tolerance and withdrawal in substance dependence

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goldennugget

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Hi all,
Just wanted to get some thoughts on this.
Lets say there is a patient who has been prescribed clonazepam 16mg total daily for the past 8 or so years from a PCP. Her medication prescription database has been checked, and she is not filling inappropriately. she has severe panic attacks and has been taking it as prescribed. no hx of doctor shopping, DUI/DWI, family problems from use. Even though she is on a whopping dose of klonopin, would she qualify for an abuse/dependence diagnosis? Or is she moreso a product of inappropriate prescribing? While she is very apprehensive about lowering the doses, she has agreed to it and over months is now down to 4mg total daily.

Another part to my question is : how do you assess for the 'tolerance' and 'withdrawal' criteria in substance dependence? For sure, if a cancer pt was given 100mg morphine PO total daily over 4 months and then the patient ran out (because the could no longer afford the medication, not because they overused and ran out early), most likely the pt would go through withdrawal. But I'm not so sure that means that the patient was addicted per se. any person prescribed that amount could go through tolerance/withdrawal.
So, in checking the criteria of dependence, do you account for tolerance and withdrawal at full face value if it occurs under any context? Or does do they really only count towards the diagnosis only if its occurred in a maladaptive sense- say they are withdrawing because they ran out early due to taking more than prescribed?

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I always thought addicted meant continuing to do something in spite of knowing it was bad for you. I think it's possible to know that you have a bad doctor who is giving bad medical treatment, so I think in that way a person could decide that they are addicted to a benzodiazepine, even though it is prescribed and you are taking it as prescribed. On the other hand, if you've been on a benzodiazepine for a very long time and are continuing to have panic attacks (which is likely as you've probably already gone through tolerance withdrawal—withdrawal from staying at the same level of medication rather than increasing), you are probably looking at a cost/benefit analysis. Continuing to stay on the drug seems like the safer decision in the short term, and perhaps even long term if you can't find a person who knows how to help you withdraw. So if addiction means doing something knowing it's bad for you, I would be less likely to say such a person is addicted. They might be doing what they think they need to in order to get by, and they could be right. Not everyone can afford to go through withdrawal (time off work, etc.).

In either case, whether a person obtains a benzodiazepine through a doctor or other means, there will be physical tolerance and withdrawal. That much seems invariable.

I myself am in the situation described. I have looked into whether inpatient treatment centers would help a person withdraw from a prescribed, regularly taken amount of a benzodiazepine. What I have found though is that they use very questionable means to accomplish this (very rapid withdrawals using phenobarbitol). It is a very odd position for a patient to be in. On the one hand the patient's doctor believes the are giving the patient therapeutic treatment. The patient on the other hand is looking for drug addiction treatment to recover from a "therapeutic" treatment. I have a doctor now who finally gets it and was willing to look at the Ashton manual (http://www.benzo.org.uk/manual/) and work with me. But she is the the first out of many to even recognize the problem.
 
This is one of the reasons why they changed the criteria in the DSM-5 so that tolerance/withdrawal are combined into a single criterion, since patients like this would get 2 of the 3 required criteria just from using a prescription medication. I think your patient should probably be diagnosed with the DSM-5 criteria, not the DSM-IV criteria. The poor girl is just doing what her doctor is telling her to do.

I had a similar patient who'd been getting too many opioids who I just called "prescription medication overuse" instead of "abuse" or "dependence." I know it's not a real diagnosis, but he didn't deserve to be called a drug abuser. He just had really bad tolerance/withdrawal. In another thread, OPD suggested calling it "habituation," which is probably the best term for it.

But if she has a mood disorder from all of the cognitive suppression from the benzos, I think it's fair to call it a substance-induced mood disorder.
 
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This is one of the reasons why they changed the criteria in the DSM-5 so that tolerance/withdrawal are combined into a single criterion, since patients like this would get 2 of the 3 required criteria just from using a prescription medication. I think your patient should probably be diagnosed with the DSM-5 criteria, not the DSM-IV criteria. The poor girl is just doing what her doctor is telling her to do.

I had a similar patient who'd been getting too many opioids who I just called "prescription medication overuse" instead of "abuse" or "dependence." I know it's not a real diagnosis, but he didn't deserve to be called a drug abuser. He just had really bad tolerance/withdrawal. In another thread, OPD suggested calling it "habituation," which is probably the best term for it.

But if she has a mood disorder from all of the cognitive suppression from the benzos, I think it's fair to call it a substance-induced mood disorder.

This seems to put quite a value judgment on people who are addicted to drugs not prescribed by a doctor (resulting in whether a person deserves to be called a drug abuser or not, as if the label is a punishment for bad behavior). And it also seems to give doctors a pass. If the distinction is the means of introduction and supply to the drug of abuse, to call the patient "poor girl" rather than "drug abuser" may seem sympathetic to the patient, but it's also elevating the doctor above what it is that a drug dealer does (and I am not saying that every interaction with a drug dealer is comparable to every interaction with a doctor, but in some cases they seem remarkably similar: dismissal of concerns, urging just to try it, giving out free samples).

