Not what I wanted to wake up to see

[birchswing]

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http://www.bbc.com/news/health-29127726

This is very depressing. The only possible light in the article is that they say they don't know cause vs. effect. Makes me extremely sad. This is already hard enough.

 

[shan564]

As much as we all try to avoid benzos, you should note that this study is pretty meaningless... I'm surprised that it got into BMJ. Of course patients with benzo prescriptions are more likely to develop dementia... people prescribe benzos for dementia prodromes (insomnia, anxiety) all the time. Also, there are several other symptoms/syndromes that put people at higher risk for dementia and also make them more likely to get a script for a benzo. If you look at their results, the patients who were exposed to benzos had less education, were less likely to be married, and had higher rates of hypertension, all of which will increase rates of dementia as measured by a MMSE (which is the main tool that they used). Unless you do a randomized trial (which will never happen for both ethical and logistic reasons), there's no way to draw any conclusions based on this sort of data.

Aside from that, they don't specify how much benzo use defines an "exposure." And they seem to have made no effort to correct for the fact that elderly patients taking benzos will have some cognitive suppression/altered mentation as a direct effect of the drug, which would confound their ability to measure dementia. Despite all of those flaws, they just barely managed to get statistical significance. I'm guessing that the reason why they didn't make an effort to control for all of those factors is that they only had 30 patients with benzo exposure and dementia, so the sample size was too small to make any further restrictions - I'll bet if they'd tried to control for any of those factors, their sample size would have dropped to the point where they no longer had statistically significant results. Also, they never explained why the patient's initial benzo exposure had to be between 3 and 5 years after the initiation of the study - I'm guessing that this is the time frame that made the data work better. And as we all know, being able to write "statistically significant with 95% confidence interval" in your abstract carries more weight than actually doing a good study.

Also interesting that this study was published 2 years ago and is just now finding its way into the BBC. Somebody didn't have enough fodder for article writing.

 

[birchswing]

As much as we all try to avoid benzos, you should note that this study is pretty meaningless... I'm surprised that it got into BMJ. Of course patients with benzo prescriptions are more likely to develop dementia... people prescribe benzos for dementia prodromes (insomnia, anxiety) all the time. Also, there are several other symptoms/syndromes that put people at higher risk for dementia and also make them more likely to get a script for a benzo. If you look at their results, the patients who were exposed to benzos had less education, were less likely to be married, and had higher rates of hypertension, all of which will increase rates of dementia as measured by a MMSE (which is the main tool that they used). Unless you do a randomized trial (which will never happen for both ethical and logistic reasons), there's no way to draw any conclusions based on this sort of data.

Aside from that, they don't specify how much benzo use defines an "exposure." And they seem to have made no effort to correct for the fact that elderly patients taking benzos will have some cognitive suppression/altered mentation as a direct effect of the drug, which would confound their ability to measure dementia. Despite all of those flaws, they just barely managed to get statistical significance. I'm guessing that the reason why they didn't make an effort to control for all of those factors is that they only had 30 patients with benzo exposure and dementia, so the sample size was too small to make any further restrictions - I'll bet if they'd tried to control for any of those factors, their sample size would have dropped to the point where they no longer had statistically significant results. Also, they never explained why the patient's initial benzo exposure had to be between 3 and 5 years after the initiation of the study - I'm guessing that this is the time frame that made the data work better. And as we all know, being able to write "confidence interval of 95%" in your abstract carries more weight than actually doing a good study.

Also interesting that this study was published 2 years ago and is just now finding its way into the BBC. Somebody didn't have enough fodder for article writing.

Thank you for putting the study into more perspective. I can only do what I can do, which is right now a taper, so I guess it's best not to worry about the future anyway. I wonder if in the future there will be more treatments to help "heal" the brain if it is in fact damaged after long-term benzodiazepine use. I know that some people experiment with flumenazil both during and after finishing a taper to help resensitize the receptors.

Edit:
Link: http://en.wikipedia.org/wiki/Flumazenil#Treatment_for_benzodiazepine_dependence_.26_tolerance

 

[TexasPhysician]

As much as we all try to avoid benzos, you should note that this study is pretty meaningless... I'm surprised that it got into BMJ. Of course patients with benzo prescriptions are more likely to develop dementia... people prescribe benzos for dementia prodromes (insomnia, anxiety) all the time. Also, there are several other symptoms/syndromes that put people at higher risk for dementia and also make them more likely to get a script for a benzo. If you look at their results, the patients who were exposed to benzos had less education, were less likely to be married, and had higher rates of hypertension, all of which will increase rates of dementia as measured by a MMSE (which is the main tool that they used). Unless you do a randomized trial (which will never happen for both ethical and logistic reasons), there's no way to draw any conclusions based on this sort of data.

Aside from that, they don't specify how much benzo use defines an "exposure." And they seem to have made no effort to correct for the fact that elderly patients taking benzos will have some cognitive suppression/altered mentation as a direct effect of the drug, which would confound their ability to measure dementia. Despite all of those flaws, they just barely managed to get statistical significance. I'm guessing that the reason why they didn't make an effort to control for all of those factors is that they only had 30 patients with benzo exposure and dementia, so the sample size was too small to make any further restrictions - I'll bet if they'd tried to control for any of those factors, their sample size would have dropped to the point where they no longer had statistically significant results. Also, they never explained why the patient's initial benzo exposure had to be between 3 and 5 years after the initiation of the study - I'm guessing that this is the time frame that made the data work better. And as we all know, being able to write "confidence interval of 95%" in your abstract carries more weight than actually doing a good study.

Also interesting that this study was published 2 years ago and is just now finding its way into the BBC. Somebody didn't have enough fodder for article writing.

The key in my opinion is that if you have any significant disorder requiring treatment, you are more likely to die earlier.

 

[birchswing]

The key in my opinion is that if you have any significant disorder requiring treatment, you are more likely to die earlier.

That seems awfully over-generalized. And the other point I would make is that I don't know of any condition, beyond some refractory types of epilepsy perhaps, that require long-term treatment with benzodiazepines. Long-term use of benzodiazepines is the disorder, IMO. The treatment is to stop taking them, which is not an easy thing. There are plenty of anxious people who live to an old-age. But benzodiazepine use is relatively new (1960s), so I think we don't know a lot about what happens to the generations who have been on them for decades. Anxiety is a significant disorder, and maybe it shortens lifespan. But I don't think anyone could argue (apart from bad doctors I've seen) that benzodiazepines are an appropriate long-term treatment for anxiety. It seems far more likely to me that benzodiazepines and not anxiety would cause long-term health problems.

 

[F0nzie]

http://www.ncbi.nlm.nih.gov/m/pubmed/24647164/

 

[birchswing]

http://www.ncbi.nlm.nih.gov/m/pubmed/24647164/

Yup, I've seen that before. It's not good news. I hope that tapering, even after being on them for over half my life will count for something.

I have resentment about the way I was treated, but I have more confusion than anything. The people who told me that these drugs were safe and that I would need to be on them for life and that they had patients on them for 20 plus years who were doing fine are still practicing.

There was absolutely no informed consent. So, yes, I have resentment, but more than that it feels like an invisible problem—like a twilight zone. And there is so little knowledge. So little research. I have severe dysautonomia (specifically in the form of POTS) that started around the time I started benzodiazepines and has gotten progressively worse. None of my doctors know whether the dysautonomia is caused by the benzodiazepines or whether it was pre-existing and I was misdiagnosed with anxiety. If it is caused by the benzodiazepines, I could certainly see how that leads to premature death. Dysautonomia makes people not move. Not moving makes dysautonomia worse. And not moving isn't good. Having a pulse in the 160s from walking around probably isn't good for you either. I reach 90% of my MHR from taking a shower. And I am getting more certain that the dysautonomia is benzo-related.

Oy, well, I just have to keep doing the next right thing. Thank you all for letting me vent here.

 

[F0nzie]

I love benzo's for mania, severe anxiety, and even psychosis for acute stabilization. With the long term benzo users I am constantly tracking my state drug monitoring program for abuse and possible diversion. It's a dangerous drug to have on board especially when combined with opioids. I get a good number of patients that do not tell me they are on opioids and I find that they are on Oxycodone, Morphine or Suboxone! If an opiate addict flies under the radar, overdoses and dies while on a benzodiazepine that would be a terrible thing.

 

[birchswing]

I love benzo's for mania, severe anxiety, and even psychosis for acute stabilization. With the long term benzo users I am constantly tracking my state drug monitoring program for abuse and possible diversion. It's a dangerous drug to have on board especially when combined with opioids. I get a good number of patients that do not tell me they are on opioids and I find that they are on Oxycodone, Morphine or Suboxone! If an opiate addict flies under the radar, overdoses and dies while on a benzodiazepine that would be a terrible thing.

