Benzo vs other options for anxiety

[bedrock]

Question for the psychiatrists here from a pain physician.

All the national guidelines I’ve read about anxiety management, state that virtually no one should be prescribed chronic daily benzodiazepines for anxiety, (particularly short acting agents such as Xanax), and definitely not tid or qid dosing. Some papers do mention a small supply for rescue benzo doses to be used 3-5 times a month max.

Everything else should be used instead of benzos, so psychotherapy, multiple SSRI, buspirone, and other meds, etc is what I read in all these national guidelines.

However from my dozen years of experience working in the community of 3 very different states, I see countless patients on chronic TID Xanax.

A decent percentage of these #90 monthly Xanax scripts are written by PCPs, but far more come from psychiatrists than I would expect.

Please help me understand this discrepancy and what is discussed in psychiatry national meetings/residencies as I’d like to better understand if there is any true quality literature support for chronic daily bzd, particularly TID, qid dosing?

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[WisNeuro]

Question for the psychiatrists here from a pain physician.

All the national guidelines I’ve read about anxiety management, state that virtually no one should be prescribed chronic daily benzodiazepines for anxiety, (particularly short acting agents such as Xanax), and definitely not tid or qid dosing. Some papers do mention a small supply for rescue benzo doses to be used 3-5 times a month max.

Everything else should be used instead of benzos, so psychotherapy, multiple SSRI, buspirone, and other meds, etc is what I read in all these national guidelines.

However from my dozen years of experience working in the community of 3 very different states, I see countless patients on chronic TID Xanax.

A decent percentage of these #90 monthly Xanax scripts are written by PCPs, but far more come from psychiatrists than I would expect.

Please help me understand this discrepancy and what is discussed in psychiatry national meetings/residencies as I’d like to better understand if there is any true quality literature support for chronic daily bzd, particularly TID, qid dosing?

Dear god I wish this were true in practice.

 

[PikminOC]

Question for the psychiatrists here from a pain physician.

All the national guidelines I’ve read about anxiety management, state that virtually no one should be prescribed chronic daily benzodiazepines for anxiety, (particularly short acting agents such as Xanax), and definitely not tid or qid dosing. Some papers do mention a small supply for rescue benzo doses to be used 3-5 times a month max.

Everything else should be used instead of benzos, so psychotherapy, multiple SSRI, buspirone, and other meds, etc is what I read in all these national guidelines.

However from my dozen years of experience working in the community of 3 very different states, I see countless patients on chronic TID Xanax.

A decent percentage of these #90 monthly Xanax scripts are written by PCPs, but far more come from psychiatrists than I would expect.

Please help me understand this discrepancy and what is discussed in psychiatry national meetings/residencies as I’d like to better understand if there is any true quality literature support for chronic daily bzd, particularly TID, qid dosing?

Alot of times these are older physicians prescribing this. Newer ones don't usually do this.

 

[birchswing]

Question for the psychiatrists here from a pain physician.

All the national guidelines I’ve read about anxiety management, state that virtually no one should be prescribed chronic daily benzodiazepines for anxiety, (particularly short acting agents such as Xanax), and definitely not tid or qid dosing. Some papers do mention a small supply for rescue benzo doses to be used 3-5 times a month max.

Everything else should be used instead of benzos, so psychotherapy, multiple SSRI, buspirone, and other meds, etc is what I read in all these national guidelines.

However from my dozen years of experience working in the community of 3 very different states, I see countless patients on chronic TID Xanax.

A decent percentage of these #90 monthly Xanax scripts are written by PCPs, but far more come from psychiatrists than I would expect.

Please help me understand this discrepancy and what is discussed in psychiatry national meetings/residencies as I’d like to better understand if there is any true quality literature support for chronic daily bzd, particularly TID, qid dosing?

(I am not a doctor or psychiatrist.)

Stahl, who is a psychiatrist and thought leader and textbook writer of psychopharmacology, continues to advocate for benzodiazepines as first-line treatment for anxiety disorders.

Where I live, it has been the standard of care. We have low reimbursement rates and have difficulty attracting psychiatrists.

I was started on Ativan 2 mg daily at age 14 by a CAP. He continues to practice now 25 years later. And he's not geriatric by any means--he was young when I saw him. This was in either late 1997 or 1998. (I also believe my diagnosis was bogus. I have since read the definition of panic attacks, and to my knowledge I have never had what I have read described as a panic attack in my life. So it was the worst possible treatment for a disease I don't even believe I ever had.)

He was opposed to psychotherapy. I spent my 20s trying to find a psychiatrist who would help me taper (my dose was increased at college by another CAP and a second benzodiazepine added). I was told things like: "A big guy like you needs a higher dose." "You'd be a mess without those." When I brought up tapering with diazepam I was told diazepam was a "dirty drug" compared to the short acting benzos I was on. I presented the Ashton Manual and was told that benzodiazepine in England are different and that it didn't apply here. These are all quotes from board certified psychiatrists.

There has only been one change I have seen in my nearly 30 years as a psych patient with regard to this. That was when doctors got spooked by the opioid epidemic and state boards applying some pressure on concomitant opioid/benzo prescribing which trickled down to a fear of benzodiazepines themselves. It wasn't a change in evidence (if you wanted evidence for harm you could find it all the way back in the 1970s). It was that people started dying, and they started dying when they had benzodiazepines in their system. Some psychiatrists near me started sending their benzodiazepine patients to psych NPs, including ones they supervised (in my state you supervise for 2 years I think), which didn't make a lot of sense to me. But yeah, where I live the future is all psych NPs, and they are just as on board with benzos as the increasingly retiring psychiatrists they are replacing (this board often says they are outcompeting them--no we would not have practitioners without them--they are running solo, cash-only practices and are difficult to get into).

