Not feeling comfortable prescribing Benzo's?

[ara96]

I'm currently doing my child fellowship, in my first year but I do some moonlighting at a community mental health clinic where I see adult patients who are referred from their PCP's. I am having a hard time prescribing Benzo's, I always get nervous when I have people coming to me expecting Xanax and then I try to sell them onto Vistaril or Gabapentin. I feel this is because my residency training highly discouraged prescribing any Benzo's and I feel they went overboard because we dealt with so many people who would abuse substances.

I'm just worried about what I will do when I go out and work in the real private world, where people will laugh if all you give for anxiety is an SSRI.

Does anyone have any advice for me? I feel so unprepared to practice on my own. Why would anyone come see me when they can get unlimited supplies of Benzo's and Ambien from their PCP's?

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[Monocles]

Do what makes you feel comfortable and what you think is morally right. If you feel like benzos are harmful then don't give them benzos, full stop.

You can always just tell them that benzos cause dependence and they'll end up more anxious in the long run.

Does anyone have any advice for me? I feel so unprepared to practice on my own. Why would anyone come see me when they can get unlimited supplies of Benzo's and Ambien from their PCP's?

Probably because their PCPs aren't giving it to them.

 

[WisNeuro]

I'm currently doing my child fellowship, in my first year but I do some moonlighting at a community mental health clinic where I see adult patients who are referred from their PCP's. I am having a hard time prescribing Benzo's, I always get nervous when I have people coming to me expecting Xanax and then I try to sell them onto Vistaril or Gabapentin. I feel this is because my residency training highly discouraged prescribing any Benzo's and I feel they went overboard because we dealt with so many people who would abuse substances.?

I would look at it more like they probably actually knew the literature on benzos in that they do not actually treat anxiety and cause infinitely more harm than good in 99% of the circumstances that they are currently used.

 

[FlowRate]

I'm very tempted to link to the archives for TLP's SSI article... The purpose of a CMHC is not just MH.

 

[Sushirolls]

I'm currently doing my child fellowship, in my first year but I do some moonlighting at a community mental health clinic where I see adult patients who are referred from their PCP's. I am having a hard time prescribing Benzo's, I always get nervous when I have people coming to me expecting Xanax and then I try to sell them onto Vistaril or Gabapentin. I feel this is because my residency training highly discouraged prescribing any Benzo's and I feel they went overboard because we dealt with so many people who would abuse substances.

I'm just worried about what I will do when I go out and work in the real private world, where people will laugh if all you give for anxiety is an SSRI.

Does anyone have any advice for me? I feel so unprepared to practice on my own. Why would anyone come see me when they can get unlimited supplies of Benzo's and Ambien from their PCP's?

People will not laugh. If you are in a group practice with a health system the colleagues will just shrug their shoulders and say "meh" and continue to prescribe xanax themselves. But you will then deal with all their emergent refills when they are on vacation...

You need to know the literature and be able to appropriately quote to the educational level of the person before you. Dependency, fall risks, PNA risks, cognitive decline, rebound anxiety with xanax, addiction potential. You also need to be well versed in tapering patients off.

The best advice I can give you is strengthen your resolve, shine your armor and be prepared every day to fight the good fight. Or seek out a practice environment where the colleagues share the same orientation. They are few, but they do exist.

I'm currently in private practice and have met with therapists in seeking referrals. They are ecstatic to know of a psychiatrist who doesn't do benzos they can refer to. Patients fill out a screen intake form asking if on benzos. I discuss ahead of time that they really aren't prescribed here unless rare circumstances. Some patients have opted not to schedule, others are open and receptive. This has reduced the frequency of these encounters when compared to being at health system where every other patient was a PCP referral on xanax or klonopin.

 

[whopper]

Unfortunately you will see a lot of doctors that prescribe benzos and like meds (e.g. Zolpidem) as if it's candy. Many patients will expect you to continue the problematic prescription and if you don't they'll get mad at you.

I will take patients on large dosages of benzos but I pretty much always tell them if they want to be my patient I will wean them off of them. I do give long periods of time. E.g. I weaned one patient off over the course of 2 years. So long as we're going in that direction even slowly I'll keep them.

You will experience a lot of anger from patients. You will also be in a sometimes uncomfortable position because while the other doctor may in fact be a poor physician (not care they're making addicts out of patients, not warning patients of long-term effects of benzos) you don't want to specifically broadcast this to the patient.

I've often told patients, "I don't know why Dr. Shmuck prescribed you Alprazolam 8 mg a day for years, but I can tell you the science doesn't back this up as safe practice except for very serious exceptions that do not fit the overwhelming majority of the cases."

I had 2 patients in the last year that came to me on dosages so high of benzos that they were almost incoherent during meetings, had to be driven to my office by someone else, and during meetings often times closed their eyes while talking as if hypnotized. Both of them ended up getting terminated. I was able to cut their benzo dosages to about half of what it was before, they were both very irate (in a cluster B manner) when their true personalities came out and did things warranting termination. 1 person kept demanding substances of abuse, the other smoked in my waiting room and was giving me several contradictory answers to the point where I couldn't trust her as a patient.

Most of the time even when I get the records from these other doctors there's no justification written in for the medication and it's dosage.

I've even confronted doctors who prescribed like the above and when asked why they did it, often got a response of a giggle, a wink, and a statement of "you know why I do it."

As you likely know, medstudents are taught and are very aware of dangers of long-term use of benzos. It's not like we psychiatrists are doing something that is so esoteric and so incredibly difficult to master that only we know about this, and I see so many psychiatrists do this type of wrong-practice too.

Also, I do find that benzos just at low dosages, or if used weekly or less are okay. E.g. a patient where we've reached maximum benefit with antidepressants, propranolol, and Buspirone with panic attacks, they've gone down to 6 a day to 1 a week, and the person takes Alprazolam 0.5 mg by mouth daily PRN on the order of about only once a week.

