« back www.benzo.org.uk. BENZODIAZEPINES: HOW THEY WORK AND HOW TO WITHDRAW (aka The Ashton Manual), Revised August 2002. AVAILABLE ONLINE HOW TO ORDER A PRINTED COPY. Professor C Heather Ashton DM, FRCP. The Ashton Manual is available from this website as an instant digital download and soft cover book. For other titles about benzos. PPT – Benzodiazepines PowerPoint presentation free to download - id: 6791df-YjFjM. The Adobe Flash plugin is needed to view this content. Get the plugin now. The Benzo Trap. Start BDZ script short term use for a clear. Ashton self-help manual for benzodiazepine.

• 5Removed section

Do Not DIY This[edit]

One key point during my personal experience with this is maintain a steady dose that means DAILY, do not skip, even if you get drunk!
This greatly reduced the side effects {mainly panic attacks}, cold turkey will have you throwing your exhausted body in front of a train several months before the pain dies down
Let us be realistic these drugs are not toxic, the only need to come off them is the side effects associated with sudden withdrawal after prolonged use
It may well be that elderly, infirm or otherwise less than physically healthy might be better off continuing managed use rather than total withdrawal as it is rather physically demanding

Cold turkey[edit]

cold turkey how long for withdrawals to last?

Hello,

You should speak to your doctor urgently, you can experience psychosis or epileptic seizures. You should read The Ashton Manual by professor heather ashton http://www.benzo.org.uk/manual/Withdrawal from short acting benzodiazepines can occur within 24 hours and more long acting benzodiazepines can occur after 3 weeks. Withdrawal symptoms especially from cold turkey withdrawal can last months or sometimes longer. I can't help you any further as wikipedia is not really the place for healthcare advice but I would say that you should seek medical attention urgently, as cold turkey withdrawal can potentially have very serious health effects. Please speak to your doctor and tell him what you have done.

Carpetman2007 02:06, 22th June 2007 (UTC)

It is well known that gradual withdrawal over a period of months even up to a year or more is needed. In the uk these guidelines are issued in the British National Formulary which almost every doctor has a copy of. The warnings against rapid withdrawal are known world wide as well with most medical authorities stating that benzos need to be gradually reduced.Detox centers shouldn't be detoxing people off of benzos as a first resort, if at all. Benzos typically cause a severe physical dependence where seizures, psychosis and other serious withdrawal effects emerge during rapid detox and can remain acute and severe for several months. Stimulants cause a mild physical dependence but cause a strong psychological dependence and opiates a moderate physical dependence and strong psychological dependence. So benzos are different in that respect. The withdrawal syndrome is often too intense and too prolonged and in some cases brutal to be done cold turkey or rapidly.The wikipedia benzodiazepine articles reflect the medical knowledge base fairly well in my opinion. Nowhere in the wikipedia benzo articles does it suggest to the reader that abrupt withdrawal is a good idea. I think that your doctor is merely ignorant of benzodiazepine dependence and how to manage it. Many of these detox centers just want to make money to be honest.--Literaturegeek (talk) 19:08, 11 April 2008 (UTC)

I just reread the following comment you made which I have highlighted in bold. 'Someone tell the medical community that they have huge issues that need to be addressed.'I wasn't sure if this comment was implying that the wikipedia benzo articles were lacking in withdrawal information or not. Were you talking about the articles or just sharing your experience? These discussion pages are really only meant to be used to discuss the article.--Literaturegeek (talk) 19:12, 11 April 2008 (UTC)

Yes it was just my experience in the medical community in the US. I applaud the Wikipedia article or I'd still be lost in very poor health. Someone needs to shove this article in the face of every doctor in the US, because I was seeing the top doctors in southern California and they seem to no nothing of this information.--Equilibriummike (talk) 06:27, 12 April 2008 (UTC)

Problem with hypnotic withdrawal section[edit]

The references in the hypnotic withdrawl section are fake and have been made up. They do not even say what they are quoted as saying, even the reference titles have been altered.--TreasureXNY (talk) 00:31, 9 August 2008 (UTC)