There are informed consent laws that are being proposed in state legislatures across the country. They are usually patient-sponsored. They require doctors to, well, basically give informed consent on the harms of benzodiazepines. The most recent has been in Massachusetts. Doctors are able to testify virtually (patients testify as well). Benzoinfo.com is a good resource if you want to get involved in the legislative efforts.

I wish I had something nicer to say, but if this does die away, and I'm not sure that it is, I think people will just patient-blame and say it was a long time ago, when it's happening now, and it really hasn't changed that much (in fact the prescription rates were steady increasing until the last few years and then increased again during the pandemic). I kind of think of like dental amalgam (the harm of benzos obviously much more quantifiable and much worse), but with dental amalgam it's sort of this thing where there's never any admission of anything, just a move away from it with no one ever really talking about it or accounting for the why. That is, again, if it actually does go away. There will no doubt be another article before too long with a headline like, "Were we wrong to condemn benzodiazepines?" Those come out from time to time.

I was very down on psychiatry before finding this forum because of my experiences. This forum will self-select for psychiatrists who care enough to talk about psychiatry outside of their daily jobs. There certainly are conscientious prescribers. It only takes one who isn't, though, to ruin many lives. And there are a lot more than one.

Edit:

Here is some of the testimony for the Massachusetts bill—I encourage you to watch to see the breadth of patient organizations working on this and to see the down up direction of this movement--so much of what these people say they heard from doctors are things I've heard:

 

[bedrock]

Thank you for your comments.

However, I’m only interested in hearing from MD/DO psychiatry attendings or residents, not from laypeople, premed students, mid level providers, etc.

 

[bedrock]

Alot of times these are older physicians prescribing this. Newer ones don't usually do this.

What is taught in contemporary psychiatry residencies regarding the use of benzodiazepines for anxiety?

 

[nexus73]

In my opinion, chronic benzos at relatively low dose have a place for some patients. It's not first line or second line. But in my experience there is a subset of patients who do not respond well to SSRI/SNRI/buspar/mirtazapine/TCA etc. Then something like lorazepam or clonazepam 0.5-1 mg twice a day works. The patient stops having panic attacks, they are no longer disabled by their anxiety. And they don't run out early or push for escalating doses, or lose their pills. And if they do show these red flags, I know that it's not going to work for them and we have to stop it. If you keep the dose relatively low and have to stop it, you're getting them off 2 mg a day instead of 8 mg a day.

I've read on some forums psychiatrists have a very clear cut position that they never use chronic benzos because "I don't need to". That they treat all their patients and never prescribe chronic benzos. It's not clear to me if these are just better doctors than me, or if the patients who don't get better with them on SSRI/SNRI/buspar/mirtazapine/TCA etc, just don't stay in their practice and get treated elsewhere.

I remember having a very cordial disagreement with a pain doctor who felt chronic opioids were very reasonable for pain, while chronic benzos were never appropriate for anxiety/panic disorder. And it was interesting that we had basically exactly opposite views.

 

[birchswing]

Thank you for your comments.

However, I’m only interested in hearing from MD/DO psychiatry attendings or residents, not from laypeople, premed students, mid level providers, etc.

Nobody wants to hear from Noam Chomsky today!

 

[PikminOC]

What is taught in contemporary psychiatry residencies regarding the use of benzodiazepines for anxiety?

We were taught not to use controlled subs at all in my residency

 

[futureapppsy2]

Two issues come to mind:
1. Older attendings who went through training when chronic benzo prescription was more medically acceptable and have not "corrected" their practice to current guidelines and standards

2. It's a lot easier (and perhaps more financially beneficial) in the short-term to just prescribe or continue prescriptions of benzos to patients who complain of anxiety than it is convince the patients to try alternative treatments that aren't going to feel as immediately effective. The siren song of more time, more money, and less stress can be very strong to some prescribers (including psychiatrists), even if it's ultimately to the detriment of patient care, health, and safety.

 

[futureapppsy2]

We were taught not to use controlled subs at all in my residency

Do you mean just for anxiety? I'd be surprised if a residency taught residents not prescribe stimulants (another controlled substance) for ADHD.

 

[ObsequiousAplomb]

What is taught in contemporary psychiatry residencies regarding the use of benzodiazepines for anxiety?

That there is a place for them. No guidelines actually say that nobody should ever take chronic benzos. They say it should be done only after careful consideration of risks and benefits, and not first line.

We're taught to consider the whole patient, come up with a plan that works for them. If they're severely anxious and there are no better alternatives, it's fine to give a short course while titrating the other medications.

Some psychiatrists give Zyprexa or Seroquel instead. My opinion is that Klonopin 0.5 to 4 mg total per day is safer than either of those for non-psychotic, non-bipolar people. Klonopin certainly wouldn't be my go-to, either though. I would prefer to start them off with an antidepressant and close followup. If they're really sick enough to warrant a benzo, I'm usually offering them therapy.

I seldom started Xanax in residency. Usually when I discussed RBA with patients they were too scared of becoming addicted. Panic disorder has a good deal of evidence for acute and maintenance benzos. The literature for maintenance says to go very high on the doses I never have gone that high for PD, but I see other doctors doing it. Half of the patients said they filled the prescription (never more than 14 days worth, no refills without multiple appointments to assess efficacy) but never took any. 12+ months later and the patient says they enjoy knowing they have a PRN available but they have never felt it was necessary. I counsel my patients that the PRN Xanax for panic disorder is meant to be an alternative to an ER trip. Again, they never really seem to need them. I don't have a particularly high dropout rate for this subset.

If the patient is severely anxious (GAD) has failed SSRI, Remeron, SNRI, TCA, and trazodone then I usually am reaching an end of what I plan to use for maintenance. I've found reasonable success with nefazodone. That same patient would probably have cycled through hydroxyzine, propranolol, and even trazodone as PRNs. As a rule they would have completed a full course of CBT as well. At that point I would consider a benzo.

