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.

16 comments:

Therapy Patient said...

Physical effects are not the only side-effects of psych drugs.

I think there ought to be a lot MORE hesitancy in prescribing ALL psych drugs. Big Pharma is benefiting from the trend away from talking therapy and towards drug therapy but I doubt the patients have benefitted across the board.

I felt like a robot devoid of feelings when I was on Abilify. In addition it diminished my short term memory. This deadening robbed me of my creativity & my quality of life while simultaneously making me "stupid" when I had started out very bright. I was relieved and grateful that my psychiatrist disagreed with the previous diagnosis and took me off all psych drugs and eventually my brain recovered seemingly back to normal. I pity the poor souls leaded deadened, uncreative, memory-poor existences as a result of drug therapy. I realize that some people's life quality is enhanced, but I'd bet a lot feel as I did.

Anonymous said...

Perfect timing.
My psychiatrist wrote me a repeat prescription for Temazepam today. Just to help me sleep - I asked for it because I'd used them before and felt they helped a lot. I'm currently dealing (or trying to) with a very recent loss.
The thing that slightly worries me is that I feel very anxious about trying to sleep without taking them. I don't want to even try not taking them. I've only been on 20mg per night for about a week now. I know I'm not addicted, but is my anxiety about having to stop taking them eventually a bit of a worry?
I've had substance abuse issues in the past but am completely recovered from those so not sure if that's relevant or is a risk factor.

Alison Cummins said...

Therapy patient: there are risks in talk therapy too, and in my experience talk therapy is recommended glibly and freely and far too easily.

Talk therapy is not free of side effects, and it's very easy to get the wrong therapist for your needs. The wrong therapist can interfere with your accessing more appropriate care in different ways - by actively discouraging you from seeking other care; by keeping you as a client when you aren't getting better; by creating such an unpleasant experience that you never want to see a therapist again. Because talk therapy is suggested so easily, as if it didn't have side effects, you can question your own judgement when seeing a therapist makes you feel worse. You might think that there is something wrong with you that you feel worse, not that there is something wrong with the therapist. (And of course there is something wrong with you or you wouldn't be seeing a therapist in the first place. Feeling dissatisfied with therapy can - for some people - reinforce the idea that they should be in therapy. With that therapist.)

My own bias is for meds because it's so much easier to talk about side effects and your doctor is unlikely to take your side effects personally.

If I tell my doctor that med A gives me headaches, we work with that. She might prescribe me a different med.

If I tell my talk therapist that I cry all day before my appointment because I know how miserable seeing her makes me feel, she may tell me that we are doing good work because therapy is supposed to hurt. Even if I see her for a year and am worse instead of better.

Good talk therapy that is a match for you is good, and it does exist. Just like appropriate medication can be good. It's just so much harder to sort through therapists. The time investment is greater, too. If a medication gives me diarrhea for a month, I switch, right? But how long to I have to see a therapist to decide that I'm getting worse instead of better and that it's time to ask around for a new therapist?

The same as for meds, if talk therapy is powerful enough to help, it is by definition powerful enough to harm as well.

Making things more complicated is that there are published lists of side effects for meds. If a med is known to cause headaches, diarrhea or apathy and you present with headaches, diarrhea or apathy, your doctor will believe you instantly and be prepared with an alternative.

But where is the known side effect list for Dinah or Clink published? Who will prescribe an alternative if I say that I am incapacitated with fear for twenty-four hours before an appointment with Roy? Won't they just tell me to let the nice therapist help me?

I do have a doctor who once gave me permission to stop seeing my talk therapist. I was so relieved.

resonance said...

As a former researcher, I believe that prescribing (or not prescribing) benzodiazepines should be based on assessments of benefits vs. risk. As a moderator of a mental health support board, I'm very aware that some people can have awful experiences with some medication.