Peer-reviewed source?[edit]

There is one source that is used quite a bit in this article, and I haven't been able to determine if it has been peer-reviewed or not. The reference in question is The Ashton Manual, and although there is no doubt that Heather Ashton is an expert on this topic, I'm concerned the article relies too heavily on this source. The relevant policy, if the Manual hasn't been peer-reviewed, is the verifiability policy on self published sources. It states, with my concern in italics: 'Self-published work is acceptable to use in some circumstances, with limitations. For example, material may sometimes be cited which is self-published by an established expert on the topic of the article, whose work in the relevant field has previously been published by reliable third-party publications. However, caution should be exercised when using such sources: if the information in question is really worth reporting, someone else is likely to have done so. For example, a reliable self-published source on a given subject is likely to have been cited on that subject as authoritative by a reliable source.'

Most of the information in the Manual has probably been published by Ashton herself in peer-reviewed journals. If that is the case, those articles are the preferred source to be used. Letsgoridebikes (talk) 16:46, 5 February 2009 (UTC)

It is not peer reviewed but I have seen it quoted or referenced a couple of times in peer reviewed articles. Also in Canada I believe it was some pharmacology department bulk ordered it for distribution in an area. It is quite a well known. But anyway you are right that it is used too much and peer reviewed sources are preferable. The info is mostly a summary of the literature, her own literature and also other researchers, tyrer, lader and others. I have got it down to being referenced 4 times in the article. I will reduce it further in the coming weeks. Thanks for the suggestion and feedback! :=)--Literaturegeek | T@1k? 18:36, 5 February 2009 (UTC)

Removed section[edit]

I removed the following section because it grossly misrepresents the citation. In fact, it seemed so different that I decided to remove it for discussion rather than slapping a fact tag on it. If I am incorrect, and the reference does in fact contain this information, I'd appreciate if someone could give me specific page numbers. (And yes Literaturegeek, I made several searches and couldn't find a single mention of PTSD, fears of going mad, or a regime coupled with reassurance.) Letsgoridebikes (talk)

Complications[edit]

Over-rapid withdrawal and lack of explanation and failure to reassure individuals that what they are experiencing is withdrawal symptoms and is temporary have led some people to experience increased panic and fears that they are going mad, with some people developing Post Traumatic Stress Disorder as a result. A slow withdrawal regime coupled with reassurance seems to improve the outcome for individuals undergoing benzodiazepine withdrawal.^[1]

Yea but I had removed the Ashton manual citation per your suggestion and left the other citation. That paragraph is based on two citations. I added back the ashton manual citation.--Literaturegeek | T@1k? 00:55, 12 February 2009 (UTC)

I must have gotten the protracted withdrawal symptoms, and the protracted withdrawal syndrome, articles mixed up. I changed the citation. By the way in one of the articles she puts a hyphen between the post and the traumatic, like post-traumatic, just if you can't find it if using a search tool.--Literaturegeek | T@1k? 01:03, 12 February 2009 (UTC)

You can also read it in Chapter 3 of the ashton manual. Here is the link.[1] By the way tip of the day you can quickly locate words using the search tool on firefox browser. :=)--Literaturegeek | T@1k? 01:06, 12 February 2009 (UTC)

I'm well aware of how to search documents and websites using a web browser, thank you. As for the paragraph as it stands, the Ashton manual doesn't say anything about people being diagnosed with PTSD, but it doesn't refer to people experiencing PTSD like symptoms. This ought to be changed. Another thing is that I don't understand why this section exists. It doesn't seem like a logical demarcation to me. Letsgoridebikes (talk) 02:55, 12 February 2009 (UTC)

I reworded it and merged the section into the detox section since it is talking about the effects of rapid withdrawal/detoxification.--Literaturegeek | T@1k? 14:26, 12 February 2009 (UTC)

Interactions BZDs, Fluoroquinolones, NSAIDS[edit]

