Are benzodiazepines + marijuana ever a reasonable option for control of anxiety and depression?

[Ligament]

I'm a pain doctor, not a psychiatrist.

Have a young male patient with profound anxiety. Seeing a psychiatrist and psychiatrist is prescribing xanax 1mg TID PRN + "medical" marijuana + atomoxetine 60mg Q24hr

Is this considered an appropriate medication combination? Not my specialty and want some opinions.

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[reca]

Bet his yelp reviews are through the roof

 

[downwithDTB]

How do you feel about the literature on durability of "medical mj" for chronic pain and is this something that you would be prescribing to this patient?

Personally, I can't imagine ever putting a patient on this regiment but I can see a slightly defensible, less ideal, rare patient: chronic severe pain after debilitating injury/cancer, failed all front line non surgical interventions for pain, gets MJ, develops severe panic disorder and fails adequate trial of three antidepressants, gets med term benzo with strict plan to taper after panic resolves, and has history of ADHD since childhood, was on stimulants but transitioned to atomox.

I'm betting that this isn't your patient...

 

[whopper]

If the Alprazolam is being using infrequently, at low dosages, and definitely less than daily, hopefully much less than this it's okay.

Marijuana: can't answer this. This is a highly complex issue and the information you provided is too sparse.

 

[wolfvgang22]

How do you feel about the literature on durability of "medical mj" for chronic pain and is this something that you would be prescribing to this patient?

Personally, I can't imagine ever putting a patient on this regiment but I can see a slightly defensible, less ideal, rare patient: chronic severe pain after debilitating injury/cancer, failed all front line non surgical interventions for pain, gets MJ, develops severe panic disorder and fails adequate trial of three antidepressants, gets med term benzo with strict plan to taper after panic resolves, and has history of ADHD since childhood, was on stimulants but transitioned to atomox.

I'm betting that this isn't your patient...

I actually have several patients like this. I still don't prescribe benzos unless there is no other choice, and even then nothing like xanax 1mg QID that I see all the time in the community. Most patients like like this wont participate in therapy, which would benefit them more in the long run.

 

[Ligament]

If the Alprazolam is being using infrequently, at low dosages, and definitely less than daily, hopefully much less than this it's okay.

Marijuana: can't answer this. This is a highly complex issue and the information you provided is too sparse.

I updated with dosages, thanks for pointing that out.

 

[dl2dp2]

This "regimen" is associated with the psychiatrist being over 50.

Younger psychiatrists generally avoid atomoxtine and alprazolam.

On the face of it, there's nothing wrong just purely based on FDA labeling (except the medical MJ thing, obv), but this regimen is way worse than something like
good dose of SSRI + sprinkle of Klonopin + Vyvanse, with that sprinkle of Klonopin gradually tapered.

 

[Ligament]

How do you feel about the literature on durability of "medical mj" for chronic pain and is this something that you would be prescribing to this patient?

Personally, I can't imagine ever putting a patient on this regiment but I can see a slightly defensible, less ideal, rare patient: chronic severe pain after debilitating injury/cancer, failed all front line non surgical interventions for pain, gets MJ, develops severe panic disorder and fails adequate trial of three antidepressants, gets med term benzo with strict plan to taper after panic resolves, and has history of ADHD since childhood, was on stimulants but transitioned to atomox.

I'm betting that this isn't your patient...

No real role for MJ in pain unless anorexia in setting of malignant pain. I'm in the PNW so see tons and tons of patients on MMJ (I never prescribe nor recommend it). It does not work, and my patients on MMJ universally do worse than those not on it.

Psychiatrically these folks on MMJ seem far more depressed and especially far more anxious than those not on it.

The only folks that Rx MMJ for chronic pain in my area are non-qualified hacks.

marijuana use for pain seems to alleviate some anxiety associated with pain for a short time (few weeks?), but not the pain itself. Then seems to make all things worse.

And no, I do not Rx chronic opioids either. Talk about psychiatric decline when folks are on chronic opioids for benign chronic pain.

 

[Ligament]

This "regimen" is associated with the psychiatrist being over 50.

Younger psychiatrists generally avoid atomoxtine and alprazolam.

On the face of it, there's nothing wrong just purely based on FDA labeling (except the medical MJ thing, obv), but this regimen is way worse than something like
good dose of SSRI + sprinkle of Klonopin + Vyvanse, with that sprinkle of Klonopin gradually tapered.

