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Dose - A comparison of different benzodiazepine equivalent dose lists.

Discussion in 'Benzodiazepines' started by Dickon, Mar 30, 2009.

  1. Dickon

    Dickon

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    I came across the following table at some unnameable place, and thought it worthy of a thread on here, as it shows clearly there is no agreed definition of equivalence. The table is presented in the "usual" way, i.e. the dose given is the equivalent to 10mg of diazepam. The columns represent individual sources of "equivalence". So for instance the column second from the left is the Ashton "equivalence" and so on. Notice the large discrepancies.

    Comparison of equivalent benzo- diazepine dose schemata
    1
    2 drug Ashton MHT Giannini Aus. Gov. FPN Plunkett DrugIntel Add. Med.
    3 Alprazolam 0.5mg 1mg 1mg 1-2mg 1mg 1mg 0.5mg 1mg
    4 Bromazepam 5-6mg 6mg 6-12mg 6 mg 6mg 6-12mg
    5 Chlordiazepoxide 25mg 50mg 25mg 25mg 25mg 25mg 20-25mg
    6 Clobazam 20mg 20mg
    7 Clonazepam 0.5mg 0.5mg 4mg 1mg 4mg 2mg 0.5mg 1-2mg
    8 Clorazepate 15mg 20mg 15mg 15mg 15mg 15mg
    9 Diazepam 10mg 10mg 10mg 10mg 10mg 10mg 10mg 10mg
    10 Estazolam 1-2mg 10mg 1-2mg
    11 Flunitrazepam 1mg 2mg 2-4mg 1mg 1mg
    12 Flurazepam 15-30mg 30mg 15mg 15mg 15-30mg 15mg 30mg
    13 Halazepam 20mg 80mg 40mg 40mg 20mg
    14 Ketazolam 15mg 15-30mg
    15 Loprazolam 1-2mg
    16 Lorazepam 1mg 2mg 2mg 2mg 2mg 1-2mg 1mg 1-2mg
    17 Lormetazepam 1-2mg 1-2mg
    18 Medazepam 10mg
    19 Nitrazepam 10mg 5mg 10-20mg 10mg 10mg 10-20mg
    20 Oxazepam 20mg 30mg 10mg 30-60mg 10mg 20mg 20mg 30mg
    21 Prazepam 10-20mg 20mg 10-20mg 10-20mg
    22 Quazepam 20mg 15mg 20mg
    23 Temazepam 20mg 20mg 15mg 20-40mg 10mg 20mg 20mg 20-30mg
    24 Triazolam 0.5mg 0.5mg 1mg 0.5mg 0.5mg 0.5mg 0.5mg
    25 Zolpidem 20mg
     
    Last edited: Apr 24, 2010
  2. Mikeymc

    Mikeymc Silver Member

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    The diagram does offer alot of conflicting dosage differences. Is there a specific reason for this such as that each one has differing effects, for example how sedating one is??? Just curious. Thanks and best wishes dickon
     
  3. cra$h

    cra$h Silver Member

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    great to see something like this. The only other one swim's seen was for opiates. Definitly gives swim some good reference points when experimenting with a new chemical!
     
  4. SeconalClerek

    SeconalClerek Silver Member

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    The reason this happens is because benzodiazapines are used for different indications ie diazepam for anxiety at 10mg would equal temazepam at 30mg but for insomnia would equal 15mg. Zolpidem 10mg equals Diazepam 20mg for insomnia but as an anticonvulsant 10mg Zolpidem is equal to about 1.25mg Diazepam.

    As you can see a huge mistake could be made.

    These comparison charts should state for what indication the comparison was made. My doctor told me this is how the comparisons are made in the BNF or British National Formulary and that cross referencing doses across indications is never done in medicine because doses vary massively per indication.
     
  5. Piglet

    Piglet Titanium Member

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    Nice work! Zolpidem isn't actually a benzodiazipine, but it is a GABA agonist. Could this work be extended to include other sedative/hypnotics? Meprobramate, Clomethiazole, Chloral Hydrate & some barbiturates are sill in use in the UK. Etifoxine is used in France. Zopiclone & Zimovane are obviously widely used in many countries.

    People who like downers may get overconfident because benzodiazepines are relatively safe in overdose, some other medications are not as forgiving & harm reduction is the game...
     
  6. Dickon

    Dickon

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    That's true, but clearly it was considered worthy of an equivalent dose comparison by Giannini (who- or whatever that is!). I think this work could definitely be extended to the other "Z-drugs" and possibly other sedative/hypnotics. As far as I know though Z-drugs and benzodiazepines exhibit some degree of cross tolerance although I cannot find exact details. My cat seems to remember a relatively low dose of zolpidem (10-20mg) being able to produce sleep when he was taking a moderate amount of diazepam (well, a lot really, I'm guessing 80mg-150mg a day). This was not a controlled experiment and was done during an opiate withdrawal, so the zolpidem could simply have been taken at a point when sleep was more likely. There is a thread here about barbiturate and benzodiazepine cross-tolerance: http://www.drugs-forum.com/forum/showthread.php?t=74422 . I see Jatelka has linked to a few pieces of literature on this that I've not yet checked out. I would advice extreme caution using any kind of equivalence table when going from benzodiazepines to barbiturates or other sedative/hypnotics since these, apart from the Z-drugs, can have very low therapeutic indices (i.e. a fatal dose is not much higher than a normal one).

