What is the equivalent dose of diazepam (Valium) for 6 shots of vodka?

Alcohol to Benzodiazepine Conversion for Acute Withdrawal Management

For acute alcohol withdrawal prophylaxis or treatment, 6 shots of vodka (approximately 90 grams of ethanol) requires diazepam 30-40 mg daily, tapered over 4 days, starting with divided doses of 10 mg three to four times daily.

Conversion Rationale and Evidence Base

The conversion from alcohol to benzodiazepines for withdrawal management is based on cross-tolerance between these GABAergic substances. Six standard shots of vodka (1.5 oz each at 40% alcohol) contains approximately 90 grams of pure ethanol, which represents significant daily consumption requiring pharmacological intervention to prevent withdrawal complications. 1

Standard Alcohol Withdrawal Dosing Protocol

• Initial diazepam dosing for alcohol withdrawal starts at 30-40 mg daily, tapered to 10 mg by day 4, with no medication on day 5 1
• The typical regimen divides this into 10 mg doses given three to four times daily initially, then tapered 1
• Lorazepam 6-8 mg daily (tapered to 2 mg by day 4) is equipotent to diazepam 30-40 mg daily for alcohol withdrawal management 1

Clinical Superiority of Benzodiazepines Over IV Ethanol

Diazepam demonstrates superior efficacy and safety compared to intravenous ethanol for alcohol withdrawal prophylaxis, contrary to persistent clinical myths. 2

• Intravenous ethanol offers no advantage over diazepam regarding efficacy or sedative effects 2
• Patients receiving IV ethanol had significantly greater deviation from target sedation levels (p = 0.020) compared to scheduled diazepam 2
• The purported benefit of avoiding excessive sedation with ethanol was not evident in controlled trials 2

Critical Safety Considerations

Respiratory Depression Risk

The combination of alcohol and benzodiazepines creates synergistic respiratory depression that is the primary cause of fatal poisonings, not the absolute dose of either substance alone. 3

• Severity of benzodiazepine poisoning is determined largely by co-ingestion of other central depressants (including ethanol) rather than benzodiazepine dose or plasma concentration 3
• Patients with diazepam alone tolerated plasma levels as high as 4,792 ng/ml with minimal sedation, but concurrent ethanol caused serious intoxication regardless of diazepam concentration 3
• Median fatal ethanol concentration drops from 3.3 g/L (ethanol alone) to 2.5 g/L when benzodiazepines are present 4

Administration Guidelines to Minimize Risk

If administering diazepam to a patient with recent alcohol consumption, use extreme caution with dosing and monitoring:

• Start with 5 mg diazepam (not 10 mg) and titrate slowly over 1-2 minutes IV 5
• Monitor oxygen saturation continuously and have respiratory support equipment immediately available 5
• Be prepared to administer flumazenil for life-threatening respiratory depression, though note it may precipitate seizures 5
• Reduce doses by 20% or more in elderly, frail, or hepatically impaired patients 5

Alternative Benzodiazepine Options

For patients requiring parenteral administration with concurrent alcohol exposure:

• Lorazepam 1 mg IV/SC (maximum 2 mg) is preferred when combined with other sedatives or in elderly/frail patients 6
• Use lower doses (0.25-0.5 mg) when co-administered with alcohol or in patients with COPD 6
• Midazolam 2.5 mg IV/SC may be used for severe agitation, with doses reduced to 0.5-1 mg when combined with alcohol 6

Common Pitfalls to Avoid

• Never administer full withdrawal doses of benzodiazepines to patients with active alcohol intoxication—wait for blood alcohol to decline below 100 mg/dL before initiating standard withdrawal protocols
• Do not use fixed-dose regimens without clinical assessment—symptom-triggered therapy using CIWA-Ar scores is more effective and uses less total benzodiazepine
• Avoid rapid IV bolus administration—always give diazepam slowly over 1-2 minutes to prevent respiratory depression 5
• Do not assume benzodiazepines are "safe" with alcohol—the combination is responsible for the majority of fatal poisonings involving these substances 4, 3