New patients evals/transfers with adderall prescription.

[deleted1100659]

---

Members don't see this ad.

Their is a such a stigma attached to benzos, because weve all see the horror stories, so its easy to just write them off in our heads. But I agree though. A middle aged person chronically on a low dose benzo with no adverse effects. You take him off, he decompensates, now you need to titrate a medication to substitute and hope it works (and hes likely been on his share of meds). For the prescribing doctor, we have plenty of time to wait for the effect. For the patient, its hell.

 

[d2305]

Let the diabetic run out of insulin…

A diabetic has to be on insulin, but there are safer medications for anxiety.

 

[clausewitz2]

That’s what I came here to say.

Let the asthmatic run out of their Flovent and they’ll be in trouble….

for an even more apt analogy, let someone with OUD run out of suboxone and they’ll be in trouble…

wtf does that prove. Physiologic dependence doesnt = addiction, pretty basic concept.

Or let someone with schizophrenia run out of their haldol.

"Somebody gets much worse when they suddenly don't have their medication anymore" is entirely consistent with "they are taking a medication that is genuinely helpful and having a positive effect on their life." It is not the only possible scenario but it is hardly prima facie evidence of addiction.

 

[FlowRate]

do have some patients on stimulants and either a benzodiazepine or z drug, mainly with narcolepsy.

One with a TBI, ADHD (on long-acting stimulant) and panic disorder who takes a PRN 0.5 mg lorazepam maybe 1-2 times a month. The other with ADHD and PTSD who takes a long acting stimulant and a low-dose PRN Z-drug for sleep that someone else put her on, and I have not had the best luck weaning.

I'm imagining OP was talking about standing benzos or very frequent PRN's. I don't think there are many compelling reasons to be prescribing TID 1mg clonazepam and BID adderall, including narcolepsy.

 

[pisekar]

Their is a such a stigma attached to benzos, because weve all see the horror stories, so its easy to just write them off in our heads. But I agree though. A middle aged person chronically on a low dose benzo with no adverse effects. You take him off, he decompensates, now you need to titrate a medication to substitute and hope it works (and hes likely been on his share of meds). For the prescribing doctor, we have plenty of time to wait for the effect. For the patient, its hell.

When I was a resident, I had a middle age patient who was referred to us for initial evaluation due to confusion and memory problems. Had MDD and GAD diagnosis, he was on benzos x4/day for years. His psychiatrists sent him to a neurologist and neurologist couldn't find anything after L/P, all dementia labs, imagining etc. 🙂)

 

[SourceOfDenial]

Also, most of these patients are not gainfully employed or going to school, what would the purpose of the stimulant be?

The way this forum approaches both the use of controlled substances and ADHD is so bizarre. It also feels telling about how ADHD is taught in med school/residency—since when does it only impact people at work or school? This is a critical misunderstanding of the ways ADHD impacts someone’s life and relationships.

 

[birchswing]

A diabetic has to be on insulin, but there are safer medications for anxiety.

It's like the Homer Simpson quote of alcohol being the solution and cause to all life's problems.

After a while, the benzodiazepines are treating an actual known physiological disease (more analogous to diabetes and insulin), rather than the more amorphous state of anxiety.

It's just that the more known physiological disease they then treat is the very disease they caused.

People call it tolerance, dependence, addiction. I just call it benzodiazepine disease. It's too weird and bizarre and has such a strange constellation of varied symptoms to make it sound comparable to something else and to reduce it to something so simple, in my opinion. It is the chemical imbalance people were told they had before they took it. It's the glutamate storm that can cause something so much worse than any anxiety state, and it's sort of ironic the population that ends up dealing with it.

Yes, benzodiazepines treat anxiety. They then treat their collateral damage—poorly.

 

[mojetter]

surprised at the hostility to the OP...when I come upon clinics like this I submit my resignation notice...not my responsibility to prescribe outside of evidence based medicine especially if the clinic and all the non-prescribes who work there are acting like you're an ass for not prescribing benzos and stimulants...especially if you're detecting a pattern

been there, done that...trust me you'll NEVER be able to get them off of those rx so long as they feel their relationship with the clinic is stronger than their relationship with you....you'll just relax your standards over time and give in ...meanwhile the clinic will throw you under the bus and apologize that your such an "ass" for changing their medications that "work for them"

 

[tr]

Their is a such a stigma attached to benzos, because weve all see the horror stories, so its easy to just write them off in our heads. But I agree though. A middle aged person chronically on a low dose benzo with no adverse effects. You take him off, he decompensates, now you need to titrate a medication to substitute and hope it works (and hes likely been on his share of meds). For the prescribing doctor, we have plenty of time to wait for the effect. For the patient, its hell.