    So, in some sense I think you answer your own question. A harm reduction approach would suggest such a table would be dangerous if misapplied, i.e. if someone taking 100mg of diazepam figured it would be ok to take 2g of sodium amytal (I am guessing at 200mg being roughly equivalent to 10mg diazepam) this could easily be fatal especially if combined with alcohol [Note: these numbers may not be exact but the idea is in essence correct].
     
  7. miffytherabbit

    miffytherabbit Silver Member

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    Rabbit thinks the reason the doses vary so wildly from one chart to the other is because the people that compiled the charts have never actually tried them.

    A friend of mine entered a manic phase of his bi-polar, and unfortunately had to be sectioned. He challenged the doctor that instructed him to begin Olanzapine therapy after the doctor had reeled off it's effects, strength and side-effects. My friend asked the doctor how he knew this and had he (the doctor) actually taken the medication himself. Obviously the doctor replied that, no, he hadn't ever taken Olanzapaine. To that answer, my friend said he would not begin Olanzapine therapy until the doctor could back up his claim as to the drugs effects, and the only reliable way to do this would be for the doctor to take the medication himself, and then report back the effects. Unfortunately, his doctor declined my friend's request! ;)

    I guess, in a round about way, what I'm trying to say is that the vast majority that work within the spheres of pharmacology: the manufacturers, and those who prescribe medication, have no idea as to the subjective effects and strengths of a drug, because they have never taken them to understand the subtle, but effective differences that make one drug more potent than the other.

    Rather than rely on some dusty professor in a science lab, I would be much likely to trust a chart developed by a group of normal (non-medical professional) people that had actually taken the list of medications themselves.
     
  8. Dickon

    Dickon

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    ^ ^ ^ While I think this an interesting perspective, I think a counter case can be argued, because the subjective effects of drugs differ so much from person to person. I can think of times on this site when people recommend certain drugs (e.g. for opiate withdrawals) that I would personally shudder to even think of taking, but that work for them. I have had to learn that just because I react well or badly to something doesn't mean others will react in the same way.
     
  9. blazelaser

    blazelaser Newbie

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    One question?

    2mg alprozolam tablets is indicated for anxiety. But 0, mg of it is equal to 10 mg diazepam.
    So, 40 mg diazepam is equal to 2 mg alprozolam tablets.

    Why alprozlam 2 mg tablets is not a high-dose while 4 10 mg valium tablets are high-dose? (and why are they produce 40 mgs of valium tabs)
     
  10. lillianni

    lillianni Silver Member

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    Initial dose indicated for anxiety of Alprazolam is 250-300mcg 3 times a day, for Diazepam it's 2mg 3 times a day.

    The maximum dose of Alprazolam is 3mg daily, maximum dose of Diazepam is 30mg daily.

    This comes from the British National Formulary, the official book used by doctors and pharmacists on all medication available in the UK.

    So 2mg of Alprazolam is indeed a high dose.
     
  11. MadOne

    MadOne Mercury Member

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    Hmmmm .I know this is a old post and i dont mean to sound disrespectful to the poster its good to get more info on the fourum. But to me that chart is extremly confusing and i been using various benzos for about 20 years. (currently on 6mg of diazepam and 10mg of nitrazepam a day) I am thinking that if someone non benzo tolerant looking for info on coverting their ocasional recreational dose might get it all wrong and take to much of something if read wrong it needs simplifying if someone has the time to do it :) im thinking of trying to change to one benzo to get my driveing licence back but am confused with this chart myself wondering whats best to be on driving wise as i have to have a medical to get my driving licence back and 2 benzos prob looks worse than 1 to the med examiner. sorry drifted little off topic there lol .

    peace all
     
  12. Mindless

    Mindless Gold Member

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    I think the thing that makes the table confusing is that there is no agreement on equivalence. I'm relying on Heather Ashton's figures, as these are widely used. So basically you want to switch to only one benzodiazepine. Nitrazepam and diazepam are both long acting benzodiazepines, so it might be simpler to switch to diazepam. This drug also has the advantage of being available in smaller doses, so it's easier to make fine, accurate adjustments to dosage. Nitrazepam is roughly equivalent to diazepam in potency in my experience as a user of both drugs. This also coincides with Ashton's figures.

    I'm assuming that your current nitrazepam use is at night, and that diazepam is used during the day. If so, you could leave your daytime dose of diazepam at 6mg, and slowly substitute the nitrazepam with diazepam. You could try taking 5mg of nitrazepam and 5mg of diazepam at night for one week, then switch over to 10mg of diazepam at night.

