Benzo vs other options for anxiety

[tr]

How the therapy is presented and the milieu matters. In a university clinic setting (that saw students and non-students) I never had anyone that did not complete a round of therapy for PTSD or panic. Zero. However, in the VA, with SC, distrust, and common myths being floated around about things like PE/CPT, the amount of people ho won't engage or drop out very early is quite high.

But, outside of VA type settings, my experience of people not being appropriate for anxiety treatments has been extremely low. A skilled therapist can work within this framework in most presentations.

That's very interesting. I learned PE in the VA and completion was poor as you say. I didn't realize it was better in other settings. I know there is a ton of perverse incentivization around PTSD dx and service connection at the VA but I guess I didn't make the connection that poor tolerance of PE was related more (or only?) to that vs to the intrinsic discomfort of the intervention. CPT does seem much more tolerable though, is engagement/completion similarly poor for CPT vs PE in VA settings?

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[WisNeuro]

That's very interesting. I learned PE in the VA and completion was poor as you say. I didn't realize it was better in other settings. I know there is a ton of perverse incentivization around PTSD dx and service connection at the VA but I guess I didn't make the connection that poor tolerance of PE was related more (or only?) to that vs to the intrinsic discomfort of the intervention. CPT does seem much more tolerable though, is engagement/completion similarly poor for CPT vs PE in VA settings?

Huge differences between VA and non-VA settings. I'd say PE was hardest to get Vets to engage in, but they also rejected CPT at a much higher clip. Though, these days, I wonder how much the EMDR propaganda machine may be harming layperson's perceptions of PE/CPT. I've beein in soe conversations and heard some of these snakeoil "providers" talk about the "dangers" of PE/CPT in an effort to sell their junk. Who knows how many patients they've poisoned the well for over the years.

 

[SeniorWrangler]

Alprazolam has high street value and used to be commonly co-prescribed with OxyContin by pill mills.

 

[cara susanna]

Scheduled benzo --> chronic GABA receptor activation --> receptor downregulation --> tolerance --> distress upon withdrawal --> vicious cycle of continued administration to avoid withdrawal. It's just a bad idea.

Benzodiazepines have been reported to impair the efficacy of exposure therapy as pointed out by the psychologists (carasusanna and WisNeuro) above on this thread. Reduction in existing GABA receptor complement does not make people 'more ready for the uncomfortable therapy.'

There is a lot of research on dropout from PTSD EBPs. Here is a brief summary of what the research overwhemingly suggests:
- Dropout is generally not related to treatment intolerance, but other factors (scheduling, external commitments, etc)
- There is some evidence that some "dropouts" may actually be early completers--people who d/c the treatment as they felt it was no longer needed.

I definitely agree that how you frame the treatment and get buy-in from the patient is of utmost importance. I'm in the VA and don't have any trouble getting people to agree to CPT or PE. I've developed a way to explain the rationale for these treatments that makes sense to me and one that I genuinely believe. I am very upfront that the patient has to choose this and can't just do it because I'm telling them to, but it's also the gold standard and the only thing that is going to actually treat the trauma symptoms. Most of my patients finish CPT. PE has a lower completion rate but usually it's due to outside commitments--PE takes a TON of time. I've said this elsewhere in SDN, but think about it: attending a 90 min session weekly, completing 3 in vivo exposure assignments (at least 30 min each) daily, listening to a 40ish minute imaginal recording daily, and listening to a 90 min session recording weekly. It's a lot.

I also think a lot of the issues we see with getting patient buy-in and adherence to PE/CPT is due to fragilization of patients and clinicians' own distress while delivering PE (it's not a fun treatment to deliver, by any means). Research suggests that very few people are not actually ready to engage in PTSD EBPs, but well-meaning clinicians will often unnecessarily delay effective treatment. Also, yes, the EMDR crowd is not helping with their demonization of PE and CPT. The other thing is, it's hard to authentically sell PE unless you believe it works, and it's hard to really believe it until you see it working. Even if the research is so convincing, delivering the therapy is so counter-intuitive and in the short-term feels the opposite of what therapists want to do, which is help their patients feel better. And if you are a therapist, you won't see it working until you have completed a case or two... which is hard to do if you can't authentically sell it. It's a Catch-22. Heck, I believe very strongly in PE, have completed cases, and I still always feel like a jerk after the first imaginal session.

 

[mistafab]

I disagree with the sentiment in this thread that therapy is somehow the perfect approach to treatment of panic disorder. Even in other areas of medicine, the best or gold standards do have a failure rate. To blame the patient or blame the therapy and say it didnt work because 1) the patient wasnt motivated enough, or 2) the therapist wasnt skilled enough is hogwash.

Some patients fail therapy. Benzos do impede therapy, however for some they have given it a fair shot and have failed the gold standard, and SRIs dont provide enough functional improvement. Refusing benzo treatment in this case due to provider preference or viewpoints is just bias, and it does not mean benzo treatment is not indicated or is somehow ineffective. Dependence is a known side effect of regular benzo use, and a discussion about the risks/benefits as well as your clinical judgement is still the approach just like any other treatment option. The data is clear clonazepam works as well if not better than SRIs. To ignore this based on bias towards therapy is just poor practice in my opinion.

In residency, however, I will say I am biased - they dont get seen by us if they are run of the mill anxiety disorders with panic attacks. They come to these quertenary care centers after failing general practitioner care, and general psychiatry care (who only prescribe SRIs and tell them to try therapy again). You need tools for this population, just like you need tools for TRD or clozapine resistant schizophrenia.

At the same time, the more often encountered phenomenon is the overprescribed benzo that you inherit - I understand the frustration there and talking people into deprescribing in that case. But severe anxiety disorders and panic disorder should have options after failing general treatments - If you refuse to provide that care you should at least send a referral to someone comfortable working with that group.