 

[Mass Effect]

There are some indications for benzos. Learn what those are and prescribe accordingly. You don't have to prescribe Xanax (and frankly, I wouldn't) and you don't have to prescribe these meds to anyone who has a substance abuse history.

 

[Mass Effect]

Also, I do find that benzos just at low dosages, or if used weekly or less are okay. E.g. a patient where we've reached maximum benefit with antidepressants, propranolol, and Buspirone with panic attacks, they've gone down to 6 a day to 1 a week, and the person takes Alprazolam 0.5 mg by mouth daily PRN on the order of about only once a week.

This exactly. I've known psychiatrists who refuse to ever prescribe a benzo (I knew one who even refused to prescribe a limited quantity for a plane ride). I feel like the education these days is going overboard in the other direction with absolutes on never prescribing unless you want to get sued or turn out addicts. Benzos, when used appropriately and rarely are okay, in my book.

 

[Armadillos]

Benzos also can be quite helpful for folks with psychotic disorders or bipolar 1. Anecdotally if you have someone on good antipsychotic or mood stabilizer then they are starting to decompensate a little, adding some Klonopin at night can sometimes pull things back together and may save an inpatient admission.

 

[WisNeuro]

This exactly. I've known psychiatrists who refuse to ever prescribe a benzo (I knew one who even refused to prescribe a limited quantity for a plane ride). I feel like the education these days is going overboard in the other direction with absolutes on never prescribing unless you want to get sued or turn out addicts. Benzos, when used appropriately and rarely are okay, in my book.

I think it's somewhat justified. We all know that there are certain, very circumscribed contexts where the benzos are useful. Problem is, I can count on one hand the patients who meet those criteria. The vast, overwhelming number of patients are on the other side or initial inappropriate prescribing, starting out on PRN but quickly escalating to 1-2mg 3-4 times a day, etc. In the OPs case, I doubt that they are referring to a patient who needs a couple xanax for a plane ride. I assume they are talking about the patients coming in who want maintenance benzos, or want them to continue or up their maintenance benzos from another provider.

 

[MedMan80]

If somebody is only asking to be put on benzos that's the easy part, the hard part will come when you inherit a patient on polypharm with benzos and you try to taper. If they meet criteria for an anxiety d/o then SSRI plus short term benzo if they're really anxious, make it clear it's short term while the SSRI kicks in. Other than that just tell them it's for short term anxiety treatment and anxiety disorders are typically a long term/chronic thing.

 

[clausewitz2]

I think it's somewhat justified. We all know that there are certain, very circumscribed contexts where the benzos are useful. Problem is, I can count on one hand the patients who meet those criteria. The vast, overwhelming number of patients are on the other side or initial inappropriate prescribing, starting out on PRN but quickly escalating to 1-2mg 3-4 times a day, etc. In the OPs case, I doubt that they are referring to a patient who needs a couple xanax for a plane ride. I assume they are talking about the patients coming in who want maintenance benzos, or want them to continue or up their maintenance benzos from another provider.

I am struggling to think of why PRNs for anxiety ever really make sense unless the object of anxiety is very circumscribed and not encountered very often in the course of normal life (an airplane, a scanner). Surely daily anxiety PRNs are just safety behavior turned up to 11?

 

[clausewitz2]

Benzos also can be quite helpful for folks with psychotic disorders or bipolar 1. Anecdotally if you have someone on good antipsychotic or mood stabilizer then they are starting to decompensate a little, adding some Klonopin at night can sometimes pull things back together and may save an inpatient admission.

Yes, I have a couple bipolar I folks with an "in case of emergency break glass" script for a one week supply of Ativan qHS. Has definitely averted a crisis or two.

 

[Mass Effect]

I think it's somewhat justified. We all know that there are certain, very circumscribed contexts where the benzos are useful. Problem is, I can count on one hand the patients who meet those criteria.

I don't mean this to be disrespectful by any means, but as a non-prescriber and specifically as a neuropsychologist, I'm pretty sure your patient population is different from the average outpatient psychiatrist's. So while you can count on one hand the patients who meet criteria, most outpatient general psychiatrists see much more.

I am struggling to think of why PRNs for anxiety ever really make sense unless the object of anxiety is very circumscribed and not encountered very often in the course of normal life (an airplane, a scanner). Surely daily anxiety PRNs are just safety behavior turned up to 11?

Benzos are FDA approved for specific short-term reasons and many patients meet that criteria.

 

[clausewitz2]

I don't mean this to be disrespectful by any means, but as a non-prescriber and specifically as a neuropsychologist, I'm pretty sure your patient population is different from the average outpatient psychiatrist's. So while you can count on one hand the patients who meet criteria, most outpatient general psychiatrists see much more.



Benzos are FDA approved for specific short-term reasons and many patients meet that criteria.

FDA approval != a good idea or theoretically sound. Based on all we know about anxiety and learning, I still have yet to hear a compelling explanation of why chronic PRNs won't inevitably make anxiety worse over time.

I 100% agree with you that in the short term for highly circumscribed situations this is not really an issue. I also agree with you that psychiatrists should not be treating benzos like they were actually the devil. At the same time, I think there is very strong reason to think that long term medicating of anxiety only really makes sense with scheduled drugs that you take in the same manner regardless of your circumstances or feelings at that moment. Otherwise you are ultimately strengthening the learning history that says "feeling anxious is very dangerous and must be avoided."

FDA indications are fine but they can only be the beginning of thinking rationally about this sort of issue. They have a very narrow purpose, consider a very narrow evidence base (typically 2-3 studies), are very rarely revised, and are highly contingent on the specific historical circumstances under which they were issued, e.g. what the manufacturer wanted to put on the label for that specific drug to maximize market share, differentiate from competitors etc.

