Benzodiazepine Equivalence
Diazepam-equivalent dose across alprazolam, lorazepam, clonazepam, midazolam, and others, with Ashton-style taper estimate.
- Planning an outpatient taper for a patient on chronic benzodiazepines
- Converting a home alprazolam dose to an inpatient lorazepam order
- Estimating a starting chlordiazepoxide / lorazepam regimen for alcohol withdrawal
- Sanity-checking a "0.25 mg as needed" patient's actual cumulative exposure
- Equivalency is approximate. The benzodiazepine literature is older, less consistent than opioid MME tables, and individual response varies — particularly in chronic high-dose users.
- Switch to diazepam (or another long-acting agent) before tapering. Trying to taper directly off alprazolam is brutal because the short half-life means inter-dose withdrawal between every dose. The Ashton method specifies switching to diazepam first, then reducing.
- Slow taper. 10% of current dose every 1–2 weeks is a typical pace; below 5 mg diazepam-eq, slow further. Forced rapid tapers (especially in inpatient settings) cause rebound anxiety, insomnia, and seizure risk.
- Choose the right agent for the indication. Lorazepam and oxazepam have no active metabolites — preferred in liver disease and elderly. Chlordiazepoxide and diazepam are CIWA standards. Alprazolam has the worst dependence profile.
- Don't combine with opioids casually. The CDC has a black-box warning on the combination — respiratory depression risk multiplies.
Benzo tapers go badly when clinicians underestimate either the equivalent dose (under-substituting and precipitating withdrawal) or the time required (rushing the reduction). A clear conversion table plus a pace estimate makes the plan concrete instead of "let's see how it goes."
Diazepam equivalent
40mg/day
| Drug | Daily dose | Half-life |
|---|---|---|
| Diazepamlong | 40mg | 20–100 hr (with active metabolites) |
| Lorazepamintermediate | 4mg | 10–20 hr |
| Alprazolamintermediate | 2mg | 6–12 hr |
| Clonazepamlong | 2mg | 18–50 hr |
| Midazolamshort | 27mg | 1–4 hr |
| Temazepamintermediate | 80mg | 8–22 hr |
| Oxazepamintermediate | 120mg | 4–15 hr |
| Chlordiazepoxidelong | 100mg | 5–30 hr (with active metabolites) |
| Triazolamshort | 0.8mg | 1.5–5 hr |
| Flurazepamlong | 60mg | 40–250 hr (with active metabolites) |
Taper estimate (Ashton-style)
Approximate plan: reduce by 4 mg diazepam-eq every 1–2 weeks (~10% of current dose). Estimated total taper: 42 weeks. Below 5 mg diazepam-eq, slow further to 0.5–1 mg every 2 weeks.
The Ashton manual uses diazepam as the long-acting "carrier" for taper because its long half-life smooths inter-dose withdrawal symptoms.
Caveats
- Alprazolam has the highest dependence and rebound-anxiety potential — the hardest taper.
- Lorazepam and oxazepam have no active metabolites — preferred in liver disease and elderly.
- Chlordiazepoxide and diazepam are first-line for alcohol withdrawal (CIWA-driven).
- Equivalencies are approximate and individual response varies — always titrate to clinical effect.
Frequently asked
What is the equivalent of alprazolam 1 mg in diazepam?
Alprazolam 1 mg is approximately equivalent to diazepam 20 mg. The standard anchor is alprazolam 0.5 mg ≈ diazepam 10 mg ≈ lorazepam 1 mg ≈ clonazepam 0.5 mg, though individual sources vary by 20–30%.
How do I taper a patient off lorazepam?
Convert to a diazepam-equivalent total daily dose, then reduce by approximately 10% of the current dose every 1–2 weeks. Below 5 mg/day diazepam-equivalent, slow the reduction further (0.5–1 mg every 2 weeks). Tapering directly from lorazepam without converting to a long-acting agent is feasible but produces sharper inter-dose withdrawal symptoms.
Why do you taper with diazepam instead of the original benzodiazepine?
Diazepam has a very long half-life (20–100 hours, with active metabolites). This smooths the inter-dose troughs that drive withdrawal symptoms and relapse, particularly when the patient was on a short-acting agent (alprazolam, lorazepam) where each dose's wearing-off triggers a craving cycle.
Is alprazolam stronger than lorazepam?
Per mg, yes — alprazolam 0.5 mg ≈ lorazepam 1 mg. Alprazolam is also harder to taper than lorazepam because of its shorter half-life and steeper inter-dose decline, which makes its dependence profile arguably the worst among commonly prescribed benzodiazepines.
Which benzodiazepine is safest in liver disease?
Lorazepam and oxazepam undergo glucuronide conjugation rather than oxidative metabolism, so they have no active metabolites and don't accumulate in cirrhosis or in elderly patients. Diazepam, chlordiazepoxide, and midazolam should be avoided or used with caution in advanced liver disease.
How fast can I taper benzodiazepines safely?
The Ashton manual and most modern references recommend ~10% of current dose every 1–2 weeks, with a slower pace below 5 mg diazepam-equivalent. Tapers of 6 months to 18 months are common for long-term users. Rapid inpatient tapers risk rebound anxiety, insomnia, and (with very abrupt cessation at high doses) seizures.