I'd choose the drug based on purported side effects. Need some sedation? Klonopin sounds good. Can't be sedated? Low dose Xanax maybe. Need Xanax daily? You're getting the XR version, just about all insurances cover it and out of pocket it is cheap. I don't escalate doses due to tolerance. The anxiolytic effects don't habituate. Just the sedating ones do. I only go up if the previous dose wasn't effective enough all along. I don't if it was helpful for a few months and now isn't. Whatever the drug, close follow up with discussions about goals and progress.

Most of my patients taking benzos I didn't start. They came to me with records, I called their last psychiatrist, and I took over care. They need to have a good reason to leave the last doctor. If it was related to the benzo then I provide a list of referrals and tell them I cannot assume their care. If they moved 50+ miles, have records, and the doc checks out then I come up with a treatment plan.

I certainly don't shy away from benzos for catatonia. I go up to 20 mg Ativan daily for the challenge. Maintenance if effective and necessary.

 

[PikminOC]

Do you mean just for anxiety? I'd be surprised if a residency taught residents not prescribe stimulants (another controlled substance) for ADHD.

No stimulants either. Very few presented with adult ADHD when I trained in the mid 2000

 

[docksan]

Thank you for your comments.

However, I’m only interested in hearing from MD/DO psychiatry attendings or residents, not from laypeople, premed students, mid level providers, etc.

Curious as to why you think their opinions are any less valuable to your need for an answer.

There are indications for benzos in patients with panic attacks and even anxiety disorders. Right patient at the right time.

I don't make it a routine part of practice to start them for anxiety, but it's irresponsible to immediately stop them.

 

[TexasPhysician]

I don’t utilize TID benzos unless Im tapering from a higher dose. Outpatient tapers can take years. Unless you are reading my notes, you may not see what im doing. It certainly looks odd when I taper things like Ativan 26mg/day.

I don’t use Xanax near as often as alternatives. That said, benzodiazepines certainly have their place.

From a risk perspective, I’d much rather take a benzodiazepine than a neuroleptic. No one bats an eye at chronic neuroleptic usage. Anxiety can be quite debilitating. That said, it’s important to watch for addiction and abuse.

 

[ObsequiousAplomb]

No stimulants either. Very few presented with adult ADHD when I trained in the mid 2000

I imagine very few presented because the standard of care for the condition wasn't being met at that facility. I've always been a little apprehensive of training programs that say they don't do a certain thing, especially when it's standard of care.

 

[bedrock]

Curious as to why you think their opinions are any less valuable to your need for an answer.

There are indications for benzos in patients with panic attacks and even anxiety disorders. Right patient at the right time.

I don't make it a routine part of practice to start them for anxiety, but it's irresponsible to immediately stop them.

If you don't understand why I value the responses from physician specialists over literally anyone else, then I question whether you are a physician and if you are a physician then I question your intelligence.

You seriously don't think that a minimum of 12 years of education and ten of thousands of hours spent in clinical work, research, conferences, etc, doesn't make a board certified psychiatrist a 100 times more qualified to answer my question than a layperson, premed, or mid level?

 

[bedrock]

That there is a place for them. No guidelines actually say that nobody should ever take chronic benzos. They say it should be done only after careful consideration of risks and benefits, and not first line.

We're taught to consider the whole patient, come up with a plan that works for them. If they're severely anxious and there are no better alternatives, it's fine to give a short course while titrating the other medications.

Some psychiatrists give Zyprexa or Seroquel instead. My opinion is that Klonopin 0.5 to 4 mg total per day is safer than either of those for non-psychotic, non-bipolar people. Klonopin certainly wouldn't be my go-to, either though. I would prefer to start them off with an antidepressant and close followup. If they're really sick enough to warrant a benzo, I'm usually offering them therapy.

I seldom started Xanax in residency. Usually when I discussed RBA with patients they were too scared of becoming addicted. Panic disorder has a good deal of evidence for acute and maintenance benzos. The literature for maintenance says to go very high on the doses I never have gone that high for PD, but I see other doctors doing it. Half of the patients said they filled the prescription (never more than 14 days worth, no refills without multiple appointments to assess efficacy) but never took any. 12+ months later and the patient says they enjoy knowing they have a PRN available but they have never felt it was necessary. I counsel my patients that the PRN Xanax for panic disorder is meant to be an alternative to an ER trip. Again, they never really seem to need them. I don't have a particularly high dropout rate for this subset.

If the patient is severely anxious (GAD) has failed SSRI, Remeron, SNRI, TCA, and trazodone then I usually am reaching an end of what I plan to use for maintenance. I've found reasonable success with nefazodone. That same patient would probably have cycled through hydroxyzine, propranolol, and even trazodone as PRNs. As a rule they would have completed a full course of CBT as well. At that point I would consider a benzo.

I'd choose the drug based on purported side effects. Need some sedation? Klonopin sounds good. Can't be sedated? Low dose Xanax maybe. Need Xanax daily? You're getting the XR version, just about all insurances cover it and out of pocket it is cheap. I don't escalate doses due to tolerance. The anxiolytic effects don't habituate. Just the sedating ones do. I only go up if the previous dose wasn't effective enough all along. I don't if it was helpful for a few months and now isn't. Whatever the drug, close follow up with discussions about goals and progress.

Most of my patients taking benzos I didn't start. They came to me with records, I called their last psychiatrist, and I took over care. They need to have a good reason to leave the last doctor. If it was related to the benzo then I provide a list of referrals and tell them I cannot assume their care. If they moved 50+ miles, have records, and the doc checks out then I come up with a treatment plan.

I certainly don't shy away from benzos for catatonia. I go up to 20 mg Ativan daily for the challenge. Maintenance if effective and necessary.

