What are interdose withdrawal symptoms and why do they occur while I am tapering off benzodiazepines?

Benzodiazepine withdrawal is an unpleasant consequence of long-term benzodiazepine use, due to benzodiazepine dependence. Doctors have cut back on prescribing benzodiazepines after noting that patients may develop severe withdrawal symptoms that may include anxiety, insomnia, and difficulty focusing, when trying to quit their prescribed benzo.

Fortunately, for patients who have become dependent on drugs such as Xanax, Klonopin, or Ativan, can follow a drug taper plan, such as the Ashton Manual taper schedule, or a similar gradual taper plan. The purpose of these dosage reduction protocols is to avoid acute withdrawal and protracted symptoms for benzodiazepine users. Protracted symptoms may include akathisia or histamine sensitivity.

First, let’s answer the question, “What is a drug taper?” Tapering off of a drug means to take less and less of the drug by making gradual reductions over time for the purpose of reducing withdrawal severity and preventing a withdrawal reaction after long term use of a benzo.

There are certain medications that cause the brain and body to become physically dependent. This means that when the medication is not taken regularly, the patient’s brain and body react with uncomfortable, or even dangerous, withdrawal symptoms.

Ideally, if a drug taper is performed slowly enough, the patient does not suffer from intolerable drug withdrawal. With an experienced doctor’s help, a patient can either do a daily micro taper, or a stepwise dosage cut and hold.

In fact, there are many drug tapering methods for people with physical dependence from long term benzodiazepine use. For benzos, such as Klonopin or Xanax, a popular method is documented in the Ashton Manual, written by Professor Heather Ashton, M.D., which involves a diazepam substitution and then a gradual dose reduction.

In addition to the Ashton Method, there are other methods for benzo tapering, including liquid tapers. However, with short-acting benzodiazepines, there is the potential for interdose withdrawal symptoms, where the body reacts to the drug wearing off between scheduled doses.

How can I avoid interdose withdrawal symptoms?

There are several ways to avoid benzo withdrawal symptoms that occur between doses taken throughout the day. If you are doing a liquid taper or water taper using an alprazolam solution, you may be instructed by your doctor to take a dose every six hours or every eight hours.

One solution that your doctor may recommend if you complain of interdose symptoms will be to take a smaller dosage more often. For example, if you are taking Xanax 0.5mg every six hours, your doctor may suggest taking 0.25mg every three hours.

You may be concerned that this schedule will make sleeping through the night difficult, since you will have to wake up every three hours. Yet, it is possible to have some flexibility, where you can take 0.5mg at bedtime with the next scheduled dose of 0.25mg six to eight hours later, upon waking.

Xanax, known also by the generic name, alprazolam, is a very fast acting benzodiazepine with a short half-life. The effects come on quickly, but it also wears off quickly. A person with Xanax interdose withdrawal may prefer to switch to a longer acting benzo.

In this case, the Ashton Method may be ideal, because it involves switching from a highly potent benzo, such as Xanax or Klonopin, to Valium, a better suited tapering medication. Valium, also known as diazepam, is very long-acting, and it is far less potent compared to Xanax or Klonopin.

The lower diazepam potency makes tapering with existing Valium 2mg tablets possible. Xanax 0.5mg is equal in potency to Valium 10mg. A patient who takes Xanax 0.5mg daily as their baseline dose could switch to Valium 10mg daily and then use 2mg tablets to cut back little by little.

Could a Xanax taper be performed with a Valium micro taper?

What if it was possible to get the best of both worlds? Could a patient on Xanax transition to Valium, as described in the Ashton Manual, and then do a liquid micro taper with Valium?

First, why would a patient on Xanax ask their doctor to switch them to Valium at all if liquid Xanax tapering is available? If the doctor is willing to prescribe a compounded Xanax solution, why go through the extra trouble of transitioning to Valium?

With Xanax, even though a liquid taper can work very well, with a stepwise, cut and hold taper, or a regular micro taper schedule, there is a higher risk for interdose withdrawal. Xanax is simply too short-acting in most cases.

The patient, under the care of their tapering physician, may first try Xanax tapering, but if interdose withdrawal symptoms are an issue, patient and doctor can then discuss a cross-taper with Valium. First, the patient would be transitioned from Xanax to Valium, and then the tapering process would commence.

Next, you may wonder, why consider using a Valium compounded liquid solution when Professor Ashton described using diazepam 2mg tablets for the taper? While it is possible to taper very gradually with the 2 mg valium pills, even at 1 mg increments by cutting them, it may still be too steep a reduction for some patients.

Using a customized compounded diazepam solution, the taper doctor can create an individualized plan for the patient to reduce their valium intake by much smaller increments, making a true micro taper possible.

How would a Klonopin taper vary from a Xanax taper?

While all benzodiazepines have common properties and a common mechanism of action, working on the GABA receptors in the central nervous system, each benzo has unique properties as well. Klonopin, also known as clonazepam, is highly potent, like Xanax, and it also starts working quickly.

However, Klonopin is differentiated from Xanax by its longer half-life. Klonopin works for a longer time period, often dosed at 8-12 hour intervals, instead of 6-8 hour intervals like Xanax.

Still, it is possible to have interdose withdrawal with Klonopin. While not as common as with Xanax, there are patients who do a Klonopin taper with a compounded benzo liquid solution, and they suffer from some interdose withdrawal symptoms.

Before deciding to switch to another benzo, such as Valium, the doctor should do a careful evaluation first. Is the patient taking their Klonopin dose at regular intervals? Are they taking consistent dosing, following the taper schedule, or are they varying the dosage?

Sometimes, patients get ahead of themselves, attempting to taper faster, or even skipping some daily doses. While this may seem to work in the short term, withdrawal symptoms will likely catch up with the patient at some point.

For the best results in your tapering experience, it is important to have honest and open communications with your doctor.

In nearly all cases, patients who come to a doctor for benzodiazepine tapering are not at all addicted to their benzo medication. While they do have a physical dependence, they do not engage in addictive drug seeking behavior.

It is important for doctors to be understanding and respectful of the fact that they are not dealing with an addiction. Additionally, the doctor can help by educating family members that benzo dependence does not equal benzo addiction. There is no need for a rehab detox program, which may be harmful if their plan is to do a fast taper within a few weeks.

While the patient does not exhibit any addictive behaviors, they may sometimes be tempted to push the taper schedule faster than advised. As you reduce your Xanax, Klonopin, Ativan, or other benzodiazepine, you start to see the end in sight, and you may want to taper faster.

In some cases, the tapering process can be accelerated. Yet, the overall tapering plan, including the dosage step downs and reduction rates, should be openly discussed and agreed upon by patient and doctor.

You may be concerned that your doctor will not agree to change your benzo taper plan, but then again, you might be surprised. The drug taper process should be, to some extent, patient directed.

If the taper rate is too fast, the doctor must help the patient by advising a slower taper. On the other hand, if the taper is too slow, patient and doctor may agree to go a bit faster, as tolerated.