What do the Ashton Manual’s withdrawal schedules actually say?
Almost everyone who has looked into coming off of a benzodiazepine has heard of the Ashton Manual. Far fewer people have read its schedules line by line. Yet, the schedules get quoted constantly, in online forums, in doctors’ offices, and in arguments between the two.
The Manual is the work of the late Professor C. Heather Ashton of Newcastle University, and its full title is “Benzodiazepines: How They Work and How to Withdraw.” Chapter II covers how to withdraw after long-term use, and a set of example withdrawal schedules follows it. You may have been told that the Manual says to cut 5 to 10 percent every two weeks, or that an Ashton taper lasts a set number of months.
Neither statement is in the text. So, what is actually on the page?
Where are the schedules, and what do they cover?
The schedules sit at the end of Chapter II of the Ashton Manual, which is free to read at benzo.org.uk. Each one is a table that starts from a specific medication at a specific daily dose. There are examples for Xanax (alprazolam), Ativan (lorazepam), Klonopin (clonazepam), Restoril (temazepam), and the z-drug zopiclone, along with a simple withdrawal from Valium (diazepam) itself. Other tables cover nitrazepam, oxazepam, and chlordiazepoxide, and the page ends with a short table on antidepressants.
Each table moves in stages. A row shows the doses for morning, midday or afternoon, and evening or night, with a final column for the daily diazepam equivalent, and the next row shows what changes. Most of the tables have two phases. First comes a gradual switch to diazepam, and then comes a slow reduction of the diazepam.
Before the tables begin, Professor Ashton explains how to read them. The chapter calls its withdrawal advice only a general guide, says that each schedule must be tailored to individual needs, and adds above the tables that schedules like these have worked for real people but may need adapting to your own needs. That instruction is easy to skip, and it changes the meaning of everything below it.
The switch to diazepam happens one dose at a time.
Why switch at all? Short-acting benzodiazepines, such as Xanax and Ativan, leave the body quickly, so the blood level rises and falls several times a day. The Manual explains that a smooth decline in blood and tissue concentrations is not possible with these drugs. Diazepam is eliminated slowly, and it comes in 2 mg tablets that can be halved, which allows for small reductions.
The switch itself is not made overnight. The chapter says to substitute one dose at a time, usually starting with the evening or night-time dose, while the other doses stay the same. The Manual’s stated reason for going stepwise is that a person switched all at once is liable to become extremely sleepy. One likely reason for starting at night is that any early drowsiness matters least at bedtime, though that is this site’s reading and not the Manual’s words.
After a week or two, the next dose is replaced, and so on, until the whole day is diazepam. This stepwise substitution is the heart of what is now called a crossover taper. This site has a separate article on how the diazepam switch works for short-acting benzos.
The Manual includes a table of equivalent doses (Table 1 in Chapter I), and a note under it says the equivalents are based on clinical experience but may vary between individuals. While the schedules make the switch look tidy, the text around them expects adjustments along the way.
How big is each step?
The Manual’s guidance is that each reduction should be small. Chapter II says you could aim at reducing the dose by up to one tenth at each step, and elsewhere suggests about one tenth or one eighth. It also says that the larger the starting dose, the larger each reduction can be. So, the steps shrink as the dose comes down.
You can see this in the tables. In the example that starts from diazepam 40 mg a day, the early steps are twice the size of the later ones. Professor Ashton introduces those figures in the chapter as “a very rough guide,” and she adds that some people might prefer to reduce faster and some might go even slower.
The time between steps in the examples is one to two weeks. That interval is an illustration, and the chapter says that you must proceed at the pace that is comfortable for you. None of this is a personal dosing instruction. The size and timing of any real reduction is a decision for you and your prescriber.
Is the rule really “5 to 10 percent every two weeks”?
No. That phrase is a later shorthand, and it does not appear in the Manual. It is easy to see how it arose, since one tenth is 10 percent, and the tables often show two weeks between rows.
Yet, the shorthand changes the meaning. “Up to one tenth” is a ceiling. “5 to 10 percent every two weeks” reads like a quota with a calendar attached. Patients often describe being handed a printed schedule with the dates already filled in, and then being told they are behind.
The Manual has no such concept as being behind. In fact, the tables do not use percentages at all. They use small fixed steps that get smaller as the dose falls. Unfortunately, a slogan travels farther than a chapter, and the slogan is what many patients and many doctors have actually heard.
Does the Manual say how long a taper should take?
