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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 26. This is the beginning of the thread.
Posted by michaels97320 on January 2, 2015, at 8:04:54
Hi all,
I had been using Diazepam 5mg PRN for a few months, probably every other day, I wouldn't say I've got much benzo tolerance, if at all.
I recently was prescribed Clonazepam 2mg PRN. I looked at the equivalence charts and saw that this was equivalent to 20mg Diazepam. I was expecting a strong effect fron the Clonazepam, but 2mg was arguably less effective than 5mg of Diazepam. I can actually "feel" the Diazepam, and while I think the Clonazepam is there, it seems very weak.
Has any one been through something similar? I'm not sure what to make of these equivalence charts now. The Diazepam to Temazepam seemed about accurate, but the Clonazepam seems way weaker than what is claimed in the tables.
Sincerely,
Michael
Posted by Phillipa on January 2, 2015, at 9:46:09
In reply to How strong is Clonazepam really?, posted by michaels97320 on January 2, 2015, at 8:04:54
When still working as RN the docs felt that klonopin was less likely to be abused so began using it. For some reason valium is supposed to be a feel good med. I haven't found this to be true. Lets one feel normal. No 5mg of valium isn't a high dose. Why not see if can take 5mg of valium two or three times a day. Klonopin to me is much stronger. Phillipa
Posted by michaels97320 on January 2, 2015, at 10:04:44
In reply to Re: How strong is Clonazepam really? » michaels97320, posted by Phillipa on January 2, 2015, at 9:46:09
That's what I mean -- Clonazepam is supposed to be much stronger, but 2mg for me does around the same or less than Diazepam. It's like I can't feel it, in comparison. I usually get a bit of sedation from benzos, but on Clonazepam very little. I'm wondering why it's been so weak for me when so many sources state how strong it is.
Posted by Christ_empowered on January 2, 2015, at 12:59:59
In reply to How strong is Clonazepam really?, posted by michaels97320 on January 2, 2015, at 8:04:54
Klonopin was originally for epilepsy. Its not terribly sedating. I think maybe you respond well to mild sedation, whereas the Klonopin is more a highly potent anti-anxiety/anti-seizure compound w/ much less sedation.
Posted by iforgotmypassword on January 2, 2015, at 15:05:26
In reply to How strong is Clonazepam really?, posted by michaels97320 on January 2, 2015, at 8:04:54
To me I find clonazepam very strong and biased towards sedative over practically anxiolytic. I found lorazepam the opposite and most usable but avoid it for its sharp cut-off. Now I take clorazepate, which while weak, cuts off slower and appears to be more memory sparing. It seems to have absorption issues however.
If clonazepam at 2 whole milligramme dosages isn't leading to therapeutic effect but 5mg of diazepam has, you may want to look up absorption and metabolism related factors, if these chemicals differ. Also consider any relevant effects of anything else you took with either drug. Details on relevant liver enzymes and bioavailability may help.
Posted by rjlockhart37 on January 2, 2015, at 23:36:09
In reply to How strong is Clonazepam really?, posted by michaels97320 on January 2, 2015, at 8:04:54
clonazepam is more of a siezure and in some ways it does calm mania, i've taken klonopin at 2mg three times a day and it made depressed, vary much, thats why it's more of choice with doctors because of less abuse potential, gives a depresso high, never taken valium but i do know it's perffered over klonopin because of better relief and mild euphoria from calming down from anxiety.....relief euphoria, valium is known more of "nerve" medication, i've always seen klonopin of a "psych" med
and klono and phenobarbital are similar, pheno is not euphoric like the other barbs, same to klono to the other benzos.....
but it is vary good for sleep
r
Posted by ed_uk2010 on January 5, 2015, at 2:56:38
In reply to How strong is Clonazepam really?, posted by michaels97320 on January 2, 2015, at 8:04:54
>Clonazepam seems way weaker than what is claimed in the tables.
It's not weak at all - but it's quite different. Clonazepam is much more slowly absorbed than diazepam. As a result, you don't feel it kick in nearly as much. It's also less muscle relaxant than diazepam. Don't be fooled into thinking it's weak though, it's certainly not - the effects are just 'spread out' differently over time, and effects on muscles, memory and mood are someone different too.