 

[whopper]

Agree with the benzo "break the glass" analogy. A benzo could prevent a manic episode or act like a bucket of water if it were like a fire. A guy who hasn't slept for a few days has a much better chance of sleeping on a benzo. In such cases the benzo could be justified. I just tell the patient, however, that they need to see me within a few days to weeks so we could use other methods and get them off the benzo.

I've also found prescribing benzos easier to deal with in private practice. E.g. in inpatient and Medicaid offices you have people with more impulse control, less grasp of delayed gratification, long-term planning and are much more likely to abuse it. Even ones that don't want to abuse it themselves and even use it responsibly are often under significant financial duress and may sell it. I pretty much never even wanted to give it out almost at all in these settings.

In private practice I don't see that problem anywhere near as much. While working in Medicaid offices over 80% of patients when I warned of the dangers of using benzos don't seem to care and want it continued while over 80% of those in my private office want off of it when warned. While I don't prescribe many benzos to begin with I don't get the enraged "give me Xanax" type patient much in private practice that I used to get almost daily in ER/Inpatient/Medicaid settings. Correspondingly I almost never treated ADHD with a stimulant in such settings for the same reason though there were some exceptions on the order of perhaps a total of less than 10 cases my entire career.

When I graduated from residency, and for the next few years, I've almost never treated ADHD with stimulants. Currently in private practice about 15% of my patients are treated for ADHD with stimulants and this was something I never would've considered as a new attending so used to kicking malingerers out of inpatient units and ERs. Of course I'll terminate or cut if off if I see signs of abuse but this isn't happening much and when it does happen I usually catch some odd behaviors within the first few months and terminate or confront the patient. Many of them are college educated, work full time, their families, friends, coworkers even report to me they're doing much better on a stimulant. E.g. the patient's husband will call me up and tell me that his wife now can sit still longer, is less frantic, sleeps better even on the stimulant, and is in general much more calm and at peace. Many of them even want off a stimulant when I give them the option of Wellbutrin or Atomoxetine.

In private practice, when you first start out you will get some problematic patients but it's not close to what it's like in an ER/inpatient/Medicaid office. In those settings maybe 1/3 or more were drug-seeking while in new-private practice it's about up to 5%. When you see about 15 patients a day that's seeing a problematic drug seeking patient less than daily and this in only in the beginning of the office practice. Over time you will either get them better, you will terminate them, or they will move on to another doctor once they've found out you will not enable their problem. So you will have some more fires to put out but after about 1 year things calm down and you have a much more easier set of patients. I can't think of any specifically problematic patient right now off the top of my head. In the last 3 months I terminated 2 problematic ones but these were only 2 out of over 1000. (They both wanted high dosage benzos to treat their Axis II disorders). My first year I was getting rid of patients very often (of course appropriately, telling them maybe they needed to actually want to go sober, or get inpatient rehab, or confront them that I wouldn't be the equivalent of a drug dealer for benzos) and would lose a problematic patient almost weekly but most of them just moved to the next doctor on their own. I'd only have to terminate about once a month in the first year.

Another added benefit is your rep will spread. Many addicts will tell their friends who are also addicts to avoid doctors who will not easily prescribe controlled substances. I'm sure that led to the much less frustrating population I now have vs when I started out.

A personal psychological issue I've gone through is when I first noticed the above phenomenon I was in denial of it. Two major factors were at play in my head. I spent my initial years as a resident fighting the urge to simply do what the patient wanted cause in the ER/Inpatient/Medicaid settings what the patient wanted was long-term self destructive. So I had to change my mental paradigm, but in private practice I was so used to the new paradigm I had to realize I had to dial it back cause this was a new patient population. The 2nd was it caused me to think I was being elitist. Most people in the ER/Inpatient/Medicaid settings are on the bottom dregs of society. The more I thought about and introspected, however, you have to face the reality that some (of course not all) are there cause their problems with addiction/impulse control/etc are why they are there and guess what? I had the same problems with entitled wealthy patients when I worked in expensive private research based treatment facilities where I too didn't want to give out any controlled substances. I noticed the factors weren't race or money but impulse-control, ability to maintain delayed gratification, and willingness to take the dangers of the controlled substance seriously.

 

[clausewitz2]

Agree with the benzo "break the glass" analogy. A benzo could prevent a manic episode or act like a bucket of water if it were like a fire. A guy who hasn't slept for a few days has a much better chance of sleeping on a benzo. In such cases the benzo could be justified. I just tell the patient, however, that they need to see me within a few days to weeks so we could use other methods and get them off the benzo.

I've also found prescribing benzos easier to deal with in private practice. E.g. in inpatient and Medicaid offices you have people with more impulse control, less grasp of delayed gratification, long-term planning and are much more likely to abuse it. Even ones that don't want to abuse it themselves and even use it responsibly are often under significant financial duress and may sell it.

In private practice I don't see that problem anywhere near as much. While working in Medicaid offices over 80% of patient when I tell them of the dangerous of using benzos don't seem to care and want it continued while over 80% of those in my private office want off of it when I warn them of the same. While I don't prescribe many benzos to begin with I don't get the enraged "give me Xanax" type patient much in private practice that I used to get almost daily in ER/Inpatient/Medicaid settings. Correspondingly I almost never treated ADHD with a stimulant in such settings for the same reason though there were some exceptions on the order of perhaps a total of less than 10 cases my entire career.

When I graduated from residency, and for the next few years, I've pretty much almost never treated ADHD without stimulants. Currently in private practice about 15% of my patients are treated for ADHD with stimulants and this was something I never would've considered as a new attending so used to kicking malingerers out of inpatient units and ERs. Of course I'll terminate it cut if off if I see signs of abuse but this isn't happening. Many of them are college educated, work full time, their families, friends, coworkers even report to me they're doing much better on a stimulant. E.g. the patient's husband will call me up and tell me that his wife now can sit still longer, is less frantic, sleeps better even on the stimulant, and is in general much more calm and at peace. Many of them even want off a stimulant when I give them the option of Wellbutrin or Atomoxetine.