As a patient, I'm grateful that benzodiazepines exist, and that psychiatrists are willing to prescribe them. Klonopin prn for mood swings gives me the ability to function effectively and consistently. Other meds (particularly seroquel) have been more effective in handling ongoing anxiety and overactivation issues for me, but klonopin enables me to be functional on days when I'd otherwise be miserable/wildly overanxious/irritable/unfocused.

I'm cheered on by news articles on scientific advances toward more effectively targeting medications to individual physiologies. I hope that really pans out.

resonance said...

I also wanted to thank Alison above for her post on talk therapy. It's not free of side effects and it's not a magic cure, although (like medication) some therapies and therapists can be very helpful to some people, while being ineffective or problematic for others. Non-directive exploration of my feelings was not very helpful to me when dealing with an abusive relationship or its aftermath, or with learning to distinguish moods/feelings that give me information about a situation from moods/feelings that are representative of the fact that I need to take medication and go calm down. Insight therapy has not been very helpful to me when my problem has been lack of skill.

CBT has been much more helpful, and medication has been about ten times as helpful as therapy in terms of getting me to a stable mental state that lets me develop and carry out solutions for difficulties with school/work/relationships.

Anonymous said...

If you want the side effects list for Dinah Clink or Roy, read thru the blog, listen to a few podcasts and you will get a sense of how you react/respond to each.
What I really want to know is, where was the side effects list for my spouse? And for my kids? They were not born with those pharmacy warning labels on them: may cause extreme fatigue; notify your doctor if you notice you have gained weight and your hips aren't where you left them.
Seriously, having had experienced bad therapy in the past, and dealing with meds, side effects, dependence etc, I will say that the medication issues concern me more because it is easier to die from the meds than bad therapy although I can think of ways bad therapy could drive you over the brink.Geez, so can bad tv. I did get away from a bad therapist and it was bad in ways that went beyond "we didn't click".it was years of bad therapy that crossed into bad territory.Still, I am having far more trouble getting off the benzos, gotta say.i do think benzos are okay for those one offs but the truth but now its been years and I think to myself that I am an addict and nobody ever said you could become addicted to this. I should have known better but given the shape I was I would have, did take whatever they threw my way.

tz said...

I'm surprised that you only have a handful of patients on chronic benzos. I run a support group, and I can tell you that there are lotsa people out there on chronic benzos. They don't seem to be addicted, they keep a stable dose, it doesn't disrupt their life, but most of em would get very very upset if you suggested dropping the benzos.

What disturbs me about benzos is how much people like them. I mean, I have seen people sing the praises of lithium or Zyprexa or Cymbalta when nothing else has worked for them and those do. But no one ever refers to those meds as "happy pills" or gets that adoring look in their eyes when they talk about how "mellow and happy" these pills make them -- like they do about their benzos. I've never taken benzos, so I find this a little creepy.

Anonymous said...

The reason we would get upset, and the reason we like them are the same. They are not good drugs for getting high, esp if you have been taking them for years. We like them because we hate the feeling that comes when they wear off, and of course to have to experience that feeling would make someone upset. In no way do I feel out of it or high or loopy on the drugs and no one would imagine I was taking anything, let alone enough to kill a horse. No glazed eyes, no double doctoring, no crime spree to buy extra off the street.No mellow, happy feeling either though. They never gave me that. You can keep a steady dose and still be dependant on the drug.

Anonymous said...

Bad psychiatrists are just as common as bad therapists. I fired 3 psychiatrists last year because they were dismissive, demeaning, or just not listening.

Finding good therapists isn't impossible though. Don't be afraid to do a little homework when looking for a therapist. Here are a few things to try:
--Getting referrals (ie: from psychiatrists, primary drs, friends, family)
--Checking Psychology Today's "Find a Therapist" search engine
--Checking their background for professional misconduct
--Research their treatment approach(cognitive-behavioral, psychodynamic, existential, humanistic) and make sure it's a good fit for you

Mr Ian said...

