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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 20 of 20. This is the beginning of the thread.
Posted by Phillipa on December 19, 2006, at 22:28:14
A lot of people including my pdoc have said I may have a tolerance to benzos even though I've never abused or raised my dose without it being prescirbed. As you know the holidays are stressful and I'll be traveling with dogs to my Daughters in Florida and she's the road rage type. So what do I do? Already called and asked the pdoc for something to sleep other than the valium and now I see it's only .25 of xanax with the valium 20mg. I have to survive. Love Phillipa
Posted by med_empowered on December 20, 2006, at 3:35:45
In reply to What Do You Do If You Develope A tolerance to Benz, posted by Phillipa on December 19, 2006, at 22:28:14
i say find another p-doc. If you've been on benzos for 20+ years, there's going to be *some* tolerance, but come on: 20mgs/valium is *nothing*--thats 1mg/Klonopin. The same docs who gasp at a patient on valium will write out prescriptions for 2, 3,4 or more mgs/day of Klonopin and/or Xanax. Its ridiculous.
You could try switching...Ativan might be good. Maybe using something benzo-ish (but not a benzo), like sonata or ambien for sleep, and then using the valium during the day would be good? Or..finding another p-doc.
Good luck.
Posted by blueberry1 on December 20, 2006, at 4:26:32
In reply to Re: What Do You Do If You Develope A tolerance to, posted by med_empowered on December 20, 2006, at 3:35:45
Jan, I don't have any good ideas about benzo tolerance. I guess the only real options are to increase the dose, switch to another benzo, or add in another anti-anxiety med like zyprexa. For immediate results (starting in 2 hours), 1.25mg zyprexa once a day or twice a day can knock anxiety on its butt.
I've said it before and I still think...that your doctor is either not taking your case seriously or is not talented enough to handle it. I wish he was doing a better job for you.
Posted by laima on December 20, 2006, at 9:41:10
In reply to What Do You Do If You Develope A tolerance to Benz, posted by Phillipa on December 19, 2006, at 22:28:14
You can develop tolerance from using benzos as prescribed- even my doctor acknowledges that. I think your options are to either increase dosage, or to try another medication, as Blueberry suggests. I have experienced cross-tolerance with different benzos, so I am not sure that switching to a different one would necessarily be the answer. In fact, I've heard that some doctors switch people around on their benzos when they wean then off. Good luck, Phillipa!
> A lot of people including my pdoc have said I may have a tolerance to benzos even though I've never abused or raised my dose without it being prescirbed. As you know the holidays are stressful and I'll be traveling with dogs to my Daughters in Florida and she's the road rage type. So what do I do? Already called and asked the pdoc for something to sleep other than the valium and now I see it's only .25 of xanax with the valium 20mg. I have to survive. Love Phillipa
Posted by Quintal on December 20, 2006, at 9:53:25
In reply to What Do You Do If You Develope A tolerance to Benz, posted by Phillipa on December 19, 2006, at 22:28:14
Tolerance to benzos can happen in as little as two weeks for some people so it would be surprising if you hadn't developed some degree of tolerance after 35 years. Tolerance occurs regardless of whether you abused them - compulsively raising the dose is called addiction. Tolerance occurs when your brain opposes the action of the benzo to restore its equilibrium, so the usual dose of the benzo has less effect. When I quit Klonopin cold turkey one time I felt as if I'd taken a huge dose of amphetamine - a rush of energy and exhilaration followed by a crash. This was probably because my brain had been fighting the depressant action of the Klonopin and having that suddenly removed my brain went into overdrive until it managed to restore its natural balance.
Have you considered Lyrica (pregabalin) as a benzo alternative or to help you deal with the anxiety while you lower your dose of Valium? You may find that Valium is doing little, if anything, to help you now - perhaps making you feel sleepy for a while at night. It could also be contributing to your depression and fatigue more than you realise.
Xanax isn't the most appropriate med for sleep. It has little hypnotic action and is short acting. The 0.25mg is equivalent to 5mg Valium. That's weaker than the average Ambien and Lunesta doses. Those two meds would be more appropriate if you could find a doctor to prescribe them.