It's so gratifying to give someone like this 5 mg of Adderall XR and have them come back saying "this has changed my life, please don't ever increase the dose."

 

[whopper]

Two factors where I become over 99% convinced the person really has ADHD.
1) They sleep better on a stimulant.
2) Their anxiety goes down with a dopamine-enhancing agent.

I had one guy with PTSD and Panic Disorder. I treated him for about 2 years with serotonin enhancing meds. He told me he slept better on coffee, I added Wellbutrin and his anxiety went down even more so than the SSRI and Buspirone were doing so we stopped those meds and his anxiety was still under control. Now he's not on any serotonin-ehnancing med. He's on Wellbutrin and a low dose Adderall. The guy came into my office for PTSD and panic attacks! Since the Wellbutrin and Adderall 10 mg daily (he takes about 2-3x a week) all of his anxiety went away and he told me he's doing much better at work and he came into my office in the first place for anxiety only!

One thing they don't teach in residency-if someone has untreated ADHD ramped up anxiety is to be expected caused by the ADHD. And this makes it confusing cause if you have someone where you suspect ADHD and they have anxiety, if you give them a dopamine enhancing med you could make their anxiety much worse, but ADHD could be the root problem.

 

[whopper]

An issue I had to deal with...and I mentioned this before.
When I first started at U of Cincinnati I took over an addiction-doctor's set of outpatients. Guess what? This idiot "ADDICTION DOCTOR" gave her patients everything they wanted.

So it was pretty much me telling over 80% of them (not 100%, cause some of them actually did want to be off of controlled substances) that I wasn't gong to give them any controlled substances unless we were going to wean them off of them.

I later figured out the previous "ADDICTION DOCTOR" left the job cause she realized she created monster-addicts and getting out of the job and joining the VA was her short-cut way to run away from the arson she created. She was too chicken to change their therapy and let her former patients bully her.

My first 3 months dealing with her patients often times resulted in patients screaming at me while I would tell them very politely to leave my office. I would look at my schedule for the day, see that out of the 10 scheduled about 7 were her former patients, and I'd cynically joke to my receptionist...."okay that means about 5 of them will scream at me before the day is done."

I had to let my boss know what was going on with that idiot cause she might've sought future employment again with U of Cincinnati. When I told him and her (they were a married couple both in clinical director positions) and a few others what was going on they also told me horror stories of the same doctor getting urine drug screen samples and pouring the urine into the sink where other doctors got their coffee. Her office which became mine was loaded with various disgusting items such a dried up mucous membranes and finger nails encrusted into the keyboard.

One of her former patients went to the pharmacy, demanded Xanax without a script, and started throwing candy at the pharmacist from the various candy trays typically in a pharmacy screaming at him to give her Xanax. He called me up and I told him about this monster the other doc created. "What should I do?" I told him to call the police and have her arrested.

 

[medstudent234]

I'm surprised that not many of you are prescribing short term benzos for severe anxiety while you taper up the SSRIs. I find that many people with panic attacks or acute on chronic anxiety are not able to tolerate starting an antidepressant (even starting at half the normal dose or less) without something like very low dose klonopin started at the same time. I prescribe it standing though (for no more than 2 months), not prn as I find that reinforces need for escape for anxiety.

 

[whopper]

A pitfall that can happen.
Antidepressants don't work anywhere close to 100%. You could prescribe several that won't work. Benzo use is often times fine for a few weeks, and from there on that's where the problems can start.

So you start the benzo the first day, tell them it's temporary, and try an antidepressant. It could be you won't find one that works well for that patient for several months. While it's not the majority, it is a realistic and expectable minority where this happens. If the person is impulsive, or otherwise has other traits making them prone to addiction, it could be like pulling out teeth trying to get them off that benzo.

This is why despite what I wrote above I don't like prescribing benzos in general especially to brand new patients. I am only comfortable prescribing benzos to patients where we have a good treatment relationship and I've known the patient to be reliable with this type of thing. I do prescribe low dosage of benzos to new patients in the situation you mention but I am hesitant, wary, and also consider other options such as a B-blocker or Gabapentin.

When you get a patient with several traits predictive of substance abuse and offer a controlled substance, they sometimes like what they got a little too much and blow up in anger when you tell them you're going to take them off of it even when you've warned them well in advance.

 

[Crayola227]

People will not laugh. If you are in a group practice with a health system the colleagues will just shrug their shoulders and say "meh" and continue to prescribe xanax themselves. But you will then deal with all their emergent refills when they are on vacation...

You need to know the literature and be able to appropriately quote to the educational level of the person before you. Dependency, fall risks, PNA risks, cognitive decline, rebound anxiety with xanax, addiction potential. You also need to be well versed in tapering patients off.

The best advice I can give you is strengthen your resolve, shine your armor and be prepared every day to fight the good fight. Or seek out a practice environment where the colleagues share the same orientation. They are few, but they do exist.

I'm currently in private practice and have met with therapists in seeking referrals. They are ecstatic to know of a psychiatrist who doesn't do benzos they can refer to. Patients fill out a screen intake form asking if on benzos. I discuss ahead of time that they really aren't prescribed here unless rare circumstances. Some patients have opted not to schedule, others are open and receptive. This has reduced the frequency of these encounters when compared to being at health system where every other patient was a PCP referral on xanax or klonopin.

can you tell me more about cognitive decline? I didn't know this was a side effect of benzos. Is it irreversible?