There is always the word "iatrogenic" that could be used. It might even be appropriate in terms of being clearer about the source of the problem.

I'm not sure why you would avoid the word dependence, though. There is almost invariable tolerance and dependence with long-term benzodiazepine use. Those don't seem like terribly judgmental terms to me. I can't be put out with Versed for example for twilight sedation—no amount will do it. I'm tolerant. The fact that I wasn't made tolerant by a street drug dealer doesn't change that. And I'm also dependent. I would be extremely sick and need emergency care if I didn't have access to the medications I've taken for a long time.
 
I'm not saying that prescription drug overuse automatically excludes somebody from the diagnosis, just that this particular patient doesn't qualify for the diagnosis because it implies a maladaptive behavioral pattern. If the patient is doctor shopping or demanding drugs from the doctor or the like, then it's different. If the patient just has tolerance/withdrawal because they think that they're doing what they're supposed to do in order to treat their anxiety, then they don't have a substance use disorder, they just have upregulation of GABA receptors.

The difference between this patient and a patient with a proper substance use disorder is that the latter patient is initiating the demand for drugs. If you go to a doctor/drug dealer and ask for a drug, that's different from going to a doctor, complaining of symptoms, and following his/her recommendations. The reason why the distinction exists is because it implies different treatment strategies. The patient in the above vignette probably just needs a benzo taper. A patient with a substance use disorder probably needs extensive motivational interviewing, then CBT/rehab.
 
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Hi all,
Just wanted to get some thoughts on this.
Lets say there is a patient who has been prescribed clonazepam 16mg total daily for the past 8 or so years from a PCP. Her medication prescription database has been checked, and she is not filling inappropriately. she has severe panic attacks and has been taking it as prescribed.

I call bs....I don't believe she is really taking 16mg of klonopin daily. how would she even take it? 8mg BID? 4mg-4mg-8mg?? That's insane.....people will go through periods of time where they will hit their favorite drug hard for several days, but no way is she taking that much every day.
 
I call bs....I don't believe she is really taking 16mg of klonopin daily. how would she even take it? 8mg BID? 4mg-4mg-8mg?? That's insane.....people will go through periods of time where they will hit their favorite drug hard for several days, but no way is she taking that much every day.

It is an extremely high dose (equivalent to 320 mg Valium). But if you develop a tolerance, I presume it's possible. Michael Jackson became so tolerant to benzos he moved to propofol.
 
I don't envy this patient. Or the doctor monitoring the taper. How do you get to 16 mg a day? This is crazy.
 
I don't envy this patient. Or the doctor monitoring the taper. How do you get to 16 mg a day? This is crazy.
I know how it starts: With a doctor who believes that long-term benzodiazepine therapy is beneficial, innocuous, and should be the first line of treatment. If you question them, they ask you if you tell the pilot how to fly the plane. It's a public policy problem in the US. It was just as much of an epidemic in the UK but was reigned in politically somewhat. I believe it is a political problem and a huger epidemic than is realized, which is why I pester the NIDA about it. It's not regulated now, and there aren't consequences for doctors who do this to patients, and place an enormous burden on our system in terms of complications and ensuing disability.

When I was on 4 mg of Ativan daily, I saw a psychiatrist whose first change he wanted to make to my meds was to increase it to 6 mg. His position was that there was no maximum dosage until anxiety was under control. You had not yet reached a "therapeutic dosage." He was in his 80s when I saw him, and he's still practicing today. I refused to go up, and he prescribed me to take Klonopin as well and complained about me being non-compliant in not wanting to take it.

I have said it before on this board, there are twilight zones of really bad psychiatry in this country.€€€
 
Thank you all for sharing your thoughts.

I myself was pretty much dubious about her actually being on 16mg dose until she took out the bottle with the full prescription label on it.
Over time I've been gradually chipping away at the dose and often providing her much reassurance that it won't be as bad as she imagines it will be. At times I am suprised that she still comes back to see me, but I think we have built a good rapport. She still would prefer to take high dose clonazepam, and rationalizes this by saying that everyone in her family is on high dose benzos or xanax, so why can't she? I tell her she is almost 60, and she can't keep taking this dose for the rest of her life. She appears to be very concrete psychologically and very much struggles with the ABC's of cognitive therapy. She is currently on prozac 80mg , klonopin 4mg total daily, and in last visit I added buspar. We will see how this holds up.

She had never seen a psychiatrist prior to coming to see me, nor has she ever been seen by a therapist. I feel like she tends to flake out and 'misses' her scheduled therapy appointments. It has definitely been challenging, but at least she is not on 16 mg klonopin anymore.

I personally don't think its her fault she is in this situation. I just think her past PCP had no idea what he/she was getting into by escalating the doses so much. Combine that with the pt's lack of experience in real treatment, and this is the outcome. Very sad, as she is a really sweet lady.
 
I'm not citing the reference and I apologize for that but I've seen published data showing that dependence can start as early as a few weeks into treatment, though from clinical experience it's likely a very low level of dependence.

