Saturday, February 16, 2008

My Three Shrinks Podcast 42: The Benzo Wars (or, Xanax Reloaded)

[41] . . . [42] . . . [43] . . . [All]

Dinah, Clink and I get into a podcast brawl about the use of benzodiazepines (such as Xanax/alprazolam, Ativan/lorazepam, and Valium/diazepam) in the practice of psychiatry. See how many rounds we go, and who is left standing at the end.



February 16, 2008: #42 The Benzo Wars

Topics include:
  • Round 1: Why Docs Don't Like Xanax (or, Xanax Reloaded). This is what started it. Then there was Xanax Blues in Podcast 19. Also, this one from Oct 10.

  • Round 2: Dose Dependence. Our blog commenters dissent.

  • Round 3: Just Say No! Clink offers sage advise to fellow prescribers.

  • Round 4: The Trouble with Tapering. How slow can you go? See Perchance to Dream.

  • Round 5: Need It Versus Want It. Is there a difference?

  • Final Round: Last Shrink Standing. What are the situations where you feel very uncomfortable prescribing benzodiazepines? Roy wraps things up by quoting from his Jan 12 comments from Dose Dependent.
[Ed: I forgot that I had transcribed a few comments from the podcast when I was on a plane recently. I've added them below, including the time in the podcast where they occur]

15:06 Dinah: "So, shut up a minute!"

17:20 Roy: "Benzo's modulate GABA receptors... You've got glutamate, which is an excitatory amino acid, and you've got GABA, which is an inhibitory amino acid. So, they kinda balance each other. If you have too much glutamate, that's bad, you can have ... seizures... If you have too much GABA, that's bad because then your brain is s-o s-l-o-w-e-d d-o-w-n that you can't do anything."
17:45 Dinah: "What's his point?"
18:00 Roy: "So, benzo's effectively increase the role that GABA plays in the brain. So does alcohol. In fact, for the most part, your brain can't tell the difference between alcohol and a benzo."

20:20 Roy: "You can be dependent but not addicted."

21:00 Clink: "Why is it that this [coming off Xanax] is so bothersome to you?"
21:22 Clink: "When you start hearing that 'this is the only thing that works', then the red flags should go up."
22:20 Clink: "I see the addictions that are started by physicians, and we need to address this as a reality."
24:00 Dinah: "We have this dilemma... is this a medicine that this person needs versus is this somebody who's addicted?"

24:20 Dinah: "There are circumstances where I encourage people to take benzos, and I'll tell you what they are..."
24:27 Roy: "Like now!"

Feel free to add your favorite quotes in the comments.

The background music is from the mash-up I made for podcast #24, Dr. Phil on Skype.






Find show notes with links at: http://mythreeshrinks.com/. The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom).

This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com.
Thank you for listening.

20 comments:

Dinah said...

I thought I'd save the results of our How Many Downloads poll here:
None

35 (34%)

1 or 2

13 (12%)

A few

16 (15%)

A bunch

13 (12%)

Most or all of them!

25 (24%)

Anonymous said...

If i want to listen to people natter at each other i will spend some more time with my kids. too shrill

Ladyk73 said...

The podcast made me want to take my klonopin!

I have a half a bottle of darvocet and bottle of klonopin sitting in front of me.

These artificats (and the bottles of wine in my fridge) makes me think I am not an addict.

When my mental health tanks, I get a deadly mix of anxious dread. I took 1.5 mg of klonopin the day I ended up in the psy ward.

It can really be upsetting to be treated like an addict when you are not.

Ladyk73 said...

Oh wait.....

The untouched bottles of wine, klonopin and darvocet

NeoNurseChic said...

Oy haven't listened to it yet but sounds....exciting....

I've got leftover bottles of klonopin (tons of it, actually), ativan, and serax in my closet from when I was on those. Never got dependent, even though I took the klonopin every night for a year. If I have a bad night once in awhile, I'll take the serax but that probably happens maybe twice a year, so I hardly ever take benzos now. Too tired all the time from everything else. I was originally on klonopin for RLS because nothing else worked, and I was constantly up all night/not having restful sleep due to the PLMs.