 

[sloop]

When I graduated from residency, and for the next few years, I've almost never treated ADHD with stimulants. Currently in private practice about 15% of my patients are treated for ADHD with stimulants and this was something I never would've considered as a new attending so used to kicking malingerers out of inpatient units and ERs. Of course I'll terminate or cut if off if I see signs of abuse but this isn't happening much and when it does happen I usually catch some odd behaviors within the first few months and terminate or confront the patient. Many of them are college educated, work full time, their families, friends, coworkers even report to me they're doing much better on a stimulant. E.g. the patient's husband will call me up and tell me that his wife now can sit still longer, is less frantic, sleeps better even on the stimulant, and is in general much more calm and at peace. Many of them even want off a stimulant when I give them the option of Wellbutrin or Atomoxetine.

I preface this by saying I'm not looking for medical advice (as I know that's such a sensitive issue on this board). I'm just using a personal situation to highlight what I believe is a problem.

I think the discomfort of lots of psychiatrists with prescribing stimulants for ADHD can be a real problem. It's well-meaning but, to be honest, I personally have not changed doctors since starting residency and it's been rather inconvenient. Being a resident and seeing how many psychiatrists are uncomfortable with stimulants makes me reluctant to switch because I really don't want to run into a situation where I show up to my appointment and my doctor tries to convince me to try to, while in residency, come off the medication that changed my life in high school and has worked really well for me for many years. TBH, that would even make me doctor shop and I don't want to deal with the stress of that. For what it's worth, the stimulant does calm me down, sit still and go to bed at a regular time. I also had an extensive workup when I was a kid before being diagnosed with this (they thought I had absence epilepsy at first, had an MRI, EEG, saw a pediatric neurologist before seeing a psychiatrist, had a full neuropsychological assessment, multiple Vanderbilt forms, tried Straterra first in an attempt to not exacerbate tics I had at the time, etc.) Unfortunately I think there are a significant number of doctors who would not care and would not prescribe stimulants.

I think the reactionary approach to controlled substances in psychiatry comes from a good place but the fact that it's not uncommon for doctors to have extreme black and white ideologies with regard to it is a problem that affects patients. I don't think that benzos and stimulants should be prescribed to everyone, but there are patients for whom they are appropriate. It would be a huge problem if a significant minority of psychiatrists were uncomfortable prescribing mood stabilizers for Bipolar I. I think that the surveys showing a good number of even psychiatrists being uncomfortable prescribing MAOIs is similarly concerning. The fact that many people graduate residency and are uncomfortable prescribing stimulants for ADHD is a real problem.

 

[Mass Effect]

can you tell me more about cognitive decline? I didn't know this was a side effect of benzos. Is it irreversible?

It's generally accepted that long-term benzo use can contribute to, if not trigger, cognitive decline, particularly with regard to visual-spatial and attentional deficits. I have run across some articles challenging this claim, but that's the general consensus.

Benzodiazepine use and cognitive decline in elderly with normal cognition

Benzodiazepine use and risk of incident dementia or cognitive decline: prospective population based study

 

[WisNeuro]

I don't mean this to be disrespectful by any means, but as a non-prescriber and specifically as a neuropsychologist, I'm pretty sure your patient population is different from the average outpatient psychiatrist's. So while you can count on one hand the patients who meet criteria, most outpatient general psychiatrists see much more.

We see the same patients, I just tend to see the older side of your patients, generally speaking. After they've been on maintenance benzos for several decades. But, I still see plenty of the 18-60 range patients as well. I work daily with other providers (neurology, neurosurgery, primary care, etc), not too mention married to a physician with a different patient population. I still stand by my assertion that the "ok" uses of benzos are few and far between, and the actual practice of prescribing benzos flies in the face of the overwhelning body of literature.

 

[Mass Effect]

I think the reactionary approach to controlled substances in psychiatry comes from a good place but the fact that it's not uncommon for doctors to have extreme black and white ideologies with regard to it is a problem that affects patients. I don't think that benzos and stimulants should be prescribed to everyone, but there are patients for whom they are appropriate. It would be a huge problem if a significant minority of psychiatrists were uncomfortable prescribing mood stabilizers for Bipolar I. I think that the surveys showing a good number of even psychiatrists being uncomfortable prescribing MAOIs is similarly concerning. The fact that many people graduate residency and are uncomfortable prescribing stimulants for ADHD is a real problem.

I agree 100%. I think the problem is that too many people are conditioned to believe all controlled substances = bad, bad, bad, and take a paternalistic approach to patient care with strict black and whites rather than weighing the risks and benefits. I've seen some psychiatrists (primarily residents) who try to taper every single person on a benzo or stimulant, regardless of time they've been on it, active symptoms, the benefit they've had, and lack of abuse. That's just bad medicine. Stimulants, like benzos, can change lives for the better when prescribed and used properly and they should be, at the very least, a consideration that's on the table for any patient with debilitating symptoms who has no substance abuse history.

 

[WisNeuro]

I am struggling to think of why PRNs for anxiety ever really make sense unless the object of anxiety is very circumscribed and not encountered very often in the course of normal life (an airplane, a scanner). Surely daily anxiety PRNs are just safety behavior turned up to 11?

I also agree. We are overpathologizing normal anxiety in many people, and just reinforcing the idea that the anxiety is dangerous in non-dangerous settings. I guess if the choice is between someone absolutely refusing an MRI vs just giving them a one time dose of 1mg, go nuts. But, these patients tend to have a lot more going on in the anxiety realm and end up getting the benzos full-time at some point.

 

[Mass Effect]

We see the same patients, I just tend to see the older side of your patients, generally speaking. After they've been on maintenance benzos for several decades. But, I still see plenty of the 18-60 range patients as well. I work daily with other providers (neurology, neurosurgery, primary care, etc), not too mention married to a physician with a different patient population. I still stand by my assertion that the "ok" uses of benzos are few and far between, and the actual practice of prescribing benzos flies in the face of the overwhelning body of literature.

I disagree and maintain that your patient population and my patient population differ as do our training, which includes indication for benzo use.