It does not fix a duration. The chapter does add up its own 40 mg example and arrives at a rough total of 30 to 60 weeks, but it presents that as a very rough guide. Professor Ashton wrote that whether withdrawal takes six months, twelve months, or eighteen months is of little significance if you have taken benzodiazepines for a matter of years. She noted that many people have taken a year or more. If you add up the rows of a table, you will get a number of weeks. That number describes the example. It does not describe you.
She was also direct about tapers that are too fast. She called the classic six-week withdrawal period adopted by many clinics and doctors much too fast for many long-term users. A six-week plan fits a clinic’s calendar very well. Nervous systems do not keep that calendar.
Why would a clinic rush? Often, it is because the clinic treats a person who takes a prescribed benzodiazepine as someone with a drug problem, and it sets a discharge date. The Manual’s subject is different. It grew out of a clinic whose patients had mostly been taking benzodiazepines prescribed by their doctors for many years, and dependence is not addiction. Physical dependence is the body’s adaptation to a drug taken over time, and the remedy is a slow reduction.
The Manual also allows for pauses. If you reach a difficult point, you can stop there for a few weeks if necessary before going on. And, there is no need to write the whole schedule in advance. Professor Ashton wrote that it is usually sensible to plan the first few weeks, and then to review and, if necessary, amend the schedule according to your progress.
Who sets the pace?
The patient does. This may be the most overlooked point in the chapter. Professor Ashton wrote that usually the best judge is you, yourself, that you must be in control, and that you must proceed at the pace that is comfortable for you.
She went further. She wrote that it is important for you to be in control of your own schedule, that you should not let your doctor impose a deadline, and that you may need to resist attempts from outsiders, including clinics and doctors, to persuade you into a rapid withdrawal. That is a remarkable thing for a professor who ran a benzodiazepine withdrawal clinic for twelve years to put in writing. It is also why the Manual is trusted by so many people who have good reason to be wary of medical advice. Their dependence began, after all, with a prescription.
Of course, patient control does not mean going it alone. The chapter’s first practical step is to consult your doctor and pharmacist, and it says the doctor’s agreement and co-operation are necessary. A doctor’s job in this arrangement is to support the pace. It is not to set a deadline. The chapter asks for flexibility, so that the rate of tapering can be amended at any time.
One point in the chapter is not flexible. Professor Ashton states that anyone withdrawing from long-term benzodiazepines must reduce the dosage slowly, and that it is unwise to stop suddenly. Abrupt or over-rapid withdrawal, especially from a high dose, can cause severe symptoms, including seizures. If a seizure or any other severe symptom occurs, call 911 or go to the nearest emergency room.
The schedules show a shape. They are not a prescription.
An analogy that might help is a staircase. The schedules describe the staircase. They show that you come down by steps and not by jumping, that the steps get shorter near the bottom, and that there are landings where you can stop and rest.
What the schedules do not tell you is how long to stand on each step. Some people pause for a week, and some pause for a month. No one is standing at the bottom with a stopwatch, or at least, no one should be.
While this is not a perfect analogy, it explains how the same tables can be used well or badly. Used well, they give you and your doctor a starting sketch. Used badly, they become a deadline with someone else’s name on it.
What has been added since Professor Ashton wrote the schedules?
The Manual’s main text was last revised in August 2002, and in her April 2011 supplement Professor Ashton wrote that its advice remains relevant and requires little updating. The field has continued to develop since then. One development is hyperbolic tapering, in which each reduction is a proportion of the current dose, so the steps keep shrinking all the way down. The Maudsley Deprescribing Guidelines describe this approach in detail. Liquid formulations now make very small reductions practical in a way that tablets alone never could.
These are not Professor Ashton’s words, and this site does not put them in her mouth. However, they are consistent with her principles, which are small steps, smaller steps at lower doses, and a pace set by the patient. In 2020, the US Food and Drug Administration (FDA) updated the label of every benzodiazepine to warn about physical dependence and withdrawal reactions, and to call for a gradual taper. Official guidance has moved toward her position.
How should you use the schedules?
It is not a bad idea to read Chapter II first, and then the tables. You may want to bring both to your prescriber, and treat the table closest to your situation as a draft. The Ashton Manual Guide taper calculator can show how a taper of this shape might look on a calendar. It is an educational planning tool, and it is not a substitute for a physician who knows your history.
For more on the method as a whole, this site has an overview of the Ashton protocol. Fortunately, the most important part of the schedules fits in one sentence. The steps are small, the landings are allowed, and the pace is yours.
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.