    This is just to give you an idea of what's possible, rather than being a definitive answer. Source: [FONT=verdana, arial, helvetica, sans-serif][FONT=verdana, arial, helvetica, sans-serif]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. [/FONT][/FONT]
     
    Last edited: Feb 14, 2012
  13. pulpfiction

    pulpfiction Newbie

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    I see you posted this years ago; If you're still around thanks! Docs giving me the diazepam and I "was" more familiar with the effects of an alprazolam dose. Super helpful my friend.
     
  14. sativa

    sativa Mercury Member

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    dudes sorry for ressurecting this tjread but i thought my questions would be right placed here.
    so hrere it goes:
    a FOAF please needs too know if he is used to alprazolam 8mg a day and 4mg at night,sometimes only 2mg at night of estazolam and sometimes only 4mg alprazolam daily.And i hid alprazolam ends and he only have the estazolam on hand,how can he convert the mgs of these two substances?
    So he can not suffer side effects or withdral?
    Also if the estazolam 2mg IR ends and the estazolam 2mg tablets ends too,and on backup plan he havd clonazepam 2mg each tablet and clonazepam2,5mg/ml and diazepam 10mg each gablet.
    how can he convert these 4 benzos too use them recreationally or just use them as told by the doc.
    untild he scores more of the benzos rhat he used too.
     
  15. Metacrias

    Metacrias Silver Member

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    Just a word to the wise; be careful with these equivalency charts (same goes for opiate equivalency charts). A lot of factors are involved in determining proper dose equivalencies and no chart captures them all as the substantial variation in the charts seen above indicate. Whether someone suffers from anxiety, panic attacks, both or neither will matter; tolerance matters (benzos are cross-tolerant, but not 100% so). The speed of onset of the benzo will matter for 'how hard it hits,' how strong it hits (at least initially) and how noticeable the comedown is. For example, notice how Xanax (Alprazolam) compares to Klonopin (Clonazepam). There is a lot of variation in the charts because it is very hard to fully and accurately measure equivalency. Although both are mostly used to fight anxiety (benzos have four broad types of effects, anti-anxiety being one, which are shared by all benzos HOWEVER certain benzos are better at causing one effect than others), Klonopin - along with Valium (Diazepam) - have a slower onset but much longer duration of action while Xanax (Alprazolam) - along with Ativan (Lorazepam) have a much faster onset and far shorter duration. These are the four classic anti-anxiety benzos with the former two being used mostly for anxiety and the latter for panic disorders. Since Xanax kicks in very fast, the initial sense of how 'high' a certain dose gets you will be different from a long-lasting drug like Klonopin. Generally, the faster you go from baseline to peak effects, the more powerful and intense the drug will feel - at first. This is why many think Xanax is stronger than Klonopin (the opposite is true); Xanax kicks in very, very fast and has a very short duration. If you take it and are sitting around it may knock you out in 15 minutes, for an hour or two you'll be real high but if you stay awake for 40 or so minutes you won't get too tired. Klonopin takes longer to begin working, and much longer to peak (with about 45 minutes for noticeable effects and 3 to 5 hours for peak effects) so the slower onset means it 'sneaks up on you.' You don't feel like it's that strong, but at some point into the experience (often upon standing) you'll suddenly realize how high you are. Xanax can be useful insofar as if you take too much, you'll be fine in a couple hours; klonopin can be more dangerous because if you take too much (EASY to do with Benzos because initial effects can be subtle and one side-effect is amnesia so people often forget how many they've taken) because you'll have to deal with the effects for a good 8 hours.

    Thus, these charts don't account for a lot of factors of importance (and likely account for different things). For my own use, as someone prescribed clonazepam for a long, long time (at a very high dose) I find the charts useful for determining what dose of another benzo is required to stop withdrawals with the same efficacy of clonazepam; the equivalency however doesn't hold when it comes to euphoria and side effects however.
     
  16. dorian.927

    dorian.927 Newbie

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    I tried nitrazepam (Mogadon) several times and found it much more potent than what is mentioned in the table above ... What do you think ?
     
  17. Sushi

    Sushi Gold Member

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    All the equivalency charts are nothing but an approximation. In general they are used to "switch" benzo dependent patients from any benzo to diazepam (due to its extremely long half-life) and then slowly decrease dosage to avoid very unpleasant withdrawal symptoms, seizures or even death. They are not the Holy Scripture, they are just meant to give doctors some orientation how to proceed with a patient.

    However, they give some comparison, even if not very precise. See the post of Metacrias above. It gives some more in-depth look into the issue.
     
  18. sci

    sci Silver Member

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    So much difference in comparisons by different people, brill table however I reckon another table displaying averages from all sources, may do that myself. Old post I know but very helpful indeedy even though your banned for some reason :p
     
  19. Built for sin

    Built for sin Silver Member

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    I will forever wonder why he was banned....
     
  20. Heideggay

    Heideggay Newbie

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    Thanks for this info.
    Sometimes I like to combine alcohol and benzos in low-ish doses, but I understand this can be dangerous, and that the risk varies from person to person. With that in mind, could someone give an idea of what a safe, and conversely, a lethal dose of valium would be, when combined with alcohol? I'm a regular drinker but have little to no benzo tolerance. Let's say the alcohol quantity in question is a bottle of wine. I'm tall/thin, BMI 21.
    Thanks.