BENZODIAZEPINES: HOW THEY WORK AND HOW TO WITHDRAW
(aka The Ashton Manual)
PROTOCOL FOR THE TREATMENT OF BENZODIAZEPINE WITHDRAWAL
Professor C Heather Ashton DM, FRCP
IMPORTANT MESSAGE FROM PROFESSOR ASHTON
Professor Ashton would like to draw attention to the following points which are mentioned in the manual but not always heeded by doctors or patients:
It is worth pointing out to your prescriber that the withdrawal schedules provided in the manual are only intended as general guides. The rate of tapering should never be rigid but should be flexible and controlled by the patient, not the doctor, according to the patient's individual needs which are different in every case.
The decision to withdraw is also the patient's decision and should not be forced by the doctor.
Note that alcohol acts like benzodiazepines and should be used, if at all, in strict moderation as advised in this manual.
Antibiotics for some reason, sometimes seem to aggravate withdrawal symptoms. However, one class of antibiotics, the quinolones, actually displace benzodiazepines from their binding sites on GABA-receptors. These can precipitate acute withdrawal in people taking or tapering from benzodiazepines. It may be necessary to take antibiotics during benzodiazepine withdrawal but if possible the quinolones should be avoided. (There are at least six different quinolones - ask your doctor if in doubt).
C. H. Ashton, January 2007
These chapters were written by request in 1999 for readers in the USA concerned about the problems associated with long-term benzodiazepine use. Inquiries from Canada, Australia and the UK have suggested that the advice in the manual might be of help to a wider audience. Accordingly, some additions have now been made, particularly for readers in the UK.
A limited list of benzodiazepines that can be prescribed on the National Health Service was introduced in the UK in 1985. These include diazepam, chlordiazepoxide, lorazepam and oxazepam for anxiety; nitrazepam and temazepam for insomnia. Triazolam was originally on the list but was later withdrawn. Other sleeping pills now available on the NHS include the benzodiazepines loprazolam and lormetazepam and two drugs, zopiclone and zolpidem, which although not benzodiazepines, act in the same way and have the same adverse effects including dependence and withdrawal reactions. Information about benzodiazepines not included in the first US edition, and suggested withdrawal schedules for chlordiazepoxide, oxazepam and zopiclone have been added here.
Unfortunately, the benzodiazepine saga is far from over. Despite the fact that benzodiazepines are only recommended for short-term use, there are still about half a million long-term benzodiazepine users in the UK who have often been prescribed benzodiazepines for years. Many of these people have problems with adverse effects including dependence and withdrawal reactions, for which they receive little advice or support. The problem is even greater in countries (Greece, India, South America and others) where benzodiazepines are available over the counter. Because of widespread prescribing and easy availability, benzodiazepines have now, in addition, entered the "drug scene". They are taken illicitly in high doses by 90% of polydrug abusers world-wide, unleashing new and dangerous effects (AIDS, hepatitis, and risks to the next generation) which were undreamt of when they were introduced into medicine as a harmless panacea nearly 50 years ago.
I hope this booklet will provide information of value to benzodiazepine users unable to find advice elsewhere and perhaps raise awareness in the medical profession about the dangers of excessive or long-term benzodiazepine prescribing. The main credit for any use this monograph may be should go to Geraldine Burns in the USA, Rand M Bard in Canada, and Ray Nimmo and Carol Packer in the UK for their energy, enthusiasm and expertise in producing and distributing this booklet and making it available to people on the Internet throughout the world.
FOREWORD TO REVISED EDITION, AUGUST 2002
This edition contains some new material which I have added in response to requests and queries from readers in many countries including Europe, North America, Australia, New Zealand, South Africa and India. Additions include further information about withdrawal of antidepressant drugs, some advice for older or "elderly" people, and a mention of complementary, non-drug, techniques helpful in benzodiazepine withdrawal. There is also an epilogue outlining areas where further action about benzodiazepines - education, research and facilities for long-term users - is urgently needed. I am glad that this monograph has been helpful to people all over the world and am grateful for the many thanks I have received. I hope also that it will encourage professionals and others to undertake properly controlled trials aimed at improving the management of benzodiazepine withdrawal. This booklet is surely not the last word on the subject.
Newcastle upon Tyne
ABOUT PROFESSOR C HEATHER ASHTON, DM, FRCP
Chrystal Heather Ashton DM, FRCP is Emeritus Professor of Clinical Psycho-pharmacology at the University of Newcastle upon Tyne, England.