I removed this section because it relies on highly speculative refs: in vitro experiments with frog neurons, mice neurons etc. finding millimolar binding etc. This is speculation on the side of the refs as well as WP:SYN. Apart from that it combines now all recent pet peeves of the recent controversies about medication side effects. Sarcasm: can't we mix some more Paroxetine in too and see what happens in a combination of Benzo WD, fluoroquinolones, Indomethacine and Paroxetine, to a mixture of mice sperm, frog neurons, ground up rat tumors and squid cells. Or instead of squid add some ground up Scientologist brains. End_Sarcasm. Seemingly everything is connected to everything in the universe again, as so often. I propose to find some clinical refs first.If Dr. Ashtray is the only one, cite her with care and keep this as a clear speculation unless there is clinical evidence, not anecdote. I am out, for a good reason, I can't see this any more.70.137.165.53 (talk) 03:56, 1 April 2009 (UTC)

Instead of reading the title, if you read the actual citation it discusses humans, including the Japanese government warning about the interaction of NSAIDs and fluoroquinolones. Infact all the health bureaucracies warn of the interaction with NSAIDs and it is in all prescriber information and patient information leaflets etc. It is one of the most important interactions and in the UK there is a CSM 'black box'/highlighted type warning in the UK. The FDA and the CSM in the UK have strong warnings about interactions of NSAIDs and quinolones. Anyway below is a quote from the frog neuron reference where it is clearly talking about humans.

Recently, however, serious convulsions havebeen reported to occur in patients co-treated with new quinoloneantimicrobials and with fenbufen, a non-steroidal antiinflammatorydrug (NSAID). Hence, the Japanese governmenthas warned against the joint use of these drugs (Ministry ofHealth and Welfare, Japan, 1986). Since there is no effectiveclinical therapy against the convulsions induced by coadministrationof these drugs, it is important to clarify themechanism underlying these convulsions.

I only used the frog study for the mechanism of action

I have used a book ref to replace the frog ref. The mouse study states that it may explain the CNS adverse effects of that NSAID in humans so I only used that to cite the mechanism of action. The CNS adverse effects in humans are not indispute and are listed as side effects. One of the risk factors for seizures from quinolones is a condition which pre-disposes to seizures. I don't think that it is disputed that benzodiazepine withdrawal lowers the seizure threshold. I have added a British National Formulary reference for this.--Literaturegeek | T@1k? 22:46, 1 April 2009 (UTC)

Ashton Manual Benzo Taper

I have removed synthesised or original research data.--Literaturegeek | T@1k? 23:10, 1 April 2009 (UTC)

No need to get Scientologists involved, this is not their fault. But I agree that the article suffers from over-reliance on animal studies. The 'syndrome' defined by Ashton is very very long-term (in this lies the uniqueness of her claims) and diagnosed on the basis of symptoms not diagnosable in a mouse. The information gleaned from animal studies might help identify productive areas for future research, but Wikipedia articles should use secondary sources based on humans when the topic is human healthcare. There is only one secondary source used for most of this article.Rose bartram (talk) 11:26, 1 April 2009 (UTC)

There are only a very small number of animal studies used in the article. I don't believe there is an over-reliance on animal studies in this article except where it was unavoidable. However, as with any article which is not a featured article it is always possible to improve the quality of references. There is a lack of secondary sources but there is more than one secondary source used in the article but still more secondary sources could be used. There are several secondary sources. For some reason this Lader paper is not listed as a review when it was a review of the literature as I read it but it would qualify as a secondary source. The article is not a featured article so improvements can always be made.--Literaturegeek | T@1k? 23:10, 1 April 2009 (UTC)