Q
Posted by laima on December 20, 2006, at 10:09:49
In reply to Re: What Do You Do If You Develope A tolerance to Benz » Phillipa, posted by Quintal on December 20, 2006, at 9:53:25
It's plausable that the valium is even contributing to your anxiety now, Phillipa, by setting you up with daily crashes. I say this because I am stunned to find that I am much less jittery after leaving klonopin behind after using it for over 4 years. I'm also sleeping sounder. Still have anxiety, but I'm WAY less jittery/panicky now. Just a thought.
Posted by Phillipa on December 20, 2006, at 18:45:16
In reply to Re: What Do You Do If You Develope A tolerance to Benz, posted by laima on December 20, 2006, at 10:09:49
Just got a call earlier from my endocrinologist first I've ever seen since I was diagnosed with Hasimotos thyroiditis. One dose change a year later and now after 9 years of being stable on synthroid. I've become hyperthryroid from hypo. And the endo has lowered the dose three time in the last two months. An alert from the lab that it was still way hyper so now lower dose of synthroid again. And no he's testing free T4, everything. So I wake in a sweat after 2-3 hours and take motrin to cool off temp in the house is 66%, pulse high too. And I take motrin, repeat with 5mg of valium and .5 xanax. Is this dangerous anyone know? As we're leaving for Florida tomorrow driving with two dogs. And I have no concentration. I don't know how my husband is remembering everything he is and so calm. Can anyone comment on this. I'm desparate now. Thanks Phillipa
Posted by Quintal on December 20, 2006, at 19:02:29
In reply to Re: What Do You Do If You Develope A tolerance to Benz, posted by Phillipa on December 20, 2006, at 18:45:16
There's nothing particularly dangerous about the meds you're taking but the hyperthyroidism will be contributing to your anxiety , night sweats and racing heart. They should improve when you've adjusted to the lower dose. Try not to worry about it though (and if you find a way of doing that tell me how......)
Q
Posted by Phillipa on December 20, 2006, at 19:39:06
In reply to Re: What Do You Do If You Develope A tolerance to Benz » Phillipa, posted by Quintal on December 20, 2006, at 19:02:29
Thank-you for validating my worrying. Love Phillipa
Posted by jimmygold70 on December 22, 2006, at 10:14:12
In reply to What Do You Do If You Develope A tolerance to Benz, posted by Phillipa on December 19, 2006, at 22:28:14
Well, I can tell you that I have the same tolerance problem with my glasses. I strated with -0.75, now -3.5. I used to be happy with my sight before I had glasses but now I can't function without them. And I would probably shoot someone if he stole my glasses (-:
Benzos are OK for several weeks. I have been taking them for years but I'm paying in slower response times and memory problems. The dark side it that you don't even FEEL those impairments. Now for most people with professions this makes little difference, but for some it's devestating. Of course it returns to normal after you stop.
So to sum up - take it as much as you like, understand that it makes you less bright while you take it. If you have chronic problems, consider ADs first. And yes - I would go to a different Doc if he refuses to prescribe doses <= 4 MG / day of Xanax or Klonopin.
Persoanlly, I think Valium is a bad benzo as it has, along with its metabolite, too long a long half life. Xanax, Ativan or Klonopin are good alternatives, each feels a bit different.
Jimmy
Posted by Quintal on December 22, 2006, at 12:39:46
In reply to Re: What Do You Do If You Develope A tolerance to Benz » Phillipa, posted by jimmygold70 on December 22, 2006, at 10:14:12
>Persoanlly, I think Valium is a bad benzo as it has, along with its metabolite, too long a long half life. Xanax, Ativan or Klonopin are good alternatives, each feels a bit different.
Why do you think this is a problem? The long half-life of Valium is generally considered an advantage in long term treatment as it minimizes withdrawal symptoms between doses and allows once-daily dosing. The long half-life may also deter abuse among certain people:
http://www.dr-bob.org/babble/20061206/msgs/711991.html
Q
Posted by Quintal on December 22, 2006, at 12:56:51
In reply to Re: What Do You Do If You Develope A tolerance to Benz » jimmygold70, posted by Quintal on December 22, 2006, at 12:39:46
I've just spotted some confusion on my part in referring to dependence in that other thread:
"Valium is certainly addictive, but perhaps less likely to induce a compulsive habit than short acting benzos like Xanax?"
