Combining Benzos and Stimulants - Am I Missing Something?

[Hash Slinging Slasher]

Basically the title. First year as an attending and I'm genuinely shocked at how common the combination of benzodiazepines and stimulants are - both among primary care AND even psychiatry - and am disheartened of having to keep having this discussion over and over again.

Sooooo many ADHD/anxiety referrals from PCPs who want to offload the difficult discussion of tapering to us. And even a local psychiatrist who retired and is sending us his patients prescribed the combo to at least 40% of his referred patients. It ends the same every time - with me trying to gently counsel them of the harmful effects with little to no avail, often getting yelled at my patients and their families, getting bad feedback, and then having to answer to administration about complaints. A colleague of mine even joked that I'm better off not fighting it arguing that there's little to no upside in fighting it and "they're stable on it, so why mess with things?". He also mentioned that poor Press Ganey scores could land the clinic and me in hot water since patients are more likely to complain to administration.

So what am I missing with this combo? Is it EVER appropriate to prescribe stimulants AND benzos? I was taught that taking "uppers" and "downers" like these together causes long-term neurotoxic effects and should almost never be done. And YET, it's so ubiquitous. Was my understanding misinformed dogma? Is there some medical merit to this combo I was never taught? Did I miss something from training?

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[brosa]

I don't think you are incorrect. Of course there are cases of stimulants and benzos. ADHD with flight fobia, for example. Nothing wrong on using benzos a few times a year for that. I don't think that is the case in your practice, and it is just likely poor psychiatry. I've met many older psychiatrist that would give benzos like candies. Sometimes it does get exhausting to discuss that with patients.

 

[splik]

So what am I missing with this combo? Is it EVER appropriate to prescribe stimulants AND benzos? I was taught that taking "uppers" and "downers" like these together causes long-term neurotoxic effects and should almost never be done. And YET, it's so ubiquitous. Was my understanding misinformed dogma? Is there some medical merit to this combo I was never taught? Did I miss something from training?

I am not aware of any data suggesting the combination of benzos and stimulants are especially neurotoxic. Combining lithium and haldol is much more neurotoxic.

More of the issue is that it usually does not make pharmacological sense to prescribe stimulants and benzos together since they have opposing actions, though there are notable exceptions. The problem is that most people on both have anxiety and ADHD or are abusing them or would be better off with some other regimen. In neuropsychiatry, we do sometimes use both together. For example patients with catatonia in the setting of severe depression, managing behavioral and psychological symptoms of dementia (expert use only), some brain injury cases (again, specialist use only), and I have some patients with various neurodegenerative diseases where we have used benzos and stimulants as part of symptom control (for example stimulants for depression or apathy and benzos for spasticity in a pt with ALS, or clonazepam for REM sleep behavior disorder and methylphenidate for depressive symptoms in Parkinson's). In palliative care, there are times where it is appropriate to use both benzodiazepines and stimulants. Narcolepsy too may sometimes be managed with both stimulants and CNS depressants.

Before the inception of modern antidepressants, uppers and downers were often used though their use was often associated with high risk of addiction. There were even 2-in-1 combos available on the market like Dexamyl which was a combo of dextroamphetamine and amobarbital. This drug was available on the market until the 1980s.

 

[Candidate2017]

Basically the title. First year as an attending and I'm genuinely shocked at how common the combination of benzodiazepines and stimulants are - both among primary care AND even psychiatry - and am disheartened of having to keep having this discussion over and over again.

Unfortunately, this is par for Big Box (hospital system) clinics and a fair number of private practices. Many students go into psych to help people, "the human aspect," the "interesting stories," etc. Alas, the reality is many patients, and the MBAs profiting off you, just need someone with a DEA license to refill uppers and downers.

I suspect you trained at a decent program. Because the transition to community practice as an attending would be much easier if you came from a terrible residency. You'd merely be mindlessly continuing the same terrible practice habits, and fit in with everyone, instead of wondering why the heck is psychiatry practiced so differently from what you were taught.

So what do you do you as an outpt doc? Open your own PP, find a PP that aligns with your training, continue at the Big Box shop but wean patients off their controlleds (and accept the forthcoming whining/yelling/threats/complaints from patients/admin), pop your own Xannys QID so you can chill out and give everyone what they want, or pop your own Addys QID so you can see 4+ patients/hour and furiously smash the controlled refill button like a hopped up monkey and make boatloads of money.

 

[comp1]

So no, this is not good medicine to start. However, once the person is on it, I do agree that there isn't specific literature that the particular combination is horribly neurotoxic. It's just not likely to be effective. That said, rapidly tapering the benzos (almost certainly the controlled drug the patient will ask to lose if forced) is likely to make things worse given the current dependence the patient has. Of course don't start this, but when tapering, really balance out the risk benefit here for the patient. Now of COURSE document, document, document every discussion you have with the patient and why you're doing what you're doing.

