Ashton taper question

[Attending1985]

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Had a patient on 4 mg of Xanax. Wanted to to Ashton taper. Uneventful until drop from 4 to 3 mg of Valium. Now reporting severe anxiety, tremor problems with balance through patient portal. This is my first time using Ashton protocol. This occurring abruptly after a 1 mg decrease in Valium is not making sense to me. Seeing the patient this week and wondering if others have seen this.

 

[Ironspy]

Had a patient on 4 mg of Xanax. Wanted to to Ashton taper. Uneventful until drop from 4 to 3 mg of Valium. Now reporting severe anxiety, tremor problems with balance through patient portal. This is my first time using Ashton protocol. This occurring abruptly after a 1 mg decrease in Valium is not making sense to me. Seeing the patient this week and wondering if others have seen this.

Sometimes I have to go slower. ~10% reduction per month. 4 mg per day is 120 mg per 30 days. I would decrease to 108 next script and have them alternate 4 and 3 mg per day or take 3.5 some days.

 

[Sushirolls]

Or near worst case scenario, patient didn't taper, but took more, and is now out and in withdrawal.

 

[annoyedpsychiatrist]

In my experience, the patients that request this have been a bit sketchy. Everytime. I absolutely hate this method unless you 100% trust the patient, two benzodiazepines at once requires the patient has strong insight/compliance.

As sushiroll said, this is very popular. Xanax and valium are the most abuseable benzodiazepines, so someone who may have underlying use disorder love the ashton method.

 

[aim-agm]

Had a patient on 4 mg of Xanax. Wanted to to Ashton taper. Uneventful until drop from 4 to 3 mg of Valium. Now reporting severe anxiety, tremor problems with balance through patient portal. This is my first time using Ashton protocol. This occurring abruptly after a 1 mg decrease in Valium is not making sense to me. Seeing the patient this week and wondering if others have seen this.

Sometimes weird things happen.
I had a patient that I was titrating off using the Ashton taper, initial conversion to diazepam 15 mg went well. Dropping from 15 to 14 mg went OK, had some difficulty for 1-2 weeks but was OK after that. But going down to 13 mg went quite badly, he reported within quite significant physical symptoms with the downtitration (and was medically frail to begin with) - this happened both times I tried to go down, and the time he tried downtitrating without being instructed to. No suspicion for misuse. Since he maintained marked improvement in symptoms and function in response to the diazepam (even compared to previous benzo), with no apparent side effects, so we decided to just leave the diazepam 14 mg be for a while.

You can try going down to 3.5 mg (1/2 of a 5 and 1/2 of a 1), or switch to liquid formulation for even smaller increments of change and see if that is tolerated better.

 

[Attending1985]

In my experience, the patients that request this have been a bit sketchy. Everytime. I absolutely hate this method unless you 100% trust the patient, two benzodiazepines at once requires the patient has strong insight/compliance.

As sushiroll said, this is very popular. Xanax and valium are the most abuseable benzodiazepines, so someone who may have underlying use disorder love the ashton method.

I have this worry as well but with this patient my suspicion for that is very low

 

[Attending1985]

Sometimes weird things happen.
I had a patient that I was titrating off using the Ashton taper, initial conversion to diazepam 15 mg went well. Dropping from 15 to 14 mg went OK, had some difficulty for 1-2 weeks but was OK after that. But going down to 13 mg went quite badly, he reported within quite significant physical symptoms with the downtitration (and was medically frail to begin with) - this happened both times I tried to go down, and the time he tried downtitrating without being instructed to. No suspicion for misuse. Since he maintained marked improvement in symptoms and function in response to the diazepam (even compared to previous benzo), with no apparent side effects, so we decided to just leave the diazepam 14 mg be for a while.

You can try going down to 3.5 mg (1/2 of a 5 and 1/2 of a 1), or switch to liquid formulation for even smaller increments of change and see if that is tolerated better.

Trying to decide whether I’m doing to go back up to say 5 mg as he’s reporting very severe symptoms or stay at 3. I’ve never gone back up in dose during a taper but his dose is so low I’m thinking about it

 

[TexasPhysician]

In addition to tapering being difficult at low doses, you may be encountering an actual anxiety issue now. With many patients, a degree of benzodiazepines really helps with baseline anxiety. Then the patient complains about some life stressor being difficult and the prescriber (whatever degree that may be) bumps up the benzo. This continues to happen to sedate normal feelings. The result is that initial tapers are relatively easy when patients aren’t in crisis. Then you reach a point where the disorder actually pops its head out.

