Key Takeaways
- The Ashton Protocol is Professor C. Heather Ashton’s framework for coming off a benzodiazepine slowly, set out in the Ashton Manual, and the names Ashton Method and Ashton taper describe the same approach.
- When a person takes a short-acting benzodiazepine such as Xanax or Ativan, or a potent one such as Klonopin, the Manual moves them gradually onto diazepam (Valium), because diazepam leaves the body slowly and its small scored tablets allow small steps.
- The switch is made one dose at a time, usually starting with the evening or night-time dose, at an approximately equivalent dose. No reduction is aimed for during the switch unless the starting dose is very large.
- The diazepam then comes down in small steps that get smaller as the dose falls. The Manual says there is no magic rate and that the person tapering is usually the best judge of the pace.
- Slow withdrawal means months, often a year or more, and the Manual calls the six-week withdrawal used by many clinics much too fast for many long-term users.
- At a difficult stretch the dose can be held for a few weeks. In this site’s view, a return to the previous step with the prescriber’s agreement can be the safer choice when symptoms after a cut are severe.
- The Manual ends its taper with a step off from 0.5 mg of diazepam. In this site’s view, continuing below that on the 1 mg/mL oral solution to about 0.1 mg is reasonable for many people, and it is a choice for the person and their prescriber.
- The doctor’s agreement and co-operation are necessary because the doctor prescribes. Stopping suddenly or reducing too fast can bring on withdrawal reactions including seizures, which are a medical emergency.
What is the Ashton Protocol?
In short: the Ashton Protocol is Professor C. Heather Ashton’s method for coming off a benzodiazepine slowly. It has four parts.
- Switch to diazepam. A short-acting benzodiazepine such as Xanax, Ativan or Klonopin is replaced with diazepam (Valium) gradually, one dose at a time, at an equivalent dose.
- Cut in small steps. The Manual suggests reducing by up to one tenth of the daily dose at each step, so the steps get smaller in milligrams as the dose falls.
- Let the person tapering set the pace. The examples space steps one to two weeks apart, a difficult point can be held for a few weeks, and the Manual says the best judge of the pace is usually you.
- Expect months, not weeks. The Manual’s own example from 40 mg of diazepam comes to roughly 30 to 60 weeks, and it calls the six-week withdrawal used by many clinics much too fast for many long-term users.
The Ashton Protocol is the approach to coming off benzodiazepines set out in the Ashton Manual, “Benzodiazepines: How They Work and How to Withdraw,” written by the late Professor C. Heather Ashton of Newcastle University after twelve years of running a benzodiazepine withdrawal clinic. Readers will also see it called the Ashton Method or the Ashton taper. Those are community names for the same approach, and this article uses them interchangeably.
The shape of the approach is easy to state. Where a person takes a short-acting benzodiazepine, the Manual moves them gradually onto diazepam, then reduces the diazepam in small steps, at a pace the person sets, toward a defined end. It is a framework rather than a rigid schedule, and Professor Ashton wrote that there is no magic rate of withdrawal.
The Manual’s subject is the dependence that develops in people taking a benzodiazepine as prescribed, which Chapter I calls therapeutic dose dependence. Dependence is not addiction. It is a predictable physical adaptation to a medication, and the response that fits it is a gradual medical taper, not an addiction program. So what does the Manual actually ask a person to do?
Why does the Manual switch short-acting benzodiazepines to diazepam?
Benzodiazepines differ mainly in how long they stay in the body. Table 1 of the Manual gives alprazolam (Xanax) a half-life of 6 to 12 hours and lorazepam (Ativan) 10 to 20 hours, while diazepam (Valium) runs 20 to 100 hours and its active metabolite has a half-life of 36 to 200 hours. A drug that leaves quickly produces peaks and troughs between doses.
Those troughs are interdose withdrawal, the symptoms that arrive a few hours after each dose and ease when the next one is taken. Chapter II explains that a smooth decline in blood and tissue concentrations is not possible with a rapidly eliminated drug, and that many people on one experience what it calls a mini-withdrawal between each dose. A reduction in such a drug lands on top of that.
Diazepam’s slow elimination smooths the curve, and its 2 mg tablets, scored down the middle, allow very small steps. So, that is the whole reason for the crossover taper, and it is why the protocol is so often described as a switch to Valium. The crossover is a means, not the method itself: a person already on diazepam simply tapers what they take, as the Manual’s own diazepam schedule does, and the Manual tapers chlordiazepoxide the same way, noting in Schedule 11 that it is long-acting and needs no diazepam substitution.
How is the crossover to diazepam carried out?
The Manual does not switch a person all at once. Chapter II says to substitute one dose at a time, usually starting with the evening or night-time dose, then to replace the other doses one by one at intervals of a few days or a week. Changing one dose at a time avoids a sudden jolt and, as the Manual notes, helps to find the equivalent dose for that particular person. The site’s article on how the diazepam switch is made walks through it in more detail.
The protocol is often summarized as switch, stabilize, then taper, and for most doses that is close to what Chapter II describes. Unless a person starts from a very large dose, the Manual says there is no need to aim for any reduction during the switch, only for an approximately equivalent dose, and the diazepam reductions begin once the substitution is complete. At high doses the two overlap. In the Manual’s schedule for alprazolam 6 mg a day, the first four stages substitute diazepam with no reduction at all, and reductions then begin while alprazolam is still being replaced.
The conversion itself comes from the Manual’s equivalence table. Ten milligrams of diazepam is roughly 0.5 mg of alprazolam or 1 mg of lorazepam, figures the Manual calls firmly based on clinical experience but liable to vary from one person to another. The site’s guide to the equivalence table explains the rest of the table, and the Ativan crossover is a worked example of a prescriber adjusting those numbers to the person in front of them.
