How Long Does an Ashton Manual Benzodiazepine Taper Take, and Why Can’t It Be Scheduled?

How long does a benzodiazepine taper take under the Ashton Manual?

Almost every patient starting a benzodiazepine taper wants a date. It is a reasonable thing to want, and it is the one thing an honest physician cannot supply. Yet, a range can be given, and it runs from months to years.

The Ashton Manual, written by the late Professor C. Heather Ashton, remains the model for a gradual taper. In Chapter II of the Manual, her very rough guide for one sizable starting dose works out to 30 to 60 weeks, and she adds that some people go slower. She notes that many people have taken a year or more, and that whether it takes 6, 12, or 18 months matters little to someone who took the drug for years.

Dr. Mark Leeds, an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida, works with similar ranges. About six months is a reasonable minimum for a patient who has taken a benzodiazepine long term. A year is common, eighteen months or longer is often appropriate, and some tapers run for several years.

Those numbers describe what tends to happen, and they cannot predict what will happen to one particular person. They are useful mainly as a correction to the seven, ten, or thirty day timelines advertised by facilities. Those timelines are set by insurance coverage, and a nervous system does not read an insurance policy.

So, if the ranges are known, why can no one name the date?

Why can the finish date not be set in advance?

The variable that decides it cannot be measured at the start. Benzodiazepines enhance the activity of gamma-aminobutyric acid (GABA), the brain’s main calming neurotransmitter. With long-term use, the brain adapts by making its GABA receptors fewer and less responsive.

That adaptation is physical dependence, and how quickly it reverses varies widely from one person to the next. Physical dependence is not addiction. In fact, the 2020 update to the boxed warning from the United States Food and Drug Administration (FDA) recognizes that it can develop even when a benzodiazepine is taken as prescribed.

How long the drug was taken, which benzodiazepine it is, whether there were earlier abrupt stops, and how sensitized the nervous system already is all influence the pace. So does the response to the first few reductions, which is information nobody has until those reductions happen.

The FDA update states that no standard tapering schedule is suitable for all patients, and it calls for a gradual taper under a plan specific to the patient. A date printed on the first day would be a guess.

What are the phases of a taper based on the Ashton Manual?

Fortunately, while the date cannot be set, the shape of the process is well known. A taper built on the Manual moves through five recognizable phases, and none of them comes with a fixed length.

First comes the crossover to diazepam, where it helps.

Patients taking a short-acting or potent benzodiazepine often do better after a crossover taper, meaning a gradual switch to an equivalent dose of diazepam. Diazepam leaves the body slowly, so blood levels stay steadier between doses, and it comes in small dose units that allow small reductions. A separate article explains why the Ashton Manual recommends switching to diazepam.

The Manual sets no fixed length for this phase. It says only that the switch should be made gradually, usually in stepwise fashion, one dose at a time. Not every patient needs a crossover, and a patient already taking a long-acting benzodiazepine may taper that drug directly.

Then come the larger early reductions.

At higher doses, each reduction can be larger. The Manual suggests aiming for up to one tenth of the current dose at each step, and it leaves the timing of the next step to the patient. This phase usually moves the fastest.

The steps shrink as the dose falls.

One tenth of a large dose is a large amount, and one tenth of a small dose is a small amount. So, the reductions get smaller as the taper goes on. The dose falls more slowly on paper, even when the patient is doing well.

Landing an airplane is a fair comparison. The descent is steepest at altitude and flattens as the runway gets closer, and everyone agrees that the wrong way to land is to fly straight down, into the ground. While this is not a perfect analogy, a taper that keeps its early step size all the way down never levels off.

The last few milligrams usually take the longest.

Near the end, even a very small step can be a large share of what remains, and the nervous system often needs longer holds between steps. Patients are often surprised that the smallest doses take the most time.

Professor Ashton advised patients not to draw out the end indefinitely, and to stop once the daily dose was very small. Her advice reflected the tablets she taught from, which could only be divided so far. With the manufactured diazepam oral solution, which can be measured in much smaller amounts, Dr. Leeds usually keeps reducing in steps sized to the remaining dose, down to a stopping point agreed with the patient in advance.

Yet, a patient who is doing well may still choose Professor Ashton’s earlier stopping point. Either way, the last step should feel like just another step, the way a good landing is barely felt. The details are in the article on how low a benzodiazepine taper should go before the final dose.