This makes no sense and sounds like you have never taken anyone off chronic benzos. You don't cut them off, watch them decompensate (i.e. go into bzd withdrawal), and then start titrating an SSRI. You start the SSRI first and then shave down the benzo in the tiniest possible steps - like 0.25 mg/d every two months - and wait until sleep/anxiety issues have completely stabilized before taking the next step. It can easily take a year. The result is extremely rewarding however. Usually the patient is thrilled to be off the benzo and notices significantly improved cognitive function.

I really don't think there is any such thing as a middle aged person chronically on a low dose benzo with no adverse effects. They just don't realize they're having the adverse effects until they're off.

 

[tr]

Or let someone with schizophrenia run out of their haldol.

"Somebody gets much worse when they suddenly don't have their medication anymore" is entirely consistent with "they are taking a medication that is genuinely helpful and having a positive effect on their life." It is not the only possible scenario but it is hardly prima facie evidence of addiction.

OK but substances that enact pharmacological dopamine release in the NAcc reward circuit are not the same as substances that do not. I don't care how many fMRIs you show me where people eat sugar and activate (physiologically) their reward circuitry. Chronic dosing of something that pharmacologically creates a runaway feedback loop in the reward system is fundamentally different from chronic dosing of something that does not.

 

[mojetter]

benzos and stimulants can and often do produce euphoria
theres a huge difference between euphoria and euthymia

for all the supporters of this prescribing know that for some patients their treatment goal is euphoria

 

[tr]

benzos and stimulants can and often do produce euphoria
theres a huge difference between euphoria and euthymia

for all the supporters of this prescribing know that for some patients their treatment goal is euphoria

It's fine with me if people want to seek euphoria. God bless.
Wanting and liking are controlled by different circuits; and it isn't the liking that's the problem, it's the wanting. Solid addicts don't even experience euphoria anymore, they're just staving off withdrawal. Go read Berridge and Robinson.

Liking, Wanting and the Incentive-Sensitization Theory of Addiction - PMC

Rewards are both ‘liked’ and ‘wanted’, and those two words seem almost interchangeable. However, the brain circuitry that mediates the psychological process of ‘wanting’ a particular reward is dissociable from circuitry that mediates the degree to ...

www.ncbi.nlm.nih.gov

 

[clausewitz2]

OK but substances that enact pharmacological dopamine release in the NAcc reward circuit are not the same as substances that do not. I don't care how many fMRIs you show me where people eat sugar and activate (physiologically) their reward circuitry. Chronic dosing of something that pharmacologically creates a runaway feedback loop in the reward system is fundamentally different from chronic dosing of something that does not.

I mean, this is of course true. All I am saying is that 'doesn't do as well when drug is stopped' is not by itself evidence of addiction.

I do cite this experience not infrequently in persuading people to come off BZDs, especially if they have addiction histories, though. 'i'm struck by the way you're talking about this medication, very much like how i imagine you talked about booze ten years ago' etc

 

[mojetter]

It's fine with me if people want to seek euphoria. God bless.
Wanting and liking are controlled by different circuits; and it isn't the liking that's the problem, it's the wanting. Solid addicts don't even experience euphoria anymore, they're just staving off withdrawal. Go read Berridge and Robinson.

Liking, Wanting and the Incentive-Sensitization Theory of Addiction - PMC

Rewards are both ‘liked’ and ‘wanted’, and those two words seem almost interchangeable. However, the brain circuitry that mediates the psychological process of ‘wanting’ a particular reward is dissociable from circuitry that mediates the degree to ...

www.ncbi.nlm.nih.gov

I absolutely agree! but euphoria addicts definitely get what they're looking for because few take that rx as prescribed and know how to dose it to keep that feeling going...theyre no fools

 

[birchswing]

I don't think euphoria is inherently a problem, is unethical, or should be considered wrong to desire.

But that's theoretical because I don't think it exists as an entity on its own through these drugs (and with benzos which is all I can speak to I don't think it exists at all).

If you could be at work being productive, interacting with your colleagues, then with your family, at the supermarket, acting ethically, would be there be anything wrong with feeling euphoric at the same time?

It's everything that comes with it in reality that is the problem.

I think we conflate the current level of technology with the ethics of a situation.

The "drugs are bad" message because of their health effects gets mixed in with the idea that they are bad because they make you feel good. Them making you feel good does not seem like their vice to me.