Yes, this psychiatrist is way over 50.

 

[downwithDTB]

No real role for MJ in pain unless anorexia in setting of malignant pain. I'm in the PNW so see tons and tons of patients on MMJ (I never prescribe nor recommend it). It does not work, and my patients on MMJ universally do worse than those not on it.

Psychiatrically these folks on MMJ seem far more depressed and especially far more anxious than those not on it.

The only folks that Rx MMJ for chronic pain in my area are non-qualified hacks.

And no, I do not Rx chronic opioids either. Talk about psychiatric decline when folks are on chronic opioids for benign chronic pain.

Then I would opine that it's definitely not a good regiment.

 

[Ironspy]

I'm a pain doctor, not a psychiatrist.

Have a young male patient with profound anxiety. Seeing a psychiatrist and psychiatrist is prescribing xanax 1mg TID PRN + "medical" marijuana + atomoxetine 60mg Q24hr

Is this considered an appropriate medication combination? Not my specialty and want some opinions.

This regimen is more than two standard deviations from the mean on a bell shaped curve

 

[calvnandhobbs68]

Yeah if this person is getting Xanax TID “PRN”...I’m gonna bet he’s using it daily.

 

[SeniorWrangler]

Medical MJ can be helpful for neuropathic pain in my experience in selected patients, but chronic use can worsen anxiety. Also, there are many different strains with different (anecdotal) effects on anxiety, pain, etc. and none of this has been studied.

I am very skeptical of chronic daily alprazolam use — it lasts only a short time and people may feel worse when it wears off, it does not mix well with other substances, and has high street value. This goes double in young folks with ADHD although at least he’s not on a psychostimulant.

 

[TexasPhysician]

You lost me at medical marijuana.

 

[Ligament]

From your professional perspectives, how often does marijuana induce anxiety/panic disorder or exacerbate preexisting anxiety/panic disorder?

From my perspective in a totally different field, it seems to do both frequently. But, my patients universally have chronic pain on top of their psych issues.

 

[reca]

Younger psychiatrists generally avoid atomoxtine and alprazolam.

Why atomoxetine? I consider it when the patient has ADHD + anxiety.

 

[Celexa]

From your professional perspectives, how often does marijuana induce anxiety/panic disorder or exacerbate preexisting anxiety/panic disorder?

From my perspective in a totally different field, it seems to do both frequently. But, my patients universally have chronic pain on top of their psych issues.

Absolutely frequently. Some patients have really poor insight into the cycle and cling to their marijuana as a cure-all keeping them together, but I've had a surprisingly high number of patients say to me some variation of 'at first marijuana seemed to help my anxiety, but now I think it's making things worse'. I'm only a PGY2 but it's happened enough times I've lost count.

Agree with the posters above re: Xanax. We sometimes use benzos, but my attendings never use Xanax unless they're continuing or tapering someone else's prescription. If starting a benzo, Klonopin or Ativan, with the majority of people having a treatment plan that involves tapering or discontinuing the benzo in the future.

 

[TexasPhysician]

From your professional perspectives, how often does marijuana induce anxiety/panic disorder or exacerbate preexisting anxiety/panic disorder?

From my perspective in a totally different field, it seems to do both frequently. But, my patients universally have chronic pain on top of their psych issues.

Often

 

[Armadillos]

From your professional perspectives, how often does marijuana induce anxiety/panic disorder or exacerbate preexisting anxiety/panic disorder?

From my perspective in a totally different field, it seems to do both frequently. But, my patients universally have chronic pain on top of their psych issues.

I guess my sample is skewed because if the MJ was fixing everything then they wouldn’t see me anymore, but MJ just seems to make almost everything worse for my patients. I may sound like an old man yelling at the sky, but the (chronic) MJ related apathy is a real problem and folks seem to just give up on doing anything to better their situation and stall out.

Then in psychosis, especially young folks early in course, MJ seems like dumping gasoline on a smoldering fire.

That being said, if a patient is working and functional and very occasionally uses MJ recreationally then doesn’t seem like much of an issue and I really don’t care.

 

[Merovinge]

Why atomoxetine? I consider it when the patient has ADHD + anxiety.

