In short: The Ashton Manual, formally titled Benzodiazepines: How They Work and How to Withdraw, is a free guide written by the late Professor C. Heather Ashton from her years running a benzodiazepine withdrawal clinic in Newcastle. It explains how benzodiazepines work, describes acute and protracted withdrawal symptoms, and teaches a slow crossover taper to diazepam (Valium), with example schedules that she called guides and a pace that the person tapering controls. Today it is a foundation that newer methods build on, such as the hyperbolic tapering described in the Maudsley Deprescribing Guidelines, and it is one careful method among several, not the only one.
What is the Ashton Manual, and why do people still talk about it?
If you have spent any time reading about how to come off of a benzodiazepine, such as Xanax, Klonopin, Ativan, or Valium, you have seen the Ashton Manual mentioned. What is it? Who wrote it? And, does a guide written more than two decades ago still have anything to teach us?
The Ashton Manual is the common name for a guide written by the late Professor C. Heather Ashton of Newcastle University in England. Its formal title is Benzodiazepines: How They Work and How to Withdraw. It is free to read online, and it has been passed from patient to patient, and from patient to doctor, for many years.
I bring up the manual often on this show, and I favor it. So, what does it say, and how is it used today?
Who was Professor Ashton?
Professor Ashton was a physician and a professor of psychopharmacology. For many years, she ran a benzodiazepine withdrawal clinic in Newcastle. Her patients had been prescribed tranquilizers and sleeping pills by their doctors, and they could not stop taking them.
She listened to her patients, and the manual grew out of those years in the clinic.
At the time, many doctors considered benzodiazepines safe for long-term use, and they expected withdrawal to be brief. A patient who said otherwise was told that their anxiety was coming back. Unfortunately, that answer has not gone out of style.
What does the manual say?
The manual has three parts: how benzodiazepines work, how to withdraw slowly after long-term use, and what symptoms to expect along the way.
Benzodiazepines boost the effect of gamma-aminobutyric acid, or GABA, the main calming chemical messenger in the brain. When a person takes the drug every day, the brain adapts by turning down its own GABA receptors. If the drug is then taken away too quickly, the nervous system is left with too little calming signal and too much excitation.
That is why the symptom list is so long. Insomnia, panic, muscle pain, burning skin, ringing in the ears, and sensitivity to light and sound are all on her pages. She also described protracted withdrawal, meaning symptoms that last for months or longer.
Today, many of us use the term benzodiazepine-induced neurological dysfunction, or BIND. The name is newer. The description was already there.
Physical dependence is not addiction, and the manual was written for people on prescribed doses.
Professor Ashton’s patients were, for the most part, taking their medication exactly as prescribed. They followed instructions, and their bodies adapted to the drug.
Physical dependence is not addiction. Dependence is a physical adaptation of the nervous system, and it can happen to nearly anyone who takes a benzodiazepine daily for long enough. In my experience, most people who want help coming off of a benzo have no addiction at all. What they need is a gradual, medically supervised taper.
People who do have an addiction deserve respect and proper medical treatment as well. These are two different conditions, and the treatment has to match the condition. Unfortunately, the detox and rehab industry often gets this wrong, with a fast taper timed to the length of an insurance-covered stay. A nervous system that adapted over years does not readjust in two weeks.
Why does the manual recommend switching to diazepam?
The best-known idea in the manual is the crossover taper. This means gradually switching from the benzodiazepine you take now to an equivalent dose of diazepam, also known as Valium, and then tapering the diazepam.
Why diazepam? It is long-acting, so the level in the body stays steady from one dose to the next. While a short-acting benzo, such as Xanax or Ativan, can wear off between doses, diazepam smooths out the peaks and valleys. It also comes in low strengths, which makes small reductions possible.
An analogy that might help is pocket change. With a dollar in quarters, you can only give it away 25 cents at a time. With a pocket full of dimes and pennies, you can let go of a very small amount, and then another.