Two issues come to mind:
1. Older attendings who went through training when chronic benzo prescription was more medically acceptable and have not "corrected" their practice to current guidelines and standards

2. It's a lot easier (and perhaps more financially beneficial) in the short-term to just prescribe or continue prescriptions of benzos to patients who complain of anxiety than it is convince the patients to try alternative treatments that aren't going to feel as immediately effective. The siren song of more time, more money, and less stress can be very strong to some prescribers (including psychiatrists), even if it's ultimately to the detriment of patient care, health, and safety.

Thank you both. Very helpful understanding the history and pressures in clinical practice, but also how this should be approached academically.

 

[docksan]

If you don't understand why I value the responses from physician specialists over literally anyone else, then I question whether you are a physician and if you are a physician then I question your intelligence.

You seriously don't think that a minimum of 12 years of education and ten of thousands of hours spent in clinical work, research, conferences, etc, doesn't make a board certified psychiatrist a 100 times more qualified to answer my question than a layperson, premed, or mid level?

Given your haughty response I'd be surprised if your questions ever venture beyond the superficial.

Feel free to weigh opinions according to your own lens, but you'll never know which ones are worth their weight if you filter them out before you hear them.

 

[bedrock]

In my opinion, chronic benzos at relatively low dose have a place for some patients. It's not first line or second line. But in my experience there is a subset of patients who do not respond well to SSRI/SNRI/buspar/mirtazapine/TCA etc. Then something like lorazepam or clonazepam 0.5-1 mg twice a day works. The patient stops having panic attacks, they are no longer disabled by their anxiety. And they don't run out early or push for escalating doses, or lose their pills. And if they do show these red flags, I know that it's not going to work for them and we have to stop it. If you keep the dose relatively low and have to stop it, you're getting them off 2 mg a day instead of 8 mg a day.

I've read on some forums psychiatrists have a very clear cut position that they never use chronic benzos because "I don't need to". That they treat all their patients and never prescribe chronic benzos. It's not clear to me if these are just better doctors than me, or if the patients who don't get better with them on SSRI/SNRI/buspar/mirtazapine/TCA etc, just don't stay in their practice and get treated elsewhere.

I remember having a very cordial disagreement with a pain doctor who felt chronic opioids were very reasonable for pain, while chronic benzos were never appropriate for anxiety/panic disorder. And it was interesting that we had basically exactly opposite views.

thank you for the answer. would all of you agree with OA, that patients don't habituate to the anxiolyic effects of benzos just to the sedation?

I ask because in the pain world, patients habituate to the pain relieving effects of opioids, but not to the side effects of respiratory depression, constipation, etc. This is a big reason why chronic standard opioids don't work well long term, (besides issues of dependence and endocrine disruption).

Outside of terminal patients, I don't feel that chronic round the clock standard opioids truly work or are indicated. When someone's mu receptors are exposed to standard opioids all day long, patients will develop opioid induced hyperalgesia, and suffer worse pain, than if they were not on opioids.

This is one of the reasons, why I wanted to understand what modern psychiatrists are taught and how you practice with BZD and anxiety.

 

[bedrock]

Given your haughty response I'd be surprised if your questions ever venture beyond the superficial.

Feel free to weigh opinions according to your own lens, but you'll never know which ones are worth their weight if you filter them out before you hear them.

it appears you are not a physician, and clearly suffer from an inferiority complex.

Sorry for you.

 

[docksan]

it appears you are not a physician, and clearly suffer from an inferiority complex.

Sorry for you.

I am actually a physician, am happy to discuss medicine on an equivalent level, and your attitude clearly demonstrates which of the two of us have a complex.

So please don't be sorry, I'm quite respected amongst my colleagues.

 

[bedrock]

I am actually a physician, am happy to discuss medicine on an equivalent level, and your attitude clearly demonstrates which of the two of us have a complex.

So please don't be sorry, I'm quite respected amongst my colleagues.

are you a board certified psychiatrist?

 

[docksan]

are you a board certified psychiatrist?

We moving the goal posts now? Did you not request MD/DO psychiatrists?

I would offer to send you a picture of my credentials, but I imagine you will then say only Ivy League practitioners with research experience can chime in.

It is a shame you cannot find value in any opinion other than those you narrow down to a pin.

 

[birchswing]

If you don't understand why I value the responses from physician specialists over literally anyone else, then I question whether you are a physician and if you are a physician then I question your intelligence.

You seriously don't think that a minimum of 12 years of education and ten of thousands of hours spent in clinical work, research, conferences, etc, doesn't make a board certified psychiatrist a 100 times more qualified to answer my question than a layperson, premed, or mid level?

You were quite right not to listen to me.

I wasn't even wearing a top hat when I wrote my response!

I should be careful of anyone not wearing a top hat. It's one of the best markers we have for epistemic validity these days.

More seriously, some of the people who do all that stuff you listed (the 12 years etc) go by "Dr. Miami" and do butt lifts live streamed on YouTube while dancing to music and take the patient consenting to have their surgeries livestreamed as payment for service. Some are running for Congress and are idiots (like brag about how they're going to win Celebrity Jeopardy and come in last, but just are generally idiots, too). (I'm talking about Dr. Oz in case it wasn't clear, a very well credentialed idiot.)

Some helped addict thousands if not millions to benzodiazepines, which is quite ironic, given that your originating post was questioning the wisdom of psychiatrists prescribing in this way. But now they're suddenly all vaunted. There's obviously heterogeneity in all populations. I can understand when people want to talk shop. But in this case, I commented because I have had a front seat to this problem for longer than I would imagine many here have been practicing medicine, so I thought myself in a position to give history as I have seen it unfold, and since you seemed concerned yourself about the practice of very credentialed psychiatrists I offered how you can advocate to change the practices through legislation. I am not offended in the least, though, if it's talking shop with your colleagues you are after, which I cannot really help with.

 

[bedrock]

We moving the goal posts now? Did you not request MD/DO psychiatrists?

I would offer to send you a picture of my credentials, but I imagine you will then say only Ivy League practitioners with research experience can chime in.

It is a shame you cannot find value in any opinion other than those you narrow down to a pin.