Picing up on one particular segment of this area, and quoting from Cink's sister post on this article:
"Many doctors, as a rule, do not like patients with substance abuse problems. They fill up the emergency room, they suck down psychiatric resources, they fill up the psychiatric inpatient beds looking for detox or housing, they fill up the inpatient medical wards with conditions resulting from their lifestyles. They take a lot of time and work and they're not always nice people to deal with."

This is a bit like saying, "If only they didn't have all these issues, I'd be more comfortable to treat them" - which to me is like saying "If only that diabetic didn't have high blood sugar and a compromised pancreas and limited ability to exercise with one leg - then I'd feel better treating them".

This is the nature of such patients - and is the very issues that need treatment. We're more or less describing the anti-social personality with co-morbid drug addictions. I'd agree they are time consuming and difficult but there are ways of dealing with such people in a clinically and therapeutically positive way.
What I think is lacking is the acceptance that this is a clinical issue, it requires a particular clinical approach and, despite best intentions, most approaches are counter-therapeutic or simply maintaining of such maladaptive behaviours.
Unfortunately, since there is little clear understanding, opinion and no specific clinical treatment pathways readily available I've simply had to formulate my own over the years of experience.

If such people are so time consuming then perhaps we ought look at the issue more thoroughly and purposefully, whilst also being able to challenge ourselves on the perpetuating dynamic of the clinical-self in these presentations.
Not exactly on thread of benzo's but is a significant factor when considering the addictive-personality types that cause doubt when prescribing them.

Anonymous said...

mr ian, i hope you are a doc or considering it. had a similar convo with a young doc recently. hope he is able to retain that perspective as the years go by.

SWF, 24, enjoys guilt trips to the doctor said...

I have this weird releationship with these drugs.
-On the one hand, I'm kind of a hoarder and that extends to many things, including magazines, sentimental crap I don't feel sentimental about, drugs, and whatever else. Hey, I may need it one day.
-With this in mind, I sometimes hope a doc will prescribe something for me maybe so I can take it only occasionally but hoard the rest.
-I do have chronic back pain, since I was about 7, and it's only partly due to poor ergonomics that can't be fixed at the moment due to office space. With this info, my doc just sent me home. I've felt my back problems have been pooh-poohed by more than one doctor. When I was 12 or so, another doc had me bend over and ran a finger down my spine to see if it was straight, then sent me home. Another in college blamed everything on my non-blinding-pain migraines and offered me long-term drugs which I wasn't interested in, so he sent me home. I'm taking Excedrin 3 work days out of 5. So, when it gets intolerable, I use some hyrocodone left over from surgery. Maybe the aspirin is appropriate, but I don't know even that.
-I've got a stash of ativan, valium, ambien, hydrocodone, some muscle relaxant, and other less controlled drugs like benzonatate. I use my ambien faithfully, but haven't touched anything but the vicodin (5x half dose) in at least 3 mos, probably more.
-I've never been addicted to ingesting anything that's not food, not even caffeine, as far as I can tell. The only feeling of addiction I had was 1 week after trying my first and last cigarette (a Marlboro which I'm told is by far one of the most addictive) at 21.
-When I get more assertive about it with a doc, I feel like a whiner and that I seem like a drug seeker. Which is reinforced by the small fact that I am...though I only intend to stash them for peace of mind.

So that leaves me confused, and I don't know what I should do. I know...generally speaking...I can take drugs for a few weeks and not get addicted. I can take ambien 5 nights a week and be fine on the two weekend nights. So addiction doesn't worry me, and I don't know if it should--they tell you about people who have addictive personalities or whatever but maybe that's BS.

Are there people who are more likely to get addicted to anything, and others who are likely to not get addicted within reasonable circumstances (i.e., I'm sure there are incredibly addictive drugs you could put someone on)?