 

[smalltownpsych]

I disagree with the sentiment in this thread that therapy is somehow the perfect approach to treatment of panic disorder. Even in other areas of medicine, the best or gold standards do have a failure rate. To blame the patient or blame the therapy and say it didnt work because 1) the patient wasnt motivated enough, or 2) the therapist wasnt skilled enough is hogwash.

Some patients fail therapy. Benzos do impede therapy, however for some they have given it a fair shot and have failed the gold standard, and SRIs dont provide enough functional improvement. Refusing benzo treatment in this case due to provider preference or viewpoints is just bias, and it does not mean benzo treatment is not indicated or is somehow ineffective. Dependence is a known side effect of regular benzo use, and a discussion about the risks/benefits as well as your clinical judgement is still the approach just like any other treatment option. The data is clear clonazepam works as well if not better than SRIs. To ignore this based on bias towards therapy is just poor practice in my opinion.

In residency, however, I will say I am biased - they dont get seen by us if they are run of the mill anxiety disorders with panic attacks. They come to these quertenary care centers after failing general practitioner care, and general psychiatry care (who only prescribe SRIs and tell them to try therapy again). You need tools for this population, just like you need tools for TRD or clozapine resistant schizophrenia.

At the same time, the more often encountered phenomenon is the overprescribed benzo that you inherit - I understand the frustration there and talking people into deprescribing in that case. But severe anxiety disorders and panic disorder should have options after failing general treatments - If you refuse to provide that care you should at least send a referral to someone comfortable working with that group.

I don't think anyone stated or implied that it was the perfect approach or even that it was an exclusive approach and not too prescribe benzos or use other medications to assist with the treatment. For a variety of reasons, traditional outpatient therapy won't work for a significant percentage of our patients regardless of disorder. I have extensive experience working with the treatment failures myself so completely get what you are saying. Part of therapy is preparation for therapy so I would encourage you to think about that aspect of the treatment. At it's most basic level, patients can benefit from talking to people. We are less anxious when we talk to people about stuff than when we are alone in our own heads. Even if they don't like talking to therapists they do talk to you and maybe others. Some of the trick to patients with negative resposnes to therapists was to have them talk to other people who weren't therapists and then sometimes to bridge them into a relationship with therapist as they started to realize that they could feel safe and receive benefit from "talking to a therapist". Again to be clear, the issue of not being able to benefit from therapy is not what I am referring to as much as the difficulty receiving benefit from relationships.

 

[tr]

Dependence is a known side effect of regular benzo use, and a discussion about the risks/benefits as well as your clinical judgement is still the approach just like any other treatment option. The data is clear clonazepam works as well if not better than SRIs. To ignore this based on bias towards therapy is just poor practice in my opinion.

The problem is not just dependence, it's also tolerance. Meaning the drug does not work anymore after being used for a period of time. The research you are referring to has short-term endpoints. Benzos are extremely effective for anxiety when used rarely/sporadically. Chronic daily use results in loss of efficacy and thereafter continued use serves only to avoid withdrawal.

 

[clausewitz2]

At it's most basic level, patients can benefit from talking to people. We are less anxious when we talk to people about stuff than when we are alone in our own heads. Even if they don't like talking to therapists they do talk to you and maybe others. Some of the trick to patients with negative resposnes to therapists was to have them talk to other people who weren't therapists and then sometimes to bridge them into a relationship with therapist as they started to realize that they could feel safe and receive benefit from "talking to a therapist". Again to be clear, the issue of not being able to benefit from therapy is not what I am referring to as much as the difficulty receiving benefit from relationships.

"It seems like you've gotten something out of our conversations, am I off base? Yeah, and you have so much going on right now, it seems like you ought to be able to talk about it with someone more often than half an hour every few weeks, that's not hardly enough. It strikes me that a therapist could totally do that. What do you think?"

 

[mistafab]

The problem is not just dependence, it's also tolerance. Meaning the drug does not work anymore after being used for a period of time. The research you are referring to has short-term endpoints. Benzos are extremely effective for anxiety when used rarely/sporadically. Chronic daily use results in loss of efficacy and thereafter continued use serves only to avoid withdrawal.

You can beat on an anti-benzo drum all day and no one will get mad.

Meds have side effects, some more problematic than others. Just because a medicine has limitations, problems, barriers, etc etc doesnt make it useless. Yes benzos cause dependence. Yes they have tolerance. Yes they are sedating. Yes they cause cognitive impairment, and yes they cause learning troubles. Yes, they also cause falls, and are deliriogenic.

So what? We provide risk benefit judgements and recommendations. Some people will fail therapy, and have significant ongoing trouble after SRI titration. So what? Evidence based medicine has limitations. So what? You look hard enough and deep enough in EBM and you will realize it is frequent that you practice in an unperfect world, where polypharmacy is the norm and not an exclusion criteria to the studies you read.

 

[birchswing]

<Not a doctor or medical student>

I can't understand the rationale for long-term benzo therapy once you concede tolerance.

Tolerance is not just a state of it working less. Rather than trying to explain what someone else said, I'll put it my own way.

I believe there is a state that I and others call tolerance withdrawal—meaning that you experience physiological withdrawal symptoms at the same dose over a long enough period of time.

The way I conceive of it is with an analogy to SSRIs.

SSRIs for most people do not work immediately (if they work). They first have to downregulate the presynaptic serotonin receptors. By the time they do that they start having a positive effect.

In about the same amount of time it takes for SSRIs to start working, benzodiazepines also have begun their own downregulation, only those are not the effects anyone wants. They down-regulate GABA-A receptors and they increase production of glutamate. This is why you can have a long-term benzo patient who starts having interdose withdrawal, starts requiring beta blockers, etc. They are known to *increase* anxiety after that initial period.