How fast does the Ashton taper go?
Chapter II suggests aiming at a reduction of up to one tenth of the dose at each step, every one to two weeks. Yet, the same chapter says that there is no magic rate, that each person must find the pace that suits them, and that the person doing the taper is usually the best judge. Steps also shrink as the dose falls, because a tenth of a small dose is a smaller cut than a tenth of a large one.
Slow withdrawal in the Manual means some months, and Professor Ashton wrote that many people have taken a year or more, adding that whether it takes six, twelve or eighteen months is of little significance to someone who has taken benzodiazepines for years. While she was patient about the length of the middle stretch, the one place she cautioned against slowing down was the very end, where she advised readers not to spin out the last small doses to a ridiculously slow rate, since recovery cannot begin until the tablets are gone. Her taper ends with a step off the last tablet: Chapter II says to take the plunge when the dose reaches 0.5 mg of diazepam a day, advice that reflected the 2 mg tablets she taught from. In this site’s view, with the manufactured 1 mg/mL diazepam oral solution, continuing below 0.5 mg in steps sized to the remaining dose and stopping at about 0.1 mg is reasonable for many people, and the 0.5 mg step-off still suits some. Which ending fits is a decision for the person and their prescriber.
What happens when symptoms get worse partway through?
Some symptoms are expected, and although the Manual notes that some people get none at all, most notice something. The Manual’s instruction for a difficult stretch is to stop there for a few weeks if necessary and to try to avoid going backwards by increasing the dose again. In fact, a hold is a legitimate part of the plan, not a failure of it.
Ashton Manual Guide adds one exception in its own voice. When symptoms after a cut are severe rather than merely unpleasant, returning to the previous step with the prescriber’s agreement can be the safer choice, and the site’s article on reinstatement during a taper covers when that applies. It also helps to know whether a symptom is withdrawal or a return of the original anxiety, which the site’s article on telling withdrawal from returning anxiety explains.
Abrupt or over-rapid withdrawal after long-term use is the one thing the Manual rules out, and the 2020 US Food and Drug Administration (FDA) benzodiazepine label update says the same: stopping suddenly or reducing too fast can bring on withdrawal reactions, including seizures, that can be life-threatening. A seizure is a medical emergency. Call emergency services for a seizure or any other medical emergency during a taper.
What kind of support does the Manual describe?
The Manual’s position on support is more modest than it is often summarized. Its instruction in Chapter II is to make sure that psychological support is adequate, and it adds that an understanding doctor may be the one to offer it.
The chapter says that support could come from a spouse, partner, family or close friend, that the help of a clinical psychologist, trained counsellor or other therapist is valuable for some, and that many people have in fact managed to come off on their own without any outside help. Of course, it does not prescribe counselling for everyone.
The Manual does treat the doctor as necessary: Chapter II says plainly that the doctor’s agreement and co-operation are needed, since the doctor prescribes the medication. Unfortunately, it also acknowledges that many doctors are uncertain how to manage benzodiazepine withdrawal and hesitate to undertake it. Finding a prescriber willing to work at the person’s pace is, in practice, the first step of the protocol.
Who does the Ashton Protocol suit?
It was written for people with therapeutic dose dependence, whatever benzodiazepine they take and however long they have taken it, and its schedules cover alprazolam, lorazepam, clonazepam, temazepam, nitrazepam, oxazepam, chlordiazepoxide, diazepam and zopiclone. Because the pace adapts to the person, the same framework serves a short history and a long one.
The Manual has its own section on withdrawal in older people. It says the methods are similar to the slow ones recommended for younger adults, that the schedule may include liquid preparations where available and careful stepwise substitution with diazepam if necessary, and, in Chapter I, that older people metabolize drugs less efficiently, so drug effects last longer and accumulation occurs more readily. One caution belongs to the site’s own voice. Diazepam and its long-lived metabolite can accumulate when liver function is impaired, a precaution the Maudsley Deprescribing Guidelines also note, so a prescriber may taper the original drug directly in that case. The same Guidelines describe that route, reducing the current medication directly and moving to a liquid at low doses. These are a prescriber’s judgments, and the site’s article on the Ashton Method in older adults looks at them more closely.
How do the calculators fit in?
Ashton Manual Guide hosts calculators that lay out taper shapes of this kind as educational planning tools. The benzodiazepine taper calculator, the general Ashton Manual Guide calculator and the Xanax taper calculator illustrate how stepwise plans are laid out. They show the shape of a plan, and whether to taper, and how fast, remains a decision for the person and their prescriber.
What else do readers ask about the Ashton Protocol?
How long does the Ashton Protocol usually take?
Some months in most cases, and a year or more for many people, depending on the drug, the dose, the length of use and how the person responds to each step. The Manual says the total length matters little compared with tapering at a pace the person can tolerate.
Can the Ashton Method be followed without a prescriber?
No. The substitution to diazepam and every reduction depend on prescriptions, and the Manual states that the doctor’s agreement and co-operation are necessary. The pace belongs to the person, and the prescribing belongs to the doctor.
Which medications does the Ashton Method use?
Diazepam, because it is eliminated slowly and comes in small, scored tablets. It replaces shorter-acting drugs such as alprazolam or lorazepam so that blood levels stay steady while the dose comes down.
Is the Ashton Protocol an official medical standard?
It is the best-known framework for benzodiazepine withdrawal, but it is not a formal standard issued by a medical body. Professor Ashton built it on clinical experience and pharmacology. The Maudsley Deprescribing Guidelines later describe reductions that get proportionally smaller as the dose falls, now called hyperbolic tapering, which Ashton Manual Guide presents as a development consistent with her principles, and the 2020 FDA label update likewise calls for gradual reduction.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