 

[clausewitz2]

I am not aware of any data suggesting the combination of benzos and stimulants are especially neurotoxic. Combining lithium and haldol is much more neurotoxic.

More of the issue is that it usually does not make pharmacological sense to prescribe stimulants and benzos together since they have opposing actions, though there are notable exceptions. The problem is that most people on both have anxiety and ADHD or are abusing them or would be better off with some other regimen. In neuropsychiatry, we do sometimes use both together. For example patients with catatonia in the setting of severe depression, managing behavioral and psychological symptoms of dementia (expert use only), some brain injury cases (again, specialist use only), and I have some patients with various neurodegenerative diseases where we have used benzos and stimulants as part of symptom control (for example stimulants for depression or apathy and benzos for spasticity in a pt with ALS, or clonazepam for REM sleep behavior disorder and methylphenidate for depressive symptoms in Parkinson's). In palliative care, there are times where it is appropriate to use both benzodiazepines and stimulants. Narcolepsy too may sometimes be managed with both stimulants and CNS depressants.

Before the inception of modern antidepressants, uppers and downers were often used though their use was often associated with high risk of addiction. There were even 2-in-1 combos available on the market like Dexamyl which was a combo of dextroamphetamine and amobarbital. This drug was available on the market until the 1980s.

Sleep disorders were the first thing to spring to mind for me. The only use case that occurs to me not on your list would be chronic psychosis folks with really bad negative symptoms who just don't sleep at all consistently on their own and don't really engage with CBT-I type approaches. Even then BZDRAs are probably a preferred options to BZDs. Generally agreed that these are rare circumstances indeed.

I think 'upper' and 'downer' should never be concepts you use to seriously think about medication effects or mechanisms. It is just not that simple.

 

[PsyDr]

So what am I missing with this combo? Is it EVER appropriate to prescribe stimulants AND benzos? I was taught that taking "uppers" and "downers" like these together causes long-term neurotoxic effects and should almost never be done. And YET, it's so ubiquitous. Was my understanding misinformed dogma? Is there some medical merit to this combo I was never taught? Did I miss something from training?

The merits:
1) It converts semi-annual appointments to monthly appointments.
2) It converts a normal "no show" rate into a "never misses" appointment rate.
3) It converts an patient panel that varies in terms of sickness into a "My panel is full, stable, and stuck on a monthly appointment cycle".

 

[smalltownpsych]

The merits:
1) It converts semi-annual appointments to monthly appointments.
2) It converts a normal "no show" rate into a "never misses" appointment rate.
3) It converts an patient panel that varies in terms of sickness into a "My panel is full, stable, and stuck on a monthly appointment cycle".

4) It increases the all-important metric of patient satisfaction scores. 😉

 

[dl2dp2]

In my practice, I unfortunately have to do it once a while. Mainly because ADHD patients who also have panic attacks, etc.

I try to gradually taper the benzo, in general, but this can take a long time. Generally convert to Klonopin first then slowly taper. This is documented in the notes. This process can take a number of years. Converting to non benzo anxiolytics is also difficult (i.e. clonidine, etc). If someone's benzo naive I try not to start them on benzo.

 

[clausewitz2]

In my practice, I unfortunately have to do it once a while. Mainly because ADHD patients who also have panic attacks, etc.

I try to gradually taper the benzo, in general, but this can take a long time. Generally convert to Klonopin first then slowly taper. This is documented in the notes. This process can take a number of years. Converting to non benzo anxiolytics is also difficult (i.e. clonidine, etc). If someone's benzo naive I try not to start them on benzo.

Just hit the one year mark of tapering with someone who at intake was on Xanax 1 mg QID and had been for multiple years. We are just now getting down to below the equivalent of 0.5 mg QID. This can be really satisfying and impactful work provided that you are prepared to take your time and realize you sometimes will have to pump the brakes for a bit (but never ever increase).

 

[Evidence Based]

Just like many things, starting something (any benzo, a stimulant, or the combo thereof) is really different than deciding whether and how to continue and whether and how to taper. Just like with opioids, just because it might be a bad idea to start these meds doesn't mean that a taper is risk free, or even that the risks will outweigh the benefits (ex. this paper showing increased mortality after benzodiazepine taper https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2813161). I have not started standing benzos on someone on a stimulant but I have continued them, coming up with a longer term taper plan (which might take years!) and trying to get buy in from the patient.