I tried to phrase it as a provocation: In-vitro and animal studies have to be cited as such, including the exact substance, species, concentrations etc., e.g. 'midazolam at a concentration of ZZZ nmol/ml caused increased expression of the protein XYZ by Y%, in vitro, on hippocampal mouse brain cells (reference)', not 'Benzodiazepines may cause increased expression of XYZ'. If cited as such, the association with clinical effects is usually so remote, that ref has at best explanatory character, if the paper includes that explicitly, or it points to future research problems. In vitro is simply too far away from the medical treatment to be of value as a reference. The reference to scientologist brain cells, in sarcasm, was a pun on their highly unusual, dangerous and unscientific approach to addiction, see Narconon. The Ashton refs have imo to be replaced by peer reviewed articles. A cite check on the Ashton bible was a dangling action point from the Temazepam article, one year ago. This was not meant as a joke at that time, regardless how well recognized she is, we have to follow citation discipline w.r.t. reliable sources, and we cannot rely on self published materials, except under very narrow circumstances. Certainly not as the leading source of the article, if at all.Don't take it wrong, but the article needs another iteration, removing SYN and OR and speculative sources, which point to future research. And the Ashton and Lader papers need to be put in perspective with broad medical consensus, I believe. As valuable as they may be, but WP should rely on sources expressing contemporary mainstream opinion in the medical field. Besides: The NSAID ref imo talks about epilepsy, and on closer inspection mentions specific NSAIDS and Fluoroquinolones in combination as dangerously epileptogenic, but doesn't explicitly talk about Benzo WD plus Fluoroquinolones plus NSAIDS. So this is likely SYN, needs a better ref, which explicitly says that. Benzo WD is not true epilepsy, e.g. carbamazepine doesn't work on it. The suspected interaction FQ/NSAIDS with the GABA transmission is a speculation and marked as such. Enough, I already wanted to stop to edit Wikipedia, but you guys threaten my WP detox... Be less speculative, guys, less is more, the basic facts get obfuscated by too much speculation and fringe aspects. Distill the facts. And move the inline refs to the point, not as a whole block at the end of the section. 'Statement (ref). Statement (ref). Statement (ref)'. Not: 'Statement, ergo could we blah blah blah...this may be blah blah blah......assume blah blah suspect...may cause blah blah...blah blah has been suspected blah blah blah needs more investigation' a whole section. ref ref ref ref ref ref ref ref ref ref ref. That is hard to verify and to debug of SYN and OR and speculation. Transform it to this citation style, and see what is left over then. (This also looks like the imbecile crap Goodson and some sock puppets were writing, I had to debunk a lot of that crap and this citation style made it hard) Note: 'epileptogenic & Benzo WD is epilepsy-like -> ergo interaction' IS already WP:SYN! The ref says no word about benzo WD. So cut it out.70.137.165.53 (talk) 07:51, 2 April 2009 (UTC)

I have fixed the sentence in the article accordingly to say animal research. Yea I know about narconon using vitamins and saunas for cold turkeys and all sorts. The Ashton Manual I don't think was used in the temazepam article. It was a peer reviewed publication Ashton made in the BMJ that was used if you are referring to the drug abuser injecting into his eyes and it was not me who made that addition to the article but I defended it because living in the UK there were major problems with an epidemic of temazepam injecting and also it was peer reviewed. Lader is or was before he retired the most senior psychopharmacologist in the UK and sat on the equiv of the UK FDA, the CSM panel for a number of years. Who should we cite if not him LOL? Like Lader, Ashton is a recognised world expert in benzos. I know the ref only talks about NSAIDs with fluoroquinolones and I used it only in that context so I didn't misrepresent it, so there is no WP:SYN. I then left a see also link for people to click for more information on quinolones. I only added it because of its relevance to GABA antagonism and because it is a very serious interaction. You have to remember that I didn't write everything in this article as well. The Ashton Manual is cited many times in google scholar. When The Ashton Manual is used it is usually backed up with other peer reviewed references in the article or else it is used to cite obvious things like caffeine may worsen withdrawal symptoms. Do I really need a peer reviewed source to say caffeine worsens withdrawal symptoms? I think not.--Literaturegeek | T@1k? 14:02, 2 April 2009 (UTC)