I'm echoing what was said above but I've seen doctors prescribe benzos like they're candy and without any warning of their potential dangers, and not stopping them after they've been given out for more than weeks. This phenomenon, unfortunately, from what I've seen is not rare. I'd go as far to say it's a significant minority (less than 50% but definitely above 30% of doctors) and possibly worse. This has been my experience in several states.

There's an opioid and benzo epidemic being created by doctors and IMHO the first line of attack on this problem needs to be the state medical licensing boards but I see them doing very very little about it. Another irony is several weaker controlled substances such as Suboxone, the DEA randomly goes to offices to make sure the docs are following the guidelines, but not with other, more addictive, and more abused meds.
 
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Even though she is on a whopping dose of klonopin, would she qualify for an abuse/dependence diagnosis? Or is she moreso a product of inappropriate prescribing?
1) Having tolerance and withdrawal are not sufficient for the abuse or dependence diagnoses in DMS IV, so if that's all you have then she clearly does not qualify.

2) You're making a weird dichotomy here -- either it's abuse/dependence, or it's inappropriate prescribing. Why can't it be both? Why does us placing the 'blame' on the prescriber preclude a diagnosis of abuse or dependence?
 
Thank you all for sharing your thoughts.

I myself was pretty much dubious about her actually being on 16mg dose until she took out the bottle with the full prescription label on it.
Over time I've been gradually chipping away at the dose and often providing her much reassurance that it won't be as bad as she imagines it will be. At times I am suprised that she still comes back to see me, but I think we have built a good rapport. She still would prefer to take high dose clonazepam, and rationalizes this by saying that everyone in her family is on high dose benzos or xanax, so why can't she? I tell her she is almost 60, and she can't keep taking this dose for the rest of her life. She appears to be very concrete psychologically and very much struggles with the ABC's of cognitive therapy. She is currently on prozac 80mg , klonopin 4mg total daily, and in last visit I added buspar. We will see how this holds up.

She had never seen a psychiatrist prior to coming to see me, nor has she ever been seen by a therapist. I feel like she tends to flake out and 'misses' her scheduled therapy appointments. It has definitely been challenging, but at least she is not on 16 mg klonopin anymore.

I personally don't think its her fault she is in this situation. I just think her past PCP had no idea what he/she was getting into by escalating the doses so much. Combine that with the pt's lack of experience in real treatment, and this is the outcome. Very sad, as she is a really sweet lady.
Way to go getting her down to 4mg. That must have been a challenge.

I'll bet she was just being compliant with meds. She went to the doctor, doctor said "here's a pill to treat your disease," and she just took it the same way that people take their antihypertensives. I'll bet the neuroplastic effects of the benzos are part of the reason why she's so concrete now.

I've seen a lot of both. Plenty of patients who are taking too much xanax, and when I tell them why I want to stop it, they just say "oh OK, thanks for fixing my meds, doctor." Then there are plenty of others who start flipping tables so that you give them some IM Ativan...
 
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When reducing dosages, I explain why and create a plan. The why usually consists of safety concerns and developing tolerance. I also explain the medication works the same on the brain as ETOH does too. Nevermind the rebound anxiety that can be associated with this class.

Now, it does beg the question if low dosage Xanax should be considered for those in treatment resistant depression along with Trileptal/Lamictal. Something to keep in the bag of tricks.

BZD will be the next battle ground after Opiates are down to a managed level.
 
I call bs....I don't believe she is really taking 16mg of klonopin daily. how would she even take it? 8mg BID? 4mg-4mg-8mg?? That's insane.....people will go through periods of time where they will hit their favorite drug hard for several days, but no way is she taking that much every day.

I believe it. I was on a maximum dose of 16 mgs of Xanax at one point. Now granted I didn't always take 16 mgs every day, the minimum I could take just to prevent withdrawal was 8-10 mgs, if I wanted any sort of therapeutic relief from panic attacks, then I'd need to up it to between 12-16. I will admit most days I did just give in and take up to the full 16 I was prescribed, because by the time I hit that level it wasn't like I was getting blitzed off my brain on it, all it did was stop the panic attacks, otherwise I felt perfectly normal (as in I wasn't stumbling, slurring my words, completely pilled off my head - plus I had other stuff I was more concerned about at the time).

As for how I hit that high a dose - years of bad prescribing by several Physicians (GPs). At one stage I begged to see a Psychiatrist for talk therapy, because I didn't want to be taking Xanax at such high doses, and got talked out of it. When I say 'talked out of it' I mean harangued until I shut up and took my medication like a good patient, because after all having a panic disorder was just like being diabetic and if I was a diabetic I wouldn't refuse to take my insulin (actual argument used). Yes at some point in the 8 or so years I was on Xanax I also struggled with an addiction to heroin. The methadone prescriber who eventually treated me kept me on Xanax, because he thought it best we tackle one problem at a time. His idea of tackling one problem at a time was to steadily increase my dosage of Xanax until he hit 16 mgs - 4 1mg tablets 4 times a day. And by that point I was so busy concentrating on getting clean and doing the right thing on the methadone program, I didn't even think to argue back, nor did I really have the mental energy to.

