Micro-Tapering Benzodiazepines With a Liquid

What is micro-tapering, and why do so many benzodiazepine tapers end up there?

Micro-tapering is a way of coming off of a benzodiazepine by making many very small dose reductions instead of a few large ones. Rather than cutting the dose once a month and waiting, the patient takes a tiny step down every day or every few days. Each step is small enough that the nervous system barely notices it.

The reason for steps that small is that the dose at the end of a taper is a fraction of the dose at the start, and a cut that was easy at the top can be intolerable near the bottom. Most patients who taper slowly find that the last part of the taper is where the tablets stop cooperating.

To be clear, micro-tapering is not addiction treatment. Nearly everyone who needs it was prescribed Xanax (alprazolam), Klonopin (clonazepam), Ativan (lorazepam), or Valium (diazepam) by a doctor and took it as directed. Physical dependence is a medical condition caused by the medication, and dependence is not addiction.

Why do tablets stop working as a tapering tool at low doses?

A tablet is made to be swallowed whole, or at most split in half along its score line. Once you go past halves, the pieces stop being equal. The drug may not be spread evenly through the tablet, so a crumb from one quarter can carry more medication than a crumb from another.

Patients often describe arriving at a first appointment with a pill cutter, a kitchen knife, and a small pile of powder they had been hoping to divide into eighths. They have no way of knowing what they took yesterday, and neither does their doctor.

The smallest tablet also sets a floor. If the smallest strength on the shelf is a quarter of a milligram and the plan calls for steps smaller than that, the tablet cannot get you there. Unfortunately, this is often the point where a less experienced prescriber tells the patient to skip days, or to stop, which is the opposite of a taper.

The same cut gets bigger as the dose gets smaller.

Consider a pay cut. A hundred dollars a month out of a large paycheck is an annoyance, and the same hundred dollars out of a small one means the rent does not get paid.

A taper works the same way. A cut of one milligram of diazepam from twenty milligrams is a twentieth of the dose. The same one milligram cut from four milligrams is a quarter of the dose, and the nervous system feels it as a much larger change. These numbers are arithmetic, not a schedule, and the numbers that fit you belong to you and your prescriber.

This is why the Maudsley Deprescribing Guidelines describe benzodiazepine tapering as hyperbolic. The relationship between the dose and the share of gamma-aminobutyric acid (GABA) receptors it occupies is a curve, not a straight line. At high doses, a large cut changes receptor occupancy very little, and at low doses, a tiny cut changes it a great deal. So, the reductions should get smaller as the dose falls, and micro-tapering is that principle in daily practice.

How does a compounded liquid make tiny steps possible?

A compounding pharmacist takes the same medication and suspends or dissolves it in a liquid at a known strength, for example one milligram in every milliliter. The patient measures each dose with an oral syringe instead of a pill cutter. A reduction that would have meant shaving dust off a tablet becomes a matter of drawing up a slightly smaller volume.

In fact, the steps can be a small fraction of a milligram, far below anything a tablet can deliver. Dr. Leeds works with compounding pharmacies for exactly this reason and prefers liquid formulations for precise dosing. He does not name those pharmacies publicly, and which one a patient uses is settled between patient and doctor.

For diazepam, a compounding pharmacy is often not needed at all. Diazepam oral solution is a manufactured product with its own federal drug label, made at one milligram in each milliliter, and Walgreens, CVS, and other major retail pharmacies can order it. Because it is made to a fixed standard, each bottle matches the last, which removes one source of variation during a taper. For patients who have crossed over to diazepam, it is usually the simplest way to take steps smaller than a tablet allows.

While a liquid is more precise, it has rules of its own. Most benzodiazepines do not dissolve well in water, so a compounded suspension must be shaken before every dose, stored as the label directs, and replaced before it expires. Once a preparation works, do not change pharmacies or formulations mid-taper without telling your doctor, because a small change in the preparation can feel like a large change to a sensitized nervous system.

What about dissolving a tablet in water at home?

Some patients make their own liquid, a method known as water titration. A tablet goes into a measured volume of water, is crushed or left to disperse, and the mixture is shaken well. A measured portion is drawn off and discarded, and what remains is the day’s dose.

Measuring a benzodiazepine by volume is older than the forums. Professor C. Heather Ashton wrote in Chapter II of the Ashton Manual that liquid preparations of some benzodiazepines are available, and that slow reduction from these can be accomplished by decreasing the volume of each dose with a graduated syringe. She chose diazepam for her schedules partly because it comes in 2 mg tablets that are scored down the middle and easily halved, so the final reductions can be made small. The Manual is free to read at benzo.org.uk.