 

[clausewitz2]

Trying to decide whether I’m doing to go back up to say 5 mg as he’s reporting very severe symptoms or stay at 3. I’ve never gone back up in dose during a taper but his dose is so low I’m thinking about it

If you are doing Ashton unless you think there is really dangerous GABAergic w/d going on pause the taper all you like but never ever ever increase.

 

[Ceke2002]

Had a patient on 4 mg of Xanax. Wanted to to Ashton taper. Uneventful until drop from 4 to 3 mg of Valium. Now reporting severe anxiety, tremor problems with balance through patient portal. This is my first time using Ashton protocol. This occurring abruptly after a 1 mg decrease in Valium is not making sense to me. Seeing the patient this week and wondering if others have seen this.

Personal experience only, but I did the Ashton taper (getting off Xanax) some years ago myself, and I have to say I would have found a full 1mg drop in Valium to have been difficult as well. Reasons for that would have been 1) Length of time I was physically dependent plus dosage (I actually tapered myself down from around 14mgs per day to 4mgs, before doing the final taper with the Ashton protocol, and 2) Already being primed for a lot of anxiety/fear around tapering due to a previous negative experience with attempted withdrawal (delerium like symptoms, followed by a grand mal seizure, not exactly a fun time), basically I was terrified that something really bad would happen again if I tapered too quickly, hence every little ache, bit of restlessness, sleepless night, the smallest amount of anxiety, etc, and I would pretty much end up working myself into a state of complete panic where my subjective experience of any actual withdrawal symptoms became greatly magnified. Reassurance, and lots of it, helped a lot for me.

 

[Stagg737]

Sometimes weird things happen.
I had a patient that I was titrating off using the Ashton taper, initial conversion to diazepam 15 mg went well. Dropping from 15 to 14 mg went OK, had some difficulty for 1-2 weeks but was OK after that. But going down to 13 mg went quite badly, he reported within quite significant physical symptoms with the downtitration (and was medically frail to begin with) - this happened both times I tried to go down, and the time he tried downtitrating without being instructed to. No suspicion for misuse. Since he maintained marked improvement in symptoms and function in response to the diazepam (even compared to previous benzo), with no apparent side effects, so we decided to just leave the diazepam 14 mg be for a while.

You can try going down to 3.5 mg (1/2 of a 5 and 1/2 of a 1), or switch to liquid formulation for even smaller increments of change and see if that is tolerated better.

I have never heard of dropping Valium by 1mg when the daily dose was 15mg. That seems unnecessarily slow and unless theirs is something strange going on mechanistically (other meds affecting metabolism, etc). If they’re having “significant physical symptoms) going from 14mg to 13mg, I’d be looking for alternative reasons for that happening.

 

[clausewitz2]

I have never heard of dropping Valium by 1mg when the daily dose was 15mg. That seems unnecessarily slow and unless theirs is something strange going on mechanistically (other meds affecting metabolism, etc). If they’re having “significant physical symptoms) going from 14mg to 13mg, I’d be looking for alternative reasons for that happening.

That's pretty standard for Ashton Method.

 

[mistafab]

For benzos, the biggest drops at the start are the easiest - and by comparison the lower numbers are the hardest.

Instead of thinking in terms of MG drop - think in terms of % drop. Much easier to drop 10%, from 10 mg to 9mg, than 4mg to 3mg (25% reduction).

You may need to do 4 -> 3.5 (12.5%) or even 4 -> 3.75 (6.25%). That is how I've found success. And as folks said, don't go up, but do stay open to "holding" for a while before you try a new drop. The patient will need time to recalibrate and build up motivation again after their uncomfortable feelings. You may even need some time to start a new anxiety treatment (SRI, Therapy, exercise, techniques like box breathing) to ameliorate the drops.

Toughest thing to do in my opinion. You're doing great work. Keep it up! Report back

 

[Candidate2017]

Or near worst case scenario, patient didn't taper, but took more, and is now out and in withdrawal.

A patient taking more benzos than prescribed during a benzo taper is probably closer to the average scenario.

But someone on Xanax 4 mg is an above average scenario, which makes the odds above average that they're absolutely not adhering to the taper schedule (taking more benzos than prescribed, running out early, and withdrawing).