Like I said, I haven't listened to it yet, but I believe there's a time and a place. I also believe that dependence and addiction are two totally different things, oft confused/interchanged, even by physicians. And I agree with Ladyk73 that it can be very upsetting to be treated like an addict when you are not one.

But then, I've ranted before about being angry with my grandma's doc for just throwing benzos at her. So I've always had mixed feelings about them.

Will listen to the podcast soon - once I get out of the hell that is 3 12's and 1 8 all in a row. My RA is on the fritz right now and I'm so exhausted that I could cry. (Today was the 3rd 12 - tomorrow is the 8 and then psychiatry appt afterwards - my first since the lovely little upsetting incident with the psychiatrist last time. Doubt if I'll mention it, but maybe...)

Take care,
Carrie

Anonymous said...

The brain can't tell the difference between a benzo and alcohol? Okay...SOMETHING in the body can tell the difference! I am super sensitive to just about all meds (have never had to raise my dose of seroquel, 25 mgs knocks me out within 45 minutes after taking it every night for over two years!!) and I am a total ligh-weight with alcohol. However, a very good friend of mine can take 2 mgs of ativan and function very well. No one would have any idea she had taken anything except the panic is no longer apparent. Give the same friend one glass of wine and she is obviously intoxicated... two glasses and shes falling down drunk.

Anonymous said...

Doctors?

The reason why people on Xanax are hesitant to go off of it is because we know that once it is taken away, we are never getting it back and for some of us who have had anxiety for years who have tried other options, Xanax is a savior we are indeed unwilling to part with. You guys are approaching it from a textbok perspective whereas patients have real ramifications when coming off of them and reentering the world of anxiety Hell.

It is that simple.

And what is with the assumption that patients might be getting it elsewhere? What if they aren't and you are taking them off or tapering them down based on that false assumption?

Anonymous said...

David said he likes the "selected comments" on the post.

Susan said...

Not all doctors assume you are getting duplicate meds elsewhere, especially if you are keeping all of your docs up-to-date on what your current cocktail of meds is. However, the number of patients who do that is in the minority.

The relationship between a doctor and a patient should be based on trust and respect. The doctor obviously needs to trust the patient with the anxiety does not wish to experience it again, but also, the patient with the anxiety needs to trust that the doctor's decision to adjust their meds may end up being better over all in the end and that if they aren't, that a solution that will return them to a livable state with their anxiety will be returned.

The key to trust and respect with your doc and patient is communication! Don't leave the office without it. You have every right as a patient to ask questions.

We (as humans) always fear leaving our comfort zones. I've done it and I've had successes and failures and have learned from both of them.

Anonymous said...

Wow...
I'll start by saying I've listened to every podcast, I think I picked up on y'all around the mid-20's and have been subscribed ever since.

Clink's attitude, and I know it's colored by the population she works with, really offended me.
It's just as wrong to presume that every patient is an addict as it is to presume that every patient isn't.

I'm not impartial here. I have a long running prescription for xanax. I take low doses, intermittently... really much less and much less often than my doctor and my husband think I should... But to be completely without it leaves me helpless in the face of a horrible spell of panic attacks - when I say that nothing else works, I mean it... this is something I've been dealing with for over 20 years. I really have tried EVERYTHING.
Ativan and Klonopin, the two most frequently offered instead of Xanax, really aren't effective for me. I have terrible rebound anxiety from Klonopin (not supposed to happen like that, I know... I'm a little unusual maybe). Ativan just doesn't do a thing... not sure why, I can take elephant doses of ativan without any relief at all.

It just seems so horribly narrow minded to automatically refuse to refill a prescription for a drug because you know that there are some people out there that misuse it.
I'm wondering if any of you would feel uncomfortable refilling Wellbutrin... the market for it isn't huge, but because of the kind of "zippy" side effects , there's a street value to that drug too (not so much for sr or xl though).
-listener in Portland

Anonymous said...

David is a prole

Anonymous said...

First, I'm glad that you three felt free to argue during your podcast and then publish it unedited. Benzos bring out passion in people, we should not pretend that they don't.

Second, here is my take on the issue: all of the really powerful inventions and innovations can be used for extreme good and also for extreme destructiveness.