Been off Xanax now for almost 10 years, Methadone (and all illicit drugs) for almost 12. Best thing I ever did coming off all that poison, because that's all it was to me in the end. Not all of us who end up on high doses of benzos are partying our ar%es off on it.
 
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Way to go getting her down to 4mg. That must have been a challenge.

I'll bet she was just being compliant with meds. She went to the doctor, doctor said "here's a pill to treat your disease," and she just took it the same way that people take their antihypertensives.

Seconding the 'way to go'. As for med compliance, I grew up in an older family and saw a lot of that myself. It's only been in the last few years my 70 year old mother has started questioning when medication is necessary rather than just going along with whatever the Doctor tells her. It's actually only been in the last 10 years or so that I've really been doing the same. The way I was raised it was more or less drummed into me that to ever question a Doctor was to show a gross disregard to their station in life. A Doctor told you to jump you were supposed to say 'Yes Sir/Maam, how high and how far?'.
 
I view getting other physicians out of Benzo trouble as a large part of our bread and butter. Adding non-addicting anxiety treatment and tapering Benzos is what we should be good at. These aren’t bumps in the road, these kind of bumps are the road.
 
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I like your glass is half-full approach MacDT. For me, it's more troublesome and difficult to decrease/discontinue "because Dr. So&So had been doing that all along and I've never heard this before."
It certainly tries my patience.

Ceke - I'd caution swinging the pendulum into the other direction in calling BZD/Opiates "Poison".
 
Ceke - I'd caution swinging the pendulum into the other direction in calling BZD/Opiates "Poison".

Sorry, perhaps I should have clarified that to me Xanax and Heroin turned out to be poison, because of the negative impact they both had on my life. I actually do still use BZD (Valium) as part of pain relief treatment so I definitely don't think all Benzo use is evil or anything like that. I also don't necessarily think Xanax in and of itself is poison, just the way it was prescribed and used with me was poisonous - perhaps that would be a better way of describing it, I got away from poisonous prescribing practices, but the medication itself can be useful when used properly (in my layperson's opinion).
 
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Thought I would revisit this after a recent experience in the ER.

I have reduced my benzo level (was at a high of 4 mg Ativan per day, always prescribed, always taken as prescribed, taken since I was 15 y/o, was told that it was not addictive, was called a spaz for doubting that).

Anyhow, was recently in the ER for sudden extreme shaking (turned out not to be a psych issue). The ER doctor said, "Big guy like you on a puny dose of Ativan? I'd get you up to 12 mg a day."

I asked him if he realized that 12 mg Ativan was equivalent to 120 mg Valium, thinking he might have a clearer idea then of how much medicine that is.

"Man, I don't know that stuff. I just see a big guy like you, seems like you're throwing peanuts at your anxiety."

I hate this image of the drug-seeking BZD patient. Maybe he exists. But I will tell you that when I do research on benzos, I invariably find recreational drug forums. And those people are giving out BETTER advice on benzos (e.g., don't take them often, withdrawal is hell; also they don't seem to like benzos in that they don't make them feel "high") than I have been given by countless psychiatrists. I have had to seek out a doctor who knows the harm and knows how to help me get off. And she is RARE where I live. She is so overwhelmed with benzo patients who were created in this area by other doctors that she's looking for a nurse practitioner to help her help more people. Ironically she practices in the same office as a psych I saw before who kept trying to up my benzo dose (he wanted me to add Klonopin to my already high Ativan dose). I know you can't trust who someone is on the Internet. But I can tell you I am someone who as a child wanted to do everything RIGHT. It would never have occurred to me to use drugs. I knew drugs were bad. As a kid, I wouldn't take Tylenol for a headache. I figured, why not just wait three hours for it to go away instead? I never, ever thought I needed to have been prepared or educated to keep myself safe from a doctor. I know it sounds offensive, but it is my truth.

This is only a guess, but I think the reasons BZD addiction/dependence doesn't get more attention are 1) that for whatever reason, drug seeking people don't seem to seek out BZDs. The people in withdrawal I've seen are like me: anxious people who didn't know they were becoming addicted when taking therapeutic doses and never taking more than prescribed. Therefore, you don't see the outrageous behavior that might call for a policy response. 2) There are protocols in place for dealing with opiate addiction. On the other hand, benzo withdrawal is seeped in mystery and misinformation. There's no good inpatient treatment option. And it's one of the only two I know of (alcohol being the other) that can be deadly.
 
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Thought I would revisit this after a recent experience in the ER.

I have reduced my benzo level (was at a high of 4 mg Ativan per day, always prescribed, always taken as prescribed, taken since I was 15 y/o, was told that it was not addictive, was called a spaz for doubting that).

Anyhow, was recently in the ER for sudden extreme shaking (turned out not to be a psych issue). The ER doctor said, "Big guy like you on a puny dose of Ativan? I'd get you up to 12 mg a day."

I asked him if he realized that 12 mg Ativan was equivalent to 120 mg Valium, thinking he might have a clearer idea then of how much medicine that is.