So, except that I don't really push my docs into prescribing things for me, I feel like I'm doing something really wrong. Everybody is making it out to be such a bad thing to have the intention of getting drugs one may not need more than occasionally; additionally, I felt extremely uncomfortable asking for a benzo when I had a string of panic attacks (my phd did not offer to set it up), and I feel guilty about asking for anything remotely related to pain whether I need it or only worry that I'll need it. So no, if I don't seem concerned about addiction, that doesn't necessarily mean I'm at risk, it's just not shown to be a problem for me in the past. Maybe I just need a shrink for the hoarding and all this will go away. And then flowers and rainbows will shoot out of my bum.

Anonymous said...

doc if you want to see what benzodiazepines do to people come to http://benzowithdrawal.com/forum/index.php and learn.. you could even do some pro bono work there helping all the people shrinks have hurt

Scott Sittlow said...

Its fine. When youre weening off just pour some out of the pill and a little more every couple days your doctor can help you with the timing. I too have had substance abuse in the past but in many cases, as in mine, people are self medicating. I had a severe opiate addiction but after going through treatment being told i was born an addict and so on i realized it was b.s. i was only using to not get sick after a four day 'binge' left me craving more ended up using for a year but had none of the symptoms of being a so called addict aside from simply having used drugs for the past year. My point is dont worry that just because u had a problem in the past means you will never get off a benzo. You are taking quite a small dose to boot. After i got clean was perscribed 4mg klonopin a day, didnt push my happy button, just releived the symptoms of anxiety i had and allowed me to get a job and maintain it. I had to change doctors because of insurance change and she immediately tapered me off as soon as possible because i had addiction in the past. I weened off within a month and felt happier but my dabilitating anxiety has never been resolved and thanks to this stigma have gone through about 7 jobs in the past year. If you need it keep taking it until you find another solution, however long it takes. Or even up the dose if you need more! People take these drugs and are fine for decades on the same dose. I personally beleive benzos ARE a temporary solution but too many doctors live by this concept and rush replacing benzos with something else and it does not help the patient. I was currently dropped straight down from 3mg xanax to 1mg (no taper) because of this stigma and guess what, lost another job and have five days to make rent! Im not craving it but the idea that if i was on the same dose and would still be doing fine kills me.

Scott Sittlow said...

Its fine. When youre weening off just pour some out of the pill and a little more every couple days your doctor can help you with the timing. I too have had substance abuse in the past but in many cases, as in mine, people are self medicating. I had a severe opiate addiction but after going through treatment being told i was born an addict and so on i realized it was b.s. i was only using to not get sick after a four day 'binge' left me craving more ended up using for a year but had none of the symptoms of being a so called addict aside from simply having used drugs for the past year. My point is dont worry that just because u had a problem in the past means you will never get off a benzo. You are taking quite a small dose to boot. After i got clean was perscribed 4mg klonopin a day, didnt push my happy button, just releived the symptoms of anxiety i had and allowed me to get a job and maintain it. I had to change doctors because of insurance change and she immediately tapered me off as soon as possible because i had addiction in the past. I weened off within a month and felt happier but my dabilitating anxiety has never been resolved and thanks to this stigma have gone through about 7 jobs in the past year. If you need it keep taking it until you find another solution, however long it takes. Or even up the dose if you need more! People take these drugs and are fine for decades on the same dose. I personally beleive benzos ARE a temporary solution but too many doctors live by this concept and rush replacing benzos with something else and it does not help the patient. I was currently dropped straight down from 3mg xanax to 1mg (no taper) because of this stigma and guess what, lost another job and have five days to make rent! Im not craving it but the idea that if i was on the same dose and would still be doing fine kills me.

Anonymous said...

I have suffered from a serious panic disorder since age 14; used benzos for over 20+ years, and never would have survived without them. I went through detox and was inadequetely treated, nor did any other psychotropic drugs help relieve my serious symptoms. I am totally fed-up with the 'pendulum' swing in mental health. Doctors need to know thy patient, and not do a sweeping alteration of drugs such as benzodazepines due to the political pull, and/or certain research. My life is being completely destroyed due to having no option, yet to come off this necessary type of medication.