I didn't create your inferiority complex... I expect it had something to do with your previous life experiences including this statement of yours that I found after a 30 second search on SDN.

"I have 3 Fs, 2Ds, and multiple Cs on my college transcripts and am now a resident"

Kudos to you for getting into a medical school, (hopefully in north america?), after that college record.

It gives you empathy toward those with less education, intelligence, and/or mistakes in their lives, which is a good thing, particularly for a psychiatrist, but it also shouldn't blind you into thinking that a medical opinion from a layperson or midlevel is remotely as valid as one from a board certified physician.

 

[bedrock]

You were quite right not to listen to me.

I wasn't even wearing a top hat when I wrote my response!

I should be careful of anyone not wearing a top hat. It's one of the best markers we have for epistemic validity these days.

More seriously, some of the people who do all that stuff you listed (the 12 years etc) go by "Dr. Miami" and do butt lifts live streamed on YouTube while dancing to music and take the patient consenting to have their surgeries livestreamed as payment for service. Some are running for Congress and are idiots (like brag about how they're going to win Celebrity Jeopardy and come in last, but just are generally idiots, too). (I'm talking about Dr. Oz in case it wasn't clear, a very well credentialed idiot.)

Some helped addict thousands if not millions to benzodiazepines, which is quite ironic, given that your originating post was questioning the wisdom of psychiatrists prescribing in this way. But now they're suddenly all vaunted. There's obviously heterogeneity in all populations. I can understand when people want to talk shop. But in this case, I commented because I have had a front seat to this problem for longer than I would imagine many here have been practicing medicine, so I thought myself in a position to give history as I have seen it unfold, and since you seemed concerned yourself about the practice of very credentialed psychiatrists I offered how you can advocate to change the practices through legislation. I am not offended in the least, though, if it's talking shop with your colleagues you are after, which I cannot really help with.

I certainly didn't want to offend you. I realize you were just trying to help, which is why I thanked you in my previous post.

However, I wanted to hear from seasoned psychiatrists who have treated thousands of patients, because the accumulation of those years of experience, papers, conferences, etc, does mean more to me than a personal anecdote.

 

[docksan]

I didn't create your inferiority complex... I expect it had something to do with your previous life experiences including this statement of yours that I found after a 30 second search on SDN.

"I have 3 Fs, 2Ds, and multiple Cs on my college transcripts and am now a resident"

Kudos to you for getting into a medical school, (hopefully in north america?), after that college record.

It gives you empathy toward those with less education and/or mistakes in their lives, which is a good thing, particularly for a psychiatrist, but it also shouldn't blind you into thinking that a laypersons medical opinion is remotely as valid as one from a board certified physician.

I don't have an inferiority complex, lol, but kudos for looking through my post history in a vain attempt to make an irrelevant point.

My past defines what is behind me, not ahead. I only wish the substance of your posts could reach the fathoms of your ego.

 

[bedrock]

I don't have an inferiority complex, lol, but kudos for looking through my post history in a vain attempt to make an irrelevant point.

My past defines what is behind me, not ahead. I only wish the substance of your posts could reach the fathoms of your ego.

I hope to hear more rational responses from psychiatrists on SDN regarding my original question, but I'm not going to further debate what is entirely obvious about you

"methinks thou dost protest too much"

 

[docksan]

I hope to hear more rational responses from psychiatrists on SDN regarding my original question, but I'm not going to further debate what is entirely obvious about you

"methinks thou dost protest too much"

Honestly I'd have a better chance teaching a textbook something new than for you to gain the perspective you need to overcome your hubris.

You assume far more about me than is true and it demonstrates my point quite nicely.

I will continue to grow. You will not.

 

[futureapppsy2]

Mod note: Everyone, please keep it civil and professional and refrain from personal attacks.

 

[untapped]

What is taught in contemporary psychiatry residencies regarding the use of benzodiazepines for anxiety?

In my residency we're being taught to pretty much never use them first line. When patients have debilitating anxiety and have exhausted other meds in addition to therapy, then faculty opinions are split, with older attendings tending to favor benzo use more than younger ones. I've never been instructed to start xanax over klonopin, valium, or ativan.

 

[Stagg737]

Mod note: Everyone, please keep it civil and professional and refrain from personal attacks.

All those title banners and not even a mod, found the nurse!

Jk, we all know you, I just couldn't resist 😋

 

[futureapppsy2]

All those title banners and not even a mod, found the nurse!

Jk, we all know you, I just couldn't resist 😋

We replaced “moderator” with “volunteer staff” a few months ago.

 

[UTsksk]

What is taught in contemporary psychiatry residencies regarding the use of benzodiazepines for anxiety?

At my program we’re encouraged to focus on alternatives aside from benzos. If we have to initiate because the person is just not functioning at all, we will do low doses of diazepam or clonazepam with an agreed upon contract. Sometimes a benzo will be used while waiting for SSRI or SNRI to get full effect.

 

[FlowRate]

I think most people here covered more or less what I'd say. If you ever see a pt on TID Xanax with my name attached, it's because I inherited them and there are bigger fish we need to fry before I can start working on tapering the Xanax. If I'm convinced they actually need the benzo, I'll work on switching to lorazepam or clonazepam.

 

[birchswing]

I certainly didn't want to offend you. I realize you were just trying to help, which is why I thanked you in my previous post.

However, I wanted to hear from seasoned psychiatrists who have treated thousands of patients, because the accumulation of those years of experience, papers, conferences, etc, does mean more to me than a personal anecdote.

No problem. I am not offended. I would just keep in mind, if you can bear one more piece of advice, you'll hear from a self-selecting group. People here graduated more recently, are conscientious enough to participate in this forum, etc. You won't find the psychiatrists who prescribe liberally and automatically here. I know because I came to this forum a long time ago with my airing of grievances and found a world of psychiatry outside that I had experienced.