You mention you have long-term users. Is that by your choice, or did you inherit them? And do they do well with them? I've been on a prescribed dose for over half my life (since age 14). My mental and physical health have deteriorated over that time. I am not a well person in terms of physical stamina, autonomic nervous system issues, not being able to drive, having severe memory issues, and having OCD that went from minimal to huge. I am disabled. From what I've read, I'm not alone. I've always ascribed a lot of my maladies to long-term benzodiazepine use because I have never found any other cause. I have absolutely no desire to abuse benzodiazepines. I wanted to withdraw for years but I was in such an agitated state I thought that any other further provocation would have been unbearable, plus I had spent years researching how dangerous withdrawal could be. In my anxious mind, reading that a person can die from a rapid withdrawal meant that I could die from any withdrawal. That's how an anxious mind works, and so I waited a very, very long time to begin a taper, which was also a process of finding someone who would do it in a way that I thought was safe. For some reason in the last few years my anxiety (panic) started getting better without increasing my dose or changing any of my meds, while my OCD continued to stay the same. My current psychiatrist thinks the years of really bad panic and uncomfortable head feelings I had while on the benzos were tolerance withdrawal.

As to your point about the risks of benzo patients abusing drugs, I have found that I am more cautious than any doctor has ever wanted me to be with benzodiazepines. I haven't had a sip of alcohol in my entire life due to taking them. I have read that it is easy to overdose when a benzo is in the mix, so I avoid everything that could potentially cause a problem. I've had psychiatrists tell me it's fine to have a glass of wine at night and skip a dose of medicine, but I don't want to risk it. If you looked me up in a state system you would see I've been prescribed benzodiazepines continuously since age 14 by only one prescriber at a time (there are so many prescribers because they're always quitting and looking for a better gig, often to return to their old jobs). What I find in the benzo communities is the same thing. They often seem to be people like me who were nervous nellies from birth and who are terrified of the drugs they're on, terrified of getting off of them, and would be terrified to do anything to make the situation worse. I don't think there is enough effort to study that type of patient and what could best help them after decades of benzodiazepine use. Certainly the other type exists, who might take benzos more erratically. There are people like me are who so neurotic that they take them dutifully every day as prescribed at a certain time and who don't take a milligram more regardless of how anxious they feel. It's an irony in that at 14 I was a tough-sell to take any medication. I was terrified of starting it.

I've had psychiatrists tell me that there is no evidence of harm with long-term benzos. I just don't know where they're getting those facts. And it doesn't jibe with my experience. I could see a good case being made for judicious prescription of benzos to anxious people. But not anything close to the way I was prescribed to take them.

 

[whopper]

It's not surprising news and has been known to doctors that actually know a thing or two.

Several doctors appear to just want their degree, practice, and make money without truly acting in resemblance to being a doctor. That is, to be a life-long learner and teacher. We are supposed to educate our patients (and students) on the process of understanding their own health and treatments. I think most docs saying benzos cause no harm are the ones that just want you out the door once they've done their billing codes. (NEXT!) Docs make money per patient and while things have mildly improved, that's the model, not spending extra quality time with patients to explain things.

 

[birchswing]

It's not surprising news and has been known to doctors that actually know a thing or two.

Several doctors appear to just want their degree, practice, and make money without truly acting in resemblance to being a doctor. That is, to be a life-long learner and teacher. We are supposed to educate our patients (and students) on the process of understanding their own health and treatments. I think most docs saying benzos cause no harm are the ones that just want you out the door once they've done their billing codes. (NEXT!) Docs make money per patient and while things have mildly improved, that's the model, not spending extra quality time with patients to explain things.

I'm not sure if I've told you specifically before but I think I have on the forum that I believe the area I live in is unusual in prescribing benzos as first-line treatment being the norm rather than the exception in many cases. From what I can gather psychiatrists are not reimbursed well in general, but in particular where I live they are reimbursed very poorly. My best-educated guess is that my region attracts the bottom of the barrel.

What is hard to understand, and where I feel like I'm in a twilight zone, is that I know people who in 2014 are being put on Klonopin or Xanax to take indefinitely and daily by psychiatrists still. It's not as if these "bad" psychiatrists I saw so many years ago disappeared. I believe they should have known better in 1998 when I was first put on them, but even in 2014 that's not the case. I don't really feel like I can complain about someone I saw so many years ago, and my current prescriber is helping me manage a taper and has been willing to learn in the last few years about benzodiazepines (the fact that she had to learn after already being a psychiatrist strikes me as odd--she's done a 180 on them in the last three years). But when there are still new addicts being created it's hard to jibe with the harm caused.

Look at how much attention is given to cigarettes. And cigarettes are products consumers voluntarily choose with informed consent of the harm—and children can't buy them. But with benzodiazepines, we have a situation where prescribing physicians are giving out drugs that have no known benefit past 6 weeks and that are known to cause physical and mental harm and shorten lifespan—and now possibly cause dementia. And in my case I was a child when prescribed to take them. I don't know how to square that away. We can agree it's bad. But how can it continue to exist? What would stop it? I feel like it should be something so simple as a psychiatrist opening up a web-browser and reading the Wikipedia page on benzodiazepines to update their antiquated knowledge on the topic. But I don't know how you can get them to do that. I think we need laws regulating their prescription. Now I think they should be nuanced. But we need something.

 

[F0nzie]

You mention you have long-term users. Is that by your choice, or did you inherit them? And do they do well with them?

Seems like every patient I inherit these days is on a benzodiazepine. I try to taper everyone. I just recently had an opiate addict at the county clinic fly under the radar and die from an accidental opiate overdose. Thankfully I had not renewed the benzo Rx after several no shows. I think Xanax should be outlawed. I rarely prescribe short acting benzodiazepines. I do have a few of my own patients that are on long-term therapy because nothing else worked and benefits outweigh the risks.

 

[OldPsychDoc]

Seems like every patient I inherit these days is on a benzodiazepine. I try to taper everyone. I just recently had an opiate addict at the county clinic fly under the radar and die from an accidental opiate overdose. Thankfully I had not renewed the benzo Rx after several no shows. I think Xanax should be outlawed. I rarely prescribe short acting benzodiazepines. I do have a few of my own patients that are on long-term therapy because nothing else worked and benefits outweigh the risks.

Preaching to the choir...

 

[PistolPete]

I have spent the last two months tapering one of my patients off of 6mg ativan which she was taking every night for sleep and is now down to 2.5mg QHS. We'll see how she tolerates the taper down as we go further. I ran into the first bit of resistance last week… Ugh. So easy to prescribe, so much work to get off...

 

[F0nzie]

I have spent the last two months tapering one of my patients off of 6mg ativan which she was taking every night for sleep and is now down to 2.5mg QHS. We'll see how she tolerates the taper down as we go further. I ran into the first bit of resistance last week… Ugh. So easy to prescribe, so much work to get off...

Good job! 6mg to 2.5mg of Ativan in just 2 months is impressive. It's normal for the tail end of the taper to be the hardest for patients. If you haven't already asked, you can see if the patient is willing to switch to an equivalent dose of Clonazepam and taper by 0.25-0.5mg per week.

 

[birchswing]

Good job! 6mg to 2.5mg of Ativan in just 2 months is impressive. It's normal for the tail end of the taper to be the hardest for patients. If you haven't already asked, you can see if the patient is willing to switch to an equivalent dose of Clonazepam and taper by 0.25-0.5mg per week.

I suppose it depends on how long the person was on the medication, but from what I've read slower is better than faster in terms of preventing relapse, reducing withdrawal symptoms, preventing protracted withdrawal syndrome, and reducing kindling. I haven't commonly heard of using Klonopin from a cross-taper. Klonopin is twice as potent per gram (theoretically) as Ativan and so it's harder to titrate the dose. Valium in comparison is 10x less potent per gram (again theoretically) than Ativan and is available in 1 mg doses, making it much easier to titrate.

 

[whopper]

Yep as OPD said. There's too many doctors out there, psychiatrist or not that just give it out like it's candy and I'm no longer shocked by it only because I see it happen so much.

Medical school is so difficult to enter, and residency is very tough, but with such tough standards to see so many doctors practice so poorly was offensive to me. It's gotten not so offensive only because I see it so often. I have seen some doctors lose licences over this but only the worst offenders...I'm talking the ones that are giving it out by the barrel and even they seem to get away with it for years and many don't get caught at all.

Where I used to practice in Cincinnati, all the of the local psychiatrists knew several in particular were the continuing offenders, but despite that an entire professional demographic in a metropolitan area knew this, nothing happened to those doctors. We're also in a position where we're not going to tell patients to avoid those specific doctors. Now that I'm in St. Louis, I'm already starting to learn who the local idiots are.

Just had a guy in the infirmary on 8 meds: Elavil, Risperdal, Depakote, Gabapentin, Trazodone, Melatonin, Vistaril, and he was on a benzo in the community. Why? I asked him. He told me he didn't know and just did what his doctor told him but that he thinks Risperdal is working to reduce his depression.

Geez.