Tolerance to me is another way of saying: This is now acting as a different drug than it did when used sporadically. It is in effect a glutamatergic drug at that point (I know it's more complicated than that but it's sort of always chasing it away and its effect at chasing away that problem becomes less and less effective). It's not a perfect analogy but similar to the way that SSRIs are serotonergic by reducing receptors—except in this case the attempt at homeostasis is an increase in glutamate in addition to downregulating GABA-A receptors. I doubt it's a coincidence that anti-glutaamatergic drugs work on OCD, while OCD is one of the effects of long-term benzodiazepine use and from its withdrawal.

I would add several caveats to long-term use: It deprives the patient of being able to use them when they can be helpful, and a long-term patient will at some point face withdrawal, even if they stay on the same dose indefinitely. More likely their practitioner will retire or move and they will find a new one who will force them to taper. It is going to be a hell worse than their original problem. I think one of the informed consent items should be: This treatment may not be available at a certain point in time, at which point in time you may have to go through a complete taper (and then list the effects of that).

You can provide a risk/benefit assessment where it makes sense in particular circumstances, but the great likelihood is that the next practitioner after you (no one has the same psychiatrist for life) will not make that assessment, and I think that is something to keep in mind. The patient is the one who will have to live with the withdrawal.

 

[tr]

You can beat on an anti-benzo drum all day and no one will get mad.

Meds have side effects, some more problematic than others. Just because a medicine has limitations, problems, barriers, etc etc doesnt make it useless. Yes benzos cause dependence. Yes they have tolerance. Yes they are sedating. Yes they cause cognitive impairment, and yes they cause learning troubles. Yes, they also cause falls, and are deliriogenic.

So what? We provide risk benefit judgements and recommendations. Some people will fail therapy, and have significant ongoing trouble after SRI titration. So what? Evidence based medicine has limitations. So what? You look hard enough and deep enough in EBM and you will realize it is frequent that you practice in an unperfect world, where polypharmacy is the norm and not an exclusion criteria to the studies you read.

Straw man. The point is not side effects. It is efficacy. It's one thing to say, this works but it will have the following side effects. It's another to say, this will work for a limited period of time, and then will stop working. You are entirely eliding the critical second half of that conversation.

 

[mistafab]

Straw man. The point is not side effects. It is efficacy. It's one thing to say, this works but it will have the following side effects. It's another to say, this will work for a limited period of time, and then will stop working. You are entirely eliding the critical second half of that conversation.

Thank you for your brief lesson on psychopharmacology regarding benzodiazepines. Hopefully you feel better now that you got that out of your system.

 

[WisNeuro]

Man, someone really needs some validation for their poor prescribing habits.

 

[whopper]

I'd be echoing most of what's been said if I gave my opinions.

What I'm going to add is I do the due diligence. I try to avoid benzos or only give temporarily such as fear of airplanes and the person is only going to fly a few times a year. I have no problems giving someone benzos who uses them less than weekly.

Now all this said I've had a few exceptional weird cases where I kept benzos going. This is about 1% of my patients. E.g. a wife and mother whose husband is in a car wreck and now permanently needs to be in a nursing home. She had to become the sole-breadwinner, take care of her kids, etc. I allowed her to take benzos for over a year and we only gave small dosages.

I had another patient where the only thing that got rid of his nightmares was a benzo. Prazosin and Trazodone already tried with no success. No conventional other meds worked well for his other stuff like depression and anxiety. SAM-E helped tremendously. Lamotrigine helped tremendously. He was nightmare free on Clonazezpam 2 mg PO Q HS. Then after being nightmare free for about 3 months we both agreed to taper him and then even lower dosages that didn't keep him nightmare free were still keeping it at bay. He got to about 0.5 mg a night.

I theorized he may have had a weird sleep disorder and recommended he see a sleep doctor but he can't afford to see one.

Well that case was going great for 1.5 years and then he fell down through a floor while urban-spellunking in an abandoned large home, broke his hip, developed PTSD from it, and nothing worked well for his PTSD, and then he started over-using Clonazepam.
That's my real tough case at this time. Only thing that worked for his nightmares was Clonazepam. Now he's abused it. Nothing else other than SAM-E and Lamotrigine worked for him out of over 10 meds tried, and yes he's taking the SAM-E and Lamotrigine but his PTSD is still severe.

In catatonia, even extremely high dosages of Lorazepam, could be justified. This doesn't occur often, and catatonia is one of those things where when it does happen, the last time it happened was so long ago the doctor is now again a catatonia-virgin they won't know WTF to do.

 

[Merovinge]

In catatonia, even extremely high dosages of Lorazepam, could be justified. This doesn't occur often, and catatonia is one of those things where when it does happen, the last time it happened was so long ago the doctor is now again a catatonia-virgin they won't know WTF to do.

Not just justified but life-saving. I've had young adults in the 20+mg of daily Ativan to keep things at bay and limit autonomic instability. Malignant catatonia is no joke and you only need to see a case or two before you feel much more empowered to push BZDs hard and taper carefully during resolution. I saw one case on the NMS to malignant catatonia spectrum where the hyperthermia was so bad the patient permanently lost cognitive functioning, psychiatry wasn't consulted until 5-7 days into symptoms and by then the emergent ECT was too late to prevent lifelong deficits. I had the fortune of being assigned this patient for outpatient f/u and it was soul crushing to see, they had been a successful college student prior to the event and could hardly function after.

 

[deleted1100659]

I disagree with the sentiment in this thread that therapy is somehow the perfect approach to treatment of panic disorder. Even in other areas of medicine, the best or gold standards do have a failure rate. To blame the patient or blame the therapy and say it didnt work because 1) the patient wasnt motivated enough, or 2) the therapist wasnt skilled enough is hogwash.

Some patients fail therapy. Benzos do impede therapy, however for some they have given it a fair shot and have failed the gold standard, and SRIs dont provide enough functional improvement. Refusing benzo treatment in this case due to provider preference or viewpoints is just bias, and it does not mean benzo treatment is not indicated or is somehow ineffective. Dependence is a known side effect of regular benzo use, and a discussion about the risks/benefits as well as your clinical judgement is still the approach just like any other treatment option. The data is clear clonazepam works as well if not better than SRIs. To ignore this based on bias towards therapy is just poor practice in my opinion.

