Presents:

THE WINSLOW LIQUID VALIUM
PROTOCOL FOR TREATMENT OF
BENZODIAZEPINE WITHDRAWAL

BENZODIAZEPINE WITHDRAWAL KIT

INTRODUCTION

The present recommendation on benzodiazepine withdrawal advises a four-step dosage reduction of diazepam tablets over a period of time. The disadvantage to this method is the step-wise nature of the reduction that many patients find difficult to manage.

The kit exploits the simple concept that an imperceptible reduction of benzodiazepine intake with each dose achieved by a process of dilution known as the Winslow method, will be successful in withdrawal, provided that the patient cooperates, and their life is stable enough to consider withdrawal. The psychological advantages to the patient other than the gradual nature of the withdrawal include
a) the unchanging volume of the dose,
b) the patient has a specific date on which they will complete withdrawal, and
c) the biggest drop in dosage is on the first day.

METHOD FOR A PATIENT ON A 5 MG. WITHDRAWAL REGIME

a) Patients should be stabilized on diazepam tablets for two weeks,and their dosage reduced to 5mg daily at a rate of 1 - 2mg every week to two weeks. The patient is then placed on the kit. The kit should be carefully explained to the patient. For patients on doses less than 5mg, see below.
b) The patient subsequently takes a 5 ml dose of the diazepam elixir removed form bottle A instead of the 5mg tablet, and replaces the exact volume of elixir removed from the bottle of elixir with 5 ml of diluent from bottle B. The bottle of elixir is then shaken, and the process repeated for the next dose. The effect of the process is fractional dilution with an exponential decline of 2% per dose. For example, if the standard 250 ml bottle of elixir is used, then the effect of one hundred doses taken in this fashion will result in a mixture of 0.67 mg of diazepam to 5 ml, at which point most patients using this technique are able to withdraw successfully.

THE STANDARD KIT CONSISTS OF THE FOLLOWING:

a) Instructions to the patient, a dosage chart and a measure.
b) A 250 ml bottle of lemon flavoured diazepam elixir at 5mg to 5 ml, greater than the commercially available strength of 2mg to 5 ml.
c) A 500 ml bottle of diluent. This is an identically flavoured dilutant for the diazepam elixir, and contains buffers and preservatives to give an open shelf-life of one year. The use of the correct dilutant which contains specific buffers and preservatives for diazepam, prevents contamination and precipitation of the elixir. Inverting the bottle before and after use is, as always, advisable. Like the bottle of diazepam, it is safe in overdoses. The kit will not be harmful if the whole is consumed in a self-poisoning attempt.

PRESCRIBING THE KIT

The prescription (for the standard kit, as example) should be written thus:

Diazepam Withdrawal kit (Martindales) X1 Elixir 5 mg to 5mls 250 mls Labeled Bottle 'A'
Dilutant 500mls Labeled Bottle 'B'
5mls to be diluted daily as directed. N.B. Because the kit comprises two separate products, there is a dual prescription charge. The daily cost of the kit to the NHS is 18p per item.

PATIENTS DEPENDENT ON BENZODIAZEPINES OTHER THAN DIAZEPAM

A common principle in withdrawal from a drug of dependence, is to change the patient to a compatible drug with a longer half life. For benzodiazepines, DIAZEPAM is the IDEAL drug for withdrawal purposes. The table below gives the equivalent dosage for transference of commonly used benzodiazepines to diazepam:
These figures vary from the equipotent therapeutic dosages quoted in the texbooks. It should not be necessary to place a patient on a dose higher than 50mg diazepam, but adjust according to clinical response. Stabilize the patient at transference dosage for two weeks, reduce gradually as described under previous method, and place on the kit at 5mg daily.

EQUIVALENT DOASGE OF BENZODIAZEPINES FOR THE PURPOSE OF TRANSFERENCE TO DIAZEPAM FOR THE PURPOSES OF WITHDRAWAL

Lorazepam 1mg = 10mg diazepam
Nitrazepam 1mg = 2mg diazepam
Oxazepam 1mg = 1mg diazepam
Chlordiazepoxide 1mg = 1mg diazepam
Temazepam 1mg = 1mg diazepam
Flourazepam 1mg = 1mg diazepam
Tranxene 1mg = 1mg diazepam
Triazolam 1mg = 20mg diazepam

PROBLEM PATIENTS

a) Intravenous drug abusers:
Supervised management, to prevent attempted i/v abuse.

b) Confused or frail patients: Supervised management may be necessary.

c) Alcoholics: Stop alcohol before attempting reduction. (Standard advise)

d) Obese patients: A slower taper will be required. See below.

PROBLEM SOLVING

Patient confusion is rare. The concept behind the kit is simple, but the patient may need to be contacted soon after the proccess is initiated, to check method.

SPLIT DOSAGES:

Best avoided. If unavoidable, the patient must be very consistent in EITHER diluting after each dose or the total sum of the day's dosage volume at the end of each day: I would advise the latter.

GOING ON HOLIDAY

It is quite acceptable to stop the taper temporarily if the kit poses problems while travelling. This can be achieved by switching at suitable pause points in the process, where the taper dosage equates with a suitable quantity of diazepam tablets. The patient stops the taper at that dosage, if necessary some days before going away, and switches to tablets until their return. This method can also be used to slow the taper for clinical reasons. See PAUSE POINTS below

PAUSE POINTS.