Yet, the water method is only as accurate as the hands that do it. A suspension that is not shaken well can deliver most of the drug in one dose and almost none in the next, and a nervous system in the lower half of a taper will notice. It can suit a patient whose benzodiazepine has no easy liquid option, but it should be set up with your doctor, not copied from a forum post. Where a manufactured or compounded liquid is available, Dr. Leeds generally prefers it.

Where does micro-tapering fit in the shape of a taper?

Usually in the lower half. In the upper half, when the dose is still relatively large, tablets may handle the reductions well enough, and many patients do fine with a cut and hold pattern, where the dose steps down and then stays put until the nervous system settles. Most of the strategies for overcoming challenges in benzodiazepine dose reduction come into play when that pattern stops being comfortable.

As the dose falls, the holds get longer or the symptoms get louder. That is the signal to shrink the step, and shrinking the step below what a tablet allows is, by definition, a micro-taper. Some patients switch to a liquid at that point, and others use one from the first day of a crossover taper to diazepam by the Ashton Manual method.

Professor Ashton wrote in Chapter II that the precise rate of withdrawal is an individual matter, and her sample schedules step diazepam down by two milligrams, then one milligram, and in some schedules half a milligram near the end. Micro-tapering does not contradict that. It takes the same total reduction and divides it into smaller, more frequent pieces. Whether daily micro-cuts feel better than a cut and hold at the same overall pace is something patients disagree about, and there is no formal evidence that settles it. Clinical experience varies, and yours is the vote that counts. At the very end, Dr. Leeds generally prefers to keep reducing below half a milligram with a liquid and stop at about 0.1 mg, rather than stepping off at half a milligram as the Manual suggests.

What should you do when a step feels like too much?

Hold. A symptom spike after a reduction is information, not failure, and the right response is to stop stepping down until the nervous system catches up. If the rate is too fast, the doctor must help the patient by slowing it. If the patient is comfortable and wants to go a bit faster, patient and doctor may agree to that, as tolerated. Patient-centric approaches to benzodiazepine dose adjustment exist because no single rate is right for everyone.

Many patients who reach this stage were once told to cut the tablet in half for a week and then stop, so they read any doctor’s suggestion with suspicion, and understandably so, because a prescription caused the dependence in the first place. A doctor who understands micro-tapering will not ask you to trust the schedule. That doctor will ask what the last step felt like, and adjust.

Never stop a benzodiazepine abruptly, and never let anyone talk you into getting it over with. The 2020 United States Food and Drug Administration (FDA) boxed-warning update for benzodiazepines states that stopping them abruptly or reducing the dose too quickly can result in withdrawal reactions, including seizures, which can be life-threatening, and that a gradual taper should be used to reduce the dose or to discontinue. If you have a seizure, or symptoms that feel like an emergency, call 911 or go to the nearest emergency room. The rest of the time, the answer is slower, and smaller, and with your doctor.

Does micro-tapering make the taper take longer?

Not by itself. It divides the same reduction into smaller pieces, so a month of daily micro-cuts can cover the same ground as one monthly cut. The overall length is set by how your nervous system responds, and a careful benzodiazepine taper commonly runs many months to a year or longer. Professor Ashton also cautioned in Chapter II against spinning out the very end of a taper to a ridiculously slow rate, and micro-tapering is about the size of each step, not a reason to never finish.

Can Xanax or Klonopin be micro-tapered, or only Valium?

Most benzodiazepines can be compounded into a liquid. Dr. Leeds usually prefers a crossover taper to diazepam where it suits the patient, because its long action smooths the gaps between doses and because diazepam already comes as a manufactured oral solution. When diazepam is not a good fit, the patient’s own benzodiazepine can be compounded instead.

Are compounded capsules an option instead of a liquid?

Yes. A compounding pharmacist can also fill capsules at precise, decreasing strengths, which some patients find easier to carry and take, and the Ashton Manual notes in Chapter II that such capsules require a prescription and can be made up by compounding pharmacists in North America. A liquid stays the more flexible tool, because the volume can be changed the same day, while capsules are made in batches.

Dr. Leeds’ practice provides medically supervised benzodiazepine tapering by telehealth to patients throughout Florida. Micro-tapering with a liquid, either the manufactured diazepam solution or a compounded preparation, is one of the tools he uses, usually in the lower half of a taper, always at a pace the patient sets. If you are stuck at the point where the tablets no longer divide, Contact the office to talk about whether a liquid could make the next step smaller.

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.