In residency, however, I will say I am biased - they dont get seen by us if they are run of the mill anxiety disorders with panic attacks. They come to these quertenary care centers after failing general practitioner care, and general psychiatry care (who only prescribe SRIs and tell them to try therapy again). You need tools for this population, just like you need tools for TRD or clozapine resistant schizophrenia.

At the same time, the more often encountered phenomenon is the overprescribed benzo that you inherit - I understand the frustration there and talking people into deprescribing in that case. But severe anxiety disorders and panic disorder should have options after failing general treatments - If you refuse to provide that care you should at least send a referral to someone comfortable working with that group.

This approach looks at the "now" but doesn't consider the "later". Let's say klonopin "works" for a patient. What happens once they get older? I promise you they become significantly less tolerated, especially long acting. Are you going to just leave them on it? Because now you have created this patient scenario, where someone has been on it several years, they start to approach the geri age, and issues start becoming more significant as far as tolerability, side effects, etc. Tapering them off if they have consistently used it for years is an absolute nightmare. I have done this for quite literally, at least 20-30 people this year, who should not have been on long term benzos, and I inherited them.

Just because a symptom is present, does not mean we need to throw every possible heavy treatment at it to get rid of it completely. Teaching people to be comfortable with their anxiety, and living with it is important. People suffer from depression every day, but they still go out there and work/function. We don't just load them with ketamine to make the population as happy as possible, lol.

Now, if you're talking about occasional rxs for benzos because the patient isnt using it often, only in emergencys, then sure I agree with you. But routine scheduled use, im pretty against that.

Also in my opinion, the addiction to benzos is vastly understated. I see it all the time in my setting.

 

[whopper]

Not just justified but life-saving

Absolutely correct and add that severe and fatal renal damage could occur from extended and prolonged catatonia. Anyone in catatonia should have a BMP and serum creatine phosphokinase ordered. A marathon runner can get CPK levels in the low thousands and then seeing a catatonia patient have it well over 5000+!

A problem being is that I've seen even inpatient psychiatrists see is so rarely that when it does happen they don't know what to do. I used to run a geriatric psych unit and noticed it occurring on the geri-unit about once every few weeks where as in regular adult inpatient noticing it about once every 1-2 years.

I brought this up to some of the bigger guys at my former university-Paul Keck, Henry Nasrallah, Doug Mossman and they responded this is exactly what becomes the start of a clinical doctor starting to broach research and encouraged I consider doing a paper on tracking catatonia in geri-units. I would've pursued it had I stayed at U of Cincinnati but I moved out of the area and my experiences at the next university made me want to leave academia altogether.

 

[Merovinge]

Absolutely correct and add that severe and fatal renal damage could occur from extended and prolonged catatonia. Anyone in catatonia should have a BMP and serum creatine phosphokinase ordered. A marathon runner can get CPK levels in the low thousands and then seeing a catatonia patient have it well over 5000+!

50k is the highest CK I have ever seen. Absolutely a concern if not being managed with aggressive hydration and BZDs. Thank all the stars to have gone to residency somewhere with neuropsychiatrists and get so much exposure to these conditions. We used to require CKs on all transfers for any psychiatric reason from OSHs, crazy having a few docs trying to send patients with these in the very high 4 digits or even 5 digit values.

 

[Candidate2017]

When you say the psychotherapy is too uncomfortable to be effective for some, I don’t know if that is the right message. A skilled psychotherapist can titrate the exposure to the feared stimuli.

The prescription pad is a heavy burden.

People who come to psychiatrists usually want a pill to solve their problems. People who come to psychologists usually want to learn how to solve their problems.

 

[smalltownpsych]

The prescription pad is a heavy burden.

People who come to psychiatrists usually want a pill to solve their problems. People who come to psychologists usually want to learn how to solve their problems.

True that. One reason I would not want to get prescription privileges. I have found that the more effective psychiatrists appreciate working closely with experienced psychologists because that can ease that pressure and vice versa. I also appreciate when the psychiatrist is deliberate in their adjustment of medications. Last Doc I worked with wouldn’t make a change in medication without running it by me. Not because I would have much input into the medication strategies so much as my more frequent contact and different relationship would provide more insight Into the overall picture. Of course, the less experienced therapists would just ask for him to change the meds when they weren’t sure what to do or if the patient was doing things they didn’t like. One of my pet peeves is people in our business telling patients how they should live their life and then attributing their not listening to that advice as a sign of their pathology.

 

[Mass Effect]

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

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

So they didn't teach the standard of care?

 

[Mass Effect]

The problem is not just dependence, it's also tolerance. Meaning the drug does not work anymore after being used for a period of time. The research you are referring to has short-term endpoints. Benzos are extremely effective for anxiety when used rarely/sporadically. Chronic daily use results in loss of efficacy and thereafter continued use serves only to avoid withdrawal.

This right here. I came into residency hating all benzos. Luckily my program taught me not to hate them even if they have their problems. I had 2 patients on Klonopin 0.5 that I refilled annually for one and every 8-9 months for the other. I saw them for 3.5 yrs until I went to another job and this regimen never changed and their anxiety was fine. I don't like daily dosing.

 

[calvnandhobbs68]

Thank you for your brief lesson on psychopharmacology regarding benzodiazepines. Hopefully you feel better now that you got that out of your system.

Aren't you like...a second year resident bud?

 

[Alemo]

Not to put too fine a point on it, but there is some discussion (controversy) on whether tolerance *to the anxiolytic effect* of benzodiazepines develops.

Tolerance to sedation and other properties has been more robustly established.