 

[SPsych6]

Basically the title. First year as an attending and I'm genuinely shocked at how common the combination of benzodiazepines and stimulants are - both among primary care AND even psychiatry - and am disheartened of having to keep having this discussion over and over again.

Sooooo many ADHD/anxiety referrals from PCPs who want to offload the difficult discussion of tapering to us. And even a local psychiatrist who retired and is sending us his patients prescribed the combo to at least 40% of his referred patients. It ends the same every time - with me trying to gently counsel them of the harmful effects with little to no avail, often getting yelled at my patients and their families, getting bad feedback, and then having to answer to administration about complaints. A colleague of mine even joked that I'm better off not fighting it arguing that there's little to no upside in fighting it and "they're stable on it, so why mess with things?". He also mentioned that poor Press Ganey scores could land the clinic and me in hot water since patients are more likely to complain to administration.

So what am I missing with this combo? Is it EVER appropriate to prescribe stimulants AND benzos? I was taught that taking "uppers" and "downers" like these together causes long-term neurotoxic effects and should almost never be done. And YET, it's so ubiquitous. Was my understanding misinformed dogma? Is there some medical merit to this combo I was never taught? Did I miss something from training?

I saw a doc one year out of residency lose their DEA license because of this type of practice. It is really awful, and so tiring. One of the reasons I left a practice run by non-doctors. They just don't get it. Old doctors tend to prescribe this combo a lot from my experience. Personally I would suggest screening new patients coming in and then having staff tell them ahead that you will not be prescribing both. It is easier for them to refuse to come see you then get yelled at during the visit. It really ruins your day. If your company doesn't want to screen these types of patients out, you should leave, that's exactly what I did. Just go cash, pick your patients, or and advertise yourself as a benzodiazapine tapering physician. That way you are only getting the ones who actually want to get away from chronic benzodiapine use. Don't change your mindset because other doctors are inept at practing ethically.

 

[annoyedpsychiatrist]

obtain 500 patients on low dose benzo+stimulant that have no other issues, and youve now produced a very successful private practice, unfortunately.

 

[Celexa]

Big difference between a stimulant + rare prn benzo and chronic of both. The former is not an issue. The latter is almost always bad prescribing, and if both are high dose, it's essentially guaranteed.

That being said, these pts didn't always get there themselves, don't always even like the meds, and are sometimes more open to switching than stereotype suggests. Had a patient this week come to me on Xanax and Adderall. We talked things through and they're happy to proceed with a stepwise plan of trying methylphenidate (they dont like the side effects of adderall) and slow taper of the xanax.

My patient panel is heavily skewed towards patients often tagged "difficult" and yet my outpatient life runs smooth. HOWEVER----I am not blind to the fact that I have multiple advantages:

-patients can only see me if referred internally and I review referrals before they are scheduled. no one comes to me expecting that I am directly taking over their meds
-my intakes are 90 minutes and I take no prior diagnoses for granted. Anyone who just wants easy med fills knows by the second half hour ill be the wrong person for that.
-i work in an academic medical clinic where the leadership is super happy im there and backs any limits i set
-i dont ever prescribe stimulants or benzos on the first visit. I sometimes don't prescribe the first visit at all. I lay out my recommendations to patients which sometimes includes telling them I think a medication is doing more harm then good and that I would not be willing to continue it
-pt can take my recommendations and decide what they want to do.
-if they don't come back, I dont care. I have a massive waitlist and most of the patients are grateful I take the time to properly understand and diagnose their issues.

If your clinic leadership cares more about press ganey than patient care, or you don't have long enough appointments to be thorough, it doesn't work.

If the patients and clinic leadership assume that a new patient seeing you means you automatically will continue someone else's plan, it doesn't work.

The worst patients will be filtered out by a simple policy and warning when they make the appointment that there is no guarantee you will fill previous prescriptions. The rest can be sorted if leadership isn't toxic. But if they are, don't expect things to get better because they won't.

 

[J ROD]

I like to refer to it as the "yo yo" effect. Got to get up to get down. I have issues with some I take over from retiring psychiatrist but overall my place has a low benzo policy and we will taper until we get there and shoot for as needed. We also do not dish off stimulants. I have told many folks I am not giving them a stimulant to perform better as they get older. Had a lady with a BA and two MA come in and tell me she is ADHD because she cannot remember like she could. I was like me too. Welcome to 40!

 

[pittfan53]

I like to refer to it as the "yo yo" effect

Our term was "chilling out at high speeds" lol

 

[milesed]

I have 1-2 on the combo at any given time. ADHD patients who take a rare prn benzo for panic or extreme fear of flying. Benzos are only #5- 10/month and rarely filled. I require a lot of trust in the patient, no substance abuse history, etc.