 

[Stagg737]

Question for the psychiatrists here from a pain physician.

All the national guidelines I’ve read about anxiety management, state that virtually no one should be prescribed chronic daily benzodiazepines for anxiety, (particularly short acting agents such as Xanax), and definitely not tid or qid dosing. Some papers do mention a small supply for rescue benzo doses to be used 3-5 times a month max.

Everything else should be used instead of benzos, so psychotherapy, multiple SSRI, buspirone, and other meds, etc is what I read in all these national guidelines.

However from my dozen years of experience working in the community of 3 very different states, I see countless patients on chronic TID Xanax.

A decent percentage of these #90 monthly Xanax scripts are written by PCPs, but far more come from psychiatrists than I would expect.

Please help me understand this discrepancy and what is discussed in psychiatry national meetings/residencies as I’d like to better understand if there is any true quality literature support for chronic daily bzd, particularly TID, qid dosing?

Agree that in my experience most of this will come from "older" psychiatrists, meaning people who completed residency 10-15+ years ago. I don't think any of the recent grads from my program would actually start a patient on high doses of benzos or Xanax regularly. There's some literature for use in panic disorder and it's technically part of the treatment algorithm for GAD, but the risk/benefit typically leans heavily enough against chronic scheduled use that they're typically advised against.

What is taught in contemporary psychiatry residencies regarding the use of benzodiazepines for anxiety?

It will vary even within programs. Most of my attendings are generally against them and the two psychiatrists who I worked directly in the pain clinic with are very against them to the point that one of them would not prescribe them at all (even in the gen psych clinic) unless there was a plan to taper. Meanwhile, one of the outpatient attendings is fairly liberal with them and will prescribe them scheduled for anxiety fairly quickly. Generally we are taught not to use them for anxiety long-term.

I don't escalate doses due to tolerance. The anxiolytic effects don't habituate. Just the sedating ones do. I only go up if the previous dose wasn't effective enough all along. I don't if it was helpful for a few months and now isn't.

Say what now? I've had plenty of patients who developed tolerance to benzos in regards to anxiety. A lot of times someone doing alright on it who then has a major stressor with elevated anxiety, and suddenly the benzo just doesn't work as well anymore. This is separate from those individuals who likely have a SUD-related component where they just keep asking for higher and higher doses.

I certainly don't shy away from benzos for catatonia. I go up to 20 mg Ativan daily for the challenge. Maintenance if effective and necessary.

20mg just for a challenge? Why not just start ECT at that point if you're certain it's catatonia?

Ativan 26mg/day.

would all of you agree with OA, that patients don't habituate to the anxiolyic effects of benzos just to the sedation?

No, I've had plenty of patients who reported habituating or developing tolerance to the anxiolytic effects and most of my patients who felt that benzos were sedating during the day did not acclimate to that. Effects on sleep are a different story ime.

 

[FlowRate]

Hijacking the thread a little, especially since OP is a pain doc. I've been getting a lot of patients lately who are being forced off of their 20 year stable lowish dose benzo+moderate dose opioid combination (no escalating doses, no early fills.) I find this to be an exceptionally frustrating situation because really nothing works like a benzo and these patients start freaking out. If it's stable for literal decades then I don't see the rush to pull them off other than well-reasoned but hamfistedly applied quality metrics regarding coprescribing. Very curious if anyone disagrees and thinks that it is urgent to pull these people off one of their meds. Half of the time this DOES lead to some issues with their opioid Rx that weren't there before because their anxiety is making the pain worse. Usually these people are already on or have already tried a bunch of other reasonable anxiety options (again, decades ago.)

 

[nexus73]

Agree that in my experience most of this will come from "older" psychiatrists, meaning people who completed residency 10-15+ years ago. I don't think any of the recent grads from my program would actually start a patient on high doses of benzos or Xanax regularly. There's some literature for use in panic disorder and it's technically part of the treatment algorithm for GAD, but the risk/benefit typically leans heavily enough against chronic scheduled use that they're typically advised against.


It will vary even within programs. Most of my attendings are generally against them and the two psychiatrists who I worked directly in the pain clinic with are very against them to the point that one of them would not prescribe them at all (even in the gen psych clinic) unless there was a plan to taper. Meanwhile, one of the outpatient attendings is fairly liberal with them and will prescribe them scheduled for anxiety fairly quickly. Generally we are taught not to use them for anxiety long-term.



Say what now? I've had plenty of patients who developed tolerance to benzos in regards to anxiety. A lot of times someone doing alright on it who then has a major stressor with elevated anxiety, and suddenly the benzo just doesn't work as well anymore. This is separate from those individuals who likely have a SUD-related component where they just keep asking for higher and higher doses.



20mg just for a challenge? Why not just start ECT at that point if you're certain it's catatonia?





No, I've had plenty of patients who reported habituating or developing tolerance to the anxiolytic effects and most of my patients who felt that benzos were sedating during the day did not acclimate to that. Effects on sleep are a different story ime.

Sometimes ECT isn’t available.

 

[Celexa]

To echo what others have said, younger docs are less likely to use chronic benzos.

In my residency we follow the guidelines you quote. Benzos are not first line. I strongly prefer to have an off ramp planned. You can easily make things worse in the long run depending on the exact dynamics and symptoms at play. There are a small number of patients who do do well on chronic low dose benzos and I'm not against it completely. However, the vast majority of patient I see on it chronically were not prescribed them in a thoughtful way. TID Xanax is never thoughtful. The patient is inevitably clutching the med desperately, has both physiologic and psychological dependence, and should have received better pharmacotherapy paired with cbt ages ago.

That being said as many people have alluded to I don't automatically judge someone for prescribing it until I know whether they were the one who started it or just stuck with it trying to nudge the pt to a better path.

We also use benzos in bipolar disorder--they can be invaluable for keeping a manic patient out of the hospital. This use tends to fall between sporadic and chronic (can be for weeks at a time, moderate to high dose).