I am a psychiatrist who tries to take the middle ground despite the fact that this approach has burned me more than once. I have had patients overdose on their benzos both intentionally and un-intentionally. I have other patients who had a very hard time getting off a benzo that I or one of their previous psychiatrists started. I have also seen patients use benzos very responsibly and in a growth promoting way. I can say that making a rule to never use a medication that can be troublesome is the easier way to go, but for me rule making is not the most honest or useful approach.

The most honest approach is to listen to the patient as best I can and then make a decision based on my best read of the situation (i.e., how would this particular patient fare with this particular medication.)

Regardless of what decision I make at that moment (a decision made with the patient's best interests at heart), I tell the patient that this is a powerful med and we will have to learn together whether the decision is the right one or not. The mutual understanding has to be that if we discover that the decision was wrong, we will act to correct the mistake.

In practice, I do have some guidelines that I use (these are not rules, because I don't apply them rigidly.) I almost never give a benzo to someone who tells me they have a history of alcohol problems. I generally won't start a benzo on someone who has severe borderline personality. I try very hard not to give a benzo to someone who is already on a stimulant for ADHD. I don't give any more than one benzo at a time. I try to confer with the patient's therapist about whether they think a benzo would be helpful or harmful to the therapy/patient.

I tell the patient during informed consent discussion that getting on a benzo is like taking out a loan, at some point they have to pay the whole loan back (i.e. get off the benzo.) But, you don't know for sure up front if you are getting the steep interest rate that will make paying back the loan very painful. (By the way, if I can tell early on that this person will not be able to "pay back the loan" without much pain and difficulty, I will generally not make the loan (first do no harm.))

It is also very complicated, but so is the rest of psychiatric practice.

Anonymous said...

Let me be blunt: docs who don't want to prescribe benzos should be lined up against a wall & shot. They have no clue as to the agony their patients go through. Sure, they've seen nervous people, but it's quite different to live it 24/7 as opposed to merely seeing it.

Dependency/addiction has no meaning when your life is a living hell and a dozen other drugs have all failed you. Deny patients benzos and don't be shocked if they find their cure in the liquor store. Or the gun shop for those who like to get the job done faster. The DEA & medical profession have blood on their hands and all the scrubbing in the world can't remove it. They produce alcoholics & suicide with the attempt to "help".

Under-prescribing benzos today isn't going to make up for the sins of 30 years ago when docs were handing out Valium like candy.

It's insane that fully competent adults have to beg for benzos. I'm not some stupid child. I know the risks of benzos and I don't care for some doc lecturing me about the evils of Xanax when I have far more personal experience with it than they do.

It shouldn't shock you that many self-medicate with booze. Liquor stores don't question your drinking habits and treat you as a junkie. The irony is that docs try to "save" patients from the evils of benzos which only turns them to booze which is vastly more addictive and dangerous.

Anonymous said...

A comment above from Feb 23 says:

"I have had patients overdose on their benzos both intentionally and un-intentionally."

How exactly is that possible? An accidental benzo OD? The fatal dose of Valium is something like 8 grams, or 800 of the largest Valium tablets. Know a lot of folks who have that much laying around? I can imagine a person forgetting they already took a pill and taking a second by accident, but hard to imagine them doing so several hundred times.

As for intentional ODs, it's not a very effective suicide method at all given the huge dose needed and the fact one is likely to vomit in cases of drug ODs. Sure, benzos can reduce the amount of alcohol needed to produce a fatal OD, but they'd still need a sky high BAC and if they're going to drink that much they risk death by alcohol poisoning alone even if they didn't have a benzo.

If somebody wants to die they're not coming to you to beg for a benzo that's unlikely to result in death. If they really want to check out they're loading a 12-gauge shotgun with 3" shells of 00buckshot.

judge said...

Thanks anonymous.

If docs could experience what many of us go through everyday, maybe they could understand why we need effective drugs such as benzos. SSRIs are not effective for anxiety disorders. Anyone with an anxiety disorder will tell you that they do something, maybe, but they are ineffective for treating these disorders.

Maybe all those years of private schooling have separated these doctors from the place that the rest of us call reality.