I think I meant: "Valium can certainly produce dependence, but is perhaps less likely to induce a compulsive habit than short acting benzos like Xanax?"
This can be discussed ad nauseum because the differences are often so subtle in real life, but I'm pretty sure Phillipa is not an 'addict' - perhaps a benzo depender, maybe a dependee - or even a dependict?
Q
Posted by notfred on December 22, 2006, at 14:44:38
In reply to Re: What Do You Do If You Develope A tolerance to Benz » Phillipa, posted by jimmygold70 on December 22, 2006, at 10:14:12
"Well, I can tell you that I have the same tolerance problem with my glasses. I strated with -0.75, now -3.5. I used to be happy with my sight before I had glasses but now I can't function without them. And I would probably shoot someone if he stole my glasses (-:"
I have seen this falsehood posted here b4. It is totally untrue. It is the natural progression of nearsighted/farsightedness to get worse with age. Glasses **in no way** effect the curvature of your eyes; that is the cause of nearsighted or farsightedness. This has nothing to do with
tolerance.With farsightedness the natural progression is to get worse till your 40's then to get better, however close vision then starts to degrade (you go nearsighted). I think the same it true for farsightedness.
A decade ago I was unable to afford an eye exam after I broke my glasses so I went without for several years. I was 20/80 at that point, 20/60 was the limit for requiring glasses to drive. Once I could afford the exam (3-4 years w/o glasses or contacts) I was 20/200.
Going without glasses causes eye strain as your eyes try harder to focus. That is why your vision goes funky for a bit if you take off you glasses. Your eyes take a bit to adjust to doing extra work to try to focus.
Going without glasses with significant vision deficiency (20/200 is pretty significant) for several years has caused my to loose quite a bit of focusing power. Forever. Thats right, eye strain can cause lasting damage. Corrected I can see 20/15 but it takes longer for my eyes to focus. It is a real problem with driving. All caused by not wearing glasses.
Consider the possible effects of your misinformation; lasting eye damage. Do not confuse cause and effect.
Posted by Quintal on December 22, 2006, at 15:28:47
In reply to glasses, posted by notfred on December 22, 2006, at 14:44:38
That's a very interesting and informative post notfred. I think jimmygold70's comment was meant as a joke though, hence the smiley face at the end of the sentance (-:
Q
Posted by jimmygold70 on December 22, 2006, at 16:23:28
In reply to Re: What Do You Do If You Develope A tolerance to Benz » jimmygold70, posted by Quintal on December 22, 2006, at 12:39:46
I don't see how Valium has less withdrawal symptoms. I mean, in theory this might be true but I haven't seen any convincing evidence that longer half life means less withdrawal symptoms. They might be much more delayed with Valium, though. It's just a feature.Long half life means much trouble with overdoses as its elimination takes ages. You can also dose clonazepam daily with a reasonable half-life. That might be the best tradeoff between compliance and toxicity.
J
> >Persoanlly, I think Valium is a bad benzo as it has, along with its metabolite, too long a long half life. Xanax, Ativan or Klonopin are good alternatives, each feels a bit different.
>
> Why do you think this is a problem? The long half-life of Valium is generally considered an advantage in long term treatment as it minimizes withdrawal symptoms between doses and allows once-daily dosing. The long half-life may also deter abuse among certain people:
>
> http://www.dr-bob.org/babble/20061206/msgs/711991.html
>
> Q
Posted by Quintal on December 23, 2006, at 8:50:15
In reply to Re: What Do You Do If You Develope A tolerance to Benz » Quintal, posted by jimmygold70 on December 22, 2006, at 16:23:28
>I don't see how Valium has less withdrawal symptoms. I mean, in theory this might be true but I haven't seen any convincing evidence that longer half life means less withdrawal symptoms. They might be much more delayed with Valium, though. It's just a feature.
No, it's not that withdrawals are just more delayed with Valium. The brain has more time to adjust to changes and maintain its equilibrium when the levels of benzodiazepine are falling slowly. With Valium do you see that the brain (and the person) has over a week to acclimatize with lower benzodiazepine levels after their last dose while with something like Xanax it can be as little as six hours - a huge shock. This usually means milder withdrawal symptoms and lower risk of seizures with Valium.