 

[F0nzie]

I suppose it depends on how long the person was on the medication, but from what I've read slower is better than faster in terms of preventing relapse, reducing withdrawal symptoms, preventing protracted withdrawal syndrome, and reducing kindling. I haven't commonly heard of using Klonopin from a cross-taper. Klonopin is twice as potent per gram (theoretically) as Ativan and so it's harder to titrate the dose. Valium in comparison is 10x less potent per gram (again theoretically) than Ativan and is available in 1 mg doses, making it much easier to titrate.

It is common practice to switch to agents with longer half lives to minimize withdrawal symptoms and in my experience patients tend to taper off better. Ativan has a decent half life so I do not see anything wrong with sticking with an Ativan taper. If the patient is experiencing a lot of distress with each reduction it may be helpful to have some extra half life to ease the transition. But yea if they have been on benzo's for a long time you want a slow taper.

 

[PistolPete]

Thanks for the tip, Fonzie. She's been on Ativan for at least 6 months, probably closer to a year (I inherited her from an outgoing resident). She's on a TCA (only) for depression which she takes at night so I think that is helping her sleep and making the taper off Ativan quite manageable so I think I'll stick to it, but klonopin isn't a bad idea if things start to get hairy.

 

[F0nzie]

Carbamazepine is also good for benzo and ETOH withdrawal. I have not tried it yet but it's in the literature.

 

[birchswing]

Klonopin has a longer half life than Ativan, but not as long as Valium and is much more difficult to titrate in terms of the dosing. The British National Formulary specifically recommends using Valium based on the research of Professor Heather Ashton. I'm not sure if the US has any such equivalent guidelines for managing benzodiazepine withdrawal.

 

[Shikima]

I have spent the last two months tapering one of my patients off of 6mg ativan which she was taking every night for sleep and is now down to 2.5mg QHS. We'll see how she tolerates the taper down as we go further. I ran into the first bit of resistance last week… Ugh. So easy to prescribe, so much work to get off...

I feel your pain, I've had several show up from PCPs with that much and then consulting me because they're not sure what the next step is in controlling mood/anxiety symptoms. The last 0.5-1mg is the hardest IMO.

 

[Ceke2002]

My mental and physical health have deteriorated over that time. I am not a well person in terms of physical stamina, autonomic nervous system issues, not being able to drive, having severe memory issues, and having OCD that went from minimal to huge. I am disabled. From what I've read, I'm not alone.

Yep I can definitely relate to long term benzo use making things a lot worse as well, totally feeling you on this one. Obviously my exact experience was different to yours, but after several years of being on an increasingly high dose of Xanax I just felt like something wasn't right. At first it wasn't anything I could put my finger on exactly, but it just felt like my brain wasn't working properly and things were slowly getting worse not better. That's when I took the ill fated decision to attempt to go cold turkey, with disasterous results. Fast forward another few years and it was no longer just a feeling that things weren't right, almost every aspect of my symptology had become amplified to the point that I was eventually informed I'd developed a paradoxical reaction. That's when I had a cross over and tapering schedule, following the Ashton Protocol, set up by a Psychiatrist to be administered by my GP. It took me a year or so to taper off fully, but since then (and despite the fact that I'm currently back on a low dose of benzos for physical reasons) I have been just so much more stable across the board. Even my worse periods of instability over the past 6 or so years still haven't even come close to the instability I experienced when I was on a long term, high dose of Xanax. Seriously it's like night and day, I sometimes look back on those times and I'm almost dumbfounded at how bad things got, and especially how, until I finally found the GP who helped me taper, a cavalcade of Doctors just outright refused to listen.

I'm sure you've probably heard some of these same, or similar words yourself.

Me: "I don't just want to take pills for the rest of my life, I'd really like to explore other treatment options like counselling. Could we arrange for a referral to a Psychiatrist, or perhaps a Psychologist, and see how I do off the medication?"

Idiot Doctor: "You have a fault in your brain chemistry so you need to take this medication to correct that, just like a diabetic needs to take insulin. You wouldn't advise a diabetic to stop taking their insulin now would you?" *completely ignores my request for counselling referral*

Me: "I don't know what's wrong exactly, but I just don't feel right. It's really starting to feel like these pills are messing with my brain somehow."

Idiot Doctor: "Sounds like you're experiencing some break through anxiety, we better increase your dosage (again)."



I really want to offer you some reassurance, patient to patient who's been there and come through the otherside, but I can't without contravening board rules regarding giving medical advice. So I will just say this - You can be benzo free, so keep going, and don't give up. I wish you all the best.

 

[birchswing]

Yep I can definitely relate to long term benzo use making things a lot worse as well, totally feeling you on this one. Obviously my exact experience was different to yours, but after several years of being on an increasingly high dose of Xanax I just felt like something wasn't right. At first it wasn't anything I could put my finger on exactly, but it just felt like my brain wasn't working properly and things were slowly getting worse not better. That's when I took the ill fated decision to attempt to go cold turkey, with disasterous results. Fast forward another few years and it was no longer just a feeling that things weren't right, almost every aspect of my symptology had become amplified to the point that I was eventually informed I'd developed a paradoxical reaction. That's when I had a cross over and tapering schedule, following the Ashton Protocol, set up by a Psychiatrist to be administered by my GP. It took me a year or so to taper off fully, but since then (and despite the fact that I'm currently back on a low dose of benzos for physical reasons) I have been just so much more stable across the board. Even my worse periods of instability over the past 6 or so years still haven't even come close to the instability I experienced when I was on a long term, high dose of Xanax. Seriously it's like night and day, I sometimes look back on those times and I'm almost dumbfounded at how bad things got, and especially how, until I finally found the GP who helped me taper, a cavalcade of Doctors just outright refused to listen.

I'm sure you've probably heard some of these same, or similar words yourself.

Me: "I don't just want to take pills for the rest of my life, I'd really like to explore other treatment options like counselling. Could we arrange for a referral to a Psychiatrist, or perhaps a Psychologist, and see how I do off the medication?"

Idiot Doctor: "You have a fault in your brain chemistry so you need to take this medication to correct that, just like a diabetic needs to take insulin. You wouldn't advise a diabetic to stop taking their insulin now would you?" *completely ignores my request for counselling referral*

Me: "I don't know what's wrong exactly, but I just don't feel right. It's really starting to feel like these pills are messing with my brain somehow."

Idiot Doctor: "Sounds like you're experiencing some break through anxiety, we better increase your dosage (again)."



I really want to offer you some reassurance, patient to patient who's been there and come through the otherside, but I can't without contravening board rules regarding giving medical advice. So I will just say this - You can be benzo free, so keep going, and don't give up. I wish you all the best.

Thank you very much for the kind words and reassurance. It's good to hear how much better you feel on the other side. And yes I've had the same conversations with doctors before about how a person with anxiety takes anti-anxiety medications. I had one psychiatrist who told me there was no dose of Ativan too high to take if I was still anxious because if I was still anxious I hadn't reached a therapeutic dose. I was having a very unusual attack during which my pulse would not come down and no amount of Ativan would touch the high pulse or the anxiety. None of the doctors I saw went as far as to compare benzodiazepines to insulin, but I have had doctors compare SSRIs to insulin, which was a common way to educate patients for some reason.

I've started looking at psychiatry differently since coming to this board. Years ago when I came here I was very angry. I now see it as a field that could be populated by specialists who have nuanced knowledge about these medications and their judicious use. I at least have in my mind the fantasy of that doctor residing somewhere. Somehow, though, some people trained specifically in psychiatry seem to have specific deficits in psychiatric medicine knowledge. I actually considered myself anti-psychiatry at some points. A board where psychiatrists talk about psychiatry attracts people who actually care about it, though, so seeing people who aren't uncurious and are knowledgable made me realize I have just seen a lot of really bad psychiatrists. They aren't all bad, though. The one I see now is the best I've found, but she's hard to work with in terms of tapering because she refuses to do calls or e-mail (which is particularly annoying as she takes texts and phone calls from her daughters in my appointments) and she works over an hour away from me. I've been on the waiting books for someone who's supposedly good and is closer to me and will see him in December to try him out. The problem is that not all psychiatrists, whether good or not, know how to handle a taper. So I'll give him a try-out appointment while keeping my current. Go to keep moving forward!

 

[whopper]

Second to last month I had a young woman come into the PES where I worked in Cincinnati suffering from an anxiety disorder and placed on heavy amounts of benzos by her psychiatrist. That psychiatrist was in the hospital and because she couldn't get her refill, she went to the PES.

It was our policy not to give benzos.

But getting to the point, the lady was zonked due to her benzos. Based on her history that was full, not filled with holes, and very descriptive, it appeared that she started suffering from GAD in college, it worsened her performance but she was able to graduate, then she saw a psychiatrist, benzos started, she's zonked, and has been for about 4 years. Since she was zonked, her psychiatrist then recommended she go on disability.