 

[Mass Effect]

I also agree. We are overpathologizing normal anxiety in many people, and just reinforcing the idea that the anxiety is dangerous in non-dangerous settings. I guess if the choice is between someone absolutely refusing an MRI vs just giving them a one time dose of 1mg, go nuts. But, these patients tend to have a lot more going on in the anxiety realm and end up getting the benzos full-time at some point.

Please cite a source for this claim because this has not been my experience at all. In my view, chronic anxiety is pathologic. "Normal anxiety" is called being nervous. Prescribing benzos for MRI scans is pretty common and I know of no literature that suggests that getting one dose of Ativan for this reason leads to full-time benzo scripts in the future. If you do, please share.

 

[WisNeuro]

I disagree and maintain that your patient population and my patient population differ as do our training, which includes indication for benzo use.

Then we agree to disagree, although the numbers on how benzos are prescribed and used, would tend to agree with my view of the vast majority of their use being inappropriate. It's a view that has been reinforced in each and every setting I've worked in over the years.

 

[WisNeuro]

Please cite a source for this claim because this has not been my experience at all. In my view, chronic anxiety is pathologic. "Normal anxiety" is called being nervous. Prescribing benzos for MRI scans is pretty common and I know of no literature that suggests that getting one dose of Ativan for this reason leads to full-time benzo scripts in the future. If you do, please share.

This is anecdotal. But, I'm sure that you can take a poll of personal experiences on here. Not many of these patients have anxiety/panic that is that circumscribed. These people generally have a lot more going on in the anxiety space.

 

[WisNeuro]

As an aside, I still treat panic disorder and PTSD as part of my general practice in addition to my neuro work, so I still see these patients in this realm in conjunction with psychiatry.

 

[Mass Effect]

Then we agree to disagree, although the numbers on how benzos are prescribed and used, would tend to agree with my view of the vast majority of their use being inappropriate. It's a view that has been reinforced in each and every setting I've worked in over the years.

The majority being prescribed inappropriately is a reasonable conclusion. I disagreed with your assertion that benzo initiation is indicated in very few patients. That's not true, in my experience. The problem is prescribing practices and people who don't know or don't care to prescribe responsibly. Patients suffer, either because they get over-treated with benzos or they don't get treated at all, even though their symptoms would meet the standard of indication.

 

[WisNeuro]

The majority being prescribed inappropriately is a reasonable conclusion. I disagreed with your assertion that benzo initiation is indicated in very few patients. That's not true, in my experience. The problem is prescribing practices and people who don't know or don't care to prescribe responsibly. Patients suffer, either because they get over-treated with benzos or they don't get treated at all, even though their symptoms would meet the standard of indication.

My problem is that the current standard of indication is not supported by the literature on anxiety and what we know about the reinforcement and continuation of chronic anxiety. Which, leads to inappropriate use and prescription.

 

[Mass Effect]

My problem is that the current standard of indication is not supported by the literature on anxiety and what we know about the reinforcement and continuation of chronic anxiety. Which, leads to inappropriate use and prescription.

Early coadministration of clonazepam with sertraline for panic disorder. - PubMed - NCBI

Evidence-based pharmacotherapy of panic disorder: an update

https://www.psychiatrictimes.com/anxiety/benzodiazepines-vs-antidepressants-anxiety-disorders

Medscape: Medscape Access

And if you want the PDF for that last link, it's here. It's the APA's treatment guidelines on panic disorder:

https://psychiatryonline.org/pb/assets/.../practice_guidelines/guidelines/panicdisorder.pdf

 

[sloop]

I also agree. We are overpathologizing normal anxiety in many people, and just reinforcing the idea that the anxiety is dangerous in non-dangerous settings. I guess if the choice is between someone absolutely refusing an MRI vs just giving them a one time dose of 1mg, go nuts. But, these patients tend to have a lot more going on in the anxiety realm and end up getting the benzos full-time at some point.

I don’t really like the idea of long-term benzos for anxiety as a matter of course and have seen bad outcomes from this even in people close to me. That said there are many reasons why benzos may be reasonably used in anxiety disorders.

The first is simply that some patients are just that sick. I have seen people for whom high doses of SSRIs, nortriptyline, gabapentin, buspirone, etc combined with CBT have failed to get them well enough to meet functional goals, but get benefit from benzodiazepines and do not abuse them.

Another is that in patients with low abuse potential, it may be worth the risk to initially give them a course of benzodiazepines to, for instance, get them back to a state where they can function at work again while you titrate their Zoloft or whatever. You can then attempt to taper off the benzo later and see where you stand. For me, personally, letting someone suffer potentially preventable, poor short-term occupational outcomes out of some sort of “principle” doesn’t make sense. Sure, there’s a risk that we’re reinforcing use of medications over development of coping skills but if that happens you can try to sort that out later in therapy. I wouldn’t say I advocate this in all cases, but again: some people are really sick.

 

[Attending1985]

I never start chronic benzodiazepines and only try to get people off of them. However the assertion that they’re not appropriate for pre MRI is ridiculous. People are often getting MRIs in the workup of a serious medical illness which is terrifying in itself. Being stuck in a loud machine is not normal and understandably anxiety provoking. This shouldn’t be looked at as exposure therapy. Saying no to easing anxiety in this context because you have an agenda against their use is just really lacking empathy and letting your emotions rule.

 

[Armadillos]

I never start chronic benzodiazepines and only try to get people off of them. However the assertion that they’re not appropriate for pre MRI is ridiculous. People are often getting MRIs in the workup of a serious medical illness which is terrifying in itself. Being stuck in a loud machine is not normal and understandably anxiety provoking. This shouldn’t be looked at as exposure therapy. Saying no to easing anxiety in this context because you have an agenda against their use is just really lacking empathy and letting your emotions rule.