After the last dose, the nervous system keeps adjusting.

The taper ends on the day of the last dose. The readjustment does not. Chapter III of the Manual observes that with slow tapering, some long-term patients have lost nearly all of their symptoms by the last dose, and that for most patients the rest fade over the following months.

However, for some patients, symptoms last longer, which is known as protracted withdrawal. The Manual is clear that a steady decline almost always continues, though it can take a long time. Another article describes what happens in the months after the last dose.

What sets the pace, if not the calendar?

The response to the last reduction sets the pace of the next one. Symptoms after a reduction are information. A manageable increase that settles within a couple of weeks suggests the step size was about right, and a sharp escalation that does not settle suggests the step was too large or came too soon.

Neither outcome is a verdict on the patient. Both are data used to size the next reduction, which is why a taper is adjusted continuously and never published in advance.

The Manual puts the patient in control of the rate. In fact, it tells patients not to let a doctor impose a deadline. The calendar belongs to the patient.

Is holding a dose a lost month?

Patients often describe a hold as falling behind. There is nothing to fall behind. Holding is standard taper management, and the Manual itself says a patient can stop at a difficult point for a few weeks if necessary.

When symptoms spike, staying at the current dose lets the nervous system catch up before more of the drug is removed. And, cutting again on schedule while the system is destabilized tends to cost more time than the hold would have.

While the Manual prefers standing still to going back up, Dr. Leeds also considers a small updose legitimate when a cut proves too large. Time spent stabilizing is part of the work.

Is a faster taper the stronger choice?

Faster is not stronger. The belief is common among patients and among some physicians, and it is biologically wrong. Speed does not demonstrate resilience in a nervous system that is chemically destabilized.

Unfortunately, a rapid taper usually produces a harder withdrawal, and rapid tapers often fail and have to be restarted from a worse position. Repeated abrupt or rapid withdrawals can also cause kindling, in which each episode makes the next withdrawal more severe. A patient who has been through two failed rapid attempts often needs a slower taper than one who has never stopped abruptly.

Stopping abruptly, or cold turkey, is the most dangerous choice of all. The FDA update warns that stopping a benzodiazepine suddenly, or reducing the dose too quickly, can cause withdrawal reactions, including seizures, which can be life-threatening. A seizure or any other medical emergency is a reason to call 911 or local emergency services right away.

Is a taper of two or three years too long?

A taper approaching three years is longer than most, and it is not a mistake. Patients who took a benzodiazepine for many years, who started from a high dose, or who went through earlier abrupt stops often need the extra time.

Is the patient doing something wrong? Is the physician being too cautious? Should the pace be forced to match an average? No. An average describes other people’s nervous systems, and a long taper that a patient can tolerate is a better result than a short one that fails.

What does progress look like, if not a falling number?

Progress in a taper is measured in tolerability before it is measured in milligrams. Sleep gets a little better. A bad afternoon replaces a bad week, and sound and light stop cutting quite so sharply.

These early markers usually appear before the dose has moved very far. The other marker is the pattern itself. Most patients move through windows, when symptoms lift, and waves, when symptoms return, and over time the windows lengthen while the waves shorten.

What should a patient do about goals, then?

Goals work better when they are set around conduct than around dates. A useful goal is steady daily dosing, an honest record of symptoms, and a hold whenever the nervous system asks for one. An unhelpful goal is a target dose by a target date.

Deadlines borrowed from work and school do not apply here. When the body misses one, the patient reads it as personal failure when it is ordinary physiology. Patients who trade the deadline for a direction generally suffer less and, in the end, tend to finish sooner.

How does Dr. Leeds set expectations with patients?

Dr. Leeds’ practice offers medically supervised benzodiazepine and z-drug tapering by secure telemedicine throughout Florida. Patients work directly with him at weekly appointments, which is what makes continuous adjustment possible.

No patient is handed a fixed schedule or pushed to finish by a particular date. If a step proves too fast, he slows the plan down, and if the patient is comfortable and wants to move, the two may agree to go a little faster.

For patients in Florida who want a taper paced by their own nervous system, with no finish date imposed, Dr. Leeds’ practice is one place to start. Contact the office to ask about a medically supervised benzodiazepine taper.

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.