Key Takeaways
- The Ashton Manual tells readers to consult their doctor before tapering and to stay in charge of their own pace.
- Professor Ashton wrote “Do not let your doctor impose a deadline,” and said the precise rate of withdrawal is an individual matter.
- A few marked pages from Chapter II and a draft reduction schedule work better at an appointment than the whole Manual.
- The 2020 FDA label update also calls for a gradual taper and a plan specific to the patient.
- You can ask whether a switch to diazepam is right for you, and for small tablet strengths or a liquid so the steps can be small.
- The Manual allows a pause of a few weeks at a difficult point, so a short hold is part of the method.
- If your prescriber says no, a second opinion is reasonable, and the medication should never be stopped abruptly.
How do you ask your prescriber for a slow benzodiazepine taper?
How do you ask the doctor who prescribes your benzodiazepine to help you come off it slowly? What if the answer is a four-week schedule, or a referral to a detox program? What if you are afraid that asking at all will put your prescription at risk?
These are fair questions. Many people who take Xanax (alprazolam), Klonopin (clonazepam), Ativan (lorazepam), or Valium (diazepam) exactly as prescribed have already been through one rushed taper, and they remember how it went. It makes sense to walk into the next appointment with some caution.
Fortunately, you do not have to invent the request yourself. Professor C. Heather Ashton of Newcastle University, who ran a benzodiazepine withdrawal clinic for twelve years, wrote down how this conversation should go. Her manual, “Benzodiazepines: How They Work and How to Withdraw,” is known as the Ashton Manual, and it is free to read at benzo.org.uk. So, what does it actually say about who is in charge of the pace?
What does the Ashton Manual say about who sets the pace?
The answer is in Chapter II, which is titled “How to withdraw from benzodiazepines after long-term use.” Before any schedule appears, Professor Ashton tells the reader to consult their doctor. She also tells the reader what to say.
She writes that many doctors are uncertain how to manage benzodiazepine withdrawal and hesitate to undertake it. Her advice is that you can reassure your doctor that you intend to be in charge of your own program and will proceed at whatever pace you find comfortable, while still valuing the doctor’s advice from time to time. Then comes the sentence that readers tend to underline: “Do not let your doctor impose a deadline.”
The Manual borrows a Quaker phrase for the right attitude, which is to “proceed as the way openeth.” It also says that the precise rate of withdrawal is an individual matter. For a person who has taken a benzodiazepine for years, the Manual says it is of little significance whether the taper takes six months, twelve months, or eighteen months.
None of this is a demand to make of a doctor. It is a division of labor. This site has a longer article on why the patient controls the speed of a benzodiazepine reduction. In brief, your prescriber writes the prescription, and you report what your nervous system can tolerate.
Why does this conversation feel so hard?
For many patients, the distrust is earned. The medication was started by a doctor, often with the assurance that it was safe to take for years, and no one mentioned a plan for stopping. It is understandable to feel wary about asking the same profession for help.
Unfortunately, the request can also be misheard. A patient who asks to go slower, or who asks for a particular benzodiazepine by name, may be treated as if the problem were drug seeking. Dependence is not addiction. Physical dependence is what happens when the body adapts to a medication taken as prescribed, and a gradual taper is the medical treatment for it.
While it is tempting to see the prescriber as the obstacle, the Manual does not. Professor Ashton’s observation was that many doctors hesitate because they are uncertain how to manage a withdrawal, not because they wish their patients harm. A short office visit is also not much time to plan a process that may take a year. A patient who arrives with a plan is solving a problem for the doctor, too.
How do you bring the Manual to an appointment?
It is not a bad idea to keep it small. A prescriber with a full waiting room will not read a book during your visit. Print the pages from Chapter II that cover the doctor’s role and the pace of withdrawal, and mark the two or three sentences that matter most to you.
The Manual also suggests drawing up a dosage reduction schedule for the early stages and giving your doctor a copy. It adds that the rate of dosage tapering can be amended at any time, so the plan stays flexible. The benzodiazepine taper calculator on this site can help you to sketch the shape of such a plan before the visit. It is an educational planning tool, not medical advice, and the actual doses are for you and your prescriber to decide.
Some prescribers respond better to a regulator than to a manual. In September 2020, the U.S. Food and Drug Administration (FDA) updated the labeling of every benzodiazepine to warn about physical dependence and withdrawal reactions, and to call for a gradual taper when the drug is reduced or stopped. The FDA also stated that no standard tapering schedule suits all patients, and that the plan should be specific to the patient. That is the Manual’s position in the government’s words.
Can you ask to switch to diazepam first?