I asked if he ever recommended an antidepressant, preferably an SSRI or SNRI-no.
Any psychotherapy? No
Anything to treat the anxiety other than benzos? No. No Beta blockers, no antihistamines, no Gabapentin, no CBT, nothing, nada, just benzos.

Her father was with her and he told me he was very upset because his daughter is young, intelligent, and if the GAD never afflicted her, she likely would've gone to graduate school and would've been self-sufficient, but now just stays home, is zonked, and the psychiatrist just recommends that the next step is disability. The doctor also had her seeing him weekly and he would only give a week's supply of benzos with each visit and she had been seeing him for years. He told me he was convinced there had to be a better way.

I told them that the first-line treatment should be an SSRI, that benzos should just be temporary and she is most likely zonked from the benzos and if she were to get her anxiety controlled with an SSRI or SNRI and weaned off the benzos, she could likely lead a self-sufficient life again. They asked why this other psychiatrist didn't offer the same advice. I told them I didn't know but what I offered to them is the standard, and frankly I didn't know why he offered what he did. I also warned them that if started on an SSRI, the likelihood is she will get better but it could take a few tries before the right one was found for her.

The father walked out that that PES very upset but also happy because he told me that's what he thought all along-that benzos were not a first-line treatment end all be all, but with the shortage of psychiatrists they couldn't get a second opinion very easily. I prescribed a B-blocker and and an SSRI and recommended she get weaned off the benzos. I also got a list of all the providers they could possibly see in the area, some of them I knew, called one of them up cause I personally knew him, and got the patient bumped ahead so they didn't have to be on a waiting list for months.

Again, a type of situation where this should be horrific and considered extremely poor care and shocking, but I see this type of thing happen EVERYDAY, so I am no longer shocked. It also made me speculate that the doctor knew what the heck was going on and that he was possibly entrapping her to be a dependent addict. I should've told them to complain to the state medical board but I only saw them once and I tend to want more information before I take the leap to request that the patient do that.

 

[birchswing]

Second to last month I had a young woman come into the PES where I worked in Cincinnati suffering from an anxiety disorder and placed on heavy amounts of benzos by her psychiatrist. That psychiatrist was in the hospital and because she couldn't get her refill, she went to the PES.

It was our policy not to give benzos.

But getting to the point, the lady was zonked due to her benzos. Based on her history that was full, not filled with holes, and very descriptive, it appeared that she started suffering from GAD in college, it worsened her performance but she was able to graduate, then she saw a psychiatrist, benzos started, she's zonked, and has been for about 4 years. Since she was zonked, her psychiatrist then recommended she go on disability.

I asked if he ever recommended an antidepressant, preferably an SSRI or SNRI-no.
Any psychotherapy? No
Anything to treat the anxiety other than benzos? No. No Beta blockers, no antihistamines, no Gabapentin, no CBT, nothing, nada, just benzos.

Her father was with her and he told me he was very upset because his daughter is young, intelligent, and if the GAD never afflicted her, she likely would've gone to graduate school and would've been self-sufficient, but now just stays home, is zonked, and the psychiatrist just recommends that the next step is disability. The doctor also had her seeing him weekly and he would only give a week's supply of benzos with each visit and she had been seeing him for years. He told me he was convinced there had to be a better way.

I told them that the first-line treatment should be an SSRI, that benzos should just be temporary and she is most likely zonked from the benzos and if she were to get her anxiety controlled with an SSRI or SNRI and weaned off the benzos, she could likely lead a self-sufficient life again. They asked why this other psychiatrist didn't offer the same advice. I told them I didn't know but what I offered to them is the standard, and frankly I didn't know why he offered what he did. I also warned them that if started on an SSRI, the likelihood is she will get better but it could take a few tries before the right one was found for her.

The father walked out that that PES very upset but also happy because he told me that's what he thought all along-that benzos were not a first-line treatment end all be all, but with the shortage of psychiatrists they couldn't get a second opinion very easily. I prescribed a B-blocker and and an SSRI and recommended she get weaned off the benzos. I also got a list of all the providers they could possibly see in the area, some of them I knew, called one of them up cause I personally knew him, and got the patient bumped ahead so they didn't have to be on a waiting list for months.

Again, a type of situation where this should be horrific and considered extremely poor care and shocking, but I see this type of thing happen EVERYDAY, so I am no longer shocked. It also made me speculate that the doctor knew what the heck was going on and that he was possibly entrapping her to be a dependent addict. I should've told them to complain to the state medical board but I only saw them once and I tend to want more information before I take the leap to request that the patient do that.

I very much believe it. I've experienced it and I still see it happening.

It just seems odd to me for it to continue when you can 1) see that there is no benefit in long-term treatment except in rare cases perhaps 2) easily quantify the harm.

I remember some years back George W. Bush devoted part of his State of the Union address to cracking down on MLB players using steroids. And I remember thinking to myself that this was a ridiculously disproportionate focus compared to drug problems we haven't even acknowledged in our country. How many State of the Union addresses has the US had since becoming the world's superpower? Maybe 60-70. Not one of which has mentioned benzodiazepines, but at least one of which has mentioned baseball players bulking up on steroids. NIDA's prescription drug abuse programs from what I can tell almost exclusively target opiate use. And there are clinics across the country for opiate abusers. Opiate withdrawal is faster and less dangerous than benzo withdrawal (and from subjective accounts less painful). But it's hard to even find a doctor who knows enough to manage a benzo taper. There's a weird position patients are in where one type of psychiatrist might call you non-compliant for not taking benzodiazepines and another type one might call you drug-seeking for wanting to continue the dose you've been on, and yet neither of those polar opposites can necessarily help you. There's definitely a demand for help. I think the thing about a long-term benzodiazepine patient is that they don't get a lot of attention because they tend to be neurotic worriers like me who are trying to do the right thing and get by. People who end up bothering society enough to get noticed and who are on benzodiazepines are likely also on alcohol or opiates and so the benzodiazepine problem isn't seen in its entirety. I think the majority of it is suffered in silence by people whom society and even their doctors don't consider addicts—people who aren't abusing other drugs and causing a ruckus.

We've got to get this on the table of consciousness somehow. If psychiatrists can't police themselves, and I'm not saying they should, it seems like there should be prescribing guidelines at a national level. But to even get to that point I think there has to be some scientific consensus in the US regarding benzodiazepines. Right now it seems like there is very divergent and equivocating thought on their role in long-term use, whereas the UK, for example, seems to have settled the matter scientifically and politically.

 

[Ceke2002]

Second to last month I had a young woman come into the PES where I worked in Cincinnati suffering from an anxiety disorder and placed on heavy amounts of benzos by her psychiatrist. That psychiatrist was in the hospital and because she couldn't get her refill, she went to the PES.

It was our policy not to give benzos.

But getting to the point, the lady was zonked due to her benzos. Based on her history that was full, not filled with holes, and very descriptive, it appeared that she started suffering from GAD in college, it worsened her performance but she was able to graduate, then she saw a psychiatrist, benzos started, she's zonked, and has been for about 4 years. Since she was zonked, her psychiatrist then recommended she go on disability.

I asked if he ever recommended an antidepressant, preferably an SSRI or SNRI-no.
Any psychotherapy? No
Anything to treat the anxiety other than benzos? No. No Beta blockers, no antihistamines, no Gabapentin, no CBT, nothing, nada, just benzos.

Her father was with her and he told me he was very upset because his daughter is young, intelligent, and if the GAD never afflicted her, she likely would've gone to graduate school and would've been self-sufficient, but now just stays home, is zonked, and the psychiatrist just recommends that the next step is disability. The doctor also had her seeing him weekly and he would only give a week's supply of benzos with each visit and she had been seeing him for years. He told me he was convinced there had to be a better way.

I told them that the first-line treatment should be an SSRI, that benzos should just be temporary and she is most likely zonked from the benzos and if she were to get her anxiety controlled with an SSRI or SNRI and weaned off the benzos, she could likely lead a self-sufficient life again. They asked why this other psychiatrist didn't offer the same advice. I told them I didn't know but what I offered to them is the standard, and frankly I didn't know why he offered what he did. I also warned them that if started on an SSRI, the likelihood is she will get better but it could take a few tries before the right one was found for her.

The father walked out that that PES very upset but also happy because he told me that's what he thought all along-that benzos were not a first-line treatment end all be all, but with the shortage of psychiatrists they couldn't get a second opinion very easily. I prescribed a B-blocker and and an SSRI and recommended she get weaned off the benzos. I also got a list of all the providers they could possibly see in the area, some of them I knew, called one of them up cause I personally knew him, and got the patient bumped ahead so they didn't have to be on a waiting list for months.

Again, a type of situation where this should be horrific and considered extremely poor care and shocking, but I see this type of thing happen EVERYDAY, so I am no longer shocked. It also made me speculate that the doctor knew what the heck was going on and that he was possibly entrapping her to be a dependent addict. I should've told them to complain to the state medical board but I only saw them once and I tend to want more information before I take the leap to request that the patient do that.