Yeah hard and fast rules to never use a class of meds is silly, you have to use reasonable clinical judgement specific to the patient at times. For me anecdotally, sometime in med school I out of nowhere started being unable to sleep at all on only the night before exams. It really had potential to be quite debilitating, so went to my pcp who knew I had no hx insomnia and no psych/substance hx, so he was happy to prescribe me a single script for a short half-life z-drug which lasted me for the rest of Med school and provided a wonderful night sleep before exams/boards. Took ten minutes, cost me a couple dollars at CVS and I ended up AOA in top of class. I’m forever thankful he didn’t try to be a hero and send me to CBT-I or something.

 

[clausewitz2]

Yeah hard and fast rules to never use a class of meds is silly, you have to use reasonable clinical judgement specific to the patient at times. For me anecdotally, sometime in med school I out of nowhere started being unable to sleep at all on only the night before exams. It really had potential to be quite debilitating, so went to my pcp who knew I had no hx insomnia and no psych/substance hx, so he was happy to prescribe me a single script for a short half-life z-drug which lasted me for the rest of Med school and provided a wonderful night sleep before exams/boards. Took ten minutes, cost me a couple dollars at CVS and I ended up AOA in top of class. I’m forever thankful he didn’t try to be a hero and send me to CBT-I or something.

All our sleep people, who are 70% psych trained and a fairly big deal research wise in that world, are all very willing to reach for z-drugs in most cases. Many of my outpatient attendings actually seem happier to start Klonopin than Ambien for insomnia, which strikes me as super weird.

Those same sleep people also hate Seroquel and one guy wears it as a badge of pride that he has prescribed it exactly once to date in his attending career.

 

[Crayola227]

I also agree. We are overpathologizing normal anxiety in many people, and just reinforcing the idea that the anxiety is dangerous in non-dangerous settings. I guess if the choice is between someone absolutely refusing an MRI vs just giving them a one time dose of 1mg, go nuts. But, these patients tend to have a lot more going on in the anxiety realm and end up getting the benzos full-time at some point.

One time I needed a biopsy of my eye, basically, a needle and scissors were coming for my eyeball, and I needed to sit still. They used retractors like in A Clockwork Orange. That was a procedure I refused to do without a benzo on board. I brought it up to my opthalmologist, and while they seemed sorta surprised, they were good with it. Really surprised it doesn't come up more in that specialty.

I saw it offered as a matter of protocol for guys getting vasectomies.

A lot of patients aren't aware. I was taught in medical school to anticipate these things. I definitely consider the utility and appropriateness for a patient depending on the procedure, without them having to bring it up. Because I know how uncomfortable things are, and with risk/benefit, if I don't think I'm going to create a benzo fiend I see no reason not to use whatever is in my arsenal not only to treat but also to decrease discomfort. Doesn't mean I would offer it to everyone in every similar situation. Tool in the toolkit of making things more accessible and adherence.

I have no issues with opioids in my history, and Tuesday I'm getting a put under for a gyn procedure that's sure to greatly annoy my uterus. I'm pushing for a tiny script of norco. They say I could get by with APAP and celebrex (which I take anyway) but if I can sleep through the cramps, why the heck not. Beyond needing to feel my uterus for complications, there's no reason to have to suffer. I'm not an opioid fiend, so I don't feel any guilt asking for the best pain control modern medicine can safely give me.

Keep in mind too that I'm aware that it's difficult to predict which opioid-naive patient is going to become a total fiend after one exposure to an opioid. It happens. I don't like to be the first person to ever expose someone to a controlled substance, partly because you have no history to tell you how they handle them. But if I'm not the first person to go there, then I look at their history and why are they getting this drug from me.

Frankly yes, I think we've gotten to a point where we are not even using common sense and just making patients have to needlessly suffer. I mean, yes, you can have discomfort and just white knuckle deal with it in the short term. But if I don't think addiction is going to be an issue from the use, and side effects can be safely managed, I don't know why we think it's a virtue to go through the scanner sober or get a needle to the eye.

That said, yeah, I think with a lot of anxiety it's important to just try to cope without benzos, some way some how.

 

[WisNeuro]

Early coadministration of clonazepam with sertraline for panic disorder. - PubMed - NCBI

Evidence-based pharmacotherapy of panic disorder: an update

https://www.psychiatrictimes.com/anxiety/benzodiazepines-vs-antidepressants-anxiety-disorders

Medscape: Medscape Access

And if you want the PDF for that last link, it's here. It's the APA's treatment guidelines on panic disorder:

https://psychiatryonline.org/pb/assets/.../practice_guidelines/guidelines/panicdisorder.pdf

Problem with most of these studies is that they are either very short-term, or that they pair the benzo with an SSRI. Huge confounds for what is happening over the long run. The last link talks about the issues with the outcome literature in general.

https://www.researchgate.net/profil...nzodiazepine-Use-An-Updated-Meta-analysis.pdf

https://www.sciencedirect.com/science/article/pii/S240584401830135X

https://onlinelibrary.wiley.com/doi/full/10.1111/j.1360-0443.2011.03563.x

Long-Term Pharmacological Treatments of Anxiety Disorders: An Updated Systematic Review

 

[WisNeuro]

One time I needed a biopsy of my eye, basically, a needle and scissors were coming for my eyeball, and I needed to sit still. They used retractors like in A Clockwork Orange. That was a procedure I refused to do without a benzo on board. I brought it up to my opthalmologist, and while they seemed sorta surprised, they were good with it. Really surprised it doesn't come up more in that specialty.

That said, yeah, I think with a lot of anxiety it's important to just try to cope without benzos, some way some how.

Like I said, I am fine with it in certain, very short-term circumstances. We're talking about the majority of these scripts coming for maintenance reasons, which is what I see in most of my patients who have been on them for decades. Or, when people pull the trigger on it for almost nothing, as in a recent elderly gentleman who reported some mild anxiety, and was given .5mg 3x/day. He was anxious because he was moderately demented and having delusions. And now he's a fall/mortality risk. I wish I could say these are rare examples, but I can honestly go through my patient reports over the past several years and pull out dozens upon dozens of these.

