Benzodiazepine equivalents

The main equivalence table

If a source you're reading disagrees on a specific number, it's usually within a factor of two. Ashton generally rates alprazolam as more potent (0.5 mg = 10 mg diazepam); many US resources use 1 mg. The right answer depends on the individual patient's tolerance.

Cross-taper from a short-acting benzodiazepine

The standard move is to switch to a longer-acting equivalent before tapering, then reduce that equivalent slowly. Diazepam or clonazepam are the usual anchors because their half-lives smooth out inter-dose withdrawal.

The Ashton protocol, in brief:

1. Calculate the current daily dose in diazepam equivalents.
2. Substitute diazepam (or clonazepam) at the equivalent dose, divided into 2 or 3 daily doses. Some patients need staged substitution (swap one alprazolam dose at a time over 1 to 2 weeks) rather than all at once.
3. Once stable on the long-acting agent, reduce the total daily dose by 5 to 10% every 2 to 4 weeks. Slower for high-dose or long-duration users. Some patients need micro-tapers (1 to 2% every 2 weeks) toward the end.
4. Don't skip doses to taper. Reduce a scheduled dose instead.

A patient on alprazolam 2 mg/day is roughly diazepam 40 mg/day. That's a lot. In practice you'd often substitute gradually (start with 10 mg diazepam replacing one of the alprazolam doses), and expect the process to take months, not weeks. Diazepam 40 mg/day is also a lot to start someone naive on, so the "equivalence" number is more permission than prescription: the receptors are already used to that level of GABA modulation.

For very-high-dose or protracted users, hyperbolic tapering (reducing by a proportional amount rather than a fixed dose) works better than linear reductions. Horowitz and Taylor made the case for hyperbolic approaches with SSRIs and it applies conceptually here too: the last third of the taper is where most people struggle, and equal-milligram cuts get harder as the dose falls.

Alcohol withdrawal dosing

CIWA-Ar-triggered dosing is the standard in most US hospitals. Common regimens:

• Chlordiazepoxide 25 to 100 mg PO per dose based on CIWA score, reassess q1 to 2 hours until CIWA under 8 for 3 consecutive reads.
• Lorazepam 1 to 2 mg PO/IV/IM per dose, same reassessment cadence. Preferred in hepatic dysfunction (no oxidative metabolism).
• Diazepam 5 to 10 mg PO/IV per dose. Loads well because of active metabolites and long half-life.

Symptom-triggered dosing (CIWA-driven) uses less total benzodiazepine and shortens length of stay compared with fixed-dose in most trials. Fixed-dose (front-loading) is still appropriate for patients who can't be reliably CIWA-scored, seizure history, delirium, or when nursing resources don't support q1h reassessment.

For patients with cirrhosis or advanced hepatic dysfunction: prefer lorazepam, oxazepam, or temazepam. All three are metabolized by glucuronidation, which is largely preserved in liver disease. Long-acting agents with active oxidative metabolites (chlordiazepoxide, diazepam) can accumulate to toxic levels.

For elderly patients: use lower doses, prefer lorazepam over chlordiazepoxide, watch for paradoxical delirium.

Adjuncts worth considering: gabapentin for milder outpatient withdrawal, phenobarbital for severe benzodiazepine-resistant withdrawal (increasingly used in ICUs), thiamine 500 mg IV daily for 3 days before glucose in anyone at Wernicke risk.

Notes on the "equivalent" concept itself

The equivalent dose is calibrated for anxiolysis, not sedation, not muscle relaxation, not anticonvulsant effect. A benzodiazepine's clinical profile at "equivalent" doses depends on receptor subtype affinity (alpha-1 vs alpha-2), lipophilicity (affects distribution and onset), and half-life (affects perceived potency between doses).

Alprazolam 0.5 mg and clonazepam 0.5 mg are not clinically the same experience even though the tables call them equivalent. Alprazolam has faster onset, shorter effect, and more inter-dose withdrawal. Clonazepam is smoother throughout the day. That's why patients dependent on alprazolam often describe clonazepam as "less effective," even though the receptor coverage is arguably better.

Common questions

How do I convert an alprazolam-dependent patient onto a taper? Convert to diazepam or clonazepam gradually. If the patient is on alprazolam 2 mg TID (6 mg/day = about 120 mg diazepam eq, which is above what you'd realistically restart), start by swapping one alprazolam dose for the diazepam or clonazepam equivalent, hold for a week, then swap the next. Once fully converted and stable, begin the 5 to 10% every 2 to 4 weeks reduction. Expect 6 to 18 months for a high-dose alprazolam taper. Don't rush. Rushing produces protracted withdrawal that lasts far longer than the taper would have.

Which benzo do I pick for a cirrhotic patient in alcohol withdrawal? Lorazepam. It's glucuronidated, has no active metabolites, and is predictable in hepatic impairment. Oxazepam and temazepam are also glucuronidated but oral-only and slower onset, so they're less useful in acute withdrawal. Avoid chlordiazepoxide and diazepam in significant cirrhosis; the desmethyldiazepam metabolite accumulates and causes prolonged sedation and delirium.

Are the equivalents really the same for anxiety and sleep? No. The equivalents are calibrated for anxiolytic effect. For sleep, faster-onset short-acting agents (triazolam, temazepam) feel more potent milligram-for-milligram than their equivalence would suggest, because getting to sleep is what the patient notices. For persistent anxiety, longer-acting agents (clonazepam, diazepam) feel more effective because they don't wear off between doses. This is why simple equivalence conversions between "sleep benzo" and "anxiety benzo" often disappoint the patient.

Why is clonazepam preferred for cross-tapers? Half-life (18 to 50 hours), no active metabolites (simpler kinetics than diazepam's desmethyldiazepam), and clean dose-response for anxiolysis. Diazepam is also fine and some clinicians prefer it because of the smaller tablet strengths available (2 mg, 5 mg, 10 mg) which allow finer titration. If you're doing a very slow micro-taper toward the end, liquid diazepam is often the practical solution.

How long is "long-acting" really? For the purposes of a cross-taper, "long-acting" means the drug plus active metabolites give a functional half-life over 24 hours, so that missing a dose doesn't produce breakthrough withdrawal. That's diazepam, clonazepam, chlordiazepoxide, clorazepate, flurazepam, clobazam. Alprazolam, lorazepam, oxazepam, and temazepam don't count as long-acting in this sense, even though alprazolam XR is often marketed that way. Alprazolam XR reduces peak-trough variability slightly but doesn't fix the inter-dose withdrawal problem.

Sources

• Ashton CH. The Ashton Manual: Benzodiazepines: How They Work and How to Withdraw. 2002, revised 2011.
• Package inserts for alprazolam, clonazepam, lorazepam, diazepam, chlordiazepoxide, oxazepam, temazepam, clobazam.
• American Society of Addiction Medicine (ASAM). Clinical Practice Guideline on Alcohol Withdrawal Management. 2020.
• Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). Br J Addict. 1989;84(11):1353-1357.
• Amato L, Minozzi S, Vecchi S, Davoli M. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev. 2010.
• Horowitz MA, Taylor D. Tapering of SSRI treatment to mitigate withdrawal symptoms. Lancet Psychiatry. 2019;6(6):538-546. (Concept extended to benzodiazepines by many authors.)
• Maudsley Prescribing Guidelines in Psychiatry, 14th edition.
• NICE NG215: Medicines associated with dependence or withdrawal symptoms.

Reviewed against current guidelines as of June 8, 2026. This is not medical advice.