Ugh that's frustrating just to read about, it must be so hard for patients, their families, and Doctors like yourself when you have to fix the incompetence of other so called 'Healthcare professionals'. My situation was a bit different in that it wasn't Psychiatrists who were misprescribing, it was GPs (or Family Doctors in the US I think they're called).

Initially when I was first prescribed Xanax I was in a crisis state, and I needed something that was going to stabilise me fast. Now I wasn't offered any alternatives to Xanax, but the Doctor I was seeing at the time made it clear that this was a short term deal only, no longer than 8 weeks just to get me back on an even keel, and then I would be tapered off. And it was strongly recommended I (re)start some sort of therapy, so I was given a referral to a Psychiatrist and went on a waiting list. Unfortunately the story didn't end there, because I moved house and transferred to another Doctor. They'd received my notes from my previous Doctor, and of course I was still expecting that the Xanax was a short term prospect only and fully expected my new Doctor would take over the upcoming taper for me. But theirs was was a high turn over 'profit based' practice, where they just saw as many patients as possible in as short an amount of time, so rather than bother with a tapering schedule it was easier for them to just get me in, write another script, and get me out as quickly as possible.

Then I moved again, and the next Doctor I ended up with was even worse. He's the one that started feeding me all the lines about brain chemistry that needed to be fixed, and how I was like a diabetic that needed insulin, and blah blah blah bull$h*t. Only by that stage I was too tired, and too anxious, and too much of an addict (not just with the pills, but with illicit drugs as well) so I just kept accepting the scripts. Even the times when I decided I really wanted to make a stand and insist that I be referred to therapy and taken off the Xanax, it didn't take him long to convince me otherwise and just get me to accept another script. And that wasn't just because being an addict I was way more of a pushover than perhaps other people might have been, he was also really good at convincing you that your ideas about treatment were just completely stupid, because he was the one with the medical degree and he knew best - so stop talking nonsense about stuff you know nothing about and just take your medication. It turned out a family of one of his patients had made a number of complaints about him to the medical board that went unheeded, so they ended up contacting a local current affairs program and set up a sting operation. They went in over a period of a week, wearing hidden cameras, and basically revealed him as a complete pill pusher that was handing out scripts for benzos like it was the frickin' Oprah Winfrey show - you get a script, and you get a script, and YOU get a script. The medical centre he worked for promptly sacked him, but instead of transferring those patients he'd kept on benzos for an extended period of time to other Doctors in order to at least taper people off the pills, they just kicked us all out. So of course I'm left staring down the barrel of having to go cold turkey, and needed to find another Doctor fast, so cue me ending up with another pill pusher who would just write out scripts, no questions asked. By this stage, even with the previous pill pushing a-hole that had lost his job, I was starting to feel really off, like off in a 'these pills are messing with my brain somehow, and I don't feel right at all' kind of way. I'd weaned myself off the Xanax a few times in this period (always far too rapidly, so I went through some pretty bad withdrawals), but I always ended up back on them because I'd go back to these so called 'Doctors' looking for alternative treatments, and walk out with yet another script (and more often than not an admonishment and a lecture about how I *had* to be on this medication on top of that).

By the time I ended up on the Methadone program I knew the Xanax was really messing with my brain, but my Methadone prescribing Doctor's attitude was 'Let's just worry about tackling one addiction at a time' and I kind of agreed with him, at that point I needed to put my energy into staying off Heroin. Only trouble was his idea of 'let's worry about tackling one addiction at a time' was to just keep prescribing me ever increasing amounts of Xanax - and by this stage I was pretty much physically addicted to Xanax to the point that I needed a minimum of at least 8-10 mgs a day just to stop me going into withdrawal (I was prescribed a maximum allowance of 16 mgs a day). Then one day I just got fed up with all of it - I'd been clean from Heroin for over a year, I was tapering off the Methadone with no issues, so I was stable from that point of view - plus I was engaged to be married, but the Xanax was just making me feel worse and worse all the time, so I thought that's it, no more, I'm done, I'm quitting these pills as of right now. I figured I'd already done several rapid detoxes in the past, and they were rough but Id gotten through them okay, and besides I'd gone cold turkey off Heroin a bunch of times, so how hard could it be to do the same with the Xanax - one grand mal seizure and an emergency ride to hospital later I found out just how wrong I was. Shortly after that is when I finally found the GP who would eventually help me get off the Xanax completely, so I told my Methadone doctor that my Xanax scripts would now be handled by her only, which he agreed to. Now she did manage to at least partially reduce my dosage in the early stages of me seeing her, but at the same time I was starting to come to the end of my Methadone taper, and I was experiencing cravings for other stuff beginning to resurface, so yeah occasionally I messed up and took too many pills. It only happened a few times, but my good GP had made it absolutely clear from the start that I would receive no early scripts from her - if I screwed up, and ran out of Xanax before I was due for my next script, then I had to accept there would be consequences to my actions (she was tough, but fair).

So that's when I ended up visiting one of the most unbelievably dodgy Doctors I have ever come across. I only saw him for about 5 appointments (because I did manage to get my **** back together pretty quickly), but I am not kidding I turned up to one appointment, and there's an uncapped, used syringe in the basin/sink, and he's so off his face he's basically alternating between being face planted on his desk and almost falling out of his chair. Then he doesn't just forget to switch off the previous patients screen notes, or bring mine up, he actually proceeds to turn the computer screen towards me and starts going through her full history - name, address, what she's diagnosed with, what medications she's prescribed. I was basically sitting there gobsmacked. Another time he asked me if I was still on Methadone, and when I said yes he turned around and went 'Oh no, no, you have to get off Methadone and go back on Heroin, it's way better' - I was like 'Well yeah that's great and all, but Heroin's kind of expensive and I don't really feel like going back to peddling my ar%e on the street to pay for my habit, thank you very much'. His answer to that was (and this is a direct quote, because I have never forgotten this), 'No, you move to Malaysia, no need sell your *slang word*, no need sell your ar%ehole, everything cheap in Malaaaasyiaaaa!!!' I really don't know what the hell he expected me to actually put down on any sort of immigration form when they asked what reason I had for wanting to migrate to their country - 'Er, the cost of Heroin in South Australia is just too damn high?' Seriously, WTF? 😵 (*further details edited upon reflection of potential TMI)

To cut a long story short, I got back on track, toed the line with whatever rules and requirements were expected of me with my good (and ethical) GP, got a proper tapering schedule written up by a Psychiatrist for her to manage, and FINALLY got off Xanax once and for all. On my two year anniversary of being completely Xanax (and Methadone) free, she gave me a beautiful note she'd written saying how proud she was of me, and how it had been an honour to see me get well and start to grow as a person away from all the pills and drugs. It was really touching. I have a new, and equally good GP now, but I've never forgotten what she did for me. 😍

 

[splik]

As much as we all try to avoid benzos, you should note that this study is pretty meaningless... I'm surprised that it got into BMJ. Of course patients with benzo prescriptions are more likely to develop dementia... people prescribe benzos for dementia prodromes (insomnia, anxiety) all the time. Also, there are several other symptoms/syndromes that put people at higher risk for dementia and also make them more likely to get a script for a benzo. If you look at their results, the patients who were exposed to benzos had less education, were less likely to be married, and had higher rates of hypertension, all of which will increase rates of dementia as measured by a MMSE (which is the main tool that they used). Unless you do a randomized trial (which will never happen for both ethical and logistic reasons), there's no way to draw any conclusions based on this sort of data.

Aside from that, they don't specify how much benzo use defines an "exposure." And they seem to have made no effort to correct for the fact that elderly patients taking benzos will have some cognitive suppression/altered mentation as a direct effect of the drug, which would confound their ability to measure dementia. Despite all of those flaws, they just barely managed to get statistical significance. I'm guessing that the reason why they didn't make an effort to control for all of those factors is that they only had 30 patients with benzo exposure and dementia, so the sample size was too small to make any further restrictions - I'll bet if they'd tried to control for any of those factors, their sample size would have dropped to the point where they no longer had statistically significant results. Also, they never explained why the patient's initial benzo exposure had to be between 3 and 5 years after the initiation of the study - I'm guessing that this is the time frame that made the data work better. And as we all know, being able to write "statistically significant with 95% confidence interval" in your abstract carries more weight than actually doing a good study.

Also interesting that this study was published 2 years ago and is just now finding its way into the BBC. Somebody didn't have enough fodder for article writing.

are you sure you are talking about the right study? this was not published 2 years ago, it has only just been published.

This is actually a good study, with all the limitations of case-control studies. That does not render it meaningless. They control for all the confounders you mention and more (anxiety, depression, insomnia, hypertension, medical comorbidity). They looked at benzo use more than 5 years prior to diagnosis to minimize the problem of getting prodromal symptoms. They also showed that the cognitive effects were unlikely to be direct effects of the drug as the OR for benzo association was higher in those who has not been exposed to benzos in a year or more vs those who had taken benzos recently. The OR is fairly small so it is not that benzos cause dementia per se. But they show a dose-dependent effect, and the totality of evidence also supports an association. That benzos are known to increase GABA-ergic excitability and affect hippocampal functioning makes an association between dementia and benzos biologically plausible. I think what we are seeing is that chronic benzo use may accelerate the process of a tauopathy leading to earlier manifestation that might not be seen otherwise.