While this is not a perfect analogy, diazepam is the pocket full of small coins. The smaller the step down, the easier it is for the nervous system to follow.
I believe the crossover is an excellent method, but it is not for everyone. Some people process diazepam unusually slowly or quickly, and some have a bad reaction to it. Patients have also told me that, in the first days of the switch, it felt as if the new medication was not working at all. That is why the switch is made in stages, with your doctor watching.
The schedules in the manual are examples, not prescriptions.
The part of the manual that most people remember is the taper schedules. The manual itself suggests writing out a schedule and giving your doctor a copy, and I agree with that. Yet, the numbers in the tables are not the point.
Professor Ashton was clear that her schedules were guides. She wrote that the person who is tapering should be in control of the pace, and that a taper may take many months, a year, or longer. That is why I will not give you milligram numbers here. A schedule that suits one person may be too fast for another, so work out the plan with your prescriber.
When symptoms flare after a reduction, that is information, not failure. If the pace is too fast, the doctor must help by slowing the taper or holding the dose. If things are going well, patient and doctor may agree to go a bit faster, as tolerated.
One thing in the manual is not flexible. Never stop a benzodiazepine abruptly. Quitting cold turkey after long-term use can cause seizures, and it is not worth the risk.
Call 911 or go to an emergency department if any of these happen during a taper or after a missed dose:
- A seizure.
- Confusion or hallucinations.
- Thoughts of harming yourself.
If you are in a mental health crisis, you can also call or text the 988 Suicide and Crisis Lifeline at any hour.
Why did the manual matter so much when it was written?
It mattered because there was almost nothing else. Imagine being told by one doctor after another that your symptoms are impossible. Then, you find a guide, written by a professor, that lists every one of them and explains why they happen.
For many people injured by prescribed benzodiazepines, it was the first proof that they were not losing their minds. Many doctors first learned about protracted withdrawal because a patient handed them the pages. While that is not how medical education is supposed to work, it worked.
Why do so many physicians miss it? That blind spot was part of my conversation with Nicole Lamberson about benzo tapers and dependence.
It was not until 2020 that the US Food and Drug Administration, or FDA, updated the labeling on all benzodiazepines, boxed warning included, to recognize physical dependence, protracted withdrawal, and the need for a gradual taper. Professor Ashton had been saying the same thing for about twenty years.
I also spoke with Christy Huff, M.D., about the Benzodiazepine Information Coalition, which works to educate doctors about these harms. I serve on its medical advisory board, so I am not a neutral party.
How is the manual used today?
Fortunately, the manual is no longer the only guide. It is now a foundation that newer methods build on. The best example is hyperbolic tapering, which is described in the Maudsley Deprescribing Guidelines. In a hyperbolic taper, the reductions get smaller as the dose gets lower.
This is because the relationship between dose and effect at the receptor is not a straight line. The last few milligrams do far more work than the first few. So, a reduction that was easy at a high dose may be too much at a low dose.
Professor Ashton’s example schedules already tend to slow down near the end. The Maudsley guidelines explain why, and they apply the same principle to antidepressants, gabapentinoids, and the sleeping pills known as z-drugs, which are also tapered gradually.
While I favor the manual and the crossover to diazepam, I am open to any careful method, including liquid micro-tapers, meaning tiny and frequent reductions, as long as it is gradual, medically supervised, and patient directed. There is no one-size-fits-all taper. I cannot tell you that one method has been proven better than another, and I cannot predict who will have an easy taper.
Is the Ashton Manual out of date?
Parts of it do show their age. Some of the drug names are British, and the term BIND did not exist yet. Yet, the core of it holds.
Dependence is physical. Withdrawal is real, and it can last. The taper must be slow, and the person coming off of the drug sets the pace. A guide does not become wrong because it became old.
If you are thinking about coming off of a benzodiazepine, it is not a bad idea to read the manual and bring it to your doctor. With time, and with a taper that is slow enough, the nervous system does heal. You set the pace.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
