both day and night. The aim is to obtain a dose of diazepam which avoids withdrawal symptoms but is not so great as to make you sleepy.

Day-time doses of diazepam are gradually phased out (Stages 17-25); in succeeding stages you only need to phase out the night-time dose by 1mg every week or two.

A mixture of 10mg, 5mg and 2mg diazepam tablets will be needed to obtain the required doses. Halve the (scored) 2mg tablets to obtain 1mg doses.


--------------------------------------------------------------------------------

Schedule 4. Withdrawal from nitrazepam (Mogadon) 10mg at
night with diazepam (Valium) substitution. (Nitrazepam
is approximately the same strength as diazepam)

  Bed-time dose
Starting dosage nitrazepam 10mg
Stage 1 (1 week) nitrazepam 5mg
diazepam 5mg  
Stage 2 (1 week) Stop nitrazepam
diazepam 10mg
Stage 3 (1-2 weeks) diazepam 9mg
Stage 4 (1-2 weeks) diazepam 8mg
Stage 5 (1-2 weeks) diazepam 7mg
Stage 6 (1-2 weeks) diazepam 6mg
Stage 7 (1-2 weeks) diazepam 5mg
Stage 8 (1-2 weeks) diazepam 4mg
Stage 9 (1-2 weeks) diazepam 3mg
Stage 10 (1-2 weeks) diazepam 2mg
Stage 11 (1-2 weeks) diazepam 1mg
Stage 12 Stop diazepam

Schedule 4 Notes:


If you are taking more than 10mg nitrazepam, replace each 5mg nitrazepam, one at a time, with 5mg diazepam, then reduce the diazepam in 1mg or 2mg stages.


--------------------------------------------------------------------------------

Schedule 5. Withdrawal from clonazepam (Klonopin) 1.5mg daily with
substitution of diazepam (Valium). (0.5mg clonazepam
is approximately equivalent to 10mg diazepam)

  Morning Midday/Afternoon Evening/Night Daily Diazepam
Equivalent
Starting dosage clonazepam 0.5mg clonazepam 0.5mg clonazepam 0.5mg 30mg
Stage 1
(1 week) clonazepam 0.5mg clonazepam 0.5mg clonazepam 0.25mg
diazepam 5mg 30mg
Stage 2
(1 week) clonazepam 0.5mg clonazepam 0.5mg Stop clonazepam
diazepam 10mg 30mg
Stage 3
(1 week) clonazepam 0.25mg
diazepam 5mg clonazepam 0.5mg diazepam 10mg 30mg
Stage 4
(1 week) clonazepam 0.25mg
diazepam 5mg clonazepam 0.25mg
diazepam 5mg diazepam 10mg 30mg
Stage 5
(1 week) Stop clonazepam
diazepam 10mg clonazepam 0.25mg
diazepam 5mg diazepam 10mg 30mg
Stage 6
(1-2 weeks) diazepam 10mg Stop clonazepam
diazepam 8mg diazepam 10mg 28mg
Stage 7
(1-2 weeks) diazepam 10mg diazepam 6mg diazepam 10mg 26mg
Stage 8
(1-2 weeks) diazepam 10mg diazepam 4mg diazepam 10mg 24mg
Stage 9
(1-2 weeks) diazepam 10mg diazepam 2mg diazepam 10mg 22mg
Stage 10
(1-2 weeks) diazepam 10mg Stop diazepam diazepam 10mg 20mg
Stage 11
(1-2 weeks) diazepam 8mg -- diazepam 10mg 18mg
Stage 12
(1-2 weeks) diazepam 6mg -- diazepam 10mg 16mg
Stage 13
(1-2 weeks) diazepam 4mg -- diazepam 10mg 14mg
Stage 14
(1-2 weeks) diazepam 2mg -- diazepam 10mg 12mg
Stage 15
(1-2 weeks) Stop diazepam  -- diazepam 10mg 10mg
Continue reducing remaining diazepam by 1 mg every 2 weeks (see Schedule 3 Stage 26)



--------------------------------------------------------------------------------

Schedule 6. Withdrawal from clonazepam (Klonopin) 3mg
daily with substitution of diazepam (Valium).
(1 mg clonazepam is equivalent to 20mg diazepam)

  Morning Midday/Afternoon Evening/Night Daily Diazepam
Equivalent
Starting dosage clonazepam 1mg clonazepam 1mg clonazepam 1mg 60mg
Stage 1
(1-2 weeks) clonazepam 1mg clonazepam 1mg clonazepam 0.5mg
diazepam 10mg 60mg
Stage 2
(1-2 weeks) clonazepam 0.5mg
diazepam 10mg clonazepam 1mg clonazepam 0.5mg
diazepam 10mg 60mg
Stage 3
(1-2 weeks) clonazepam 0.5mg
diazepam 10mg clonazepam 0.5mg
diazepam 5mg clonazepam 0.5mg
diazepam 10mg 55mg
Stage 4
(1-2 weeks) clonazepam 0.5mg
diazepam 10mg clonazepam 0.5mg
diazepam 5mg Stop clonazepam
diazepam 15mg 50mg
Stage 5
(1-2 weeks) clonazepam 0.25mg
diazepam 10mg clonazepam 0.5mg
diazepam 5mg diazepam 15mg 45mg
Stage 6
(1-2 weeks) clonazepam 0.25mg
diazepam 10mg clonazepam 0.25mg
diazepam 5mg diazepam 15mg 40mg
Stage 7
(1-2 weeks) Stop clonazepam
diazepam 10mg clonazepam 0.25mg
diazepam 5mg diazepam 15mg 35mg
Stage 8
(1-2 weeks) diazepam 10mg Stop clonazepam
diazepam 5mg diazepam 15mg 30mg
Stage 9
(1-2 weeks) diazepam 10mg diazepam 2.5mg diazepam 15mg 27.5mg
Stage 10
(1-2 weeks) diazepam 12mg Stop diazepam diazepam 15mg 27mg
Stage 11
(1-2 weeks) diazepam 10mg -- diazepam 15mg 25mg
Stage 12
(1-2 weeks) diazepam 10mg -- diazepam 14mg 24mg
Stage 13
(1-2 weeks) diazepam 10mg -- diazepam 12mg 22mg
Stage 14
(1-2 weeks) diazepam 10mg -- diazepam 10mg 20mg
Continue from Schedule 5, Stage 10

Schedule 6 Notes:


The small reduction (27.5mg to 27mg) between Stages 9 and 10 is to allow you to adjust to twice daily dose.