"Man, I don't know that stuff. I just see a big guy like you, seems like you're throwing peanuts at your anxiety."

I hate this image of the drug-seeking BZD patient. Maybe he exists. But I will tell you that when I do research on benzos, I invariably find recreational drug forums. And those people are giving out BETTER advice on benzos (e.g., don't take them often, withdrawal is hell; also they don't seem to like benzos in that they don't make them feel "high") than I have been given by countless psychiatrists. I have had to seek out a doctor who knows the harm and knows how to help me get off. And she is RARE where I live. She is so overwhelmed with benzo patients who were created in this area by other doctors that she's looking for a nurse practitioner to help her help more people. Ironically she practices in the same office as a psych I saw before who kept trying to up my benzo dose (he wanted me to add Klonopin to my already high Ativan dose). I know you can't trust who someone is on the Internet. But I can tell you I am someone who as a child wanted to do everything RIGHT. It would never have occurred to me to use drugs. I knew drugs were bad. As a kid, I wouldn't take Tylenol for a headache. I figured, why not just wait three hours for it to go away instead? I never, ever thought I needed to have been prepared or educated to keep myself safe from a doctor. I know it sounds offensive, but it is my truth.

This is only a guess, but I think the reasons BZD addiction/dependence doesn't get more attention are 1) that for whatever reason, drug seeking people don't seem to seek out BZDs. The people in withdrawal I've seen are like me: anxious people who didn't know they were becoming addicted when taking therapeutic doses and never taking more than prescribed. Therefore, you don't see the outrageous behavior that might call for a policy response. 2) There are protocols in place for dealing with opiate addiction. On the other hand, benzo withdrawal is seeped in mystery and misinformation. There's no good inpatient treatment option. And it's one of the only two I know of (alcohol being the other) that can be deadly.

I agree with almost everything that you say here, except for the part about drug-seekers not seeking benzos. I see plenty of drug-seeking behavior for benzos, and they're always quite upset to learn that they came to the wrong place. I haven't given much thought to this, but if I had to guess why drug-seeking behavior isn't more problematic for benzos, I'd say it's because it's so easy to get a prescription and/or because it's so easy to satisfy the withdrawal symptoms with alcohol, which is even easier to get.

One of the problems with benzos is that they work so well for anxiety, so doctors and patients both get positive reinforcement about them.
 
I hate this image of the drug-seeking BZD patient. Maybe he exists. But I will tell you that when I do research on benzos, I invariably find recreational drug forums. And those people are giving out BETTER advice on benzos (e.g., don't take them often, withdrawal is hell; also they don't seem to like benzos in that they don't make them feel "high") than I have been given by countless psychiatrists.

Oh believe me, they exist. Even before I fell 'victim' (I put that in commas because if I'm honest I was complicit in what happened as well, and I have to take responsibility for that) to bad prescribing practices, I was a drug seeking benzo user, because they were part of my overall drug/party lifestyle. There was a group of us who'd get together and hit up the local GPs to see what we could get, it was almost a challenge in a way, like just how far can I push the con with this Doctor. We'd get back and compare and display our scripts like they were badges of honour - "dude! OMG you got Klonopin? What did you get?...Oh I only got Valium....That sucks, check it out so and so friggin' scored an authority Xanax script with repeats!!!' There was a definite heirachy as well, the better you were at the game, and the more scripts/stronger stuff you could scam the more respect you earned and the higher up the ladder you were considered. Some of us were such experts at spinning BS that I swear 99% of Doctors we hit up didn't even see us coming - we had our con down to an art form. And then of course we'd just party our collective backsides off. I can remember going to 'byo' pill parties where everyone would dump their bottle of pills into a candy dish like they were mixed lollies and then proceed to get absolutely blitzed. Or we'd all use them as an adjunct to other illicit drugs we were taking, smooth out the edges of the meth, or the E's, or the acid we were dropping.

I'm not proud of my behaviour back then, not in the slightest. I do feel a lot of shame for what I did, but in some ways I wish I had just stuck to scamming pills and partying on them a couple of times a week, rather than having ended up in the situation I eventually did with a script happy Doctor practically pushing pill's down my throat and me being too much of an addict at the time to really stand up and say 'no' when by that point all I wanted was out. That's partly what I think these people on the recreational drug forums are talking about. The party doesn't last, and if you inevitably find yourself in a position where things have screwed up to the point that you're now a full blown addict facing physical withdrawal if you try and stop, then you're left wondering 'was it even worth it?'. And the answer to that is invariably 'no'.
 
IMHO state medical boards need to have a check-balance system where if a patient is on some mega-dose of it, other doctors can report them. You could argue we could do that anyway but the problem here is they rarely do anything so then you'll end up being the guy crying wolf though the problem is real. The only case where I've seen docs get in trouble with this is with Suboxone because like I said, they put you under a microscope for that med but not other controlled substances, and another guy in Ohio who was literally one of the biggest prescribers of opioids in America. It seems like they'll only go after you if you got a Suboxone license or if you very. very, very, very, very, very, much over-the-top abuse your power as a doc. Even for that one doc he ran a pill mill for several years before they even did anything.

http://www.vintondaily.com/news/pil...cle_f1efc18e-5757-11e1-bf63-0019bb2963f4.html

I just had a patient about 2 weeks ago in the PES, a nurse on mega dosages of Xanax and opioids for no reason I could find appropriate. We have a program called OARRS in Ohio that allows me to see every single prescriber in the state that prescribed her a controlled substance and she was getting it from multiple pharmacies but all the same doctor.