But anyway, I generally agree with what tr is saying here. I don’t think any psychiatrist who has seriously examined The Literature can deny that if one is prescribed benzos regularly for their chronic daily anxiety disorder (with no other treatment), the illness will at the very least never get better, and most likely worsen with reinforced maladaptive learning and association.

Also problems like specific phobias are literally some of the only things in psychiatry that can be cured!! With “talk therapy” no less!! One of the only times one can launch into their Billy Mays infomercial sales pitch (as one does) with unrestrained optimism and zeal approaching religious fervor, shouting “Yes Virginia, I and my exposure therapy handbook can fix this.”

 

[littlefred]

So they didn't teach the standard of care?

Weak argument, bloodletting was standard of care a couple of years back.

 

[Mass Effect]

Weak argument, bloodletting was standard of care a couple of years back.

What?

 

[Merovinge]

Aren't you like...a second year resident bud?

Interestingly, I felt like I knew more about psychiatry as a PGY2 than being an attending for over half of a decade. The practice of medicine is humbling if one keeps their eyes open.

 

[clausewitz2]

Interestingly, I felt like I knew more about psychiatry as a PGY2 than being an attending for over half of a decade. The practice of medicine is humbling if one keeps their eyes open.

Oh yeah, this was definitely me. You couldn't tell late PGY2 me nothin.

Then I had to take care of a large-ish panel longitudinally and oh god what do I do now

 

[Chrish]

DEA has gone after shady pain doctors in past few years after that infamous CDC guidelines of limiting opioid dose 90 mme for non-malignant conditions. Same needs to happen to benzos.

Basically benzos need to become control 2 substances with strict prescribing guidelines and no refill on these prescriptions.

I am honesty surprised stimulants are C ll while benzos aren’t. Abuse potential and long term harm are far greater with the later.

 

[Merovinge]

DEA has gone after shady pain doctors in past few years after that infamous CDC guidelines of limiting opioid dose 90 mme for non-malignant conditions. Same needs to happen to benzos.

Basically benzos need to become control 2 substances with strict prescribing guidelines and no refill on these prescriptions.

I am honesty surprised stimulants are C ll while benzos aren’t. Abuse potential and long term harm are far greater with the later.

I agree. If you look at intentional and accidental overdose deaths and compared the number with psychostimulants compared to the number with benzodiazapines and then look at the scheduling of the two classes of drugs, something feels very amiss.

 

[whopper]

Absolutely a concern if not being managed with aggressive hydration and BZDs.

As a medstudent a resident made me pull out medical journals on CPK levels correlating with exercise. The article showed various exercises, durations, and the correlating CPK levels. Highest levels were found in college football training after a specific amount of hours and marathon running.

It also gave figures on where the CPK levels became worrisome. What is not emphasized in psych residency training is when these levels are worrisome. Anything above the low thousands should be of significant concern. When over 5000 start freaking out and considering IV.

This is stuff not taught in psych residency and should be. Patients will die cause a psychiatrist-catatonia virgin not educated on the subject.

 

[Desired Member]

I don't like prescribing benzodiazepines because both the overdose and the withdrawal can be deadly.

 

[lockian]

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 think the answer is benzos may not start out being the long term plan, but they work so darn well and are so addictive that they very easily *become* the long term plan. Tapering off benzos takes effort and nothing is ever quite as good again. So since most patients and unfortunately providers are complacent, I get transfers all the time who are elderly and have been on benzos for 20 years, and they don’t believe me when I say that it’s a matter of time until they have a nasty fall or stop breathing from their untreated sleep apnea, because “well, I’ve never had a problem yet!” It’s never a problem until it is, and then it’s too late. /rant

 

[Stagg737]

Scheduled benzo --> chronic GABA receptor activation --> receptor downregulation --> tolerance --> distress upon withdrawal --> vicious cycle of continued administration to avoid withdrawal. It's just a bad idea.

Benzodiazepines have been reported to impair the efficacy of exposure therapy as pointed out by the psychologists (carasusanna and WisNeuro) above on this thread. Reduction in existing GABA receptor complement does not make people 'more ready for the uncomfortable therapy.'

I do agree with this generally, but if we want to talk about the actual addiction cycle, I think rapid onset medications are going to be more likely to prime people for actual addiction as this is typically most similar to intoxication/binge. I can see the argument that scheduled, longer-acting benzos are more likely to precipitate withdrawal, but this is why we taper. Diazepam can hit both of those phases d/t its quick onset and long half-life, so I'm always cautious with it and typically use very small doses unless I'm cross-titrating/tapering.

That being said, in the rare instances that I do start a benzo, it's usually PRN and only in patients I think will only need it 2-3x per week or for an acute identifiable stressor with the understanding that there won't be refills. In those cases I don't mind Xanax or Ativan as much knowing I'm only prescribing 10-15 tabs. I have had a couple of patients with severe panic disorder with agoraphobia who were essentially non-functional that I scheduled benzos for so they could leave their house. I always discuss the goals that we're eventually going to try and taper off and that seeking therapy is a requirement. In these cases, I also like clonazepam as the half-life is a good length for BID dosing, patients don't "feel it" acutely like with Xanax or diazepam, it's known serotonergic effects, and just that it has the strongest evidence for benzos for panic disorder.

 

[Stagg737]

There is a lot of research on dropout from PTSD EBPs. Here is a brief summary of what the research overwhemingly suggests:
- Dropout is generally not related to treatment intolerance, but other factors (scheduling, external commitments, etc)
- There is some evidence that some "dropouts" may actually be early completers--people who d/c the treatment as they felt it was no longer needed.