--------------------------------------------------------------------------------

Schedule 7. Withdrawal from alprazolam (Xanax) 4mg daily with
diazepam (Valium) substitution (4mg alprazolam is
approximately equivalent to 80mg diazepam)

  Morning Midday Afternoon Evening Daily Diazepam
Equivalent
Starting dosage alprazolam 1mg alprazolam 1mg alprazolam 1mg alprazolam 1mg 80mg
Stage 1
(1 week) alprazolam 1mg alprazolam 1mg alprazolam 1mg alprazolam 0.5mg
diazepam 10mg 80mg
Stage 2
(1 week) alprazolam 1mg alprazolam 0.5mg
diazepam 10mg alprazolam 1mg alprazolam 0.5mg
diazepam 10mg 80mg
Stage 3
(1 week) alprazolam 0.5mg
diazepam 10mg alprazolam 0.5mg
diazepam 10mg alprazolam 1mg alprazolam 0.5mg
diazepam 10mg 80mg
Stage 4
(1 week) alprazolam 0.5mg
diazepam 10mg alprazolam 0.5mg
diazepam 10mg alprazolam 0.5mg
diazepam 10mg alprazolam 0.5mg
diazepam 10mg 80mg
Stage 5
(1 week) alprazolam 0.5mg
diazepam 10mg alprazolam 0.5mg
diazepam 10mg alprazolam 0.5mg
diazepam 10mg alprazolam 0.5mg
diazepam 10mg 80mg
Stage 6
(1-2 weeks) alprazolam 0.5mg
diazepam 10mg alprazolam 0.25mg
diazepam 10mg alprazolam 0.5mg
diazepam 10mg diazepam 20mg 75mg
Stage 7
(1-2 weeks) alprazolam 0.25mg
diazepam 10mg alprazolam 0.25mg
diazepam 10mg alprazolam 0.5mg
diazepam 10mg diazepam 20mg 70mg
Stage 8
(1-2 weeks) alprazolam 0.25mg
diazepam 10mg alprazolam 0.25mg
diazepam 10mg alprazolam 0.25mg
diazepam 10mg diazepam 20mg 65mg
Stage 9
(1-2 weeks) alprazolam 0.25mg
diazepam 10mg Stop alprazolam
diazepam 10mg alprazolam 0.25mg
diazepam 10mg diazepam 20mg 60mg
Stage 10
(1-2 weeks) Stop alprazolam
diazepam 10mg diazepam 10mg alprazolam 0.25mg
diazepam 10mg diazepam 20mg 55mg
Stage 11
(1-2 weeks)
diazepam 10mg diazepam 10mg Stop alprazolam
diazepam 10mg diazepam 20mg 50mg
Stage 12
(1-2 weeks)
diazepam 10mg diazepam 5mg diazepam 10mg diazepam 20mg 45mg
Stage 13
(1-2 weeks)
diazepam 5mg diazepam 5mg diazepam 10mg diazepam 20mg 40mg
Stage 14
(1-2 weeks)
diazepam 5mg diazepam 5mg diazepam 5mg diazepam 20mg 35mg
Stage 15
(1-2 weeks)
diazepam 5mg diazepam 5mg diazepam 5mg diazepam 15mg 30mg
Stage 16
(1-2 weeks)
diazepam 5mg diazepam 5mg diazepam 5mg diazepam 12.5mg 27.5mg
Stage 17
(1-2 weeks)
diazepam 5mg diazepam 5mg diazepam 5mg diazepam 10mg 25mg
Stage 18
(1-2 weeks)
diazepam 5mg diazepam 2.5mg diazepam 5mg diazepam 10mg 22.5mg
Stage 19
(1-2 weeks)
diazepam 5mg Stop diazepam diazepam 5mg diazepam 10mg 20mg
Stage 20
(1-2 weeks)
diazepam 4mg -- diazepam 5mg diazepam 10mg 19mg
Stage 21
(1-2 weeks)
diazepam 4mg -- diazepam 4mg diazepam 10mg 18mg
Stage 22
(1-2 weeks)
diazepam 4mg -- diazepam 3mg diazepam 10mg 17mg
Stage 23
(1-2 weeks)
diazepam 3mg -- diazepam 3mg diazepam 10mg 16mg
Stage 24
(1-2 weeks)
diazepam 3mg -- diazepam 2mg diazepam 10mg 15mg
Stage 25
(1-2 weeks)
diazepam 2mg -- diazepam 2mg diazepam 10mg 14mg
Stage 26
(1-2 weeks)
diazepam 2mg -- Stop diazepam diazepam 10mg 12mg
Stage 27
(1-2 weeks) Stop diazepam -- -- diazepam 10mg 10mg
Continue reducing diazepam by 1mg every 2 weeks (see Schedule 3, Stage 26)

Schedule 7 Notes:


The evening diazepam dose can be taken at bed-time, rather than with alprazolam if that is usually taken earlier.


--------------------------------------------------------------------------------

Schedule 8. Withdrawal from lorazepam (Ativan) 3mg daily with
diazepam (Valium) substitution. (3mg lorazepam
is approximately equivalent to 30mg diazepam)

  Morning Midday/Afternoon Evening/Night Daily Diazepam
Equivalent
Starting dosage lorazepam 1 mg lorazepam 1 mg lorazepam 1 mg 30mg
Stage 1
(1 week) lorazepam 1 mg lorazepam 1 mg lorazepam 0.5mg
diazepam 5mg 30mg
Stage 2
(1 week) lorazepam 0.5mg
diazepam 5mg lorazepam 1 mg lorazepam 0.5mg
diazepam 5mg 30mg
Stage 3
(1 week) lorazepam 0.5mg
diazepam 5mg lorazepam 0.5mg
diazepam 5mg lorazepam 0.5mg
diazepam 5mg 30mg
Stage 4
(1 week) lorazepam 0.5mg
diazepam 5mg lorazepam 0.5mg
diazepam 5mg Stop lorazepam
diazepam 10mg 30mg
Stage 5
(1 week) Stop lorazepam
diazepam 10mg lorazepam 0.5mg
diazepam 5mg diazepam 10mg 30mg
Stage 6
(1 week) diazepam 10mg Stop lorazepam
diazepam 10mg diazepam 10mg 30mg
Stage 7
(1-2 weeks) diazepam 10mg diazepam 8mg diazepam 10mg 28mg
Stage 8
(1-2 weeks) diazepam 8mg diazepam 8mg diazepam 10mg 26mg
Stage 9
(1-2 weeks) diazepam 8mg diazepam 6mg diazepam 10mg 24mg
Stage 10
(1-2 weeks) diazepam 6mg diazepam 6mg diazepam 10mg 22mg
Stage 11
(1-2 weeks) diazepam 6mg diazepam 4mg diazepam 10mg 20mg
Stage 12
(1-2 weeks) diazepam 6mg diazepam 2mg diazepam 10mg 18mg
Stage 13
(1-2 weeks) diazepam 6mg Stop diazepam diazepam 10mg 16mg
Stage 14
(1-2 weeks) diazepam 5mg -- diazepam 10mg 15mg
Stage 15
(1-2 weeks) diazepam 4mg -- diazepam 10mg 14mg
Stage 16
(1-2 weeks) diazepam 3mg -- diazepam 10mg 13mg
Stage 17
(1-2 weeks) diazepam 2mg -- diazepam 10mg 12mg
Stage 18
(1-2 weeks) diazepam 1mg -- diazepam 10mg 11mg
Stage 19
(1-2 weeks) Stop diazepam -- diazepam 10mg 10mg
Continue reducing night time diazepam by 1 mg every 1-2 weeks (See Schedule 3, Stage 26)



--------------------------------------------------------------------------------

Schedule 9. Withdrawal from temazepam (Restoril) 30mg
nightly with diazepam substitution. (30mg temazepam is
approximately equivalent to 15mg diazepam)

  Night time
Equivalent diazepam dosage
Starting dosage temazepam 30mg  15mg
Stage 1 (1-2 weeks) temazepam 15mg
diazepam 7.5mg 15mg
Stage 2 (1-2 weeks) temazepam 7.5mg
diazepam 12mg 15.75mg
Stage 3 (1-2 weeks) Stop temazepam
diazepam 15mg 15mg
Stage 4 (1-2 weeks) diazepam 14mg 14mg
Stage 5 (1-2 weeks) diazepam 13mg 13mg
Stage 6 (1-2 weeks) diazepam 12mg 12mg
Stage 7 (1-2 weeks) diazepam 11mg 11mg
Stage 8 (1-2 weeks) diazepam 10mg 10mg
Stage 9 (1-2 weeks) diazepam 9mg 9mg
Stage 10 (1-2 weeks) diazepam 8mg 8mg
Stage 11 (1-2 weeks) diazepam 7mg 7mg
Stage 12 (1-2 weeks) diazepam 6mg 6mg
Stage 13 (1-2 weeks) diazepam 5mg 5mg
Stage 14 (1-2 weeks) diazepam 4mg 4mg
Stage 15 (1-2 weeks) diazepam 3mg 3mg
Stage 16 (1-2 weeks) diazepam 2mg 2mg
Stage 17 (1-2 weeks) diazepam 1mg 1mg
Stage 18 Stop diazepam --