Honestly I did catch the sarcasm about Scientology, and if you check the history of the article you will see that have contributed almost nothing to it and am certainly not responsible for any of the problems you (correctly) identify. My concern is that the issue goes way beyond this particular article. There are approximately 100 articles linking to this one, and many have the same material. We have here a Sorcerer's Apprentice situation and I doubt anyone can stop the brooms from replicating. If we used Ashton's strategy with alcohol (and many of these references could equally well support application to alcohol dependence as it is also GABA-mediated) we would have all our 'recovering' alkies measuring their vodka with graduated cylinders, a milliliter less per week. Wikipedia is in no way neutral on this point and I applaud any attempt to improve the situation, but with a sense of despair. The part that particularly galls me BTW is the idea of replacing e.g. alprazolam with diazepam in a 1 to 20 ratio, not specified in this article but clearly suggested in at least two of the links. Rose bartram (talk) 12:19, 2 April 2009 (UTC)

The comparison to the alkies is probably skewed, in fact you detox alkies with long benzos, or in the old days with 'Distraneurin', which is a heavy duty sedative. Then you reduce slowly, to avoid DT, because once the guy has DT and sees spiders etc. his brain cells can fry due to excitotoxic mechanism, and also subsequent more destruction, seizures, excitotoxic damage is introduced by a kindling mechanism. It appears only logical to apply the same treatment to heavy duty benzo addicts, for the exactly same reasons, you don't want excitotoxic damage, kindling and unnecessary high overshoot of the system, out of concerns for subsequent damage. That alcohol itself is not gradually reduced is explained by the toxicity of the enormous amounts of alcohol to the whole body, which are required for such a detox, but I believe substitution by chloral hydrate was used in the old days.That you avoid rapid fluctuations of sedative effect is reqd for the same reasons, namely avoiding kindling and excitotoxicity.So I agree with Ashton's methods, they are so far mainstream, and I believe this is also reflected in mainstream literature. To reduce somebody so quickly that he gets seizures or spiders etc. is just dangerous. The Ashton source is however practical and imo does not cite carefully, and mostly to dated references, and it is addressed to patients and practitioners dealing with benzo addiction and does a whole lot of biased and exaggerated case reports and scare stories for harm reduction. This is your brain on benzos, fry, sizzle, sizzle etc. And this how is your feet turn black and rot off after you inject tablets into your arteries. And this is the man dangling from a wall in a basket in an institution, after all his limbs had to be amputated, etc. etc.I regard it as a self-help and help manual and last resort for addicts, and she may have saved a whole lot of people. But her clients seem to be the most desperate cases, also with polytoxicomania and heroin etc. etc. and normally all bets are off for them. They are just like poor Lazarus, and finally a dog finds mercy for him and licks his wounds. So her manual has its justification, if you remember how powerless medicine is in refractory cases of hard addiction.But it is also written with a whole lot of purpose and fervor for those patients, and I do not regard it main stream or a peer reviewed reference for that reason. The conversion factors between e.g. Alprazolam and Diazepam are maybe optimistic, but like with methadone treatment you better err on the side of a bit too much, and the guy stops shooting up the street dirt or ground up tablets and is able to come off this habit and give up the false friends and then to reduce slowly under medical supervision. If you do this wrong and it hurts too much, he relapses and you find him dead and blue in some shithouse. Of course you also have to give all psychological and spiritual support to really let him know that you want him on your side, with the living. Do we agree? With this in mind, we have to filter for encyclopedic content vs. 'how to help' or at least find some compromise.70.137.165.53 (talk) 13:41, 2 April 2009 (UTC)

[Edit conflict with 70.137, posting at same time. :)] If Rose you are suggesting that Ashton a world peer reviewed expert is fringe for suggesting 1 - 2 weekly reductions of 10% of dosage you would have to add to the list of fringe organisations the Department of Health substance misuse management UK guidelines, the Committee on Safety of Medicines guidelines which are published to every UK prescriber in the British National Formulary and Clinical Knowledge Summaries National Health Service guidelines for prescribing doctors which is national guidance for GPs. Opiates such as methadone and buprenorphine are often withdrawn in a similar fashion. Alcohol is short acting, toxic and there are no drugs which are fully cross tolerant with it so it usually requires a cold turkey approach with partially cross tolerant benzos or similar to manage it.--Literaturegeek | T@1k? 13:53, 2 April 2009 (UTC)