Diazepam is useful for 'when needed' use because of its very rapid onset of action. It is more rapidly absorbed than most others benzos by far, particularly on an empty stomach. It is noticeable very soon after a dose in the non-tolerant. The duration of action is surprisingly short after intermittent/occasional doses but increasingly long after regular dosing. Diazepam accumulates with repeated dosing due to slow elimination.
Unlike diazepam, clonazepam is almost invariably faily long-acting right from the first dose... but after long-term use it is not as long-acting as diazepam is after long-term use, it doesn't accumulate to the same extent.
You can see that comparing the doses of the two drugs is difficult due the different rates of absorption, distribution around the body, and excretion... as well as due to differences in pharmacological effects such as muscle relaxation. There is therefore no precise equivalent dose, all suggestions are nothing more than vague estimates which hold true for some people but not others.
Be aware, if you use 2mg of clonazepam regularly (including on alternate days), substantial physical dependence is likely to develop after a month or more of use and the drug may be very difficult to stop. Using 5mg of diazepam on alternate days is probably less likely to produce marked withdrawal symptoms when discontinued.
Posted by michaels97320 on January 5, 2015, at 10:44:47
In reply to Re: How strong is Clonazepam really?, posted by ed_uk2010 on January 5, 2015, at 2:56:38
Thanks for that ed, I learned a lot from your post. What you're saying actually seems to make sense, from my experience.
Diazepam is said to be long acting, but I find it to come on quite quickly, I can definitely "feel" it and after the initial 2-3 hour peak effect, loses its potency. Clonazepam seemed to be less distinct in the time of onset, but there was an overall mood stabilizing effect.
One of the major advantages of benzos for me is the "relief euphoria" which occurs with diazepam, not really with clonazepam. If taking 2mg clonazepam is likely to get me addicted within a month, it's not worth it for me. 5mg diazepam as needed, as you said, would be more suitable.
It's a pity as I was expecting a lot from clonazepam. I had heard it was excellent for social anxiety and a very strong anxiolytic. It feels more like a mood stabilizer than anything. That's not a bad thing, but I can take an actual mood stabilizer for that and not get a benzo addiction out of it.
Posted by former poster on January 5, 2015, at 18:34:45
In reply to How strong is Clonazepam really?, posted by michaels97320 on January 2, 2015, at 8:04:54
As I recall...Clonazepam originally was an anti-seizure med. Gained a good boost in sales when it was prescribed off-label for bipolar episodes back in the 80's. Seems at the time it was the most powerful mood stabiliser of the benzo's. later found to be excellent for anxiety.
Posted by ed_uk2010 on January 6, 2015, at 10:14:21
In reply to Re: How strong is Clonazepam really?, posted by michaels97320 on January 5, 2015, at 10:44:47
>Diazepam is said to be long acting....
Most information you read will state that diazepam is always long acting because it has a 'long half life' - this is misleading and is based on poor knowledge of the drug. The long half life refers to the slow elimination phase of the drug from the body. In practice, elimination half life is only one factor controlling a drug's real-life duration of action. Long half life drugs accumulate after regular repeated dosing and the duration of action always *becomes* long, regardless or whether or not it was long initially. In contrast, the duration of action after single or isolated doses is not controlled solely by the drugs half life. In the case of diazepam and clonazepam, it is controlled partly by fat solubility. Diazepam is extremely fat soluble (lipid soluble), the result of this is that is rapidly absorbed, and penetrates into the brain very quickly. Its action often wears off sharply around 3 hours after a single dose because it is redistributed out of the brain into fatty tissues elsewhere in the body... this terminates its sedative effect. If it's not at high levels in the brain, it's not going to help. Its action after a single dose is therefore not terminated by it being eliminated from the body - but by it being redistributed out of the brain. It has a short 'distribution half life' in spite of its long elimination half life.
After repeated dosing (usually at least daily), fat stores become saturated and diazepam's long-acting metabolite also reaches high levels (the metabolite is a new substance produced from diazepam in the liver). As a result, the level in the brain remains high and the drug is now truly long-acting.