I definitely agree that how you frame the treatment and get buy-in from the patient is of utmost importance. I'm in the VA and don't have any trouble getting people to agree to CPT or PE. I've developed a way to explain the rationale for these treatments that makes sense to me and one that I genuinely believe. I am very upfront that the patient has to choose this and can't just do it because I'm telling them to, but it's also the gold standard and the only thing that is going to actually treat the trauma symptoms. Most of my patients finish CPT. PE has a lower completion rate but usually it's due to outside commitments--PE takes a TON of time. I've said this elsewhere in SDN, but think about it: attending a 90 min session weekly, completing 3 in vivo exposure assignments (at least 30 min each) daily, listening to a 40ish minute imaginal recording daily, and listening to a 90 min session recording weekly. It's a lot.

I also think a lot of the issues we see with getting patient buy-in and adherence to PE/CPT is due to fragilization of patients and clinicians' own distress while delivering PE (it's not a fun treatment to deliver, by any means). Research suggests that very few people are not actually ready to engage in PTSD EBPs, but well-meaning clinicians will often unnecessarily delay effective treatment. Also, yes, the EMDR crowd is not helping with their demonization of PE and CPT. The other thing is, it's hard to authentically sell PE unless you believe it works, and it's hard to really believe it until you see it working. Even if the research is so convincing, delivering the therapy is so counter-intuitive and in the short-term feels the opposite of what therapists want to do, which is help their patients feel better. And if you are a therapist, you won't see it working until you have completed a case or two... which is hard to do if you can't authentically sell it. It's a Catch-22. Heck, I believe very strongly in PE, have completed cases, and I still always feel like a jerk after the first imaginal session.

A huge problem with some VAs is also the limited availability of therapy. Where I rotated we could refer patients for therapy, but they could only be guaranteed 12 sessions. Most patients would not be able to continue d/t availability, and for patients going through PE/CPT this can be disastrous if the therapy has to suddenly be discontinued.

Straw man. The point is not side effects. It is efficacy. It's one thing to say, this works but it will have the following side effects. It's another to say, this will work for a limited period of time, and then will stop working. You are entirely eliding the critical second half of that conversation.

True, but this isn't going to be the case for everyone. It is most definitely a concern, but I did inherit patients who had been on low doses of benzos for 10+ years and they were still effective for anxiety. I certainly don't advocate for this approach, but there is a certain population (granted a very limited one) where this may be necessary to maintain functionality.

I believe there is a state that I and others call tolerance withdrawal—meaning that you experience physiological withdrawal symptoms at the same dose over a long enough period of time.

This is part of the cycle of chemical dependence. I used to use this chart when I had to lead groups at our inpatient addiction program as it resonated with the patients a lot and gave them an actual visual representation of how they got to where they were and what substances had done to them.

 

[littlefred]

A huge problem with some VAs is also the limited availability of therapy. Where I rotated we could refer patients for therapy, but they could only be guaranteed 12 sessions. Most patients would not be able to continue d/t availability, and for patients going through PE/CPT this can be disastrous if the therapy has to suddenly be discontinued.


True, but this isn't going to be the case for everyone. It is most definitely a concern, but I did inherit patients who had been on low doses of benzos for 10+ years and they were still effective for anxiety. I certainly don't advocate for this approach, but there is a certain population (granted a very limited one) where this may be necessary to maintain functionality.


This is part of the cycle of chemical dependence. I used to use this chart when I had to lead groups at our inpatient addiction program as it resonated with the patients a lot and gave them an actual visual representation of how they got to where they were and what substances had done to them.

View attachment 354530

Where'd you get that graph? Would be interested to read the material where it came from.

 

[Stagg737]

Where'd you get that graph? Would be interested to read the material where it came from.

Here you go: (PDF) Individual differences in the neuropsychopathology of addiction

 

[tr]

True, but this isn't going to be the case for everyone. It is most definitely a concern, but I did inherit patients who had been on low doses of benzos for 10+ years and they were still effective for anxiety. I certainly don't advocate for this approach, but there is a certain population (granted a very limited one) where this may be necessary to maintain functionality.

Do you mean intermittent low-dose (totally agreed) or chronic low-dose?

If the latter, beg pardon but how could you tell the medications were still effective for anxiety if the patients were taking them chronically? In this case it's impossible to tell the difference between treatment of anxiety and mitigation of benzo withdrawal. The only way to know if the benzo was actually treating the anxiety is to taper the patient slowly off the benzo (can take a long time) and see if their anxiety is higher once they have been off long enough that withdrawal sx are no longer relevant.

 

[clausewitz2]

If the latter, beg pardon but how could you tell the medications were still effective for anxiety if the patients were taking them chronically? In this case it's impossible to tell the difference between treatment of anxiety and mitigation of benzo withdrawal. The only way to know if the benzo was actually treating the anxiety is to taper the patient slowly off the benzo (can take a long time) and see if their anxiety is higher once they have been off long enough that withdrawal sx are no longer relevant.

Yeah, the fact that drinking rum makes the shakes go away doesn't make it an anti-convulsant.

My discussion of goals of treatment with anyone I am treating for an anxiety disorder includes my emphatic statement that our main objective is not to make them less anxious. Anxiety sucks and nobody would volunteer for it, sure, and if it goes away during treatment or gets more muted, great, that's gravy. But we're not setting out to stop it and I don't pretend that we can do this consistently. Instead, our focus is going to be on making sure anxiety has no power whatsoever to stop them from doing anything that they care about or is at all important to them. The end goal is to be able to respond to whatever the worry/fear is with a sentiment like "cool story, brain, what's for dinner?"

Trying to stop feeling anxious qua feeling anxious is a good way to make sure you keep feeling anxious. Trying to make your anxiety irrelevant to how you live your life is much more doable and much more important. I hate the way we talk about controlling anxiety the way we talk about controlling a diabetic's blood sugars. we are helping people shape their behavior and experiences, not picking antibiotics to cover the right classes of bacteria.

 

[Stagg737]

Do you mean intermittent low-dose (totally agreed) or chronic low-dose?