--------------------------------------------------------------------------------

Schedule 10. Withdrawal from oxazepam (Serax) 20mg three times
daily (60mg) with diazepam (Valium) substitution (20mg
oxazepam is approximately equivalent to 10mg diazepam)

  Morning Midday Evening/Night Daily Diazepam
Equivalent
Starting dosage oxazepam 20mg oxazepam 20mg oxazepam 20mg 30mg
Stage 1
(1 week) oxazepam 20mg oxazepam 20mg oxazepam 10mg
diazepam 5mg 30mg
Stage 2
(1 week) oxazepam 10mg
diazepam 5mg oxazepam 20mg oxazepam 10mg
diazepam 5mg 30mg
Stage 3
(1 week) oxazepam 10mg
diazepam 5mg oxazepam 10mg
diazepam 5mg oxazepam 10mg
diazepam 5mg 30mg
Stage 4
(1-2 weeks) oxazepam 10mg
diazepam 5mg oxazepam 10mg
diazepam 5mg Stop oxazepam
diazepam 8mg 28mg
Stage 5
(1-2 weeks) Stop oxazepam
diazepam 8mg oxazepam 10mg
diazepam 5mg diazepam 8mg 26mg
Stage 6
(1-2 weeks) diazepam 8mg Stop oxazepam
diazepam 8mg diazepam 8mg 24mg
Stage 7
(1-2 weeks) diazepam 10mg diazepam 2mg diazepam 10mg 22mg
Stage 8
(1-2 weeks) diazepam 10mg Stop diazepam diazepam 10mg 20mg
Stage 9
(1-2 weeks) diazepam 8mg -- diazepam 10mg 18mg
Continue as on Schedule 2 from Stage 12

Schedule 10 Notes:


Oxazepam is short-acting (half-life 4-15 hrs) so substitution to diazepam (long-acting) is recommended.

Diazepam need only be taken twice a day.

A change from 5mg to 2mg diazepam tablets is necessary from Stage 4 onwards.


--------------------------------------------------------------------------------

Schedule 11. Withdrawal from chlordiazepoxide (Librium) 25mg
three times daily (75mg). (25mg chlordiazepoxide
is approximately equivalent to 10mg diazepam)

  Morning Midday Evening/Night
Starting dosage chlordiazepoxide 25mg chlordiazepoxide 25mg chlordiazepoxide 25mg
Stage 1
(1-2 weeks) chlordiazepoxide 25mg chlordiazepoxide 20mg chlordiazepoxide 25mg
Stage 2
(1-2 weeks) chlordiazepoxide 20mg chlordiazepoxide 20mg chlordiazepoxide 25mg
Stage 3
(1-2 weeks) chlordiazepoxide 20mg chlordiazepoxide 20mg chlordiazepoxide 20mg
Stage 4
(1-2 weeks) chlordiazepoxide 25mg chlordiazepoxide 5mg chlordiazepoxide 25mg
Stage 5
(1-2 weeks) chlordiazepoxide 25mg Stop chlordiazepoxide chlordiazepoxide 25mg
Stage 6
(1-2 weeks) chlordiazepoxide 20mg -- chlordiazepoxide 25mg
Stage 7
(1-2 weeks) chlordiazepoxide 20mg -- chlordiazepoxide 20mg
Stage 8
(1-2 weeks) chlordiazepoxide 15mg -- chlordiazepoxide 20mg
Stage 9
(1-2 weeks) chlordiazepoxide 15mg -- chlordiazepoxide 15mg
Stage 10
(1-2 weeks) chlordiazepoxide 10mg -- chlordiazepoxide 15mg
Stage 11
(1-2 weeks) chlordiazepoxide 10mg -- chlordiazepoxide 10mg
Stage 12
(1-2 weeks) chlordiazepoxide 5mg -- chlordiazepoxide 10mg
Stage 13
(1-2 weeks) chlordiazepoxide 5mg -- chlordiazepoxide 5mg
Stage 14
(1-2 weeks) chlordiazepoxide
2.5mg (½ tablet) -- chlordiazepoxide 5mg
Stage 15
(1-2 weeks) chlordiazepoxide
2.5mg (½ tablet) -- chlordiazepoxide
2.5mg (½ tablet)
Stage 16
(1-2 weeks) Stop chlordiazepoxide -- chlordiazepoxide
2.5mg (½ tablet)
Stage 17 -- -- Stop chlordiazepoxide

Schedule 11 Notes:


Chlordiazepoxide is long-acting so there is no need to take it more frequently than twice a day (hence Stages 4 and 5).

Because chlordiazepoxide is long-acting, there is no need for diazepam substitution.

If you are taking chlordiazepoxide capsules, change to tablets which can be halved for stages 14 onwards.


--------------------------------------------------------------------------------

Schedule 12. Withdrawal from zopiclone (Zimovane) 15mg
with diazepam (Valium) substitution. (15mg zopiclone
is approximately equivalent to 10mg diazepam)

  Night time Daily Diazepam
Equivalent
Starting dosage zopiclone 15mg 10mg
Stage 1
(1 week) zopiclone 7.5mg
diazepam 5mg 10mg
Stage 2
(1 week) Stop zopiclone
diazepam 10mg 10mg
Stage 3 (1-2 weeks) diazepam 9mg 9mg
Stage 4 (1-2 weeks)  diazepam 8mg 8mg
Then continue reducing diazepam by 1mg every 1-2 weeks as on Schedule 2

Schedule 12 Notes:


It is possible to withdraw directly from zopiclone using the smallest available tablets (3.75mg), but this dose of zopiclone is equivalent to 2.5mg diazepam making for rather abrupt dosage reductions.

This method can also be used for withdrawing from loprazolam and lormetazepam. 1mg of each of these is approximately equivalent to 10mg diazepam; their half-lives are 6-12 and 10-12 hrs respectively.