If the tech were better, I don't see the issue with enhancing experiences. People could argue like they do about so many things that something is only worthwhile if you put in the effort, that reading is better than watching a movie, that reading a paper book is better than an audiobook, blah blah blah. Taking a drug is the easy way out. Well if it is easy *and* safe (again hypothetically), I don't see the problem.

We've associated drug dependence and bad health effects with the "easy way out" (which it really isn't given the former) because of the limitations of the technology which seem more like an accident of history than anything else. Leo Sternbach discovered benzodiazepines instead of something that keeps working indefinitely and doesn't cause tachyphylaxis.

In other areas of medicine like primary care and cardiology, doctors are practically begging patients to take statins, as an example, despite that being an easy way to prevent deaths from CVD. They are easy. They work to some extent whether or not you change your lifestyle. And they don't stop working. In fact, over time, they stabilize plaques and continue to improve health. Actual health. Not just symptoms. To me it just seems like an accident of fate and history and biology that nervous system disorders drugs are the ones that have such limitations.

 

[mojetter]

I don't think euphoria is inherently a problem, is unethical, or should be considered wrong to desire.

But that's theoretical because I don't think it exists as an entity on its own through these drugs (and with benzos which is all I can speak to I don't think it exists at all).

If you could be at work being productive, interacting with your colleagues, then with your family, at the supermarket, acting ethically, would be there be anything wrong with feeling euphoric at the same time?

It's everything that comes with it in reality that is the problem.

I think we conflate the current level of technology with the ethics of a situation.

The "drugs are bad" message because of their health effects gets mixed in with the idea that they are bad because they make you feel good. Them making you feel good does not seem like their vice to me.

If the tech were better, I don't see the issue with enhancing experiences. People could argue like they do about so many things that something is only worthwhile if you put in the effort, that reading is better than watching a movie, that reading a paper book is better than an audiobook, blah blah blah. Taking a drug is the easy way out. Well if it is easy *and* safe (again hypothetically), I don't see the problem.

We've associated drug dependence and bad health effects with the "easy way out" (which it really isn't given the former) because of the limitations of the technology which seem more like an accident of history than anything else. Leo Sternbach discovered benzodiazepines instead of something that keeps working indefinitely and doesn't cause tachyphylaxis.

In other areas of medicine like primary care and cardiology, doctors are practically begging patients to take statins, as an example, despite that being an easy way to prevent deaths from CVD. They are easy. They work to some extent whether or not you change your lifestyle. And they don't stop working. In fact, over time, they stabilize plaques and continue to improve health. Actual health. Not just symptoms. To me it just seems like an accident of fate and history and biology that nervous system disorders drugs are the ones that have such limitations.

I see your point but euphoria is not sustainable...sure its good, its damn great...but lets say you expect to feel euphoric with every movie book you read...is that realistic?

Also the problem with euphoria assisted with medication is that it isn't real....and people will over time lose motivation to seek things that naturally produce euphoria which is exactly why recreational drugs got a bad rap to begin with...people using them sought the pleasures of the drugs and slowly lost motivation to do anything else...it ruined families, communities and societies

not to put benzos and Adderall in that category per se but putting euphoria in that category

and statins for example aren't the complicated chemistry of the brain which will up or down regulate the targeted receptors of psychotropic medications... leading to tolerance and needing more of the drug to produce the same effects...I wish it were different but these things are what they are
no the drugs aren't bad but the goal of treatment isn't euphoria...patients have to know this too

Edit: the definition of sustained euphoria is mania ...lol, well not completely but manic patients love mania

 

[deleted1100659]

This makes no sense and sounds like you have never taken anyone off chronic benzos. You don't cut them off, watch them decompensate (i.e. go into bzd withdrawal), and then start titrating an SSRI. You start the SSRI first and then shave down the benzo in the tiniest possible steps - like 0.25 mg/d every two months - and wait until sleep/anxiety issues have completely stabilized before taking the next step. It can easily take a year. The result is extremely rewarding however. Usually the patient is thrilled to be off the benzo and notices significantly improved cognitive function.

I really don't think there is any such thing as a middle aged person chronically on a low dose benzo with no adverse effects. They just don't realize they're having the adverse effects until they're off.

My point is that ive seen psychiatrists out there quickly taper off the benzo without establishing some form of response from SSRI or alternative because of the way they perceive the benzo. Ive seen PCPs, plenty of times, start a benzo irresponsibly, as well as taper one off irresponsibly.

I have never had a patient who was on benzos for years, become thrilled to be tapered off it. Well, I had one, but she was fairly intelligent and had good insight.