I have this worry as well but with this patient my suspicion for that is very low

Medicine is about ruling out bad stuff with objective evidence (i.e., UDS). Patients don't always take HTN, DM, UTI, etc. medications as prescribed, which is why PCPs take BP, glucose, or UA prior to adjusting meds. We have to be on the lookout for positive countertransference, especially with outpatients.

The fact is someone who has worked up to Xanax 4 mg would be expected to have dependence. Egro, I would expect them to act like most anyone with a dependence issue, which is to ignore my well thought out plans and press the lever for more feelgoodies. Personally, I find giving a 1-month supply of benzos, with the expectation of decreasing the dose next month, is a recipe for endless calls/complaints prior to the end of the month (i.e., patient uses more than prescribed and runs out early). Nowadays, I write a series of 7-day scripts, with the dose decreased weekly. I still get the moaning of course, but the early calls to complain about "worst sleep, anxiety, etc. of my life" are pretty much non-existent.

 

[Ceke2002]

In my experience, the patients that request this have been a bit sketchy. Everytime. I absolutely hate this method unless you 100% trust the patient, two benzodiazepines at once requires the patient has strong insight/compliance.

As sushiroll said, this is very popular. Xanax and valium are the most abuseable benzodiazepines, so someone who may have underlying use disorder love the ashton method.

Sorry for the bump, I missed this before. This is a really good point, and something I think Doctors need to be aware of. I did the Ashton method taper off Xanax in 2003, when I didn't even know that's what it was called (Psychiatrist set it up, my GP took care of the rest). At that time the vast majority of people I interacted with, who were doing the same sort of taper, on support forums were absolutely legit. But then something else started creeping in where folks became keen to do an Ashton taper as either a way to seriously prolong having to come off benzos, or to scam more benzos by pretending they were serious about tapering, and oh look at this great taper method I've just randomly discovered.

Obviously you don't have to 'punish' (for want of a better word) those patients who would legitimately benefit from doing this type of taper, but I agree with being wary and proceeding with an abundance of caution.

 

[clausewitz2]

Sorry for the bump, I missed this before. This is a really good point, and something I think Doctors need to be aware of. I did the Ashton method taper off Xanax in 2003, when I didn't even know that's what it was called (Psychiatrist set it up, my GP took care of the rest). At that time the vast majority of people I interacted with, who were doing the same sort of taper, on support forums were absolutely legit. But then something else started creeping in where folks became keen to do an Ashton taper as either a way to seriously prolong having to come off benzos, or to scam more benzos by pretending they were serious about tapering, and oh look at this great taper method I've just randomly discovered.

Obviously you don't have to 'punish' (for want of a better word) those patients who would legitimately benefit from doing this type of taper, but I agree with being wary and proceeding with an abundance of caution.

I avoid the two benzos at a time issue by being fairly aggressive about the cross taper to valium in the first place and being incredibly rigid about pill counts. Sometimes people do get stuck but honestly enough people seem to find valium unpleasant compared to Xanax/Klonopin that this is actually not the majority. As long as they get stuck at a lower overall equivalent dose I'll count it as progress.

 

[Ceke2002]

I avoid the two benzos at a time issue by being fairly aggressive about the cross taper to valium in the first place and being incredibly rigid about pill counts. Sometimes people do get stuck but honestly enough people seem to find valium unpleasant compared to Xanax/Klonopin that this is actually not the majority. As long as they get stuck at a lower overall equivalent dose I'll count it as progress.

I do remember being crossed over to Valium fairly quickly myself, which I was fine with. I eventually developed a paradoxical reaction to Xanax, and was basically losing my proverbial at the time, so it was actually a relief to be crossed over to something else and then weaned off that. The GP who took care of my taper, once it was set up, was fantastic. She knew about my previous attempt to jump off cold turkey when I was on about 6mgs, and my being absolutely petrified of withdrawal symptoms because of that, but she was really kind and reassuring throughout the whole thing. Definitely made me feel safe and more willing to not just get stuck because I was freaking out over some minor twinge or something. Having said that we also had an agreement upfront that I messed u and ran out of my script early, then I would not get a script refill until the proper time. If that happened I had to deal with the consequences; which was absolutely fair enough as far as I was concerned. I was just so happy to be getting off the Xanax, it was like, "Yep, whatever you need from me, Doctor, just let me know".

Sounds like you have a good set up, although having seen your posts over several years I would expect nothing less. You've always struck me as an excellent Physician.