Lg, am I right?70.137.165.53 (talk) 14:33, 2 April 2009 (UTC)

LOL, I was quite impressed! I think that you should head up a department for the neuroscience and best practice for substance dependence. You should apply. :) You get more money in such a job than an electrician so I hear. ;-)--Literaturegeek | T@1k? 14:57, 2 April 2009 (UTC)

BTW you missed the drama with Mwalla. See my talk page and follow the link to sock investigation. They had to be blocked for 3 months.--Literaturegeek | T@1k? 15:01, 2 April 2009 (UTC)

Ok I just added some good quality peer reviewed secondary sources review articles for the lead. The Ashton Manual reference was used for the entire lead which was not appropriate for the lead. I think the article is better referenced now so thank you for raising the problems with the article.--Literaturegeek | T@1k? 16:03, 2 April 2009 (UTC)

Question on sentence clarity[edit]

In the following sentence taken from this article, I am unsure how the word 'consuming' fits in the sentence.It may make more sense to others and if so, could someone explain it to me? If it is wrong, is this the sort of thing one should point out, or do most people just ignore it?Thanks ID

Patients consuming who are physically dependent on short acting anxiolytic benzodiazepines may experience what is known as interdose withdrawal. —Preceding unsigned comment added by 152.130.7.129 (talk) 04:53, 3 April 2009 (UTC)

I have fixed this. Well spotted!--Literaturegeek | T@1k? 10:48, 3 April 2009 (UTC)

Ashton Benzo Taper

Reference #32 for 'electric shock sensations' as a w/d effect cites exactly one patient, who also had temporal lobe spikes on EEG and the author admitted to being totally unsure what if any significance could be attached to her experiences as they were so atypical. I was going to take it out, but there are two subsequent references to the same article which would have lost their citation if I took that one out without attaching the citation to the next use of the article, and the article is so incredibly long that I could not find them. Also the link in note #80 is dead.Rose bartram (talk) 14:34, 11 April 2009 (UTC)

Yea I know it is a case report. I might see if I can find a better reference after the weekend for electric shocks. I reread the paper and could not find where the author said anything about being unsure or similar. Could you copy and paste that here? I fixed the dead link. Looks like British National Formulary changed about their URLs.--Literaturegeek | T@1k? 21:42, 11 April 2009 (UTC)

Can't copy/paste, it's a pdf. Check p 78, first column; I think that's where it came from. Also, are you aware that those of us beyond the bounds of the great empire on which the sun never sets have to pay 150 of those green things we heathens use for money, to get a glimpse of what's on the BNF, now that the link works? I hope that didn't sound uncivil. It was only meant to sound frustrated. It would be different if there were a chance of finding it in a library.Rose bartram (talk) 17:22, 12 April 2009 (UTC)

WikiProject Psychology Classification[edit]

I took a stab at the classification and importance for the new WikiProject Psychology header. I'm not a professional in any kind of related field, however. My B classification was based on the fact that this is a well-sourced article with a fair depth of explanation for such a narrow topic (and matches the other classifications/categories). I gave it Mid importance due to the fact that I know Benzodiazepine addiction is a significant concern in the medical field, but at the same time, this only applies to one particular aspect (withdrawal) of one particular class of drugs. Also, I think it's probably less important to psychology specifically as compares to the broader field of medicine.

If anybody disagrees with my assessment, by all means, feel free to change it. —RobinHood70^{(talk • contribs)} 21:00, 10 December 2009 (UTC)

Ashton Protocol Benzo Taper

Looks like a good judgement call to me. I agree with your reasoning. Thanks.--Literaturegeek | T@1k? 21:01, 10 December 2009 (UTC)

WP:MEDMOS[edit]

Have attempted to get this page compliant with WP:MEDMOS.Doc James (talk · contribs · email) 19:50, 29 May 2010 (UTC)

Benzo Uk Ashton Manual

Looks like an improvement to me. Good job.--Literaturegeek | T@1k? 01:38, 30 May 2010 (UTC)

Ashton Manual Benzo

Dr Heather Ashton Benzo Taper Manual