 

[Mass Effect]

Like I said, I am fine with it in certain, very short-term circumstances. We're talking about the majority of these scripts coming for maintenance reasons, which is what I see in most of my patients who have been on them for decades. Or, when people pull the trigger on it for almost nothing, as in a recent elderly gentleman who reported some mild anxiety, and was given .5mg 3x/day. He was anxious because he was moderately demented and having delusions. And now he's a fall/mortality risk. I wish I could say these are rare examples, but I can honestly go through my patient reports over the past several years and pull out dozens upon dozens of these.

Actually, what you said was that even given benzos for an MRI is likely to lead to full-time prescriptions, implying that even for scans, they should be avoided. That's exactly the type of problematic thinking @Crayola227 is referencing.

 

[Armadillos]

Like I said, I am fine with it in certain, very short-term circumstances. We're talking about the majority of these scripts coming for maintenance reasons, which is what I see in most of my patients who have been on them for decades. Or, when people pull the trigger on it for almost nothing, as in a recent elderly gentleman who reported some mild anxiety, and was given .5mg 3x/day. He was anxious because he was moderately demented and having delusions. And now he's a fall/mortality risk. I wish I could say these are rare examples, but I can honestly go through my patient reports over the past several years and pull out dozens upon dozens of these.

Nobody doubts you see the benzo train wrecks. But you have a MASSIVE sampling bias. Tons of patients get a short term benzo script from a pcp in their life. A small fraction of those see a psychiatrist at somepoint. An even smaller fraction of those will see a neuropsychologist. Pretty much by definition your only seeing patients on benzos where the benzos are problematic or not effective.

(And please nobody think I’m a benzo apologist, I’ve literally never started long term benzos on someone without catatonia/psychosis/mania.)

 

[WisNeuro]

Actually, what you said was that even given benzos for an MRI is likely to lead to full-time prescriptions, implying that even for scans, they should be avoided. That's exactly the type of problematic thinking @Crayola227 is referencing.

I never said that, I said that in many patients, they are asking for the benzos for a variety of anxiety producing situations. These are the patients who go on to maintenance situations. The reference was to the actual practice of prescribing to be very cavalier in nature, rather than examining specific contexts.

 

[WisNeuro]

Nobody doubts you see the benzo train wrecks. But you have a MASSIVE sampling bias. Tons of patients get a short term benzo script from a pcp in their life. A small fraction of those see a psychiatrist at somepoint. An even smaller fraction of those will see a neuropsychologist. Pretty much by definition your only seeing patients on benzos where the benzos are problematic or not effective.

(And please nobody think I’m a benzo apologist, I’ve literally never started long term benzos on someone without catatonia/psychosis/mania.)

Well, actually, I have two sampling biases. My spouse is a PCP who inherits patients all of the time on maintenance benzos. Her policy is that they either agree to a slow wean/taper schedule, or get their management of benzos from another provider. She also rarely sees the short-term scripts.

 

[Mass Effect]

I never said that, I said that in many patients, they are asking for the benzos for a variety of anxiety producing situations. These are the patients who go on to maintenance situations. The reference was to the actual practice of prescribing to be very cavalier in nature, rather than examining specific contexts.

Your anecdotal evidence is in direct contrast with mine. This is what I meant when I said that as a non-prescriber, we are not seeing the same patients nor are we examining the risks and benefits in the same circumstances.

 

[WisNeuro]

Your anecdotal evidence is in direct contrast with mine. This is what I meant when I said that as a non-prescriber, we are not seeing the same patients nor are we examining the risks and benefits in the same circumstances.

The epidemiological data on prescribing and the number of people who have been on benzos for years is in direct agreement with many of my statements.

 

[sloop]

Like I said, I am fine with it in certain, very short-term circumstances. We're talking about the majority of these scripts coming for maintenance reasons, which is what I see in most of my patients who have been on them for decades. Or, when people pull the trigger on it for almost nothing, as in a recent elderly gentleman who reported some mild anxiety, and was given .5mg 3x/day. He was anxious because he was moderately demented and having delusions. And now he's a fall/mortality risk. I wish I could say these are rare examples, but I can honestly go through my patient reports over the past several years and pull out dozens upon dozens of these.

I don't think that anybody here is claiming that there aren't people with disastrous prescribing practices out there or that there aren't a lot of patients who get put on maintenance benzos inappropriately with bad outcomes. Both the city where I went to med school and the city where I now do my residency each have at least one highly notorious physician who prescribes benzos (like QID Xanax) to large numbers of patients, does not answer calls to their office to discuss patients even on the 2-3 days a week it's open and gets people dependent on these things regularly. Their patients would come to the hospital all the time and we'd be left to sort out a gigantic mess without any input from the people who caused the mess in the first place. Everyone knew their names and I'm surprised they still have licenses.

This is not really about those cases. This is about whether benzos have a role in the treatment of anxiety. They do. This is like debating whether opioids have a role in the treatment of pain. They do. There are legitimate concerns about long-term use for chronic problems, but not every case can be handled the same way and they're tools to be used judiciously while weighing risk and benefit.

 

[WisNeuro]

This is not really about those cases. This is about whether benzos have a role in the treatment of anxiety. They do. This is like debating whether opioids have a role in the treatment of pain. They do. There are legitimate concerns about long-term use for chronic problems, but not every case can be handled the same way and they're tools to be used judiciously while weighing risk and benefit.

They do, and I have agreed with that for the most part. But, that is not how they are used in many cases. In many cases, people will pull the trigger on benzos with little hesitation or thought of first trying behavioral methods, without any real thought of this person becoming dependent and now on this medication for a life time. There is a cost-benefit analysis, and regarding long-term use, the costs are demonstrably very high compared to the benefits. Especially when we have other ways of treating these things.