If the latter, beg pardon but how could you tell the medications were still effective for anxiety if the patients were taking them chronically? In this case it's impossible to tell the difference between treatment of anxiety and mitigation of benzo withdrawal. The only way to know if the benzo was actually treating the anxiety is to taper the patient slowly off the benzo (can take a long time) and see if their anxiety is higher once they have been off long enough that withdrawal sx are no longer relevant.

Because I did exactly that. 6+ months of taper, patient was off them for at least 2 months and became severely agoraphobic to the point that their CM had to go to their houses so we could actually have an appointment. I didn't get to see them much after that as it was the end of my 3rd year, but I'm convinced she could have actually functioned if she had stayed on a low dose benzo. Also had a similar situation with a patient I've seen in my current clinic for 2+ years. Was able to get them down from clonazepam 2mg BID to 0.5 BID over about a year. Anytime we went lower she became non-functional. She still had significant anxiety at the 0.5mg dosing, but could at least hold a job.

I'm aware that it can require several months of monitoring to ensure the anxiety isn't prolonged withdrawal which can be extremely difficult to convince patients to tolerate. But in the second case above, she did go to 0.25mg dosing for about 4 months which we increased back up after the follow-up when she was fired for missing too much work. There was not a significant personality component with this patient, and she had been through extensive therapy. This is in people with normal cognitive functioning, I can give plenty of examples in patients with ID who decompensated without the benzodiazepine or dose decreases.

Like I said, I don't like to prescribe them chronically and very rarely do for my patients. I also never start a benzo for anxiety without clear understanding that I will only prescribe it acutely. I may be biased by personal experience, but I do think there are individuals for whom they truly are necessary. I do think that benzo's place in the algorithm of treating anxiety is generally incorrect though and that they should be more akin to how we view MAOIs for depression than a med some see as interchangeable with buspirone for anxiety.

My discussion of goals of treatment with anyone I am treating for an anxiety disorder includes my emphatic statement that our main objective is not to make them less anxious. Anxiety sucks and nobody would volunteer for it, sure, and if it goes away during treatment or gets more muted, great, that's gravy. But we're not setting out to stop it and I don't pretend that we can do this consistently. Instead, our focus is going to be on making sure anxiety has no power whatsoever to stop them from doing anything that they care about or is at all important to them. The end goal is to be able to respond to whatever the worry/fear is with a sentiment like "cool story, brain, what's for dinner?"

Idk that I'd go as far as the bolded, but generally agree that eliminating anxiety is a fool's errand and that management of it is the correct approach. How do you accomplish this for the patients who are chronically so anxious that just getting out of bed triggers is seen as impossible when they don't have something to inhibit their sympathetic system? I've used thorazine with one patient but there were also indications for it. How do you get those patients to a place where they can even start to ignore or minimize that level of anxiety when years of therapy have failed? Genuinely curious.

 

[mistafab]

Page 3 and I still think there is a lot of bologna/bias in this thread, Just as opioids have a place for pain, benzos have a place for panic disorder. Yes, opoiods for chronic pain can be problematic, yet there are pain clinics dedicated to chronic, appropriate pain management of which opioids play a huge part.

Bunch of malarkey here. Maybe you’ve met the golden therapist who can cure everyone of panic disorder. Heck, maybe this therapist even has AVAILiBILITY. And heck, maybe your patients have the resources to get therapy as well! Or maybe your patients are high functioning enough to get the most out of it!

Some people need to stay out of the hospital. If chronic benzo makes the agoraphobia go away, and brings down ED presentations, and their chronic low dose clonazepam keeps the boogyman away so they have less than 2 small attacks a month and can hold a job, then you’re going to do whats best for the patient and not bible thump the anti benzo rhetoric (which we all agree with). Over time you will reduce the benzo to as negligible a chronic amount that the patient can manage, and at some point you will figure put how it can go away.

 

[smalltownpsych]

Page 3 and I still think there is a lot of bologna/bias in this thread, Just as opioids have a place for pain, benzos have a place for panic disorder. Yes, opoiods for chronic pain can be problematic, yet there are pain clinics dedicated to chronic, appropriate pain management of which opioids play a huge part.

Bunch of malarkey here. Maybe you’ve met the golden therapist who can cure everyone of panic disorder. Heck, maybe this therapist even has AVAILiBILITY. And heck, maybe your patients have the resources to get therapy as well! Or maybe your patients are high functioning enough to get the most out of it!

Some people need to stay out of the hospital. If chronic benzo makes the agoraphobia go away, and brings down ED presentations, and their chronic low dose clonazepam keeps the boogyman away so they have less than 2 small attacks a month and can hold a job, then you’re going to do whats best for the patient and not bible thump the anti benzo rhetoric (which we all agree with). Over time you will reduce the benzo to as negligible a chronic amount that the patient can manage, and at some point you will figure put how it can go away.

There are no absolutes in our business. The best treatments still have the non-responders and vice versa not all patients have anxiety get worse with benzos. Just making up numbers but even if 80% of patients get worse because of using benzos for anxiety, then maybe 10% are neutral and 10% it helps. I believe that there are people for whom it has been a beneficial part of their treatment because I have worked with some of them and seen sustained gains and decrease in use/reliance on over the course of a few years. If you exclude people with higher addiction potential or history of addiction, then you probably shift those numbers quite a bit to support benzos being more positive. Just like I don’t think anyone should suffer pain needlessly because of people with addiction, i also feel the same way about panic attacks.

 

[tennisall]

I think we’re neglecting the potential harms of SSRIs. Both SSRIs and long-acting benzos form dependence. Neither are addictive. Benzodiazepines likely work at least as well, are better tolerated (no emotional and sexual numbing, no risk of chronification of depression—Nardi, 2012). If anxiolytic tolerance does develop with benzos (which I’m not sure is true) why wouldn’t this also occur with SSRIs? Is there something special about the GABA receptor that leads to tolerance? Or were benzos inappropriately maligned when Prozac came out only to find over the last 30 years that SSRIs have their problems, too.