On the dosage schedule in appendix 2, the doses marked with an asterisk precede the points in time
when the patient can rest on a whole of half, 2mg or 5mg, tablet, or a combination of tablets. If not using the standard kit, or the dosage regime is other than the standard regimen, then please contact Dr. Clark. Pause points can be arranged at any dose by using ordinary diazepam elixir, but please contact Dr. Clark or an experienced pharmacist to calculate the dose required.

WITHDRAWAL SYMPTOMS

If they occur are less with the kit. They may start about day 25 but will disappear after ten days. Treat symptomatically if necessary. If the patient experiences them badly, First emphasize that they should keep going. Second, consider pause as described in the above paragraph. Third, it is acceptable to take a slightly higher dose of the elixir for a few days, say 5.5 mls instead of 5mls but always to dilute the same volume as is taken. This does not have a seriously adverse effect on the process.

DO NOT INSTRUCT THE PATIENT TO TAKE THE ELIXIR WITHOUT DILUTING IT.

Adjuvant therapy includes Gaminil for insomnia, Inderal for anxiety, Imodium for diarrhoea etc: Remember that depression may be masked by benzodiazepine dependence and may be a symptom of withdrawal. IF A PATIENT HAS TO ABANDON THE PROCESS, THEY CAN PROBABLY BE PUT BACK ON TABLETS AT A LOWER DOSE THAN THEIR ORIGINAL ONE.

Advise is available if in difficulty form Dr. Clark on 01296 714504.

OBESE PATIENTS

Because of the unusual physical properties of diazepam, the obese patient should be withdrawn at a slower rate. A 1% taper, using a 10mg to 5ml kit, 250 mls elixir and 500mls dilutant, but DILUTING ONLY 2 mls. DAILY will give a 5mg taper at 1% a day over 200 days.

USING THE KIT FOR DOSES BETWEEN 5mg. AND 10mg.

Do NOT issue a standard kit and instruct the patient to dilute a larger volume than 5mls. An 8mg kit is available, with 600mls of dilutent in bottle B. A 10mg to 5ml kit (with the same parameters as the standard kit) is available to provide a 1% taper, diluting 2.5mls a day.

USING THE KIT FOR DOSES ABOVE 10 mgs.

The kit can be used to drop a patients diazepam dosage smoothly in 4 mg stages. Using the standard kit for 5mg of their daily dosage, after 81 days of using the kit the elixir will be diluted to 1mg. The patient can then be switched to tablets equal to their dose on day 81 before continuing on a further taper.

EXAMPLES OF VARIOUS STARTING LEVELS FOR USING THE KIT

1) 8mg kit, 5mls diluted daily,
2) 6.5mg a day - 8mg kit, 4mls diluted daily.
3) 5mg a day Standard kit, 5mls diluted daily.
4) 4mg a day - Standard kit, 4mls diluted daily,
5) 3mg a day - standard kit, 3mls diluted daily.

If the tapering process using the standard kit has to be abandoned, I suggest a 10mg to 5mls kit diluting 2.5mls daily for a patient on 5mg a day, giving a 1% taper.

REFERENCES:

Lancet Letters, 21st Oct 1989, 9th Dec 1989, 6th Jan 1990.

This protocol was compiled by:
Dr. Iain Clark, MA (Cantab) MB BChir,
Principle in General Practice,
Horn Street Surgery, Winslow, Buckinghamshire,
Postcode MK18 3AL
Telephone:Winslow (01296)714504
12th January 1997
The kit can be ordered from Martindales Pharmaceuticals on 0170 838 6660
For patient advice and information,
the Council for Involuntary Tranquilliser Addiction (CITA)
can be contacted on 0151 949 0102

BENZODIAZEPINE WITHDRAWAL KIT
INSTRUCTIONS FOR THE PATIENT.

Your doctor has perscribed this kit in order to help you withdraw from a medication that you may have found rather difficult to stop. The idea behind the kit is very simple, but it is important to read these instructions carefully. If you do not understand these instructions, please take the kit, including this piece of paper to your doctor: The doctor will explain to you what to do.

1) The regular dose of medicine you must take is one measure from the bottle labelled *A*. Note your starting date on the dose chart,
and cross off each dose once taken.

2) You will find the measure in the box that these instructions come in, and you must take the medicine as many times a day as your doctor tells you.

3) After you have taken each dose of the medicine from bottle *A*, then top up bottle *A* with the dilutant from bottle *B* directly. Shake the bottle again. If you have more than one bottle of dilutant, which will be labelled *C* or *D*, then use bottle *B* first, then bottle *C* then bottle *D*.

4) Each time you do this, the medicine in bottle *A* becomes very slowly weaker, so gradually, in fact, that you will not notice the difference from one dose to the next. The table below ( not shown here ) shows this gradual change. By the time you finish using the contents of bottle *B*, you will be able to stop the medication without any difficulty.

5) If you have difficulties when you have finished bottle *B*, then consult your doctor.

6) Do not discard the kit for seven days after completion. If you have any difficulties on completion then speak to your doctor of counsellor.