From the ages of 15-20, I drank heavily to combat my social anxiety. After getting health insurance at 20 years old, I was finally able to see a psychiatrist. She agreed to prescribe me Klonopin and an Zoloft despite my past substance abuse. I now take Klonopin only. I take it almost everyday although if I'm going to be home alone and don't need it I often go days at a time without it. Am I an addict? I think not.

So frustrating how idiotic people with an MD at the end of their name can be.

Anonymous said...

The three of you are hilarious. You make me feel almost normal. I have chronic pain; GAD, treatment resistant depression, kidney stones, high blood pressure, and I use to have panic attacks all the time. I am an accidental dependant Klonopin user (not abuser). I have been on Klonopin for over four years. I started having extreme anxiety due to job stress (military), school, wife’s miscarriage, and deaths in the family etc. My PDOC prescribed a SSRI which made me start having instant panic attacks. My Pdoc then tried some other antidepressants and started me on Klonopin while the antidepressants kicked in. Well, it turns out that I am treatment resistant and most psyche meds mess me up. The Klonopin was covering up the fact that the antidepressants were making me more anxious (Almost manic). I ended up on seven mg of Klonopin and Cymbalta before I finally was so screwed up that I had to be hospitalized. I am not assigning blame to my PDOC because I had other medical conditions that played a part. For instance, I was taking a beta blocker for my migraines and it caused me to go into a major depression. I only learned that was the cause a year later when I tried the Inderal as a preventative again. I had no prior depression problems before. Anyway, when I was in the hospital they took me off of the 7 mg of Klonopin in ten days. That was the easy part. After I got home and the Phenobarbital and Librium cleared my system I started having severe intention tremor, became unstable, agitated and the list goes on. I refrained from using any Klonopin for two months until I couldn’t take the protracted withdrawal symptoms anymore. I slowly increased the dose until I stabilized at two mg. fast forward two more years. I went back to the hospital to come off of Oxycontin that was prescribed for legitimate chronic pain. I just became tolerant and told my doctor that rather than increasing I would like to detoxify and take a med holiday to restore the anesthesia. Anyway, while I was in the hospital they detoxified me off the 2 mg of Klonopin as well and I quickly became unstable again. Yeah don't detoxify 125 mg Oxycodone and 2 mg of Klonopin in five days. This time I knew the drill so I started the Klonopin right back up because I was very agitated and unsafe. I didn't go there to be detoxed off Klonopin anyway. I didn't start the Oxycodone for another three months with the use of a little Dexamethasone and Toradol although the pain was still bad. Again, I do have a litigate reason for the pain pills and never run out etc. Cigarettes are my only abused item. I only drink about six times a year. Finally to my point, once I stabilized in about four days I decided to do research on benzodiazepines and found the best website ever. The Ashton manual! After reading that manual I went to my new PDOC (The other one moved) and told her that I wanted to change my Klonopin prescription. She said we could go up a little but then I informed her that I wanted to do a 1 year withdrawal because of what I learned and had experienced first hand. You shouldn't be in any hurry to take a long term benzodiazepine user off quickly. It's inhumane and leads to other problems. As of today I am down to a little less than 1.5 mg a day. I just cut the dose slowly and wait a few weeks or however long I need to and don’t set any schedule. My only rule is that once I make a dosage cut, I won’t go back up. I think this is the only way to go because it gives the brain time to heal while I am reducing my dosage. I know some of the Psychiatrists in the US don’t get the slow concept. When you get a new patient you should have them read the Ashton manual and agree to come off the benzodiazepine by Dr Aston’s method. If they would actually read it then they would understand that most people will be better off without the benzodiazepine. I can't wait to get my short term memory back! I'm a full time student working on half a brain.
Oh, on a side note, for weirdoes like me that can’t take antidepressants. I find Seroquel works just as fast as the benzodiazepine to restore sleep which, as you know helps with anxiety. I'm not a doctor but for someone like me (resistant). I would prescribe a benzodiazepine for overwhelming anxiety (short term) and Seroquel at a low dose to help the anxious mind get some sleep and get over the anxiety. The only problems I had with Seroquel were the munchies which ultimately led to high cholesterol that the statins couldn't keep up with. I now only use it once or twice a week and it helps me turn off my mind when nothing else will. Moderation is the key. I also like the short half life of Seroquel compared to OTC meds. I don’t feel groggy after eight hours of sleep. As for the panic attacks, after about a year my mind finally figured out that I wasn’t going to die and the minute I wasn’t scared anymore they went away. Now I get that high level of anxiety but attack. Thanks I love you podcasts and just wanted to add my 2, well, 3 million cents. Keep up the good work.