--------------------------------------------------------------------------------

Schedule 13. Antidepressant Withdrawal Table

Drugs Dosage strengths and formulations*
Tricyclics  
    amitriptyline (Tryptizol, Elavil) tabs 10, 25, 50mg; liquid 25mg/5ml
    amoxapine (Asendis) tabs 25, 50, 100mg
    clomipramine (Anafranil) caps 10, 25, 50mg; syrup 25mg/5ml  
    dothiepin (Prothiaden) tabs 25, 75mg
    doxepin (Sinequan) caps 10, 25, 50, 75mg
    imipramine (Tofranil) tabs 10, 25mg syrup 25mg/5ml
    lofepramine (Gamanil) tabs 70mg; liquid 70mg/5ml
    nortriptyline (Allegron, Pamelor) tabs 10, 25mg
    protriptyline (Concordin, Vivactil) tabs 5, 10mg
    trimipramine (Surmontil) tabs 10, 25mg
Related antidepressants  
    maprotiline (Ludiomil) tabs 10, 25, 50, 75mg
    mianserin (Bolvidon, Norval) tabs 10, 30mg
    trazodone (Molipaxin, Desyrel) caps 50, 100mg; tabs 150mg; liquid 50mg/5ml
    viloxazine (Vivalan) tabs 50mg
MAOIs (monoamine oxidase inhibitors)    
    phenelzine (Nardil) tabs 15mg
    moclobemide (Mannerix) tabs 150mg
    tranylcypromine (Parnate) tabs 10mg
SSRIs (selective serotonin reuptake inhibitors)  
    citalopram (Cipramil, Celexa) tabs 10, 20, 40mg; liquid 40mg/ml (drops)
    fluoxetine (Prozac) caps 20, 60mg; liquid 20mg/5ml
    fluvoxamine (Faverin, Luvox) tabs(s) 50, 100mg
    paroxetine (Seroxat, Paxil) tabs(s) 20, 30mg; liquid 20mg/5ml
    sertraline (Lustral, Zoloft) tabs 50, 100mg
    escitalopram (Cipralex, Lexapro) tabs 5, 10(s), 20mg(s)
Others  
    mirtazapine (Zispin, Remeron) tabs(s) 30mg
    nefazodone (Dutonin, Serzone) tabs(s) 100, 200mg
    reboxetine (Edronax, Vestra) tabs(s) 4mg
    venlafaxine (Efexor, Effexor) tabs 37.5, 75mg
* tabs: tablets, (s) scored; caps: capsules; 5ml = 1 teaspoon

Schedule 13 Notes:


Guidelines for benzodiazepine users who are also taking an antidepressant and wish to withdraw from both drugs

Complete the benzodiazepine withdrawal before starting to taper the antidepressant.

Allow at least 4 weeks after stopping benzodiazepines before starting on antidepressant withdrawal.

Consult your doctor before starting to withdraw the antidepressant and agree on a tapering schedule.

Antidepressant withdrawal must be gradual to avoid withdrawal effects.

Make each dose reduction as small as possible, e.g. by halving the tablets or using a liquid preparation.

If smaller doses are not available, reduce by taking a tablet every other day, then every third day, etc.

Allow 1-2 weeks between each dosage reduction.

If withdrawal symptoms are severe (Chapter 3, Table 2) increase the dosage slightly (e.g. to the dose at your last reduction). When symptoms have settled, resume withdrawal at a slower rate.

With slow tapering, as outlined above, withdrawal symptoms from antidepressants are usually absent, or if they occur, are mild and short-lived.


--------------------------------------------------------------------------------

Index · Contents · Introduction · Chapter I · Chapter II · Withdrawal Schedules · Chapter III
Medical Disclaimer · Order A Printed Copy · Professor Ashton's Main Page

© Copyright 1999-2008, Professor C H Ashton, School of Neurosciences, Division of Psychiatry,
The Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, England




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Index · Contents · Introduction · Chapter I · Chapter II · Withdrawal Schedules · Chapter III
Medical Disclaimer · Order A Printed Copy · Professor Ashton's Main Page
The Ashton Manual in other languages

    
CHAPTER I: THE BENZODIAZEPINES: WHAT THEY DO IN THE BODY

BENZODIAZEPINES: HOW THEY WORK
AND HOW TO WITHDRAW
(aka The Ashton Manual)

• PROTOCOL FOR THE TREATMENT OF BENZODIAZEPINE WITHDRAWAL
• Medical research information from a benzodiazepine withdrawal clinic

Professor C Heather Ashton DM, FRCP
Revised August 2002

• Ashton Manual Index Page
• Contents Page
• Introduction
• Chapter I: The benzodiazepines: what they do in the body
• Chapter II: How to withdraw from benzodiazepines after long-term use
• Chapter II: Slow withdrawal schedules
• Chapter III: Benzodiazepine withdrawal symptoms, acute & protracted




CHAPTER I

THE BENZODIAZEPINES: WHAT THEY DO IN THE BODY

Background

About this chapter

The benzodiazepines
Potency
Speed of elimination
Duration of effects
Therapeutic actions of benzodiazepines
Mechanisms of action

Adverse effects of benzodiazepines
Oversedation
Drug interactions
Memory impairment
Paradoxical stimulant effects
Depression, emotional blunting
Adverse effects in the elderly
Adverse effects in pregnancy
Tolerance
Dependence
    Therapeutic dose dependence
    Prescribed high dose dependence
    Recreational benzodiazepine abuse


Socioeconomic costs of long-term benzodiazepine use

Further reading

Table 1. Benzodiazepines and similar drugs
Table 2. Therapeutic actions of benzodiazepines
Table 3. Some socioeconomic costs of long-term benzodiazepine use
Fig. 1. Diagram of mechanism of action of the natural neurotransmitter GABA (gamma aminobutyric acid) and benzodiazepine on nerve cells (neurons) in the brain
BACKGROUND

For twelve years (1982-1994) I ran a Benzodiazepine Withdrawal Clinic for people wanting to come off their tranquillisers and sleeping pills. Much of what I know about this subject was taught to me by those brave and long-suffering men and women. By listening to the histories of over 300 "patients" and by closely following their progress (week-by-week and sometimes day-by-day), I gradually learned what long-term benzodiazepine use and subsequent withdrawal entails.

Most of the people attending the clinic had been taking benzodiazepines prescribed by their doctors for many years, sometimes over 20 years. They wished to stop because they did not feel well. They realised that the drugs, though effective when first prescribed, might now be actually making them feel ill. They had many symptoms, both physical and mental. Some were depressed and/or anxious; some had "irritable bowel", cardiac or neurological complaints. Many had undergone hospital investigations with full gastrointestinal, cardiological and neurological screens (nearly always with negative results). A number had been told (wrongly) that they had multiple sclerosis. Several had lost their jobs through recurrent illnesses.

The experiences of these patients have since been confirmed in many studies, by thousands of patients attending tranquilliser support groups in the UK and other parts of Europe, and by individuals vainly seeking help in the US. It is interesting that the patients themselves, and not the medical profession, were the first to realise that long-term use of benzodiazepines can cause problems.

ABOUT THIS CHAPTER

Some readers may decide to go directly to the chapter on benzodiazepine withdrawal (Chapter II). However, those who wish to understand withdrawal symptoms and techniques (and therefore to cope better with the withdrawal process) are advised to become acquainted first with what benzodiazepines do in the body, how they work, how the body adjusts to chronic use, and why withdrawal symptoms occur. These issues are discussed in this chapter.

THE BENZODIAZEPINES

Potency. A large number of benzodiazepines are available (Table 1). There are major differences in potency between different benzodiazepines, so that equivalent doses vary as much as 20-fold. For example, 0.5 milligrams (mg) of alprazolam (Xanax) is approximately equivalent to 10mg of diazepam (Valium). Thus a person on 6mg of alprazolam daily, a dose not uncommonly prescribed in the US, is taking the equivalent of about 120mg of diazepam, a very high dose. These differences in strength have not always been fully appreciated by doctors, and some would not agree with the equivalents given here. Nevertheless, people on potent benzodiazepines such as alprazolam, lorazepam (Ativan) or clonazepam (Klonopin) tend to be using relatively large doses. This difference in potency is important when switching from one benzodiazepine to another, for example changing to diazepam during the withdrawal, as described in the next chapter.