I definitely would not throw Strattera under the bus or even mention it in the same breath as rubbish like daily QID Xanax and "medical" marijuana for psychiatric disorders. Clearly benefits some patients with ADHD, relatively low SE burden, 0 abuse, no dealing with controlled subs (easier for patients and doctors). It's also certainly less effective than stimulants but with relatively low risks that the benefits/risks ratio is very often positive. If you are talking CAP work, should definitely be done after several stimulant trials unless there is need to avoid stimulants in which case it becomes quite reasonable as monotherapy or with alpha-2-agonist.

 

[Ligament]

These are all useful insights, thank you folks.

 

[PikminOC]

Yeah if this person is getting Xanax TID “PRN”...I’m gonna bet he’s using it daily.

Or selling it daily

 

[SeniorWrangler]

You lost me at medical marijuana.

Medical Cannabis for Neuropathic Pain.
Review article
Lee G, et al. Curr Pain Headache Rep. 2018.

Citation
Curr Pain Headache Rep. 2018 Feb 1;22(1):8. doi: 10.1007/s11916-018-0658-8.
Abstract
PURPOSE OF REVIEW: Many cultures throughout history have used cannabis to treat a variety of painful ailments. Neuropathic pain is a complicated condition that is challenging to treat with our current medications. Recent scientific discovery has elucidated the intricate role of the endocannabinoid system in the pathophysiology of neuropathic pain. As societal perceptions change, and legislation on medical cannabis relaxes, there is growing interest in the use of medical cannabis for neuropathic pain.
RECENT FINDINGS: We examined current basic scientific research and data from recent randomized controlled trials (RCTs) evaluating medical cannabis for the treatment of neuropathic pain. These studies involved patients with diverse etiologies of neuropathic pain and included medical cannabis with different THC concentrations and routes of administration. Multiple RCTs demonstrated efficacy of medical cannabis for treating neuropathic pain, with number needed to treat (NNT) values similar to current pharmacotherapies. Although limited by small sample sizes and short duration of study, the evidence appears to support the safety and efficacy of short-term, low-dose cannabis vaporization and oral mucosal delivery for the treatment of neuropathic pain. The results suggest medical cannabis may be as tolerable and effective as current neuropathic agents; however, more studies are needed to determine the long-term effects of medical cannabis use. Furthermore, continued research to optimize dosing, cannabinoid ratios, and alternate routes of administration may help to refine the therapeutic role of medical cannabis for neuropathic pain.

 

[NickNaylor]

My impression is that cannabis can be helpful - at least subjectively - in the short-term for anxiety for some patients, but long-term it isn't helpful. I. believe this is backed up by studies, but I'm too lazy to search to find something.

As with all things cannabis, even if there are studies there are going to be issues with generalizability (what cannabis strain are they taking? how are THC/CBD levels being measured, and are they consistent? how often?) that make them, IMO, almost useless. Perhaps there are some better studies looking at CBD, but again, I'm too lazy to do a lit review while enjoying my coffee.

 

[calvnandhobbs68]

Medical Cannabis for Neuropathic Pain.
Review article
Lee G, et al. Curr Pain Headache Rep. 2018.

Citation
Curr Pain Headache Rep. 2018 Feb 1;22(1):8. doi: 10.1007/s11916-018-0658-8.
Abstract
PURPOSE OF REVIEW: Many cultures throughout history have used cannabis to treat a variety of painful ailments. Neuropathic pain is a complicated condition that is challenging to treat with our current medications. Recent scientific discovery has elucidated the intricate role of the endocannabinoid system in the pathophysiology of neuropathic pain. As societal perceptions change, and legislation on medical cannabis relaxes, there is growing interest in the use of medical cannabis for neuropathic pain.
RECENT FINDINGS: We examined current basic scientific research and data from recent randomized controlled trials (RCTs) evaluating medical cannabis for the treatment of neuropathic pain. These studies involved patients with diverse etiologies of neuropathic pain and included medical cannabis with different THC concentrations and routes of administration. Multiple RCTs demonstrated efficacy of medical cannabis for treating neuropathic pain, with number needed to treat (NNT) values similar to current pharmacotherapies. Although limited by small sample sizes and short duration of study, the evidence appears to support the safety and efficacy of short-term, low-dose cannabis vaporization and oral mucosal delivery for the treatment of neuropathic pain. The results suggest medical cannabis may be as tolerable and effective as current neuropathic agents; however, more studies are needed to determine the long-term effects of medical cannabis use. Furthermore, continued research to optimize dosing, cannabinoid ratios, and alternate routes of administration may help to refine the therapeutic role of medical cannabis for neuropathic pain.

yeah count up how many of these patients are taking “short term, low dose cannabis vaporization” and get back to me.