He was a guy in his mid 80s, still practicing, and I called his practice. I asked them to let me talk to the doc but they wouldn't let me. I told his staff members that I could in no way shape or form see how his prescribing practices on this patient could be considered appropriate and that if we saw similar cases from this same guy I would contact the state medical board, and they need to let him know this.
 
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Hi all,
Just wanted to get some thoughts on this.
Lets say there is a patient who has been prescribed clonazepam 16mg total daily for the past 8 or so years from a PCP. Her medication prescription database has been checked, and she is not filling inappropriately. she has severe panic attacks and has been taking it as prescribed. no hx of doctor shopping, DUI/DWI, family problems from use. Even though she is on a whopping dose of klonopin, would she qualify for an abuse/dependence diagnosis? Or is she moreso a product of inappropriate prescribing? While she is very apprehensive about lowering the doses, she has agreed to it and over months is now down to 4mg total daily.

Another part to my question is : how do you assess for the 'tolerance' and 'withdrawal' criteria in substance dependence? For sure, if a cancer pt was given 100mg morphine PO total daily over 4 months and then the patient ran out (because the could no longer afford the medication, not because they overused and ran out early), most likely the pt would go through withdrawal. But I'm not so sure that means that the patient was addicted per se. any person prescribed that amount could go through tolerance/withdrawal.
So, in checking the criteria of dependence, do you account for tolerance and withdrawal at full face value if it occurs under any context? Or does do they really only count towards the diagnosis only if its occurred in a maladaptive sense- say they are withdrawing because they ran out early due to taking more than prescribed?

You are asking multipart questions:
1) Even though she is on a whopping dose of klonopin, would she qualify for an abuse/dependence diagnosis? [without any Hx of doctor shopping, impaired function despite use, etc.]; and,
2) How do you assess for the 'tolerance' and 'withdrawal' criteria in substance dependence?

To answer these questions you need to understand the meaning of the terms, abuse. dependence, tolerance, and withdrawal (also called abstinence syndrome). You also need to understand the meaning of the term, addiction, which you refer to when you ask if the patient was addicted...

Prescription drug abuse means that a drug is being used by a patient in ways and for purposes that were not intended by the prescriber. You say that the patient has been taking Klonopin as prescribed so she hasn't been abusing the prescription.

Dependence is a term that refers to a psychophysiological state whereby exposure to a drug leads to the development of a situation in which the patient will experience adverse effects if the drug is discontinued. This essentially means that the patient will experience what are called withdrawal symptoms when the drug dose is lowered (too quickly) or discontinued. Dependence is usually due to changes in the expression (up or down-regulation) of cellular drug receptors, and can be seen with drugs "of abuse" like opiates,and benzodiazepines, as well as other drugs, like beta blockers...

Tolerance, also called tachyphylaxis, refers to a physiological response to a drug whereby the patient essentially develops a resistance to the effects of a drug with continued exposure to it. This means that an increasing amount of the drug is needed to obtain the drug's intended "effect." For opiates the intended effect is usually pain relief.

Addiction, as you indicate, refers to a psychological problem, whereby a patient exhibits dysfunctional and harmful behavior driven by some need for the patient to engage in the "addictive" behavior (in this case taking a drug) and such behavior continues despite the harm it may cause. Drug addiction is usually associated with the development of drug tolerance, dependence (and associated withdrawal symptoms).

I hope this helps answer your questions.
 
You are asking multipart questions:
1) Even though she is on a whopping dose of klonopin, would she qualify for an abuse/dependence diagnosis? [without any Hx of doctor shopping, impaired function despite use, etc.]; and,
2) How do you assess for the 'tolerance' and 'withdrawal' criteria in substance dependence?

To answer these questions you need to understand the meaning of the terms, abuse. dependence, tolerance, and withdrawal (also called abstinence syndrome). You also need to understand the meaning of the term, addiction, which you refer to when you ask if the patient was addicted...

Prescription drug abuse means that a drug is being used by a patient in ways and for purposes that were not intended by the prescriber. You say that the patient has been taking Klonopin as prescribed so she hasn't been abusing the prescription.

Dependence is a term that refers to a psychophysiological state whereby exposure to a drug leads to the development of a situation in which the patient will experience adverse effects if the drug is discontinued. This essentially means that the patient will experience what are called withdrawal symptoms when the drug dose is lowered (too quickly) or discontinued. Dependence is usually due to changes in the expression (up or down-regulation) of cellular drug receptors, and can be seen with drugs "of abuse" like opiates,and benzodiazepines, as well as other drugs, like beta blockers...