>Long half life means much trouble with overdoses as its elimination takes ages. You can also dose clonazepam daily with a reasonable half-life. That might be the best tradeoff between compliance and toxicity.
Benzo overdose is rarely life threatening if taken alone and fairly easy to treat. Yes, in theory Valium's long half life would make it a little more complicated for treatment of overdose. It's the short acting benzos that tend to cause problems for more people in long term treatment - for instance when they develop tolerance and start having withdrawal symptoms between doses or become addicted and try to quit.
That said, many people have been able to quit Xanax without the help of a taper with longer acting benzos. Also many people (myself included) have taken overdoses of Valium and not needed hospital treatment at all.
Yes, Klonopin allows once daily dosing yet I still had severe withdrawal symptoms when had to withdraw abruptly. Valium was bad, but not as terrifying as Klonopin.
Q
Posted by Quintal on December 23, 2006, at 8:57:19
In reply to Re: What Do You Do If You Develope A tolerance to Benz, posted by Quintal on December 22, 2006, at 12:56:51
>This can be discussed ad nauseum because the differences are often so subtle in real life, but I'm pretty sure Phillipa is not an 'addict' - perhaps a benzo depender, maybe a dependee - or even a dependict?
Just reading that again I realize that may be offensive to you Phillipa - and I apologise if that's the case. I'm just thinking there should be a word for people who have become dependent on meds as well as those who have become addicted.
Q
Posted by jimmygold70 on December 24, 2006, at 7:52:48
In reply to Re: What Do You Do If You Develope A tolerance to Benz » jimmygold70, posted by Quintal on December 23, 2006, at 8:50:15
An iteresting point. I might taper my Klonopin (3MG) futher in the future. Going down is really a hell. The question is what is the equadose of 3MG in Valium terms? 60 MG says the tables, this seems too much. What do you think?
> >I don't see how Valium has less withdrawal symptoms. I mean, in theory this might be true but I haven't seen any convincing evidence that longer half life means less withdrawal symptoms. They might be much more delayed with Valium, though. It's just a feature.
>
> No, it's not that withdrawals are just more delayed with Valium. The brain has more time to adjust to changes and maintain its equilibrium when the levels of benzodiazepine are falling slowly. With Valium do you see that the brain (and the person) has over a week to acclimatize with lower benzodiazepine levels after their last dose while with something like Xanax it can be as little as six hours - a huge shock. This usually means milder withdrawal symptoms and lower risk of seizures with Valium.
>
> >Long half life means much trouble with overdoses as its elimination takes ages. You can also dose clonazepam daily with a reasonable half-life. That might be the best tradeoff between compliance and toxicity.
>
> Benzo overdose is rarely life threatening if taken alone and fairly easy to treat. Yes, in theory Valium's long half life would make it a little more complicated for treatment of overdose. It's the short acting benzos that tend to cause problems for more people in long term treatment - for instance when they develop tolerance and start having withdrawal symptoms between doses or become addicted and try to quit.
>
> That said, many people have been able to quit Xanax without the help of a taper with longer acting benzos. Also many people (myself included) have taken overdoses of Valium and not needed hospital treatment at all.
>
> Yes, Klonopin allows once daily dosing yet I still had severe withdrawal symptoms when had to withdraw abruptly. Valium was bad, but not as terrifying as Klonopin.