Clonazepam has a moderately long half life, but not as long as diazepam or its metabolite, and therefore accumulates to a lesser extent. Its low lipid solubility results in a more gradual onset of action after taking a dose. It may not provide the very sudden/abrupt relief that you get with an adequate dose of diazepam after a single dose. It is absorbed over several hours, penetrates the brain more slowly... and leaves the brain more slowly. It lasts many hours right from the start. It has a long 'distribution half life'. After daily dosing for weeks or months, it may need to be given more frequently than diazepam - unlike diazepam, it lacks a long acting metabolite.
>Diazepam... I find it to come on quite quickly, I can definitely "feel" it and after the initial 2-3 hour peak effect, loses its potency. Clonazepam seemed to be less distinct in the time of onset, but there was an overall mood stabilizing effect.
That is typical. Most doctors will just tell you that both drugs are long-acting. This is not correct because the duration of action of diazepam is highly dependent on whether it is used 'when needed' or regularly. Clonazepam is much easier to understand, it is simply long-acting in most situations.
>One of the major advantages of benzos for me is the "relief euphoria" which occurs with diazepam, not really with clonazepam.
This property is very useful for ending a panic attack, for example, but can be problematic for anyone who likes the effect too much. If you ensure that you only take it when you absolutely need it, rather than when you want it, you should be OK. If you don't truly need a dose, don't take it - there is much more risk of developing tolerance and dependence if you do. Alternate day dosing can still produce some physical dependence, however, but taking 5mg of diazepam on alternate days will not produce such intense dependence as taking regular clonazepam 2mg.
>a very strong anxiolytic. It feels more like a mood stabilizer than anything. That's not a bad thing, but I can take an actual mood stabilizer for that and not get a benzo addiction out of it.
I don't personally find it especially helpful, it's too 'flattening'. Many people do benefit from it, however.
..............................
Here is a summary of duration of action....
Diazepam - duration of action after a single dose: usually surprising short, except in the frail or elderly, where it can last much longer. There may be some mild persistent effects for many hours but most of the effects are gone within a few hours. For me, single doses last 2-3 hours at most.
Duration of action after regular dosing for weeks or more: now long. Some people who take it regularly find it lasts all day every day with once daily dose. This property makes diazepam a useful drug for long term users to gradually taper off benzos.Lorazepam - duration of action after a single dose: medium. Duration of action after repeated dosing: still medium.
As a result, those who take it regularly for anxiety normally take it 2-3 times a day, sometimes 4. It often lasts about 6-12 hours, which changes little over time.Clonazepam: duration of action after a single dose: quite long. Duration of action after repeated dosing: still quite long.
It's most commonly given twice a day for severe anxiety, but 1-3 times a day is common. 2mg is a lot to take at once, for someone who doesn't usually take it. The most common dose is between 0.25mg and 1mg twice a day (usually 0.5-1mg twice a day for panic disorder). Very high doses are sometimes used in psych units to calm severe agitation.............................
Speed of onset of action after a single dose (regular dosing at a suitable time intervals should not produce large ups and downs):
Diazepam: Extremely fast on an empty stomach. With food: still fast but not as fast.
Lorazepam: Moderate, clearly slower than diazepam (this applies to both sublingual and oral routes). Often helps after about an hour.
Clonazepam: tends to build up gradually over a few hours. May end up being much stronger than it first appeared, and this can catch you by surprise due to its gradual nature.
Posted by phidippus on January 6, 2015, at 15:39:08
In reply to Re: How strong is Clonazepam really? » michaels97320, posted by ed_uk2010 on January 6, 2015, at 10:14:21
>taking 5mg of diazepam on alternate days will not produce such intense dependence as taking regular clonazepam 2mg.
not everyone becomes dependent on cualquier benzodiazapine.
Eric
Posted by baseball55 on January 6, 2015, at 19:33:32
In reply to Re: How strong is Clonazepam really? » ed_uk2010, posted by phidippus on January 6, 2015, at 15:39:08
Ed - I'm just curious. I am going on a trip soon that will completely screw up my sleep cycle. In the past, when I have traveled, my p-doc prescribed valium to get me to sleep on the new time zone.
Is valium best for this? I need something to knock me out on demand and not keep me out for more that 6-8 hours.