 

[downwithDTB]

RECENT FINDINGS: We examined current basic scientific research and data from recent randomized controlled trials (RCTs) evaluating medical cannabis for the treatment of neuropathic pain. These studies involved patients with diverse etiologies of neuropathic pain and included medical cannabis with different THC concentrations and routes of administration. Multiple RCTs demonstrated efficacy of medical cannabis for treating neuropathic pain, with number needed to treat (NNT) values similar to current pharmacotherapies. Although limited by small sample sizes and short duration of study, the evidence appears to support the safety and efficacy of short-term, low-dose cannabis vaporization and oral mucosal delivery for the treatment of neuropathic pain. The results suggest medical cannabis may be as tolerable and effective as current neuropathic agents; however, more studies are needed to determine the long-term effects of medical cannabis use. Furthermore, continued research to optimize dosing, cannabinoid ratios, and alternate routes of administration may help to refine the therapeutic role of medical cannabis for neuropathic pain.

The longest RTC cited in that paper had 15 days of treatment. I don't think that counts as the sort of durable efficacy that I would want to see before prescribing an addictive, frequently abused drug to a chronically ill patient. Opioids work great for lots of acute pains OR briefly for chronic pains, but not durably for chronic pains... and now look at the mess we're in because of abundant prescribing for the later before the evidence came in.

 

[TexasPhysician]

Medical Cannabis for Neuropathic Pain.
Review article
Lee G, et al. Curr Pain Headache Rep. 2018.

Citation
Curr Pain Headache Rep. 2018 Feb 1;22(1):8. doi: 10.1007/s11916-018-0658-8.
Abstract
PURPOSE OF REVIEW: Many cultures throughout history have used cannabis to treat a variety of painful ailments. Neuropathic pain is a complicated condition that is challenging to treat with our current medications. Recent scientific discovery has elucidated the intricate role of the endocannabinoid system in the pathophysiology of neuropathic pain. As societal perceptions change, and legislation on medical cannabis relaxes, there is growing interest in the use of medical cannabis for neuropathic pain.
RECENT FINDINGS: We examined current basic scientific research and data from recent randomized controlled trials (RCTs) evaluating medical cannabis for the treatment of neuropathic pain. These studies involved patients with diverse etiologies of neuropathic pain and included medical cannabis with different THC concentrations and routes of administration. Multiple RCTs demonstrated efficacy of medical cannabis for treating neuropathic pain, with number needed to treat (NNT) values similar to current pharmacotherapies. Although limited by small sample sizes and short duration of study, the evidence appears to support the safety and efficacy of short-term, low-dose cannabis vaporization and oral mucosal delivery for the treatment of neuropathic pain. The results suggest medical cannabis may be as tolerable and effective as current neuropathic agents; however, more studies are needed to determine the long-term effects of medical cannabis use. Furthermore, continued research to optimize dosing, cannabinoid ratios, and alternate routes of administration may help to refine the therapeutic role of medical cannabis for neuropathic pain.

Poor evidence at best. I could probably find equal evidence regarding holograms in shoes.

Still, how do you determine “medical cannabis”? What concentrations and frequencies is medical vs recreational? What strains? Through what vector? Where are the cutoffs in safety?

Medical cannabis is more of a political statement than actually having scientific data. “Medical cannabis” doesn’t exist.

While we are making things up, can I ask the spouse for medical whiskey for tonight? It was actually prescribed decades ago.........

 

[meow1985]

What everyone else said.

I don't practice in a state with medical marijuana, but if someone reported to me that they were smoking marijuana regularly, I would not prescribe them ANY controlled substance for even a day - benzos, stimulants, or anything else. In my understanding, the only difference between medical marijuana and the marijuana you buy on the street is that you have a guarantee that it's not laced with anything even more harmful, and you have data on how much THC it contains.

Reading between the lines, I'm concerned about poor distress tolerance in this patient (young man, using MJ, likely hx of ADHD, a short-acting benzo). He needs a good therapist, and the psychiatrist is only feeding into his focus on short term fixes.

 

[birchswing]

and now look at the mess we're in because of abundant prescribing for the later before the evidence came in.