Speed of elimination. Benzodiazepines also differ markedly in the speed at which they are metabolised (in the liver) and eliminated from the body (in the urine) (Table 1). For example, the "half-life" (time taken for the blood concentration to fall to half its initial value after a single dose) for triazolam (Halcion) is only 2-5 hours, while the half-life of diazepam is 20-100 hours, and that of an active metabolite of diazepam (desmethyldiazepam) is 36-200 hours. This means that half the active products of diazepam are still in the bloodstream up to 200 hours after a single dose. Clearly, with repeated daily dosing accumulation occurs and high concentrations can build up in the body (mainly in fatty tissues). As Table 1 shows, there is a considerable variation between individuals in the rate at which they metabolise benzodiazepines.

Table 1. BENZODIAZEPINES AND SIMILAR DRUGS5

Benzodiazepines5 Half-life (hrs)1
[active metabolite] Market Aim2 Approximately Equivalent
Oral dosages (mg)3
Alprazolam (Xanax) 6-12 a 0.5
Bromazepam (Lexotan, Lexomil) 10-20 a 5-6
Chlordiazepoxide (Librium) 5-30 [36-200] a 25
Clobazam (Frisium) 12-60 a,e 20
Clonazepam (Klonopin, Rivotril) 18-50 a,e 0.5
Clorazepate (Tranxene) [36-200] a 15
Diazepam (Valium) 20-100 [36-200] a 10
Estazolam (ProSom) 10-24  h 1-2
Flunitrazepam (Rohypnol) 18-26 [36-200] h 1
Flurazepam (Dalmane) [40-250] h 15-30
Halazepam (Paxipam) [30-100] a 20
Ketazolam (Anxon) 30-100 [36-200] a 15-30
Loprazolam (Dormonoct) 6-12 h 1-2
Lorazepam (Ativan) 10-20 a 1
Lormetazepam (Noctamid) 10-12 h 1-2
Medazepam (Nobrium) 36-200 a 10
Nitrazepam (Mogadon) 15-38 h 10
Nordazepam (Nordaz, Calmday) 36-200 a 10
Oxazepam (Serax, Serenid, Serepax) 4-15 a 20
Prazepam (Centrax) [36-200] a 10-20
Quazepam (Doral) 25-100 h 20
Temazepam (Restoril, Normison, Euhypnos) 8-22 h 20
Triazolam (Halcion) 2 h 0.5
Non-benzodiazepines with similar effects4,5      
Zaleplon (Sonata) 2 h 20
Zolpidem (Ambien, Stilnoct) 2 h 20
Zopiclone (Zimovane, Imovane) 5-6 h 15
Eszopiclone (Lunesta) 6 (9 in elderly) h 3

Half-life: time taken for blood concentration to fall to half its peak value after a single dose. Half-life of active metabolite shown in square brackets. This time may vary considerably between individuals.

Market aim: although all benzodiazepines have similar actions, they are usually marketed as anxiolytics (a), hypnotics (h) or anticonvulsants (e).

These equivalents do not agree with those used by some authors. They are firmly based on clinical experience but may vary between individuals.

These drugs are chemically different from benzodiazepines but have the same effects on the body and act by the same mechanisms.

All these drugs are recommended for short-term use only (2-4 weeks maximum).

Duration of effects. The speed of elimination of a benzodiazepine is obviously important in determining the duration of its effects. However, the duration of apparent action is usually considerably less than the half-life. With most benzodiazepines, noticeable effects usually wear off within a few hours. Nevertheless the drugs, as long as they are present, continue to exert subtle effects within the body. These effects may become apparent during continued use or may appear as withdrawal symptoms when dosage is reduced or the drug is stopped.

Therapeutic actions of benzodiazepines. Regardless of their potency, speed of elimination or duration of effects, the actions in the body are virtually the same for all benzodiazepines. This is true whether they are marketed as anxiolytics, hypnotics or anti-convulsants (Table 1). All benzodiazepines exert five major effects which are used therapeutically: anxiolytic, hypnotic, muscle relaxant, anticonvulsant and amnesic (impairment of memory) (Table 2).

Table 2. THERAPEUTIC ACTIONS OF BENZODIAZEPINES (IN SHORT-TERM USE)

Action Clinical Use
Anxiolytic - relief of anxiety - Anxiety and panic disorders, phobias
Hypnotic - promotion of sleep - Insomnia
Myorelaxant - muscle relaxation - Muscle spasms, spastic disorders
Anticonvulsant - stop fits, convulsions - Fits due to drug poisoning, some forms of epilepsy
Amnesia - impair short-term memory - Premedication for operations, sedation for
  minor surgical procedures

Other clinical uses, utilising combined effects:


Alcohol detoxification

Acute psychosis with hyperexcitability and aggressiveness

These actions, exerted by different benzodiazepines in slightly varying degrees, confer on the drugs some useful medicinal properties. Few drugs can compete with them in efficacy, rapid onset of action and low acute toxicity. In short-term use, benzodiazepines can be valuable, sometimes even life-saving, across a wide range of clinical conditions as shown in Table 2. Nearly all the disadvantages of benzodiazepines result from long-term use (regular use for more than a few weeks). The UK Committee on Safety of Medicines in 1988 recommended that benzodiazepines should in general be reserved for short-term use (2-4 weeks only).

Mechanisms of action. Anyone struggling to get off their benzodiazepines will be aware that the drugs have profound effects on the mind and body apart from the therapeutic actions. Directly or indirectly, benzodiazepines in fact influence almost every aspect of brain function. For those interested to know how and why, a short explanation follows of the mechanisms through which benzodiazepines are able to exert such widespread effects.

All benzodiazepines act by enhancing the actions of a natural brain chemical, GABA (gamma-aminobutyric acid). GABA is a neurotransmitter, an agent which transmits messages from one brain cell (neuron) to another. The message that GABA transmits is an inhibitory one: it tells the neurons that it contacts to slow down or stop firing. Since about 40% of the millions of neurons all over the brain respond to GABA, this means that GABA has a general quietening influence on the brain: it is in some ways the body's natural hypnotic and tranquilliser. This natural action of GABA is augmented by benzodiazepines which thus exert an extra (often excessive) inhibitory influence on neurons (Fig. 1).

Fig. 1. Diagram of mechanism of action of the natural neurotransmitter GABA (gamma-aminobutyric acid) and benzodiazepines on nerve cells (neurons) in the brain



(1,2) Nerve impulse causes release of GABA from storage sites on neuron 1
(3) GABA released into space between neurons
(4) GABA reacts with receptors on neuron 2; the reaction allows chloride ions (Cl-) to enter the neuron
(5) This effect inhibits further progress of the nerve impulse
(6,7) Benzodiazepines react with booster site on GABA receptors
(8) This action enhances the inhibitory effects of GABA; the ongoing nerve impulse may be completely blocked

The way in which GABA sends its inhibitory message is by a clever electronic device. Its reaction with special sites (GABA-receptors) on the outside of the receiving neuron opens a channel, allowing negatively charged particles (chloride ions) to pass to the inside of the neuron. These negative ions "supercharge" the neuron making it less responsive to other neurotransmitters which would normally excite it. Benzodiazepines also react at their own special sites (benzodiazepine receptors), situated actually on the GABA-receptor. Combination of a benzodiazepine at this site acts as a booster to the actions of GABA, allowing more chloride ions to enter the neuron, making it even more resistant to excitation. Various subtypes of benzodiazepine receptors have slightly different actions. One subtype (alpha 1) is responsible for sedative effects, another (alpha 2) for anti-anxiety effects, and both alpha 1 and alpha 2, as well as alpha 5, for anticonvulsant effects. All benzodiazepines combine, to a greater or lesser extent, with all these subtypes and all enhance GABA activity in the brain.