Posted by ed_uk2010 on January 7, 2015, at 7:48:09
In reply to Re: How strong is Clonazepam really? » ed_uk2010, posted by phidippus on January 6, 2015, at 15:39:08
> >taking 5mg of diazepam on alternate days will not produce such intense dependence as taking regular clonazepam 2mg.
>
> not everyone becomes dependent on cualquier benzodiazapine.Not everyone becomes dependent no, but it's extremely easy for this to happen when taken regularly. I'm referring to physical dependence and withdrawal symptoms.
Posted by ed_uk2010 on January 7, 2015, at 8:09:45
In reply to Re: How strong is Clonazepam really?, posted by baseball55 on January 6, 2015, at 19:33:32
> Ed - I'm just curious. I am going on a trip soon that will completely screw up my sleep cycle. In the past, when I have traveled, my p-doc prescribed valium to get me to sleep on the new time zone.
>
> Is valium best for this? I need something to knock me out on demand and not keep me out for more that 6-8 hours.If you're only taking it for a few days, diazepam (Valium) should be fine. It is likely to work for you unless you take benzos regularly, in which cause it may not cause drowsiness. Occasional doses don't normally cause much 'hangover' unless the dose is high. High doses taken regularly will cause daytime sedation in most people until tolerance develops. Individual response varies but around 5-7.5mg Valium should help you sleep without causing daytime sedation - there is a risk of mild effects the next day, as with any sleep drug. If you've responded well to it before it seems like a good idea to use it again. Be guided by the dose you tried before, unless it's many years ago in which case you could take a bit less (assuming no use of other benzos recently). If you weren't satisfied with it, one of the options below could be suitable.
Zolpidem (Ambien), zopiclone and eszopiclone (Lunesta) usually cause minimal next day effects at their lowest recommended doses but max doses may cause considerable morning impairment in some people, which can actually be greater than standard doses of benzos. The full dose of zopiclone (7.5mg) has been shown to cause considerably more impairment of driving ability the following morning than usual doses of temazepam (Restoril). It seems the Z-drugs are considerably more potent than they are often given credit for. They are effective but there are risks, like with any night sedative. If you respond well to diazepam you are likely to find temazepam (Restoril) similarly useful. It doesn't usually cause morning sedation at low doses eg. 15mg or less.
Some people use melatonin tablets when changing time zones, to help 'reset' their circadian rhythm in the new zone. The usual dose is about 3mg at night, taken for a few days, until your sleep in normal. You can take melatonin plus a small dose of a sleep drug if needed eg. melatonin 3mg plus zolpidem 5mg or diazepam 5mg.
Hope this helps.
Posted by ed_uk2010 on January 7, 2015, at 8:16:53
In reply to Re: How strong is Clonazepam really?, posted by baseball55 on January 6, 2015, at 19:33:32
> Ed - I'm just curious. I am going on a trip soon that will completely screw up my sleep cycle. In the past, when I have traveled, my p-doc prescribed valium to get me to sleep on the new time zone.
>
> Is valium best for this? I need something to knock me out on demand and not keep me out for more that 6-8 hours.Just the thought. I don't know too much about you! The doses I mentioned for Valium were just a guide for adults 18-60, approx, assuming little or no tolerance. Older people need lower doses, as a rule, unless they are tolerant. The same applies to anyone who is very underweight.
Posted by phidippus on January 7, 2015, at 16:32:34
In reply to Re: How strong is Clonazepam really?, posted by ed_uk2010 on January 7, 2015, at 7:48:09
I believe psychological dependence is worse than physical dependence, but I digress...
I have taken 2 mg of Clonazepam for at least a year and was ableto stop without incurring any physical withdrawal symptoms.
Eric
Posted by ed_uk2010 on January 7, 2015, at 16:49:35
In reply to Re: How strong is Clonazepam really? » ed_uk2010, posted by phidippus on January 7, 2015, at 16:32:34
> I believe psychological dependence is worse than physical dependence, but I digress...
Benzodiazepines, particularly large doses of high potency drugs taken over a long period of time, can cause intense physical dependence and the withdrawal syndrome can be relatively prolonged. Over rapid withdrawal can result in severe symptoms, occasional including withdrawal seizures and delirium. More common symptoms include intense panic, sweating, tremor and perceptual changes. Sedatives can produce the the most serious withdrawal symptoms of any class of drugs, and the symptoms represent far more than psychological dependence.