Tolerance, also called tachyphylaxis, refers to a physiological response to a drug whereby the patient essentially develops a resistance to the effects of a drug with continued exposure to it. This means that an increasing amount of the drug is needed to obtain the drug's intended "effect." For opiates the intended effect is usually pain relief.

Addiction, as you indicate, refers to a psychological problem, whereby a patient exhibits dysfunctional and harmful behavior driven by some need for the patient to engage in the "addictive" behavior (in this case taking a drug) and such behavior continues despite the harm it may cause. Drug addiction is usually associated with the development of drug tolerance, dependence (and associated withdrawal symptoms).

I hope this helps answer your questions.
Unfortunately, your explanation provides more clarity than the DSM-5 I don't know why so many people get confused by this, it's basic neurobiology and about the best understood. One thing I would add is that I like to distinguish between physical and psychological dependence.
 
You are asking multipart questions:
Prescription drug abuse means that a drug is being used by a patient in ways and for purposes that were not intended by the prescriber. You say that the patient has been taking Klonopin as prescribed so she hasn't been abusing the prescription.

Dependence is a term that refers to a psychophysiological state whereby exposure to a drug leads to the development of a situation in which the patient will experience adverse effects if the drug is discontinued. This essentially means that the patient will experience what are called withdrawal symptoms when the drug dose is lowered (too quickly) or discontinued. Dependence is usually due to changes in the expression (up or down-regulation) of cellular drug receptors, and can be seen with drugs "of abuse" like opiates,and benzodiazepines, as well as other drugs, like beta blockers...

Tolerance, also called tachyphylaxis, refers to a physiological response to a drug whereby the patient essentially develops a resistance to the effects of a drug with continued exposure to it. This means that an increasing amount of the drug is needed to obtain the drug's intended "effect." For opiates the intended effect is usually pain relief.

Addiction, as you indicate, refers to a psychological problem, whereby a patient exhibits dysfunctional and harmful behavior driven by some need for the patient to engage in the "addictive" behavior (in this case taking a drug) and such behavior continues despite the harm it may cause. Drug addiction is usually associated with the development of drug tolerance, dependence (and associated withdrawal symptoms).

I hope this helps answer your questions.

I so need to have this on hand for when people are asking me about my past BZD use, and I have to explain how it's possible for someone to go from being an addict, to being a dependent addict, to just being dependent without being an addict. For people who don't have a working or first hand knowledge of addiction/substance dependence it's all one and the same.
 
I view getting other physicians out of Benzo trouble as a large part of our bread and butter. Adding non-addicting anxiety treatment and tapering Benzos is what we should be good at. These aren’t bumps in the road, these kind of bumps are the road.

When you look at the number of patients on jacked up benzo and stimulant regimens(often together), a disproportionate number of them(relative to the total number of controlled prescriptions written) are from psychiatrists.

The idea we are the ones 'getting other physicians out of benzo trouble' is more fantasy than reality imo. And tapering benzos is hardly something only a psychiatrist could do- it would require an iq of about 85. I've not uncommonly seen situations where the psychiatrist has the patient on xnax 6mg daily and a stimulant....the patient runs out of money or loses insurance or whatever, and their primary care dr has to handle this aspect of the pt's care.
 
When you look at the number of patients on jacked up benzo and stimulant regimens(often together), a disproportionate number of them(relative to the total number of controlled prescriptions written) are from psychiatrists.

The idea we are the ones 'getting other physicians out of benzo trouble' is more fantasy than reality imo. And tapering benzos is hardly something only a psychiatrist could do- it would require an iq of about 85. I've not uncommonly seen situations where the psychiatrist has the patient on xnax 6mg daily and a stimulant....the patient runs out of money or loses insurance or whatever, and their primary care dr has to handle this aspect of the pt's care.

No doubt, there are plenty of bad psychiatrists out there writing all kinds of conflicting prescriptions, but the reasonably good ones are tapering a lot more Benzos than they are creating addiction. Maybe I do work in a psychiatry clinic and don’t see all of the tapering GPs are doing for us, but it sure feels like it is the other way around where I stand.
 
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No doubt, there are plenty of bad psychiatrists out there writing all kinds of conflicting prescriptions, but the reasonably good ones are tapering a lot more Benzos than they are creating addiction. Maybe I do work in a psychiatry clinic and don’t see all of the tapering GPs are doing for us, but it sure feels like it is the other way around where I stand.

well it all depends on the way your clinic does things.....if you're not initiating a lot of benzos and then continuing to push the dose at your clinic, of course you're going to be on the other end of things.

I will say that a lot of psychiatrists who inherit addicts on massive doses of benzos and accept the pt and start them on a long outpt benzo taper(starting at a high dose of course because they came in on such a high dose) are being played. What happens in many cases is that the patient ran out of self pay money or got fired from the other doc, and is just going to accept whatever he can from the new psychiatrist in the form of a taper while he supplements from wherever else he can get benzos(his aunt, friends, etc).....then when the taper gets to the point it's not worth it to him anymore, he just drops out of treatment and shops around again.