 

[whopper]

Speaking of incompetence and this is non-psychiatric, my father-in-law, a very good guy, suffered from rhabdomyolysis from a statin. His doctor never caught it. I was only asked to look into it after he suffered abour 4 years of progressive muscle loss, weakness, loss of weight, and going from no renal disease to stage IV in just a few months.

He saw a number of specialists and none of them caught it. He told me what was going on and I told him this sounded like ALS to me but that it's so freaking rare it couldn't be that. I asked for his meds and he was on Lipitor. I told him it could be that medication (turned out it was). He then saw a top neurologist in Mayo Clinic specializing in ALS and the doc also concluded it was like the Lipitor.

This type of reaction is one of those side-effects that is taught to be the first to look out for with a statin, so it's effect isn't some never-known, only the top doctor in the country can find it type thing. His PCP, and the idiot endocrinologist that ordered it never detected it, his nephrologist just told him each time he saw him "I'll see you in six months" while his kidneys went up another stage in renal disease each time without doing any real interventions until it got to stage IV, and my father-in-law's permanent damage is now to the degree where he has problems breathing when he lies down (so he can't sleep well) and can't even lift 20 lbs. It's likely permanent.

This was one of the few cases where I'd say sue the doctors, and for a hefty amount. It was a problem that's commonly known, even medstudents know about this side effect, and when it came about nothing was done other than to bump him to the next doctor (Hmm, you have muscle fatigue, see a rheumatologist). It went on for years.

When asked why they didn't tell me about it earlier, he told me he didn't want to bother me. I didn't tell him this aloud but I was mentally yelling at him (keeping quiet on the outside) --"stage IV!!!?!?!?!! You don't hold back for that!"

And for #$%@#$%'s sake, I'm a psychiatrist. I'm the least connected with the physical aspects of medicine and all of those losers missed it. I figured it out in about 5 minutes.

Point is, this type of poor practice is happening all across the board with all fields of medicine. Doctors tend to put in 10 seconds of thought process and not even a few minutes because of the billing nature. You make money PER PATIENT.

 

[Ceke2002]

Speaking of incompetence and this is non-psychiatric, my father-in-law, a very good guy, suffered from rhabdomyolysis from a statin. His doctor never caught it. I was only asked to look into it after he suffered abour 4 years of progressive muscle loss, weakness, loss of weight, and going from no renal disease to stage IV in just a few months.

He saw a number of specialists and none of them caught it. He told me what was going on and I told him this sounded like ALS to me but that it's so freaking rare it couldn't be that. I asked for his meds and he was on Lipitor. I told him it could be that medication (turned out it was). He then saw a top neurologist in Mayo Clinic specializing in ALS and the doc also concluded it was like the Lipitor.

This type of reaction is one of those side-effects that is taught to be the first to look out for with a statin, so it's effect isn't some never-known, only the top doctor in the country can find it type thing. His PCP, and the idiot endocrinologist that ordered it never detected it, his nephrologist just told him each time he saw him "I'll see you in six months" while his kidneys went up another stage in renal disease each time without doing any real interventions until it got to stage IV, and my father-in-law's permanent damage is now to the degree where he has problems breathing when he lies down (so he can't sleep well) and can't even lift 20 lbs. It's likely permanent.

This was one of the few cases where I'd say sue the doctors, and for a hefty amount. It was a problem that's commonly known, even medstudents know about this side effect, and when it came about nothing was done other than to bump him to the next doctor (Hmm, you have muscle fatigue, see a rheumatologist). It went on for years.

When asked why they didn't tell me about it earlier, he told me he didn't want to bother me. I didn't tell him this aloud but I was mentally yelling at him (keeping quiet on the outside) --"stage IV!!!?!?!?!! You don't hold back for that!"

And for #$%@#$%'s sake, I'm a psychiatrist. I'm the least connected with the physical aspects of medicine and all of those losers missed it. I figured it out in about 5 minutes.

Point is, this type of poor practice is happening all across the board with all fields of medicine. Doctors tend to put in 10 seconds of thought process and not even a few minutes because of the billing nature. You make money PER PATIENT.

A high school friend of mine's Mum went to her Doctor on numerous occasions complaining of persistent back, abdominal and pelvic pain, abdominal swelling, a dragging 'full' feeling in her pelvic region, heartburn and fatigue. Her Doctor ran no tests...nothing wrong, nothing to see her, she was experiencing normal menstrual difficulties that's all...then it went a little something like this (paraphrased) "Oh wait, you've been through menopause? Oh then it's just menopausal" - "No wait you're hormonal, you're menopausal and hormonal, here's a script for HRT" - "You're already on HRT? Okay well maybe you've just strained something?" - "You're sure you haven't strained anything? Well I understand you've also had a recent break up..." (And cue the start of accusations of histrionics, attention seeking, time wasting, malingering, drug seeking, etc etc). 18 months later - "There is absolutely nothing wrong with you Mrs X, but fine, I'll refer you for some tests."

By the time the Ovarian Cancer was discovered it had already metastasised extensively, and her condition was diagnosed as being terminal. She was given 6 months to live; she managed to make it to just over 2 years (with chemo). But of course there wasn't anything 'really' wrong with her, she was just some menstrual, menopausal, hormonal, histrionic, attention seeking, time wasting, malingering, drug seeking, pain in the proverbial, middle aged woman. Obviously the cancer must have missed that memo somehow. 🙄🙄🙄🙄🙄

 

[nancysinatra]

This type of reaction is one of those side-effects that is taught to be the first to look out for with a statin, so it's effect isn't some never-known, only the top doctor in the country can find it type thing. His PCP, and the idiot endocrinologist that ordered it never detected it, his nephrologist just told him each time he saw him "I'll see you in six months" while his kidneys went up another stage in renal disease each time without doing any real interventions until it got to stage IV, and my father-in-law's permanent damage is now to the degree where he has problems breathing when he lies down (so he can't sleep well) and can't even lift 20 lbs. It's likely permanent.

This was one of the few cases where I'd say sue the doctors, and for a hefty amount. It was a problem that's commonly known, even medstudents know about this side effect, and when it came about nothing was done other than to bump him to the next doctor (Hmm, you have muscle fatigue, see a rheumatologist). It went on for years.

I bet that happens a lot, not just with lipitor being missed but with other basic medical situations. I don't think it's surprising that you, as a psychiatrist, picked this up because it's something you probably learned in med school or intern year that stuck with you. An internist knows about lipitor too, but they know a lot of other things that can cause those same symptoms and they just might overlook the lipitor.

In much the same way, every time I see propranolol and albuterol prescribed at the same time, I get into a med student mode, and feel like this has to be stopped! People in this country are way over medicated - not just with psych meds but with everything else - and this stuff is going on all over the place. I think it is the result of lawsuits, managed care and other organizations that are not run by doctors but tell doctors what to do, and super-specialization.

Look at how many super-specialists your father-in-law saw. The PCP is the one who probably should have caught it, but then again the PCP also wasn't the one who prescribed it. I find it's a lot harder to figure out connections between side effects and medications when the medication was prescribed by someone else.

In this day and age every doctor is super-specialized and no one is watching to store, so to speak. It's just as true in psychiatry. Look how many patients have addiction issues that general psychiatrists either don't catch, or don't know how to treat. Look at how each and every subspecialty is starting to require not only a board exam, but a fellowship, and protecting their turf and making it look like you have to be "in the club" to know the material. This is true even in forensic psychiatry. I see over and over that general psychiatrists have no clue about forensic matters. They don't feel obligated to know basic things about capacity, for example. They misunderstand state laws about commitment, and no one cares. And all they have to say is, "I'm not a board certified forensic psychiatrist, so I don't know this." It's this way all over the place.

 

[nancysinatra]

Yep as OPD said. There's too many doctors out there, psychiatrist or not that just give it out like it's candy and I'm no longer shocked by it only because I see it happen so much.

Medical school is so difficult to enter, and residency is very tough, but with such tough standards to see so many doctors practice so poorly was offensive to me. It's gotten not so offensive only because I see it so often. I have seen some doctors lose licences over this but only the worst offenders...I'm talking the ones that are giving it out by the barrel and even they seem to get away with it for years and many don't get caught at all.

Where I used to practice in Cincinnati, all the of the local psychiatrists knew several in particular were the continuing offenders, but despite that an entire professional demographic in a metropolitan area knew this, nothing happened to those doctors. We're also in a position where we're not going to tell patients to avoid those specific doctors. Now that I'm in St. Louis, I'm already starting to learn who the local idiots are.