 

[hamstergang]

Both SSRIs and long-acting benzos form dependence. Neither are addictive.

Are you claiming that benzos with longer half lives aren't addictive?

If anxiolytic tolerance does develop with benzos (which I’m not sure is true) why wouldn’t this also occur with SSRIs? Is there something special about the GABA receptor that leads to tolerance?

There certainly can be differences in how different neurotransmitter systems react over time, so I wouldn't think it's a given that tolerance has to develop with them all. But also, it's true that benzos inhibit learning and SSRIs enhance BDNF, right? In this way, I think it makes at least theoretical sense that SSRIs allow you to actually overcome anxiety long term while benzos keep you stuck where you are.

 

[randomdoc1]

vitamin CBT and DBT. btw, kind of off topic, but it reminds me of a psychiatrist who recently retired. He had everyone on benzos and wow, what a great clinical lesson on benzo side effects. I don't think it says in the literature benzos are necessarily associated with weight gain. But when you're on a lot, I think patients are so sedentary that they do gain weight. There were some morbidly morbidly obese patients and I can't help but wonder. Great case study material.

 

[calvnandhobbs68]

I think we’re neglecting the potential harms of SSRIs. Both SSRIs and long-acting benzos form dependence. Neither are addictive. Benzodiazepines likely work at least as well, are better tolerated (no emotional and sexual numbing, no risk of chronification of depression—Nardi, 2012). If anxiolytic tolerance does develop with benzos (which I’m not sure is true) why wouldn’t this also occur with SSRIs? Is there something special about the GABA receptor that leads to tolerance? Or were benzos inappropriately maligned when Prozac came out only to find over the last 30 years that SSRIs have their problems, too.

Are you arguing that anxiolytic tolerance does not occur with benzos or other GABA modulators?

 

[tr]

I think we’re neglecting the potential harms of SSRIs. Both SSRIs and long-acting benzos form dependence. Neither are addictive. Benzodiazepines likely work at least as well, are better tolerated (no emotional and sexual numbing, no risk of chronification of depression—Nardi, 2012). If anxiolytic tolerance does develop with benzos (which I’m not sure is true) why wouldn’t this also occur with SSRIs? Is there something special about the GABA receptor that leads to tolerance? Or were benzos inappropriately maligned when Prozac came out only to find over the last 30 years that SSRIs have their problems, too.

Benzodiazepines, like all drugs of abuse, stimulate dopamine release in the nucleus accumbens, pharmacologically hijacking the reward system to produce a runaway positive signal. SSRIs do not.

Diazepam Concurrently Increases the Frequency and Decreases the Amplitude of Transient Dopamine Release Events in the Nucleus Accumbens

Benzodiazepines are commonly prescribed anxiolytics that pose abuse liability in susceptible individuals. Although it is well established that all drugs of abuse increase brain dopamine levels, and benzodiazepines are allosteric modulators of the GABA[A] ...

www.ncbi.nlm.nih.gov

Effect of antidepressants on striatal and accumbens extracellular dopamine levels

The effect of the selective serotonin (5-hydroxytryptamine, 5-HT) reuptake inhibitor, fluoxetine (10 mg/kg s.c.), two tricyclic antidepressants, clomi…

www.sciencedirect.com

 

[docksan]

An argument can be made that any substance that has potential to produce a conditioned response can result in dependence, specially because of the mesoaccumbens axis and its interaction with the limbic system.

Edit: just to be clear I don't think SSRI dependence is a thing outside of the hypothetical.

 

[tennisall]

Benzodiazepines, like all drugs of abuse, stimulate dopamine release in the nucleus accumbens, pharmacologically hijacking the reward system to produce a runaway positive signal. SSRIs do not.

Diazepam Concurrently Increases the Frequency and Decreases the Amplitude of Transient Dopamine Release Events in the Nucleus Accumbens

Benzodiazepines are commonly prescribed anxiolytics that pose abuse liability in susceptible individuals. Although it is well established that all drugs of abuse increase brain dopamine levels, and benzodiazepines are allosteric modulators of the GABA[A] ...

www.ncbi.nlm.nih.gov

Effect of antidepressants on striatal and accumbens extracellular dopamine levels

The effect of the selective serotonin (5-hydroxytryptamine, 5-HT) reuptake inhibitor, fluoxetine (10 mg/kg s.c.), two tricyclic antidepressants, clomi…

www.sciencedirect.com

There are levels of abuseability. Low-dose, long-acting benzodiazepines like clonazepam probably don’t yield a signal comparable to amphetamines and opiates, or Xanax or Valium. This runaway positive signal you speak of would predict benzo users escalating their doses over time and losing benefit, which they do not according to the limited long-term data available (Nardi, 2012 among others). Anxious patients without a substance use history don’t ruin their lives with escalating drug-seeking behavior (a signal of addiction) from taking benzodiazepines like klonopin. They ruin it when tapering too quickly, just as with SSRIs.

Sure, there may be tolerance to the mild euphoria over time, but I this is not incompatible with sustained anxiolysis in the right patient.

 

[tennisall]

Are you arguing that anxiolytic tolerance does not occur with benzos or other GABA modulators?

It’s a good question—the limited data we have (a few 1-3 year follow up studies in PD) indicate that anxiolytic tolerance does not form and that side effect burden is much less than with SSRIs. This is not the strongest evidence base but it does tell us something.

Even if tolerance does occur, an important question is: is this complete tolerance? (Pt is back at baseline prior to starting the benzo) or partial tolerance? And how much? 30-40% tolerance means 60-70% sustained relief in a treatment-resistant anxiety patient who has done the therapy, SRIs, buspar, Remeron, atypical antipsychotics heaven forbid, what have you.

Finally, if anxiolytic tolerance does occur with benzos, I don’t see why this cannot also apply to SSRIs. Unless we collectively feel like the benzo-induced “euphoria” to which tolerance develops is the anxiolysis itself.