Yes, you can ask. For short-acting benzodiazepines such as Xanax and Ativan, the Manual advises switching to a long-acting one, usually diazepam, before reducing. It calls this substitution, and many readers know it as a crossover taper. The reason given is that short-acting drugs leave the body quickly, so blood levels rise and fall between doses, while diazepam declines slowly and smoothly.
The Manual describes the switch as gradual, made one dose at a time, often beginning with the evening dose. Table 1 in Chapter I lists approximate equivalent doses, and the numbered schedules in Chapter II show how the changeover and the reduction can look. Professor Ashton is clear that those schedules are general guides and that each person’s needs are different. This site explains the method in more detail in its article on the Ashton protocol.
Substitution is not right for everyone. Some people process diazepam unusually slowly or quickly, and some react badly to it. So, the honest form of the request is a question: “Would a switch to diazepam be appropriate for me, and if not, why not?”
Why do small tablet strengths or a liquid matter?
The second thing to ask for is a dose form that allows small steps. This is simple arithmetic. By the Manual’s Table 1, Xanax 0.5 mg is roughly equal to Valium 10 mg, so the smallest Xanax tablet, 0.25 mg, equals about 5 mg of diazepam. Removing one such tablet is a large step for a sensitized nervous system.
Diazepam, as the Manual points out, comes in 2 mg tablets that are scored and can be halved. Liquid preparations allow smaller steps still. A prescriber can write for the lowest tablet strength, a manufactured oral solution, or a compounded liquid, and a pharmacist can explain what is available.
Small steps matter most near the end. In the Manual’s schedules, the reductions get smaller as the dose gets lower. The Maudsley Deprescribing Guidelines, published years after the Manual, describe a similar shape called hyperbolic tapering, in which each reduction is a proportion of the current dose instead of a fixed amount. That later method is consistent with Professor Ashton’s principles, and it is one more reason to ask for the smallest tablet strength, and for a liquid once tablets can no longer make the steps small enough.
You can ask for holds, and for no deadline.
The third request is permission to pause. The Manual says that if you reach a difficult point, you can stay at that dose for a few weeks if necessary. A hold is part of the method. It is not a failed taper.
An analogy that might help is two people carrying a couch down a staircase. The person at the top can see the whole staircase. The person at the bottom is walking backward, feeling for each step with one foot.
When the person at the bottom says “hold on,” the person at the top stops. Nobody calls that being difficult, and nobody announces that the couch must reach the ground floor by Friday. And, the couch still gets downstairs.
While this is not a perfect analogy, the roles are about right. Your prescriber can see the pharmacology, the drug interactions, and the risks you may not know about. You are the one who feels each step. Say “hold” when you need to hold.
What if your prescriber says no?
It happens. Some doctors believe a fast taper is safer, some are under pressure to reduce benzodiazepine prescribing, and the Manual itself acknowledges that a doctor may have views on whether stopping is appropriate at all. In fact, a refusal is not always the end of the conversation. Ask what the concern is, and ask whether the Manual’s text or the FDA label would be acceptable common ground.
If the answer is still no, a second opinion is a reasonable next step, and asking for one is ordinary medicine. While you look, there is one rule that does not bend. Do not stop the medication abruptly, and do not let a prescription run out to prove a point. The Manual and the FDA label both warn that abrupt withdrawal can be dangerous and can cause seizures.
If you have a seizure, severe confusion, or symptoms that frighten you, call 911 or go to the nearest emergency room, and in the United States the 988 Suicide and Crisis Lifeline answers calls and texts at any hour.
The taper belongs to both of you.
The Manual does not ask you to win an argument. It asks you to take charge of the pace and to keep your doctor as an adviser you value. Those two things fit together more often than people expect.
You may be worried that your prescriber will not agree to a slower plan. Yet, a doctor who is handed a calm request, a few marked pages, and a draft schedule has been given something workable. If the taper turns out to be too fast, the doctor should help you to slow it down. If it is slower than you need, the two of you may agree to go a bit faster, as tolerated.
A few more questions come up often.
Should you give your prescriber the whole Ashton Manual?
A few marked pages usually work better than the whole document. Chapter II is the practical chapter, and Table 1 in Chapter I covers dose equivalence. You can offer the web address, benzo.org.uk, to a prescriber who wants to read more.
How long does the Manual say a slow taper should take?
It does not set a fixed length. The Manual says the precise rate is an individual matter, that many people have taken a year or more to complete a withdrawal, and that the person tapering must be in control and proceed at a pace that is comfortable. Your prescriber can help you to decide when to move and when to wait.
Can you taper without switching to diazepam?
Yes. People who cannot take diazepam can taper the benzodiazepine they already take, and small tablet strengths or a liquid matter even more in that case. Whether to switch is a decision to make with your prescriber.
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.