As a consequence of the enhancement of GABA's inhibitory activity caused by benzodiazepines, the brain's output of excitatory neurotransmitters, including norepinephrine (noradrenaline), serotonin, acetyl choline and dopamine, is reduced. Such excitatory neurotransmitters are necessary for normal alertness, memory, muscle tone and co-ordination, emotional responses, endocrine gland secretions, heart rate and blood pressure control and a host of other functions, all of which may be impaired by benzodiazepines. Other benzodiazepine receptors, not linked to GABA, are present in the kidney, colon, blood cells and adrenal cortex and these may also be affected by some benzodiazepines. These direct and indirect actions are responsible for the well-known adverse effects of dosage with benzodiazepines.

ADVERSE EFFECTS OF BENZODIAZEPINES

Oversedation. Oversedation is a dose-related extension of the sedative/hypnotic effects of benzodiazepines. Symptoms include drowsiness, poor concentration, incoordination, muscle weakness, dizziness and mental confusion. When benzodiazepines are taken at night as sleeping pills, sedation may persist the next day as "hangover" effects, particularly with slowly eliminated preparations (Table 1). However, tolerance to the sedative effects usually develops over a week or two and anxious patients taking benzodiazepines during the day rarely complain of sleepiness although fine judgement and some memory functions may still be impaired.

Oversedation persists longer and is more marked in the elderly and may contribute to falls and fractures. Acute confusional states have occurred in the elderly even after small doses of benzodiazepines. Oversedation from benzodiazepines contributes to accidents at home and at work and studies from many countries have shown a significant association between the use of benzodiazepines and the risk of serious traffic accidents. People taking benzodiazepines should be warned of the risks of driving and of operating machinery.

Drug interactions. Benzodiazepines have additive effects with other drugs with sedative actions including other hypnotics, some antidepressants (e.g. amitriptyline [Elavil], doxepin [Adapin, Sinequan]), major tranquillisers or neuroleptics (e.g. prochlorperazine [Compazine], trifluoperazine [Stelazine]), anticonvulsants (e.g. phenobarbital, phenytoin [Dilantin], carbamazepine [Atretol, Tegretol]), sedative antihistamines (e.g. diphenhydramine [Benadryl], promethazine [Phenergan]), opiates (heroin, morphine, meperidine), and, importantly, alcohol. Patients taking benzodiazepines should be warned of these interactions. If sedative drugs are taken in overdose, benzodiazepines may add to the risk of fatality.

Memory impairment. Benzodiazepines have long been known to cause amnesia, an effect which is utilised when the drugs are used as premedication before major surgery or for minor surgical procedures. Loss of memory for unpleasant events is a welcome effect in these circumstances. For this purpose, fairly large single doses are employed and a short-acting benzodiazepine (e.g. midazolam) may be given intravenously.

Oral doses of benzodiazepines in the dosage range used for insomnia or anxiety can also cause memory impairment. Acquisition of new information is deficient, partly because of lack of concentration and attention. In addition, the drugs cause a specific deficit in "episodic" memory, the remembering of recent events, the circumstances in which they occurred, and their sequence in time. By contrast, other memory functions (memory for words, ability to remember a telephone number for a few seconds, and recall of long-term memories) are not impaired. Impairment of episodic memory may occasionally lead to memory lapses or "blackouts". It is claimed that in some instances such memory lapses may be responsible for uncharacteristic behaviours such as shop-lifting.

Benzodiazepines are often prescribed for acute stress-related reactions. At the time they may afford relief from the distress of catastrophic disasters, but if used for more than a few days they may prevent the normal psychological adjustment to such trauma. In the case of loss or bereavement they may inhibit the grieving process which may remain unresolved for many years. In other anxiety states, including panic disorder and agoraphobia, benzodiazepines may inhibit the learning of alternative stress-coping strategies, including cognitive behavioural treatment.

Paradoxical stimulant effects. Benzodiazepines occasionally cause paradoxical excitement with increased anxiety, insomnia, nightmares, hallucinations at the onset of sleep, irritability, hyperactive or aggressive behaviour, and exacerbation of seizures in epileptics. Attacks of rage and violent behaviour, including assault (and even homicide), have been reported, particularly after intravenous administration but also after oral administration. Less dramatic increases in irritability and argumentativeness are much more common and are frequently remarked upon by patients or by their families. Such reactions are similar to those sometimes provoked by alcohol. They are most frequent in anxious and aggressive individuals, children, and the elderly. They may be due to release or inhibition of behavioural tendencies normally suppressed by social restraints. Cases of "baby-battering", wife-beating and "grandma-bashing" have been attributed to benzodiazepines.

Depression, emotional blunting. Long-term benzodiazepine users, like alcoholics and barbiturate-dependent patients, are often depressed, and the depression may first appear during prolonged benzodiazepine use. Benzodiazepines may both cause and aggravate depression, possibly by reducing the brain's output of neurotransmitters such as serotonin and norepinephrine (noradrenaline). However, anxiety and depression often co-exist and benzodiazepines are frequently prescribed for mixed anxiety and depression. Sometimes the drugs seem to precipitate suicidal tendencies in such patients. Of the first 50 of the patients attending my withdrawal clinic (reported in 1987), ten had taken drug overdoses requiring hospital admission while on chronic benzodiazepine medication; only two of these had a history of depressive illness before they were prescribed benzodiazepines. The depression lifted in these patients after benzodiazepine withdrawal and none took further overdoses during the 10 months to 3.5 years follow-up period after withdrawal. In 1988 the Committee on Safety of Medicines in the UK recommended that "benzodiazepines should not be used alone to treat depression or anxiety associated with depression. Suicide may be precipitated in such patients".

"Emotional anaesthesia", the inability to feel pleasure or pain, is a common complaint of long-term benzodiazepine users. Such emotional blunting is probably related to the inhibitory effect of benzodiazepines on activity in emotional centres in the brain. Former long-term benzodiazepine users often bitterly regret their lack of emotional responses to family members - children and spouses or partners - during the period when they were taking the drugs. Chronic benzodiazepine use can be a cause of domestic disharmony and even marriage break-up.

Adverse effects in the elderly. Older people are more sensitive than younger people to the central nervous system depressant effects of benzodiazepines. Benzodiazepines can cause confusion, night wandering, amnesia, ataxia (loss of balance), hangover effects and "pseudodementia" (sometimes wrongly attributed to Alzheimer’s disease) in the elderly and should be avoided wherever possible. Increased sensitivity to benzodiazepines in older people is partly because they metabolise drugs less efficiently than younger people, so that drug effects last longer and drug accumulation readily occurs with regular use. However, even at the same blood concentration, the depressant effects of benzodiazepines are greater in the elderly, possibly because they have fewer brain cells and less reserve brain capacity than younger people.

For these reasons, it is generally advised that, if benzodiazepines are used in the elderly, dosage should be half that recommended for adults, and use (as for adults) should be short-term (2 weeks) only. In addition, benzodiazepines without active metabolites (e.g. oxazepam [Serax], temazepam [Restoril]) are tolerated better than those with slowly eliminated metabolites (e.g. chlordiazepoxide [Librium], nitrazepam [Mogadon]). Equivalent potencies of different benzodiazepines are approximately the same in older as in younger people (Table 1).

Adverse effects in pregnancy. Benzodiazepines cross the placenta, and if taken regularly by the mother in late pregnancy, even in therapeutic doses, can cause neonatal complications. The foetus and neonate metabolise benzodiazepines very slowly, and appreciable concentrations may persist in the infant up to two weeks after birth, resulting in the "floppy infant syndrome" of lax muscles, oversedation, and failure to suckle. Withdrawal symptoms may develop after about two weeks with hyperexcitability, high-pitched crying and feeding difficulties.