My lay historical knowledge is that the period of US history in which opiate/opioid use was not as common was more the exception than the rule, beginning around the temperance movement and ending around the early 1970s (I think?) with advent of synthetic opioids being pushed by pharmaceutical companies. Anyhow, I think the risk of dependence has been known at least going back to revolutionary days. Probably longer but I only know a bit about the US history.

 

[downwithDTB]

My lay historical knowledge is that the period of US history in which opiate/opioid use was not as common was more the exception than the rule, beginning around the temperance movement and ending around the early 1970s (I think?) with advent of synthetic opioids being pushed by pharmaceutical companies. Anyhow, I think the risk of dependence has been known at least going back to revolutionary days. Probably longer but I only know a bit about the US history.

Look at the change in Rx frequency over time and the opioid deaths in the 90s, then find the early pain literature where it would abundantly state that you couldn't develop addiction from using opioids to appropriately treat pain. Then remember getting 90 Vicodin for getting your wisdom teeth out.

 

[birchswing]

Look at the change in Rx frequency over time and the opioid deaths in the 90s, then find the early pain literature where it would abundantly state that you couldn't develop addiction from using opioids to appropriately treat pain. Then remember getting 90 Vicodin for getting your wisdom teeth out.

Did people really believe it at the time? Was it because they were synthetic rather than directly derived from opium they were believed to be less addicting? It just seems like there's such a long history with opiates that people would have known. I was one of the few people who got their wisdom teeth out with local anesthetic and just ibuprofen after. I saw how sick my friends were who went under sedation and were vomiting from whatever pain pills they were taking after. It seemed to draw out the misery and become a week long affair of being sick in bed. I can see why people would have kept taking them. They seemed miserable, but I almost thought it seemed like they were miserable in part from the medication. But it can be hard to distinguish what is causing what and you maybe would just keep taking it I guess because you felt so bad. When I had my appendectomy, I was in such pain after the surgery and they kept trying to give me Norco. I kept asking the nurse to just give me Tylenol because I was on benzos and I could see my 02 sat was already at 93. She said she couldn't because it wasn't on the list of meds (even though Tylenol is in Norco). So I finally took a Norco and my 02 dropped into the 80s and they gave me oxygen—but I had to alert them and they took their pulse ox off because they were annoyed with me calling them in (I had my own from home I kept monitoring with). I was still sent home with Norco which made no sense given the experience I had in the hospital. I never took any of it despite having had pathological exertion in emergence from anesthesia, which caused a lot of pain and weakness. Fortunately I knew the connection between benzos and opioids. But I guess a lot of misinformation runs rampant because they were happy to give me both and seemingly not concerned about my 02 sats.

 

[Ligament]

Did people really believe it at the time? Was it because they were synthetic rather than directly derived from opium they were believed to be less addicting? It just seems like there's such a long history with opiates that people would have known. I was one of the few people who got their wisdom teeth out with local anesthetic and just ibuprofen after. I saw how sick my friends were who went under sedation and were vomiting from whatever pain pills they were taking after. It seemed to draw out the misery and become a week long affair of being sick in bed. I can see why people would have kept taking them. They seemed miserable, but I almost thought it seemed like they were miserable in part from the medication. But it can be hard to distinguish what is causing what and you maybe would just keep taking it I guess because you felt so bad. When I had my appendectomy, I was in such pain after the surgery and they kept trying to give me Norco. I kept asking the nurse to just give me Tylenol because I was on benzos and I could see my 02 sat was already at 93. She said she couldn't because it wasn't on the list of meds (even though Tylenol is in Norco). So I finally took a Norco and my 02 dropped into the 80s and they gave me oxygen—but I had to alert them and they took their pulse ox off because they were annoyed with me calling them in (I had my own from home I kept monitoring with). I was still sent home with Norco which made no sense given the experience I had in the hospital. I never took any of it despite having had pathological exertion in emergence from anesthesia, which caused a lot of pain and weakness. Fortunately I knew the connection between benzos and opioids. But I guess a lot of misinformation runs rampant because they were happy to give me both and seemingly not concerned about my 02 sats.

People believed it. Yes. Sad. Lots of lies and propaganda resulted in billions of profit for big pharma.

 

[cara susanna]

I can't speak from the pharmacological perspective, but generally marijuana and/or benzos function as avoidance and theoretically this is thought to maintain or worsen anxiety in the long-term.