In this way, a lot of the psychiatrists who are supposedly anti-benzos actually end up writing a lot more benzos for misuse than psychiatrists(and pcps) who prescribe moderate doses of benzos to regular patients.

If I was in an outpt practice and saw an intake on 8mg of Klonopin for supposedly 3 years, I'd just explain to him that I am not interested in going down that long taper path and I would encourage him to seek treatment somewhere else.
 
Of course, psychiatrists are the ones doing it wrong and other doctors are the ones doing it right. Because Vistaril said so. Based on no more evidence than the opposing side has, but said with more confidence.
 
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Of course, psychiatrists are the ones doing it wrong and other doctors are the ones doing it right. Because Vistaril said so. Based on no more evidence than the opposing side has, but said with more confidence.

I didn't say that at all. And note that I didn't make a definitive comment on what is 'right' to begin with.
 
When you look at the number of patients on jacked up benzo and stimulant regimens(often together), a disproportionate number of them(relative to the total number of controlled prescriptions written) are from psychiatrists.
Source please?
 
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I did a quick search on this and came up with Vistaril. I did find a web site about how to convince your shrink you have ADHD.

http://exiledonline.com/adderall-tips-how-to-convince-your-shrink-you-have-addadhd/

Love this comment : "Wow, just….wow. I find it ridiculous that you are completely content with the exploitation of amphetamines. That, and you are incredibly pretentious to think you know what a psychiatrist is thinking. I feel as if the years of common intellect you’ve adorned yourself with frail in comparison to mastering of a degree."
 
I didn't say that at all. And note that I didn't make a definitive comment on what is 'right' to begin with.
This is so disingenuous. Sure, you didn't clearly state one was right and one was wrong, but that can be clearly inferred. Are you going to now claim that when you said:

"When you look at the number of patients on jacked up benzo and stimulant regimens(often together), a disproportionate number of them(relative to the total number of controlled prescriptions written) are from psychiatrists. "

you were NOT implying that psychiatrists are going wrong by getting "patients on jacked up benzo and stimulant regimens"?? At least have some integrity and stand behind your posts instead of pretending you don't believe that which you implied.
 
This is so disingenuous. Sure, you didn't clearly state one was right and one was wrong, but that can be clearly inferred. Are you going to now claim that when you said:

"When you look at the number of patients on jacked up benzo and stimulant regimens(often together), a disproportionate number of them(relative to the total number of controlled prescriptions written) are from psychiatrists. "

you were NOT implying that psychiatrists are going wrong by getting "patients on jacked up benzo and stimulant regimens"?? At least have some integrity and stand behind your posts instead of pretending you don't believe that which you implied.

you're making assumptions on a number of levels here. For starters, just because psychiatrists are going to prescribe a disproportionate number of high benzo regimens doesn't neccessarily mean they are unethical or lazy in every case. Psychiatrists are going to prescribe a disproportionate number of such drugs(again relative to the total number of controlled prescriptions written) just because they see a disproportionate number of these patients. Yes, primary care treats a lot....but they're also treating hypertension, kidney disease, HLD, etc......we aren't. You could also say that pain physicians write a disproportionate number of high dose opiates relative to the total number of practitioners.

But I'm not going to go on a wild goose chase trying to sort out all the assumptions you are making.
 
you're making assumptions on a number of levels here. For starters, just because psychiatrists are going to prescribe a disproportionate number of high benzo regimens doesn't neccessarily mean they are unethical or lazy in every case. Psychiatrists are going to prescribe a disproportionate number of such drugs(again relative to the total number of controlled prescriptions written) just because they see a disproportionate number of these patients. Yes, primary care treats a lot....but they're also treating hypertension, kidney disease, HLD, etc......we aren't. You could also say that pain physicians write a disproportionate number of high dose opiates relative to the total number of practitioners.

But I'm not going to go on a wild goose chase trying to sort out all the assumptions you are making.
... assuming you have correct assumptions.
 
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you're making assumptions on a number of levels here. For starters, just because psychiatrists are going to prescribe a disproportionate number of high benzo regimens doesn't neccessarily mean they are unethical or lazy in every case. Psychiatrists are going to prescribe a disproportionate number of such drugs(again relative to the total number of controlled prescriptions written) just because they see a disproportionate number of these patients. Yes, primary care treats a lot....but they're also treating hypertension, kidney disease, HLD, etc......we aren't. You could also say that pain physicians write a disproportionate number of high dose opiates relative to the total number of practitioners.

But I'm not going to go on a wild goose chase trying to sort out all the assumptions you are making.
I think your assumption that psychiatrists are prescribing the most because they are seeing exclusively patients that need psychotropics might be a bit off. I am not going to research it to provide a source but I am pretty sure that the medical docs are prescribing psychotropics more than psychiatrists just because there are so many more of them. We don't even have a psychiatrist in our town of about 10k but we have lots of medical docs, NPs, and PA's. Where do you think the patients get their Benzos?
 
A Pfizer rep. once told me that she spends more than 2/3rds of her time with primary care docs because they outnumber her psychiatrists 10:1 and are responsible for the majority of her sales.
 
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