Benzodiazepines in therapeutic doses appear to carry little risk of causing major congenital malformations. However, chronic maternal use may impair foetal intrauterine growth and retard brain development. There is increasing concern that such children in later life may be prone to attention deficit disorder, hyperactivity, learning difficulties, and a spectrum of autistic disorders.

Tolerance. Tolerance to many of the effects of benzodiazepines develops with regular use: the original dose of the drug has progressively less effect and a higher dose is required to obtain the original effect. This has often led doctors to increase the dosage in their prescriptions or to add another benzodiazepine so that some patients have ended up taking two benzodiazepines at once.

However, tolerance to the various actions of benzodiazepines develops at variable rates and to different degrees. Tolerance to the hypnotic effects develops rapidly and sleep recordings have shown that sleep patterns, including deep sleep (slow wave sleep) and dreaming (which are initially suppressed by benzodiazepines), return to pre-treatment levels after a few weeks of regular benzodiazepine use. Similarly, daytime users of the drugs for anxiety no longer feel sleepy after a few days.

Tolerance to the anxiolytic effects develops more slowly but there is little evidence that benzodiazepines retain their effectiveness after a few months. In fact long-term benzodiazepine use may even aggravate anxiety disorders. Many patients find that anxiety symptoms gradually increase over the years despite continuous benzodiazepine use, and panic attacks and agoraphobia may appear for the first time after years of chronic use. Such worsening of symptoms during long-term benzodiazepine use is probably due to the development of tolerance to the anxiolytic effects, so that "withdrawal" symptoms emerge even in the continued presence of the drugs. However, tolerance may not be complete and chronic users sometimes report continued efficacy, which may be partly due to suppression of withdrawal effects. Nevertheless, in most cases such symptoms gradually disappear after successful tapering and withdrawal of benzodiazepines. Among the first 50 patients attending my clinic, 10 patients became agoraphobic for the first time while taking benzodiazepines. Agoraphobic symptoms abated dramatically within a year of withdrawal, even in patients who had been housebound, and none were incapacitated by agoraphobia at the time of follow-up (10 months to 3.5 years after withdrawal).

Tolerance to the anticonvulsant effects of benzodiazepines makes them generally unsuitable for long-term control of epilepsy. Tolerance to the motor effects of benzodiazepines can develop to a remarkable degree so that people on very large doses may be able to ride a bicycle and play ball games. However, complete tolerance to the effects on memory and cognition does not seem to occur. Many studies show that these functions remain impaired in chronic users, recovering slowly, though sometimes incompletely, after withdrawal.

Tolerance is a phenomenon that develops with many chronically used drugs (including alcohol, heroin and morphine and cannabis). The body responds to the continued presence of the drug with a series of adjustments that tend to overcome the drug effects. In the case of benzodiazepines, compensatory changes occur in the GABA and benzodiazepine receptors which become less responsive, so that the inhibitory actions of GABA and benzodiazepines are decreased. At the same time there are changes in the secondary systems controlled by GABA so that the activity of excitatory neurotransmitters tends to be restored. Tolerance to different effects of benzodiazepines may vary between individuals - probably as a result of differences in intrinsic neurological and chemical make-up which are reflected in personality characteristics and susceptibility to stress. The development of tolerance is one of the reasons people become dependent on benzodiazepines, and also sets the scene for the withdrawal syndrome, described in the next chapter.

Dependence. Benzodiazepines are potentially addictive drugs: psychological and physical dependence can develop within a few weeks or months of regular or repeated use. There are several overlapping types of benzodiazepine dependence.

Therapeutic dose dependence. People who have become dependent on therapeutic doses of benzodiazepines usually have several of the following characteristics.

They have taken benzodiazepines in prescribed "therapeutic" (usually low) doses for months or years.

They have gradually become to "need" benzodiazepines to carry out normal, day-to-day activities.

They have continued to take benzodiazepines although the original indication for prescription has disappeared.

They have difficulty in stopping the drug, or reducing dosage, because of withdrawal symptoms.

If on short-acting benzodiazepines (Table 1) they develop anxiety symptoms between doses, or get craving for the next dose.

They contact their doctor regularly to obtain repeat prescriptions.

They become anxious if the next prescription is not readily available; they may carry their tablets around with them and may take an extra dose before an anticipated stressful event or a night in a strange bed.

They may have increased the dosage since the original prescription.

They may have anxiety symptoms, panics, agoraphobia, insomnia, depression and increasing physical symptoms despite continuing to take benzodiazepines.

The number of people world-wide who are taking prescribed benzodiazepines is enormous. For example, in the US nearly 11 per cent of a large population surveyed in 1990 reported some benzodiazepine use the previous year. About 2 per cent of the adult population of the US (around 4 million people) appear to have used prescribed benzodiazepine hypnotics or tranquillisers regularly for 5 to 10 years or more. Similar figures apply in the UK, over most of Europe and in some Asian countries. A high proportion of these long-term users must be, at least to some degree, dependent. Exactly how many are dependent is not clear; it depends to some extent on how dependence is defined. However, many studies have shown that 50-100 per cent of long-term users have difficulty in stopping benzodiazepines because of withdrawal symptoms, which are described in Chapter III.

Prescribed high dose dependence. A minority of patients who start on prescribed benzodiazepines begin to "require" larger and larger doses. At first they may persuade their doctors to escalate the size of prescriptions, but on reaching the prescriber's limits, may contact several doctors or hospital departments to obtain further supplies which they self-prescribe. Sometimes this group combines benzodiazepine misuse with excessive alcohol consumption. Patients in this group tend to be highly anxious, depressed and may have personality difficulties. They may have a history of other sedative or alcohol misuse. They do not typically use illicit drugs but may obtain "street" benzodiazepines if other sources fail.

Recreational benzodiazepine abuse. Recreational use of benzodiazepines is a growing problem. A large proportion (30-90 per cent) of polydrug abusers world-wide also use benzodiazepines. Benzodiazepines are used in this context to increase the "kick" obtained from illicit drugs, particularly opiates, and to alleviate the withdrawal symptoms of other drugs of abuse (opiates, barbiturates, cocaine, amphetamines and alcohol). People who have been given benzodiazepines during alcohol detoxification sometimes become dependent on benzodiazepines and may abuse illicitly obtained benzodiazepines as well as relapsing into alcohol use. Occasionally high doses of benzodiazepines are used alone to obtain a "high".

Recreational use of diazepam, alprazolam, lorazepam, temazepam, triazolam, flunitrazepam and others has been reported in various countries. Usually the drugs are taken orally, often in doses much greater than those used therapeutically (e.g.100mg diazepam or equivalent daily) but some users inject benzodiazepines intravenously. These high dose users develop a high degree of tolerance to benzodiazepines and, although they may use the drugs intermittently, some become dependent. Detoxification of these patients may present difficulties since withdrawal reactions can be severe and include convulsions.

The present population of recreational users may be relatively small, perhaps one tenth of that of long-term prescribed therapeutic dose users, but probably amounts to some hundreds of thousands in the US and Western Europe, and appears to be increasing. It is a chastening thought that medical overprescription of benzodiazepines, resulting in their presence in many households, made them easily available and undoubtedly aided their entry into the illicit drug scene. Present sources for illicit users are forged prescriptions, theft from drug stores, or illegal imports.

