Wednesday, February 27, 2008

When A Shrink Picks A Benzodiazepine

I'm still talking about our not-so-favorite shrink medications, those calming, addictive benzodiazepines: valium, librium, ativan, klonopin, and everyone's favorite: Xanax.

If you listened to our podcast The Benzo Wars, you know this is a heated topic among the three Shrink Rappers, and then ClinkShrink had to go post again in Sober Thoughts. Okay, it finally happened, I finally agreed with something Clink said about benzos. She writes:

Doctors aren't soothsayers or mind readers, and taking a good history or talking to relatives won't always turn up the problem prior to writing a prescription. We want to care for people and relieve distress and a prescription is one way to do that. Unfortunately, it is also possible to create a new addiction in a person who never had one before and we have no way of knowing ahead of time which patient this will happen to.
ClinkShrink is right here: some patients take a medicine and it gathers a life of it's own, an addiction forms. And there's not a way of knowing if that post-operative Percocet will start an addiction or make the patient vomit or simply relieve the pain. Clink has made the point that it's never worth the risk in the case of benzodiazepines: take them and your life could dissolve and you could end up being her inmate.

While she's right about the unknown risk, I'll make the point that life is full of uncertainties. With her thinking, one should never try a drink-- it could (oh, and it often does) lead to alcoholism. I don't know when I prescribe any medication who will get diabetes from it, who will have a bad side effect, whose kidneys and thyroid will be compromised, who will become suicidal from that SSRI, or who will have a horrible time with withdrawal symptoms when they decide to stop it. I don't know who will become addicted, I do my best to take a guess.

I do prescribe benzodiazepines for short-term use for acute anxiety. I don't see a problem with giving someone a tablet of Ativan for an MRI or a few to deal with post-9/11 flying anxiety. And if someone is having panic attacks, they are a good temporary measure until a prophylactic agent kicks in. I've seen plenty of patients on benzodiazepines (yes, even Xanax) where I tell them to stop the medicine, and they do so without arguing, bargaining, complaining, or insisting it's the only thing that helps. I only prescribe them in my private practice where I follow the patients very closely and know them well. In the clinics where I've worked, very few doctors have used these medications, and it is very rare that I'll start them in that setting.

So what helps me feel a little more comfortable prescribing a benzodiazepine?

1) If a patient has been on them in the past and stopped them without difficulty. I don't hesitate to check with old docs and pharmacies.
2) If the patient has never had a problem with alcohol-- benzodiazepines bind to the same receptors and there is cross-tolerance.
3) If there is no personal history of substance abuse or addiction
4) If there is no family history of substance abuse or addiction
5) If the patient understands that it's a short-term solution, not a permanent thing.
6) And yes, I've had patients come to me already on these medications where I just can't get them to taper off and I can't really pinpoint how exactly the medication is hurting them. I will continue such a patient on a low dose. It's been just a handful of people over the years, most people don't seem to need or want chronic benzodiazepines.

Funny, but ClinkShink writes:
I say: "Respect your gut." If you think it may be a problem for you, it could be. If your loved ones or doctor is encouraging you to take more and you're not comfortable with that, say so. Repeatedly if necessary.
My experience-- and I have no data to support this, it's just my "gut"-- is that when I tell patients that the medication can be addictive, the people who express concern are the ones I worry least about-- you're supposed to worry about getting addicted, you're supposed to watch out for a craving for the drug. It's the people who immediately say, "Oh, I won't get addicted," that I worry about the most.

Life is full of risks-- I'll give you a list if you'd like, but they'll include the heart attack you can have when you get on the treadmill and the concussion you can get when you fly off your bicycle.

At this point, I feel a little anxious when I write a new prescription for almost any medication.