Theres clearly two schools of people here- people that are anti benzos no matter what, and people who aren't. I don't think benzos are a great medication, and I rarely prescribe them, but I also don't completely rule them out in every patient automatically either. I think physicians on SDN also commonly reference idealistic situations rather than realistic situations.

 

[tr]

My point is that ive seen psychiatrists out there quickly taper off the benzo without establishing some form of response from SSRI or alternative because of the way they perceive the benzo. Ive seen PCPs, plenty of times, start a benzo irresponsibly, as well as taper one off irresponsibly.

I have never had a patient who was on benzos for years, become thrilled to be tapered off it. Well, I had one, but she was fairly intelligent and had good insight.

Theres clearly two schools of people here- people that are anti benzos no matter what, and people who aren't. I don't think benzos are a great medication, and I rarely prescribe them, but I also don't completely rule them out in every patient automatically either. I think physicians on SDN also commonly reference idealistic situations rather than realistic situations.

I'm not anti benzo no matter what. I'm anti *chronic* benzo. Benzos are great for getting on a plane a couple of times a year. Significantly less useful and more harmful when taken daily.

 

[Mass Effect]

It would be analogous for let's say a patient that has bipolar disorder, you give them an antidepressant and they become manic. Then you give them an antipsychotic to help with the mania, and then you keep them on both (Symbyax, lol).

Don't see the scientific backing for having people on benzodiazepines and stimulants at the same time, just anecdotal evidence which as we know is the lowest level of evidence.

People with bipolar disorder are on antidepressants all.the.time. Like literally, that's part of the treatment algorithm for bipolar depression. We don't jump to an antipsychotic for mania. We jump to mood stabilizers and yes, sometimes we use antipsychotics.

Others have told you that stimulant + benzo isn't that unusual if they're being used responsible (infrequent use of benzo). I'm not a fan of chronic benzo use regardless, but dismissing it as malpractice is a bit much.

What field are you in?

 

[Mass Effect]

Thanks for your input. Do you ask for employment/school status to continue stimulants?

Employment/school status should not dictate whether or not someone gets a stimulant. People with clinically significant ADHD need a stimulant to function. You shouldn't punish people if they're not working or not in school when the reason they're not working or not in school may very well be because they have ADHD.

 

[mojetter]

The poster clearly is saying IF it then caused mania

That's a completely different scenario than what you're describing

 

[Mass Effect]

The poster clearly is saying IF it then caused mania

That's a completely different scenario than what you're describing

If it then caused mania, what? I don't understand what you're saying here or how what I said is different from what the poster said?

The poster was saying that prescribing a stimulant with a benzo is akin to prescribing an antidepressant in bipolar d/o that then causes mania that you treat with an antipsychotic.

 

[mojetter]

If it then caused mania, what? I don't understand what you're saying here or how what I said is different from what the poster said?

The poster was saying that prescribing a stimulant with a benzo is akin to prescribing an antidepressant in bipolar d/o that then causes mania that you treat with an antipsychotic.

The poster is actually correct... If you are not on an antidepressant and have bipolar disorder and someone gives a SSRI and patient THEN becomes manic the treatment is:

-stop the anti depressant
-prescribe a medication for the acute phase of mania which can very well be an antipsychotic there are 7 FDA approved and on inpatient we often use those more than mood stabilizers because they work far faster and are available in IM forms

from what you said the bipolar patient who is ALREADY on a SSRI and becomes manic there is less of a chance it was the ssri and not usually targeted or removed from the treatment regimen depending how manic the patient is

 

[Mass Effect]

The poster is actually correct... If you are not on an antidepressant and have bipolar disorder and someone gives a SSRI and patient THEN becomes manic the treatment is:

-stop the anti depressant
-prescribe a medication for the acute phase of mania which can very well be an antipsychotic there are 7 FDA approved and on inpatient we often use those more than mood stabilizers because they work far faster and are available in IM forms

from what you said the bipolar patient who is ALREADY on a SSRI and becomes manic there is less of a chance it was the ssri and not usually targeted or removed from the treatment regimen depending how manic the patient is

I'm well aware of how to treat bipolar disorder. I'm saying that the poster to suggest this is something bad, much like his/her opinion of a stimulant/benzo combo doesn't make sense, as the treatment of bipolar depression IS often an antidepressant and in a patient with bipolar disorder, you don't put them on an unopposed SSRI. This is a standard thing and done all the time so the poster to imply it's a bad thing or shouldn't be done is perplexing. That's my point.

 

[myPsychAlt]

It feels easier to vilify stimulants and benzos in a black and white fashion. In my experience it’s really shades of gray.

The shades involved tend to be described a "Egg" and "Dark Anthracite" however...