>
> Q
Posted by Cecilia on December 25, 2006, at 2:57:56
In reply to Re: What Do You Do If You Develope A tolerance to » Quintal, posted by jimmygold70 on December 24, 2006, at 7:52:48
One of Dr. Bob's benzo equivalency charts says 0.25 mg clonazepam = 5 mg diazepam, the other says 2 mg clonazepam =10 mg diazepam. I'm going to try switching over to see if the diazepam helps me sleep better; my doctor said the 1.5 mg clonazepam I'm taking would be equivalent to 15 mg diazepam, but according to Dr. Bob's chart the 1.5 mg clonazepam COULD equal anywhere from 7.5 to 30 mg diazepam. I'll find out, I guess. He did say to switch over gradually, substituting just one of my 0.5 mg clonazepam tablets for 5 mg diazepam ones at first, so at least I won't go into massive withdrawal if the 1st chart is correct. Cecilia
Posted by Quintal on December 25, 2006, at 14:47:18
In reply to Re: What Do You Do If You Develope A tolerance to » Quintal, posted by jimmygold70 on December 24, 2006, at 7:52:48
The usual equivalence ratio given for clonazepam/diazepam is 0.5mg/10mg so 3mg clonazepam ~ 60mg diazepam. From personal expereience I'd say this is true, though diazepam is more sedating and has a more pronounced hypnotic action per unit dose. This can cause problems for some people when they try to switch from shorter acting, less sedating benzos and Heather Ashton has some advice about this problem in this article:
--------------------------------------------------
16. SHOULD I SWITCH TO ANOTHER BENZODIAZEPINE SUCH AS VALIUM BEFORE TAPERING?Keep in mind that some people feel that switching to Valium is not for everyone and many have tapered their drug of dependency and have recovered very well. However, if you are considering this recommended method, there are three reasons that are often cited for switching to Valium for purposes of withdrawal.
First, Valium has a far longer half-life than most other benzodiazepines (see above). This allows for a steady, smooth reduction in dose over time. It also permits you to take your dose less often. In some cases, you can take your entire daily dosage before bedtime. This reduces problems of micro-managing your dose by taking another pill every few hours. It also can aid in sleep, which can be a large issue during withdrawal.
Second, Valium is low in potency relative to most other benzodiazepines and comes in tablets of 2mg, 5mg and 10mg. As a practical matter, you can make cuts as small as 0.5mg. This is the equivalent of somewhere between 1/20th and 1/40th mg of Xanax or Klonopin. Given the importance of making the smallest cuts possible, particularly as you approach the end of your taper, this is a very large benefit.
Finally, some people, including some experts believe that the newer, high potency benzodiazepines such as Xanax, Klonopin, and Ativan tend to produce more severe withdrawal syndromes. So far the evidence of this is purely anecdotal. There do not appear to be any studies that conclusively correlate severity of withdrawal with benzodiazepine type.
If you do decide to switch to Valium it is important to observe the proper dose equivalencies. These are special equivalencies for purposes of switching to Valium. (see table above)
The cross-over process also needs to be carried out gradually, usually in stepwise fashion, substituting one dose at a time. Many people have suffered because they have been switched too quickly. Making the changeover one dose (or part of dose) at a time avoids this difficulty. Depending on the size of your dose, the period of dose substitution may be anywhere from 3 weeks to about 3 months.
Valium is a more potent sleep agent than most high potency benzodiazepines even at the equivalent therapeutic dose and many people may find it initially more sedating. However, most benzodiazepine users rapidly develop a tolerance to the sleep inducing (hypnotic) effects of benzodiazepines, so that it is likely that this oversedation will recede within the first few weeks.
During this period of dose substitution, sometimes cuts to your total dose are made, and other times, slight increases are made. If you experience extreme oversedation and no withdrawal symptoms, that is a sign that the equivalency dose is too high for you, and you may wish make a small cut in your total dose as you cross over. If, on the other hand, you begin to experience heightened withdrawal symptoms during cross-over, you may wish to make a small increase in your dose during cross-over. Because the proper equivalencies vary from person to person, the cross-over process can be a matter of trial and error. However, it is important to understand that the end result of switching to Valium should be that you are relatively stable after the switch is complete, meaning that you are experiencing either no withdrawal or very mild withdrawal symptoms.
Professor Ashton has circulated detailed protocols based upon switching to Valium and explaining the method in detail (see above and below).
Librium is another long acting benzodiazepine that is sometimes (but rarely) used as a substitute. This author has insufficient information regarding the effectiveness of Librium substitution to provide a meaningful comment at this time. It is not necessary to switch from Librium to Valium. Librium may be tapered directly, although there is a problem in that it comes only in 5mg capsules in North America. Ideally, for Librium withdrawal, the capsule should be opened and the contents halved to make 2.5mg cuts. Of course, if it is possible to make even smaller cuts, that is most preferable."
--------------------------------------------------http://www.benzo.org.uk/FAQ1.1.htm
Q
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