Just had a guy in the infirmary on 8 meds: Elavil, Risperdal, Depakote, Gabapentin, Trazodone, Melatonin, Vistaril, and he was on a benzo in the community. Why? I asked him. He told me he didn't know and just did what his doctor told him but that he thinks Risperdal is working to reduce his depression.

Geez.

This sure is the truth.

It is incredibly hard to deal with benzos. It's sad, because pharmacologically speaking, they are neat medications. If you think benzos are risky, think about having to deal with barbiturates. I actually think we should be utilizing the barbiturates a little more than we do - they can be used for withdrawal, for example, preferably in an in-patient setting. Many of the sedative medications are pretty cool in some ways, but they shouldn't be used on a widespread basis.

Elavil is another big offender. I have nothing against it in a non-psychiatric population, but PCPs prescribe it a lot and then I get some halfway suicidal person coming in on it and I'm stuck figuring out how to tell the patient I won't continue it. Now if the person needs it for depression and is a good candidate and has failed other options, that's a different situation, but often what I see is it being used at low doses for sleep. It's hard to fault PCPs, because they have to address so much in a short time. Rather I think our society has gone off the deep end with insomnia problems and demands for meds.

I don't agree with outlawing xanax - I think it should never be prescribed for general use however. But it's almost perfect for someone who needs to get an MRI, or for people with specific phobias that are hard to treat with psychotherapy, such as fear of flying in airplanes. Versed is sort of similar, in that it has a very limited use for which it's very effective. Why xanax would be prescribed for generalized anxiety I have no idea. This is where the DEA should start paying more attention.

In the city where I did residency, there were some notorious doctors who ran pill mills, and from time to time the newspaper or medical board would catch onto them. The most they ever got was a slap on the wrist. And the patients love them, because they give them their candy. They would give out xanax by the boatload even to kids. They had thousands and thousands of patients.

With all benzos, I find that I am constantly being asked for them by patients. Yes a lot of them also take opiates. I see young patients coming in sometimes on huge doses of benzos and narcotics and the other usual suspects. There is a reason deaths from unintentional overdoses have risen to alarming rates.

It doesn't help that almost no one in our society wants to come up with better solutions than benzos. People often don't want to address underlying problems, especially if the problems are big and multifactorial. The drug companies don't want to invent newer, better medications for anything because they can make money putting out replicas of what's out there now.

It also doesn't help that forever, it has been considered "unprofessional" for one doctor to criticize another.

 

[TexasPhysician]

Where are these numerous patients that want off benzos after thorough education? I can't tell you how many times I've discussed addiction, cognitive dulling, etc and been told it's all worth it.

I'm frequently attempting to taper benzos outpatiently, but usually it's not met with compliance. I work at an addiction center as well, and most of those patients admit to shopping around. They never wanted to hear the word taper or listen to education.

I'm not saying that some docs aren't liberal in prescribing, but I am not seeing the poorly informed benzo users described in above posts.

I would strongly oppose limiting benzo usage as they have a largely beneficial role. I say this and I'm conservative in my usage in my opinion.

 

[birchswing]

Where are these numerous patients that want off benzos after thorough education? I can't tell you how many times I've discussed addiction, cognitive dulling, etc and been told it's all worth it.

I'm frequently attempting to taper benzos outpatiently, but usually it's not met with compliance. I work at an addiction center as well, and most of those patients admit to shopping around. They never wanted to hear the word taper or listen to education.

I'm not saying that some docs aren't liberal in prescribing, but I am not seeing the poorly informed benzo users described in above posts.

I would strongly oppose limiting benzo usage as they have a largely beneficial role. I say this and I'm conservative in my usage in my opinion.

My first education regarding benzodiazepines came not from a doctor but years after I had been taking them from http://benzo.org.uk where I first found the Ashton Manual which was adopted by the British National Formulary as the guide for how to taper patients. Up until finding that and even before psychiatrists I met with saw no need to discontinue use—one added a second benzo to my treatment, some wanted to increase my dose, and other said that if I insisted on going down that I would just need to split my pills, which in my opinion was unwise (a slow, gradual taper is less likely to cause withdrawal symptoms, kindling, and protracted withdrawal syndrome).

There are thousands of patients helping each other withdraw at http://www.benzobuddies.org/forum/index.php and there is a web-site called http://benzodocs.com where readers share doctors who are familiar with techniques in helping patients withdraw. There was even a site at one point (can't remember it now) that had a form letter you could print out that gave the bulleted points on benzodiazepines and why a patient wanted to withdraw that you could print out to give your doctor. It is only my most recent psychiatrist, whom upon meeting her three years ago, was willing to be clued into the fact that I thought benzodiazepines were a problem for me. When I first met her she didn't think that they were, but she has since changed her mind and uses the Ashton protocol. As a result of how bad the benzo-prescribing problem is in my area, she says she is having difficulty managing all of the patient she sees and wants to find a nurse to train to help manage the number of patients and request she's getting.

If I had any clue as to what benzodiazepines were, I never would have taken them. I started at 14 on 2 mg Ativan a day. I was a child who was terrified of everything, including medicine. I was my same nervous self in the psychiatrist's office and was asking him about the medication. I remember two things he told me. He told me that if I looked up the side effects of aspirin I would never take it because every medication has terrifying side effects. Second, I remember he got angry toward the end of our very brief appointment and said, "Do you tell the pilot how to fly the plane?"

 

[TexasPhysician]

My first education regarding benzodiazepines came not from a doctor but years after I had been taking them from http://benzo.org.uk where I first found the Ashton Manual which was adopted by the British National Formulary as the guide for how to taper patients. Up until finding that and even before psychiatrists I met with saw no need to discontinue use—one added a second benzo to my treatment, some wanted to increase my dose, and other said that if I insisted on going down that I would just need to split my pills, which in my opinion was unwise (a slow, gradual taper is less likely to cause withdrawal symptoms, kindling, and protracted withdrawal syndrome).

There are thousands of patients helping each other withdraw at http://www.benzobuddies.org/forum/index.php and there is a web-site called http://benzodocs.com where readers share doctors who are familiar with techniques in helping patients withdraw.

I'm well aware of those sites, but the number of patients that want off despite thorough education is rare in my experience. Even the patients that tell me they want to taper it come up with reasons as to why they aren't actually trying.

Despite education, patients in general don't want to try alternatives, especially those that take time to work (SSRI's, etc).

I would love for more patients to agree and want off benzos, but usually it is a long hard struggle with frequent reinforcement, education, etc. to get a patient on board if they ever agree.

While benzos are addictive, they work very well. Conservative use, education, and frequent attempts to taper are all part of my practice.

 

[birchswing]

I'm well aware of those sites, but the number of patients that want off despite thorough education is rare in my experience. Even the patients that tell me they want to taper it come up with reasons as to why they aren't actually trying.

Despite education, patients in general don't want to try alternatives, especially those that take time to work (SSRI's, etc).

I would love for more patients to agree and want off benzos, but usually it is a long hard struggle with frequent reinforcement, education, etc. to get a patient on board if they ever agree.

While benzos are addictive, they work very well. Conservative use, education, and frequent attempts to taper are all part of my practice.

You're a very different type of psychiatrist than many if not most where I live (I am in southeastern Virginia). In my case the educational efforts have been in the reverse direction of what you describe. And the patients that come to you have to have been prescribed by someone. I wouldn't underestimate the fear that drives people to not want to withdraw or to be afraid of it even if they say they want to. I could have tried withdrawing years ago but I never felt safe without having a doctor who would do it slowly and who would follow something at least close to the Ashton protocol. The fact that they didn't know that withdrawal could be dangerous gave me great pause. I will be frank and say I could have started tapering a lot longer ago, but I was still incredibly anxious and withdrawal was a terrifying prospect. I had mental images of having seizures and cardiac arrest. The drugs cause tolerance but also a psychological addiction, especially when you read people's withdrawal horror stories. In my case, I associated benzodiazepines with the ability to breathe better at a young age, as my chief complaint was always feeling like I couldn't get a good enough breath. It forms a very strong imprint. So I was not willing to withdraw in 7 days or by splitting pills in half as was suggeted--it was too fast based on the research I had seen.

From hearing your description of reinforcement and encouragement, etc., you sound like a normal human being. My cardiologist is the sweetest man. If someone like him with his intelligence had been helping me with this, I would have felt great relief and felt safer and started this a long time ago. As I tell my therapist, the psychiatrists where I live often don't even pass as normal human beings with normal communication skills. For people in the healing arts, it's quite odd. You're less likely to be verbally abused by a random vagabond on the street than these doctors. I swear they are some of the weirdest people. When I think of what it's like to go to my GP or my cardiologist or my dentist, and I then think of the psychiatrists I've seen, it's this shock. It's hard to understand how the two could exist in the same world. I am sure this is hard to believe but one in particular runs a cult as his practice. You'll have to take my word for it or not because to prove it I would have to provide his name, which is possibly unethical—I'm not sure. It was group psychiatry (not group therapy), and there was nothing close to the ability to have a conversation about withdrawal. In fact in the first two weeks of attending you weren't allowed to talk during sessions. I really don't think anyone would believe me because this case was so unique that it's almost hard for me to believe that what happened to me happened. I then think that in the same city a few miles away a really nice, intelligent cardiologist exists, and it's hard to reconcile the two.