There are also a very, very small number of parents with chronic catatonia who genuinely need high dose benzos long term. This is completely different from prescribing for anxiety and exceedingly rare--but it does exist.

I never prescribe Xanax when I'm starting a benzo.

 

[tr]

Hijacking the thread a little, especially since OP is a pain doc. I've been getting a lot of patients lately who are being forced off of their 20 year stable lowish dose benzo+moderate dose opioid combination (no escalating doses, no early fills.) I find this to be an exceptionally frustrating situation because really nothing works like a benzo *to stave off benzodiazepine withdrawal*

FTFY

and these patients start freaking out. If it's stable for literal decades then I don't see the rush to pull them off other than well-reasoned but hamfistedly applied quality metrics regarding coprescribing.

If it's been stable for decades that implies they are moving into late middle age or geriatric phase and are at high risk for falls, dementia, and milder forms of cognitive impairment from the benzo. Agreed that chronic benzo dosing should never be pulled off 'in a rush' (as per TexasPhysician's post above it can take months or even years). But it absolutely should be done.

Very curious if anyone disagrees and thinks that it is urgent to pull these people off one of their meds. Half of the time this DOES lead to some issues with their opioid Rx that weren't there before because their anxiety is making the pain worse. Usually these people are already on or have already tried a bunch of other reasonable anxiety options (again, decades ago.)

I've tapered lots of patients off their chronic benzos and I have never seen one who missed them once they were done with the process. Usually they are thrilled to recover cognitive function they didn't know they had. Chronic benzo use is not treating the baseline anxiety; it is treating the anxiety that is a symptom of benzodiazepine withdrawal.

 

[ObsequiousAplomb]

Agree that in my experience most of this will come from "older" psychiatrists, meaning people who completed residency 10-15+ years ago. I don't think any of the recent grads from my program would actually start a patient on high doses of benzos or Xanax regularly. There's some literature for use in panic disorder and it's technically part of the treatment algorithm for GAD, but the risk/benefit typically leans heavily enough against chronic scheduled use that they're typically advised against.


It will vary even within programs. Most of my attendings are generally against them and the two psychiatrists who I worked directly in the pain clinic with are very against them to the point that one of them would not prescribe them at all (even in the gen psych clinic) unless there was a plan to taper. Meanwhile, one of the outpatient attendings is fairly liberal with them and will prescribe them scheduled for anxiety fairly quickly. Generally we are taught not to use them for anxiety long-term.



Say what now? I've had plenty of patients who developed tolerance to benzos in regards to anxiety. A lot of times someone doing alright on it who then has a major stressor with elevated anxiety, and suddenly the benzo just doesn't work as well anymore. This is separate from those individuals who likely have a SUD-related component where they just keep asking for higher and higher doses.



20mg just for a challenge? Why not just start ECT at that point if you're certain it's catatonia?





No, I've had plenty of patients who reported habituating or developing tolerance to the anxiolytic effects and most of my patients who felt that benzos were sedating during the day did not acclimate to that. Effects on sleep are a different story ime.

In my experience the "older" ones freely giving benzos completed their residency more like 30-50+ years ago. Definitely getting less common over the years as the pendulum swings against benzos.

As to the habituation: sounds like most of the patients you're talking about have an acute stressor / crisis, which is different than what I was referring to. Some patients may serve to go up from Klonopin 2 mg to 4 mg per day over many years, but I generally don't do that. The ones who come to me are more inclined to stay at 2 through a crisis or go lower as their general plan and I ally with their reluctance to increase by doing something other than increase it. I've never increased a chronic patient above the equivalent of 2 mg Klonopin per day. I have no reluctance to bring a 0.25 or 0.5 up to 2 if it really seems indicated and they don't have a history of difficulty tapering. I would probably go up to 4 mg in the short term for certain indications, but those happen so seldom that they're nothing for me to comment on.

The first time I had to cover for a colleague in the outpatient setting I saw that a lot of patients were getting Xanax 2 TID and many "ran out" of the 30 day supply with 2 refills every time he went on vacation. His notes weren't up to my satisfaction for that, but they were his patients not mine. Interestingly, some patients transferred over to me and we went ahead with a taper (I didn't actively encourage this, it seemed to be the patients' plans since it was one of the first things they said and I didn't put up any resistance). If I were giving 6 mg of Xanax it would absolutely be the XR. They could have trazodone 25-50 mg TID if they want something they can feel during the day.

As to the ECT: where I practice only one place does ECT and it's voluntary only. If I'm going to be getting ECT for a catatonic or psychotic patient it usually takes a year to arrange. I strongly desire to move somewhere that ECT is available, it's always been a dream job for me. I usually don't have access to an IV either. None of the local psych units do and the IM services refuse to admit a patient to get IV Ativan.

So I go Ativan 2-4 mg PO q2HPRN until I see a response or hit ~24 mg / day for one week without a response. Pretty easy to get that up to 20 mg in no time. I've never had a problem with AE when going that high for catatonia, and there's no reason to taper if it's been less than a week and wasn't at all effective.

I also do amantadine/memantine, clozapine, Remeron, Ritalin, and/or other typically used agents, depending on the exact presentation / response.

 

[FlowRate]

FTFY



If it's been stable for decades that implies they are moving into late middle age or geriatric phase and are at high risk for falls, dementia, and milder forms of cognitive impairment from the benzo. Agreed that chronic benzo dosing should never be pulled off 'in a rush' (as per TexasPhysician's post above it can take months or even years). But it absolutely should be done.




I've tapered lots of patients off their chronic benzos and I have never seen one who missed them once they were done with the process. Usually they are thrilled to recover cognitive function they didn't know they had. Chronic benzo use is not treating the baseline anxiety; it is treating the anxiety that is a symptom of benzodiazepine withdrawal.