>I have taken 2 mg of Clonazepam for at least a year and was able to stop without incurring any physical withdrawal symptoms.
Lucky you. Most people would be ill. Please do not wrongly assume that everyone is the same as you, they aren't. Physical dependence can develop rapidly in some people.
Posted by baseball55 on January 7, 2015, at 19:12:00
In reply to Re: How strong is Clonazepam really? » baseball55, posted by ed_uk2010 on January 7, 2015, at 8:09:45
Thanks Ed. I am flying 17 hours to a time zone 12 hours ahead of me and want to be able to go right to sleep when I get there, so I can function the next day. In the past, valium knocked me right out. So I will try that again. Or maybe ambien. I've never taken those Z drugs.
Posted by Phillipa on January 7, 2015, at 20:06:36
In reply to Re: How strong is Clonazepam really? » phidippus, posted by ed_uk2010 on January 7, 2015, at 16:49:35
I often wonder how I took 400 or could have been 450mg of miltown with 15mg of valium and one day just decided didn't want to take the miltown any longer so stopped it. Never felt a thing different. I remember seeing the doc that prescribed it and when told him what I did his mouth literally fell open. He could not believe no side effects. At the time had three kids at home, was teaching Aerobic Dance & going to RN school. Why do you think it was just stop? Phillipa
Posted by Christ_empowered on January 8, 2015, at 1:32:14
In reply to Re: How strong is Clonazepam really? » ed_uk2010, posted by Phillipa on January 7, 2015, at 20:06:36
maybe having the valium on board reduced side effects?
Posted by ed_uk2010 on January 8, 2015, at 8:39:48
In reply to Re: How strong is Clonazepam really?, posted by Christ_empowered on January 8, 2015, at 1:32:14
> maybe having the valium on board reduced side effects?
Yes, it will have reduced the withdrawal, and it sounds like you were taking a very small amount of meprobamate (Milltown) anyway.
Posted by phidippus on January 8, 2015, at 15:10:48
In reply to Re: How strong is Clonazepam really? » phidippus, posted by ed_uk2010 on January 7, 2015, at 16:49:35
>Please do not wrongly assume that everyone is the same as you, they aren't.
We're on the same team. My contention was simply that some people don't habituate to benzodiazapines. In turn I would never assume everyone is like myself.
What is the highest dose one can take of Clonazepam?
Eric
Posted by Phillipa on January 8, 2015, at 19:51:27
In reply to Re: How strong is Clonazepam really? » ed_uk2010, posted by phidippus on January 8, 2015, at 15:10:48
20mg for seizures only. Phillipa
Posted by ed_uk2010 on January 9, 2015, at 9:40:12
In reply to Re: How strong is Clonazepam really? » ed_uk2010, posted by phidippus on January 8, 2015, at 15:10:48
>We're on the same team.
Of course :)
>My contention was simply that some people don't habituate to benzodiazepines.
I agree, it's just unfortunate that the risk appears to be high. The aren't many other meds (apart from other sedative drugs eg. barbiturates) which can produce life-threatening withdrawal symptoms such as grand mal seizures.
Posted by ed_uk2010 on January 9, 2015, at 9:47:29
In reply to Re: How strong is Clonazepam really? » phidippus, posted by Phillipa on January 8, 2015, at 19:51:27
>20mg for seizures only. Phillipa
In theory. It's not clear what the maximum dose should be. In the UK the maximum recommend dose for epilepsy is 8mg per day, but clonazepam is not widely used in epilepsy... It's too sedating, tolerance develops to its anti-epileptic properties over time and high doses often produce psychiatric disturbances in epilepsy, as well as rebound seizures on attempted withdrawal. There are better choices for most people with epilepsy, but benzodiazepines retain a vital place in the acute treatment of prolonged seizures, and for temporary 'cover' while adjusting other meds.
In psychiatry, it's usual to avoid more than 4mg per day here, and more than 2mg per day is rarely prescribed beyond the acute phase of illness. Up to 1mg per day is probably optimal for most types of generalised anxiety, and 1-2mg for panic disorder +/- agoraphobia. Older people are often treated with less eg. 0.25mg once or twice a day.
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