As far as efficacy, I agree. My aunt has used 5 mg of Valium occasionally throughout her life and they still work for her, so I agree there can be judicious use of them. I on the other hand can't even be put to sleep with conscious sedation (Versed) even when combined with several other drugs in a cocktail. Unfortunately the useful parts of benzos, such as going on a plane, don't apply to me anymore.

I havent received any of the reinforcement or education. I think it would be helpful to have an encouraging support person. I only see my psychiatrist every 3 months, and while she has helped me taper following the Ashton protocol, I wouldn't call her encouraging of it. I'm on a waiting list for another one closer by who hopefully I would be able to see more often. But going into it, I honestly have no idea if he's "benzo wise" or not. That's my biggest concern. There are doctors around here who will tell you to go to a clinic for 7 days to go off using phenobarbital (which is both unwise and cruel IMO) or those who just don't care, don't know. I'm crossing my fingers for this one. He's one of the few in the area I haven't seen, but his long waiting list is a good sign.

 

[nancysinatra]

Where are these numerous patients that want off benzos after thorough education? I can't tell you how many times I've discussed addiction, cognitive dulling, etc and been told it's all worth it.

I'm frequently attempting to taper benzos outpatiently, but usually it's not met with compliance. I work at an addiction center as well, and most of those patients admit to shopping around. They never wanted to hear the word taper or listen to education.

I'm not saying that some docs aren't liberal in prescribing, but I am not seeing the poorly informed benzo users described in above posts.

I would strongly oppose limiting benzo usage as they have a largely beneficial role. I say this and I'm conservative in my usage in my opinion.

I hope I didn't give that impression. I have almost never come across a patient who wants to be off benzos. Almost no one ever has more than their usual supply left at the end of the month. The doctors who are prescribing huge quantities are a minority, for sure, but they draw a lot of attention to themselves.

 

[whopper]

I'm not saying that some docs aren't liberal in prescribing, but I am not seeing the poorly informed benzo users described in above posts.

I can't answer your question because I don't work where you do but I have noticed these things can highly vary. In working to upper class patients (so think private practice or private inpatient facility) it seems to be where I've encountered the patients not knowing it was addictive and had they known they would've avoided it.

In community-care settings, there's a lot of people who don't know but a lot of people who do know (cause they're addicts) and unfortunately that demographic didn't seem to care much that it was addictive, they just wanted it.

I remember something to the effect of 80%-plus of patients on benzos not wanting off of it when I took over care in a community-care center when they were told the medication was addictive,. My theory was it was a mixture of worse education, lower self-esteem (backgrounds of parental abuse so these people didn't give a damn about themselves and didn't think of their futures), and desire to sell the med due to a street value.

In private practice with a lower-middle class to upper class clientele, it was something on the order of 80%+ of people wanting off of it when they knew it was addictive. My theory was it was because these demographics: better education, better self-esteem, thinking of their futures.

Another factor is it tends to be specific docs that can be identified if you see their patients quite a bit that are big offenders. In an ER you see that because you get a slice of several different doctor's patients. If you just do PP you only see your own patients.

But on one occasion, a specific PP doctor in the area no longer took insurance and went out-of-pocket only and several doctors in the area took her patients because they wanted someone that would take their insurance. They were all on massive amounts of benzos. I talked to my colleagues about this and some of them and some of them refused to see her patients because every single one of them had to be told the benzo usage was highly suspicious, even dangerous and often times those patients would be angry, even screaming. "Why did she give me 8mg of Xanax a day if it's bad for you?!?! I don't believe you!"

That doctor, Dr. W. (I'll leave it at that) is the running joke among several docs in the Cincinnati area. We all know she is the benzo drug-dealer. Anyone practicing in Cincinnati for just about 1-2 years that is not isolated (e.g. communicates with other doctors, just doesn't do PP all the time) will know who she is.

 

[shan564]

are you sure you are talking about the right study? this was not published 2 years ago, it has only just been published.

This is actually a good study, with all the limitations of case-control studies. That does not render it meaningless. They control for all the confounders you mention and more (anxiety, depression, insomnia, hypertension, medical comorbidity). They looked at benzo use more than 5 years prior to diagnosis to minimize the problem of getting prodromal symptoms. They also showed that the cognitive effects were unlikely to be direct effects of the drug as the OR for benzo association was higher in those who has not been exposed to benzos in a year or more vs those who had taken benzos recently. The OR is fairly small so it is not that benzos cause dementia per se. But they show a dose-dependent effect, and the totality of evidence also supports an association. That benzos are known to increase GABA-ergic excitability and affect hippocampal functioning makes an association between dementia and benzos biologically plausible. I think what we are seeing is that chronic benzo use may accelerate the process of a tauopathy leading to earlier manifestation that might not be seen otherwise.

Ah, I see it now. For some reason, I was looking at another study published 2 years ago by the same group in the same journal.

 

[clusterF]

I agree with Texas, for the most part. The vast majority of people do not want to be tapered off their benzos even after repeated education about risks. "I'm different" "it's the only thing that helps" "I don't want the side effects of those other medications" and "i know my body" are among the various things I hear on a daily basis.
There are a very small few percentage who will want to be off the medications after they hear about the risks but this is highly unusual.

 

[birchswing]

I agree with Texas, for the most part. The vast majority of people do not want to be tapered off their benzos even after repeated education about risks. "I'm different" "it's the only thing that helps" "I don't want the side effects of those other medications" and "i know my body" are among the various things I hear on a daily basis.
There are a very small few percentage who will want to be off the medications after they hear about the risks but this is highly unusual.

Again, I can only speak from my experience, but I have seen a lot of psychiatrists and there was never any education to begin with. The education that took place was going from patient to doctor.

The other part that doesn't make sense, unless I am physiologically different from most and I don't think I am, is that these medicines stop working. It would be one thing if there was a risk for Alzheimer's but the meds kept working until then. But they don't, in my experience. Benzodiazepines do work very, very well. In fact I can remember the first day I took them in high school. Going to class become so effortless and I remember saying, "Is this how people feel every day?" But that didn't last long. I suppose if you kept increasing the dose, maybe it would keep working for you. Or maybe the patients you see have been on them a much shorter time than I have.

The other thing to the point that your patients say nothing else works is that you have to wonder if they were tried on anything else first. It's probably difficult to suggest an SSRI or beta blocker if the first thing they were tried on was a very addictive medication. I don't think a lot of people are getting addicted to benzos because they get them on the street. There is an initial prescriber.

The sad part about all of this is that person with anxiety becomes equated with person who needs/wants addictive drugs. I remember my dad once saying that there were no free rides in life and that you can't treat anxiety without this coming back to bite you. But I don't agree. This problem seems very specific to benzodiazepines (and their predecessors) versus other classes of psychiatric drugs. I told him that what he said would be like me telling him that he's going to increase his risk of high blood pressure over time because he takes a high blood pressure medicine. It doesn't necessarily have to be this way; it happens to be that the drugs that have traditionally been used to treat anxiety are addictive and don't work well long-term.

I asked on this forum many years ago if anyone knew about XBD-173. It appears to now have a new name:

http://en.wikipedia.org/wiki/Emapunil

I've also asked why they don't prescribe Lyrica for anxiety.

But when I ask doctors about these things they look at me like a space alien.

Why don't new drugs come out? And when they do, why does no one seem to know about them?

 

[whopper]

The education that took place was going from patient to doctor.

Docs make money per patient. Explaining things doesn't make money. There's an actual federal law stating that doctors must give a reasonable explanation of the risks and benefits, but I've rarely seen doctors even do that for me when I'm their patient.

A litmus test for me when I have a doctor treating me is I try to intentionally not tell them I'm a doctor (sometimes unavoidable), or my wife's doctor will treat them and we'll intentionally not tell her doctor I'm one. I then rate the doctor's performance as if he/she is a resident. If they do what a good resident would do-fine. Otherwise they're likely not a good doctor.

So one time, my wife's Ob-gyn prescribed a 3rd line med (as the first treatment), no explanation of the side effects (Some of which could've been fatal. The doc presribed a high dose corticosteroid with a taper down but never explained the danger of not following the taper down religiously), and was condescending the entire time. I told my wife to tear up the script and get a new doctor.

I was going to tell the Ob-Gyn that I too was a medical doctor and had she been my resident I would've noted her performance as sub-par but I don't think she would've gave a damn because she didn't care in the first place about healing others.

Why don't new drugs come out? And when they do, why does no one seem to know about them?

Because they don't get paid to study the new stuff despite that they are expected to do so.