Anonymous said...

What a weak discussion.

The major reason to go off a benzo is because it interferes with reaching one's full potential. When I went off benzo (klonopin), it was very difficult with withdrawal. However, it was as if a cloud or veil were lifted from my eyes. So when you ask people how they are on the meds and they say "fine", they might not really know because they haven't experienced what it's like to be off it.

So, my anecdotal evidence says that one should try to be off medicine and drug free.

I subscribe to Dr. Ashton's manual on tapering (it's online). She advocates a very slow taper.

Heidi said...

I took Klonopin as needed very rarely until Jan. 08. My father was diagnosed with a terminal illness and I upped my Klonopin to deal with the anxiety and having to travel by plane. I then developed a painful shoulder injury and was put on Valium 5mgs as needed for 3 months and other strong narcotics. A few weeks after stopping these drugs I suddenly developed extreme anxiety like I had never had before, internal tremors, agoraphobia, insomnia. Dr's did every test in the book and nothing was wrong. Finally, I got on the internet and did a lot of research and found out that Klonopin was addictive! I had never, ever been told that. I know believe what is wrong with me is tachyphylaxis. I get no relief from the Klonopin yet I am unable to stop it. Dropping the dose just a small amount leaves me with psychotic thoughts and severe convulsive body movement. What am I supposed to do now? Am I the acceptable statistic? My life is ruined and I can't find a Dr. who will help me try a Valium taper. I was a perfectly healthy 49 yo Mom with 3 grown kids, active in politics and my community. Now I can't go to the store. All because of prescribed benzodiazepines.

xanax alprazolam said...

Basically I take it as needed. I am diagnosied with Bipolar 2 and am prone to anxiety attacks. Whenever I feel a trigger come about that I know is going to cause a mood swing towards hypomanic, I can take .5 of a xanax and I can be relaxed. The only downfall is that it only works for me if I take it "as needed". When I use it to take care of smaller panic attacks over and over again, it stops working and I am left with an unmanagable panic attack.

Anonymous said...

Too bad docs hesitation to prescribe benzos or severely under-prescribe them to patients that need it has created a black market for un-patented ones like phenazepam and etizolam(both just as strong as Xanax, one short acting one very long acting). If someone has anxiety their gonna get a med that works whether flustered docs will prescribe to them or not. I'm personally lucky I have a doc that will prescribe me klonopin 2mg a day for my GAD that has helped me tremendously.

Much as the illegal status of other drugs has created a whole new market for research chemicals(synthetic cannabinoids, dopamine releasing agents etc etc.. ), so to has the reluctance of licensed medical practitioners to prescribe meds that work to patients that need them given way to thearaputic agents that flow through the same channels of commerce as recreational legal drugs to replace the illegal ones people arn't going to stop using anyways. A gram of phenazepam can be had for around 30 bucks( the typical valuable dose is 1mg and goes up from there like klonopin). That's 1000 doses about a years supply for someone who would take 1mg a day to manage mild anxiety, and about half a years worth for someone like me who would probably take 1mg morning and night to manage my symptoms.

So don't worry about your fancy degrees, you're damn right if you don't want to help out and treat everyone who asks for a medicine that works or a renewed script out and treat us all like addicts someone else will. And flat out refusing to consider prescribing anxiolics in any case like is one of the professionals preferences? I don't even... wow just speechless at that statement lol

before benzos there was miltown which is briefly mentioned in the podcast. Back in the days when anxiety wasn't even fully regarded as a real mental disorder. maybe that's the mentality of some of these professonals were all just making up our symptoms to score our modern miltowns, we're all addicts anxiety is just made up or over eggagerated among those of us wanting to numb ourselves from reality.

Sickening sickening podcast I won't be prescribing to hear any of their non-sense again that's for sure lol