Socioeconomic costs of long-term benzodiazepine use. The socio-economic costs of the present high level of long-term benzodiazepine use are considerable, although difficult to quantify. Most of these have been mentioned above and are summarised in Table 3. These consequences could be minimised if prescriptions for long-term benzodiazepines were decreased. Yet many doctors continue to prescribe benzodiazepines and patients wishing to withdraw receive little advice or support on how to go about it. The following chapter gives practical information on withdrawal which, it is hoped, will be of use both to long-term benzodiazepine users and to their physicians.

TABLE 3. SOME SOCIOECONOMIC COSTS OF LONG-TERM BENZODIAZEPINE USE

Increased risk of accidents - traffic, home, work.

Increased risk of fatality from overdose if combined with other drugs.

Increased risk of attempted suicide, especially in depression.

Increased risk of aggressive behaviour and assault.

Increased risk of shoplifting and other antisocial acts.

Contributions to marital/domestic disharmony and breakdown due to emotional and cognitive impairment.

Contributions to job loss, unemployment, loss of work through illness.

Cost of hospital investigations/consultations/admissions.

Adverse effects in pregnancy and in the new-born.

Dependence and abuse potential (therapeutic and recreational).

Costs of drug prescriptions.

Costs of litigation.

FURTHER READING

Ashton, H. Benzodiazepine withdrawal: outcome in 50 patients. British Journal of Addiction (1987) 82,665-671.

Ashton, H. Guidelines for the rational use of benzodiazepines. When and what to use. Drugs (1994) 48,25-40.

Ashton, H. Toxicity and adverse consequences of benzodiazepine use. Psychiatric Annals (1995) 25,158-165.

Ashton, H. Benzodiazepine Abuse, Drugs and Dependence, Harwood Academic Publishers (2002), 197-212, Routledge, London & New York.


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Index · Contents · Introduction · Chapter I · Chapter II · Withdrawal Schedules · Chapter III
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Beating the blues naturally

Nov 09, 2008 - 0 comments

Depression is a common illness that strikes about one in 15 Americans each year. It is the number one complaint heard by primary-care physicians, according to Richard Brown, M.D. author of Stop Depression Now (Penguin Putnam, 1995), and more than 50 percent of the American population suffers from moderate depression at least once in a lifetime.

Rather than just "getting over it," men and women who are depressed often require treatment of the illness. According to the National Institute of Mental Health, symptoms of depression may include a persistent sad or empty feeling; a loss of energy and appetite; and a lack of interest in socializing, work or hobbies. Depression can come in various forms ranging from mild to moderate or severe. Mild depression is characterized by difficulty in maintaining normal activities; moderate depression may involve impaired functioning at work or in social activities; and severe depression, which may involve delusions or hallucinations, markedly interferes with a person's ability to function normally and may lead to suicide. Genetic factors may put a person at greater risk for developing depression, and alcohol or drug use can make symptoms worse.

Current biochemical theories of depression suggest that biogenic amines may play a significant role in depression. This group of chemical compounds transmits nerve impulses across a synapse - a junction where nerve impulses pass to a neuron or another cell. Amines such as neropinephrine, serotonin and, to a lesser extent, dopamine, acetylcholine and epinephrine have been extensively studied for their roles in the pathophysiology of depression. Serotonin, in particular, has been the subject of intense research for the past 25 years.

Antidepressant medications affecting these amines include monoamine oxidase (MAO) inhibitors, tricyclic antidepressants and selective serotonin inhibitors (SSRI). MAO inhibitors increase norepinephrine levels, SSRIs block serotonin inactivation, and tricyclics enhance norepinephrine transmission. Psychotherapies combined with conventional antidepressant drugs such as Prozac and Paxil have become more widely used in the past several years and have been found to be effective remedies. However, patients have reported unpleasant side effects such as dry mouth, nausea, headache, or impaired sexual function or sleep. (For more information on the various side effects of the drugs commonly used to treat depression click here.) Because of these side effects, many patients have turned to natural treatments such as amino acid supplementation and herbal phytomedicines as an aid in treating mild depression. Popular choices include 5-hydroxytryptophan (5-HTP), SAM-e, St. John's Wort, Kava kava and Ginkgo Biloba. Researchers continue to study the benefits of these products and suggest that natural alternatives may provide fewer or less severe side effects than most conventional antidepressants drugs.

Amino Acids and Other Precursors

Amino Acids can act as neurotransmitters or precursors to other neurotransmitters such as serotonin. Supplementing with amino acids can ease symptoms of depression. Amino acids and related compounds used in the treatment of depression include L-tryptophan, L-tyrosine, L-phenylalanine and 5-HTP. Other players such as melatonin and SAM-e have also been suggested as effective antidepressant therapies.

L-tyrosine: A precursor to norepinephrine; may be valuable to the people who do not respond to most antidepressant drugs except amphetamines.


L-phenylalanine: Converted to tyrosine (a naturally occuring form of phenylalanine); D-phenylalanine (which does not normally occur in the body or in food) is metabolized to phenylethylamine (PEA), an amphetamine-like compound that occurs normally in the human brain and has been shown to have mood elevating effects. Studies have shown that depressed people commonly have low levels of phenylethylamine.


5-HTP: A close relative to tryptophan and a part of the metabolic pathway that leads to serotonin production. Studies from around the world have found that 5-HTP has true antidepressant properties.


SAM-e: A chemical compound found in all living cells; SAM-e can be found in more than 40 biomedical processes in the body. Supplementing the diet with SAM-e in depressed patients can result in increased levels of serotonin, dopamine and phosphatides, improve binding of neurotransmitters to receptor sites and increase serotonin and dopamine activity. The key to SAM-e's effectiveness is its ability to make brain cells more responsive to neurotransmitters such as serotonin and dopamine.


Phytomedicines

Phytomedicines such as St. John's wort, kava kava and Ginkgo biloba may also have compounds that can aid in treating depression. Phytomedicines can not only serve as weak MAO inhibitors but can also help alleviate specific symptoms of depression. According to Harold H. Bloomfield, M.D., author of Healing Anxiety with Herbs (Harper Collins, 1998), anxiety and depression frequently occur in tandem. "Irritability, difficulty concentrating, indecision, guilt, fatigue, sleep and eating disturbances, and chronic aches and pains are symptoms common to both disorders," said Bloomfield. In addition, almost half of the people who suffer repeated panic attacks develop a major case of depression, which can be attributed to low levels of serotonin found in individuals who suffer from either anxiety disorders or depression. With this in mind, herbs such as kava and ginkgo, which have been proven to help with anxiety, may also help in treatment of depression.

St. John's Wort: Researchers have discovered that this herb works like an SSRI (a class of antidepressant medication) and a weak MAO inhibitor. Numerous studies have confirmed that St. John's Wort does possess antidepressive effects in cases of mild to moderate depression.


Kava kava: Has soothing and stress relieving qualities; studies have shown its effectiveness in treating anxiety and depression.


Ginkgo biloba: Improves blood flow through the brain, accounting for its use as an aid in mental acuity. Appears to normalize neurotransmitter levels; a potent antioxidant that protects nervous system cells and regulates blood platelet stickiness. Studies have shown that ginkgo biloba may be used to improve mood and may be useful in conjunction withy standard antidepressants to enhance effectiveness in patients who are resistant to standard drug therapies. Another study showed ginkgo's effectiveness in decreasing sexual dysfunction problems caused by antidepressant drugs.


[HSR® Health Supplement Retailer, Vol. 6. No. 6, June 2000, pgs. 14-20.]  

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