Professor Ashton is a graduate of the University of Oxford and obtained a First Class Honours Degree (BA) in Physiology in 1951. She qualified in Medicine (BM, BCh, MA) in 1954 and gained a postgraduate Doctor of Medicine (DM) in 1956. She qualified as MRCP (Member of the Royal College of Physicians, London) in 1958 and was elected FRCP (Fellow of the Royal College of Physicians, London) in 1975. She also became National Health Service Consultant in Clinical Psychopharmacology in 1975 and National Health Service Consultant in Psychiatry in 1994.
She has worked at the University of Newcastle upon Tyne as researcher (Lecturer, Senior Lecturer, Reader and Professor) and clinician since 1965, first in the Department of Pharmacology and latterly in the Department of Psychiatry. Her research has centred, and continues, on the effects of psychotropic drugs (nicotine, cannabis, benzodiazepines, antidepressants and others) on the brain and behaviour in man. Her main clinical work was in running a benzodiazepine withdrawal clinic for 12 years from 1982-1994.
She is at present involved with the North East Council for Addictions (NECA) of which she is former Vice-Chairman of the Executive Committee on which she still serves. She continues to give advice on benzodiazepine problems to counsellors and is patron of the Bristol & District Tranquilliser Project. She was generic expert in the UK benzodiazepine litigation in the 1980s and has been involved with the UK organisation Victims of Tranquillisers (VOT - Phone 01202 311 689. Victims of Tranquillisers offer support to anyone who has suffered medical and/or legal problems that are the result of tranquilliser use). She has submitted evidence about benzodiazepines to the House of Commons Health Select Committee.
She has published approximately 250 papers in professional journals, books and chapters in books on psychotropic drugs of which over 50 concern benzodiazepines. She has given evidence to various Government committees on tobacco smoking, cannabis and benzodiazepines and has given invited lectures on benzodiazepines in the UK, Australia, Sweden, Switzerland and other countries.
Professor Ashton may be contacted at:
Department of Psychiatry
Royal Victoria Infirmary
Newcastle upon Tyne
SUMMARY OF CONTENTS
This monograph contains information about the effects that benzodiazepines have on the brain and body and how these actions are exerted. Detailed suggestions on how to withdraw after long-term use and individual tapering schedules for different benzodiazepines are provided. Withdrawal symptoms, acute and protracted, are described along with an explanation of why they may occur and how to cope with them. The overall message is that most long-term benzodiazepine users who wish to can withdraw successfully and become happier and healthier as a result.
The material published in this online Manual is for general health information to the public. The author and publisher are not engaged in rendering medical, health, psychological advice or any other kind of personal or professional services on this site.
The material should not be considered complete and does not cover all diseases, ailments, physical conditions or their treatment. The information about drugs contained on this site is general in nature. It does not cover all possible uses, actions, precautions, side effects, or interactions of the medicines mentioned.
The material provided on this site should not be used for diagnosing or treating a health problem or disease. It is not a substitute for professional care nor should it be used in place of a call or visit to a medical health or other competent professional, nor is the information intended as medical advice for individual problems or for making an evaluation as to the risks and benefits of taking a particular drug.
The author and the operator of this site do not assume responsibility for any inaccuracies or omissions or for consequences from use of material obtained on this site and the author and the operator of this site specifically disclaim all responsibility for any liability, loss or risk, personal or otherwise, which may be incurred as a consequence, directly or indirectly, of the use and application of any of the material on this site.
It is suggested that readers consult other sources of information as well as obtain direct consultation with a physician when making decisions about their health care. If you have, or suspect you may have, a health problem, you should consult your professional health care provider. The material on the site is in no way intended to replace medical advice offered by physicians or a complete medical history and physical examination by a physician. In any event and before adopting any of the suggestions in this Manual or drawing inferences from it, you should consult your professional health care provider.
Elli Oxtoby (Solicitor)
Research & Innovation Services
University of Newcastle Medical School
Telephone: 0191 222 5508
IMPORTANT NOTICE: Any advice given on this site should not be substituted for the advice of a physician who is well-informed about benzodiazepine addiction and withdrawal. All advice given here is therefore to be followed at your own risk. You are advised never to stop taking any medication abruptly. Tony Pirog, Webmaster, June 5, 2008
Index · Contents · Introduction · Chapter I · Chapter II · Withdrawal Schedules · Chapter III · Medical Disclaimer `
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