Fair points, I think you hit on exactly my objection which is I'm usually getting them after they're rushed off the benzo by their PCP so as you point out it probably is withdrawal. I am in total agreement with goal to taper off at a reasonable pace.

 

[comp1]

I'd recommend the OP contact the prescribers and ask them. I spend a good chunk of my day talking to the more active prescribers of controlled substances. We don't talk enough doctor to doctor.

 

[the5thelement]

Its the patients who have been on them for long periods who are the most resistant."Why did the last doctor give it to me if its no good? If it aint broke why are you trying to fix it? etc."
I think a good therapeutic alliance goes a long way.
The literature discourages chronic benzo use. Short term use (<1 month) while initiating SSRIs can help reduce some on the initial anxiety associated with starting antidepressants and they defintely work as a short term anxioltyic (used as rescue).
Even if the patient is resistant, our ultimate duty is to do no harm and to gently educate the patient about the long term harm which can result from chronic benzo use.

 

[futureapppsy2]

I'd recommend the OP contact the prescribers and ask them. I spend a good chunk of my day talking to the more active prescribers of controlled substances. We don't talk enough doctor to doctor.

This is an excellent point. There may be specifics for a given patient that make a clinician decision that looks weird or poor on paper make perfect sense for that patient's history and circumstances.

 

[Ironspy]

Chronic benzos are only started by me for for Catalonia or palliative care. I’ve inherited a number of elderly patients on chronic low dose benzos. They understand the risks of this regimen and most don’t want to taper. I document this discussion and move on as the benefits of tapering an otherwise healthy 80 year old with a 30+ year benzo HX aren’t great IMO. Younger patients on benzos get tapered off. They are in control of the speed of taper (can be years if there are no acute concerns) but that’s the stated plan. If they are not on board they vote with their feet which is fine. Lots of other places to get benzos around here

 

[Stagg737]

Hijacking the thread a little, especially since OP is a pain doc. I've been getting a lot of patients lately who are being forced off of their 20 year stable lowish dose benzo+moderate dose opioid combination (no escalating doses, no early fills.) I find this to be an exceptionally frustrating situation because really nothing works like a benzo and these patients start freaking out. If it's stable for literal decades then I don't see the rush to pull them off other than well-reasoned but hamfistedly applied quality metrics regarding coprescribing. Very curious if anyone disagrees and thinks that it is urgent to pull these people off one of their meds. Half of the time this DOES lead to some issues with their opioid Rx that weren't there before because their anxiety is making the pain worse. Usually these people are already on or have already tried a bunch of other reasonable anxiety options (again, decades ago.)

I generally agree with you. Obviously, if these patients can get off both meds that's great, but IMO maintaining a decent QoL is just as important as getting off the meds. It's always a risk v benefit discussion, and sometimes the benefits of those meds outweigh the perceived risks.

In my experience the "older" ones freely giving benzos completed their residency more like 30-50+ years ago. Definitely getting less common over the years as the pendulum swings against benzos.

As to the habituation: sounds like most of the patients you're talking about have an acute stressor / crisis, which is different than what I was referring to. Some patients may serve to go up from Klonopin 2 mg to 4 mg per day over many years, but I generally don't do that. The ones who come to me are more inclined to stay at 2 through a crisis or go lower as their general plan and I ally with their reluctance to increase by doing something other than increase it. I've never increased a chronic patient above the equivalent of 2 mg Klonopin per day. I have no reluctance to bring a 0.25 or 0.5 up to 2 if it really seems indicated and they don't have a history of difficulty tapering. I would probably go up to 4 mg in the short term for certain indications, but those happen so seldom that they're nothing for me to comment on.

The first time I had to cover for a colleague in the outpatient setting I saw that a lot of patients were getting Xanax 2 TID and many "ran out" of the 30 day supply with 2 refills every time he went on vacation. His notes weren't up to my satisfaction for that, but they were his patients not mine. Interestingly, some patients transferred over to me and we went ahead with a taper (I didn't actively encourage this, it seemed to be the patients' plans since it was one of the first things they said and I didn't put up any resistance). If I were giving 6 mg of Xanax it would absolutely be the XR. They could have trazodone 25-50 mg TID if they want something they can feel during the day.

As to the ECT: where I practice only one place does ECT and it's voluntary only. If I'm going to be getting ECT for a catatonic or psychotic patient it usually takes a year to arrange. I strongly desire to move somewhere that ECT is available, it's always been a dream job for me. I usually don't have access to an IV either. None of the local psych units do and the IM services refuse to admit a patient to get IV Ativan.

So I go Ativan 2-4 mg PO q2HPRN until I see a response or hit ~24 mg / day for one week without a response. Pretty easy to get that up to 20 mg in no time. I've never had a problem with AE when going that high for catatonia, and there's no reason to taper if it's been less than a week and wasn't at all effective.

I also do amantadine/memantine, clozapine, Remeron, Ritalin, and/or other typically used agents, depending on the exact presentation / response.

Fair point about ECT, I suppose I've been a bit spoiled in that sense. We've gone as high 25-30mg to treat catatonia in patients whose guardians/DPOAs don't want ECT. I've never seen a situation of going that high for the challenge portion unless we were certain it was catatonia though.

Short term use (<1 month) while initiating SSRIs can help reduce some on the initial anxiety associated with starting antidepressants and they defintely work as a short term anxioltyic (used as rescue).

I know this is considered acceptable, but I've found that doing this creates far more problems than benefits. I've never had a patient who tolerated the "short-term" benzo who didn't then request that it be continued. The argument is always "it works so much better than the antidepressant, why can't I just continue it?" If the antidepressant-related anxiety should only be transient anyway and if it doesn't resolve in a few weeks it shouldn't be continued anyway. I don't see a reason to throw on another med to alleviate what should be a relatively mild and transient side effect, especially something like a benzo.

 

[Stagg737]

Chronic benzos are only started by me for for Catalonia or palliative care.

I don't see a reason why people from Catalonia should get a special exception