Patients on benzos and an opiate?

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resident1985 said:
I saw a 60 year old guy today who had panic disorder with agoraphobia that caused him to quit his job and was placed on Prozac and Xanax 0.5 mg tid twenty years ago with resolution of symptoms and no dose escalations or recurrence for twenty years. His pcp wanted a second opinion on the Xanax. He had no side effects so we discussed risks and he elected to stay on it. I didn’t suggest a unilateral taper because I don’t do that without evidence of abuse or physical harm when someone comes to me dependent on Benzos. Just interesting to see someone who had benefited for so long without issues. Maybe primary care sees this more?
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I have heard of this in the benzo community. And withdrawal experiences are similarly heterogeneous—a rare minority claiming to experience minimal symptoms.


Edit: That doesn't change my opinion based on what I know about benzos. To me, it just means there's a deficit of knowledge in that area. There are similarly some people who should have by all accounts have contracted HIV due to repeated high-risk behavior but never have for unknown reasons.
 
WingedOx said:
Eh, I think his case is typical enough, actually. The bigger thing I notice here is that the patient is 60... so whatever.

Now what happens when the patient is 70? 75? What about when they start having cognitive or mobility issues? Hell, I inherited a patient a few years ago who's now 93 and still has an bottle of alprazolam, that thankfully he only uses every 6 months or so.

Just because the patient is "doing fine" doesn't mean you've done your job as a clinician. If that patient is well controlled on 0.5 TID, then there's no reason they can't handle taking one of the three doses down to 0.375, then two doses down to 0.375 a few months later.

Your job as a clinician is not to achieve zero distress for your patient. Coming off benzos is uncomfortable. A fall in the shower or an auto accident is worse.
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I agree completely. the stance I’ve taken is not forcing people off and he was not open to a decrease right now. I think once people feel safe they are much more open and tolerate these things better so maybe he will consider in the future now that he knows I won’t strong arm him.
 
There is nothing so queer as folk.
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I don't think I mentioned this much but I almost became an artist.

And to hear this lady say she's an artist...well that's not art. That's you getting your jollies thinking you're a Jedi Knight based on some non-psychotic narcissistic cognitive distortion.

There's a reason why we get rammed with Biochemistry, Organic Chemistry, Physics, Physiology, etc. And it's so ironic that I struggled with this classes yet so many science people I know did easily well in those classes but don't know what science is really about.

Real art, good art usually is usually hard to do. What she was doing wasn't hard except for the suffering on the patient's part.
 
resident1985 said:
I agree completely. the stance I’ve taken is not forcing people off and he was not open to a decrease right now. I think once people feel safe they are much more open and tolerate these things better so maybe he will consider in the future now that he knows I won’t strong arm him.
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At some point you gotta bite that bullet. Otherwise he'll be the next resident's problem and the cycle will continue and then it's too late. Might as well get practice in for these types of conversations while you still have the luxury of being in training.
 
futuredo32 said:
Sometimes it's the ONLY med that helps, tried everything else even tiagabine. All the "other great treatment options" including therapy don't always work for panic disorder. Most of my patients are in therapy either with me or someone else. I think I have two patients on benzos not in therapy one is in his 60s and did 30 years of therapy and one works worldwide about 90 hours a week, the rest are in therapy. Thanks to all for your opinion. I am going to make people pick, opiate or benzo. One poor patient switched from methadone to suboxone, sucks to be her, and she was using it for pain....... But that is what my psychiatrist is doing for liability reasons. I'm going to follow suit and do the CYA. I have 3 in my pp and a few at a one day a week independent contractor job.
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I just want to point out that our most effective psychotherapies for panic aren't going to work as well (or at all) if the patient is simultaneously taking benzos. You may already be aware of this, but just in case.
 
cara susanna said:
I just want to point out that our most effective psychotherapies for panic aren't going to work as well (or at all) if the patient is simultaneously taking benzos. You may already be aware of this, but just in case.
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Why treat something correctly in the long-term, when you can make the patient happy in the short-term, while damaging them in the long-term? Medicine is easier when you don't think about it.
 
cara susanna said:
I just want to point out that our most effective psychotherapies for panic aren't going to work as well (or at all) if the patient is simultaneously taking benzos. You may already be aware of this, but just in case.
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Quoted for truth... especially alprazolam.
 
WisNeuro said:
Why treat something correctly in the long-term, when you can make the patient happy in the short-term, while damaging them in the long-term? Medicine is easier when you don't think about it.
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No kidding. Being a bad doctor is super easy and, assuming you don't care about doing the right thing, pretty satisfying.
 
I've worked in 4 states, in 3 geographic regions. WingedOx's experiences mirror what I have seen everywhere I have worked. Also, I doubt that all of these patients have tried exposure therapy. I ask my patients with significant anxiety and/or panic disorder, who have been prescribed benzos, how many of them have tried exposure therapy. The number answering in the affirmative is still in the single digits. Man, I don't know what hold this love of benzos has on you, but it is strong. Unfortunately, the negative effect it has on some patients, is stronger, and more damaging.
 
@futuredo32

Where in Michigan are you practicing (and more importantly, where did you train)?, because as a Genesee County exile myself, I find your generalizing about the state the way you do to be really really weird.
 
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WisNeuro said:
Eww, Genesee County. St. Clair County is where it was at.
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You have no idea how many times I've had people ask me if I've met Michael Moore...

Though I was down in southern Macomb last weekend. That part of suburban Detroit is kinda depressing even though it's where my extended family was for a long time. At least there was a Buddy's Pizza next door to where I was staying.
 
WingedOx said:
You have no idea how many times I've had people ask me if I've met Michael Moore...

Though I was down in southern Macomb last weekend. That part of suburban Detroit is kinda depressing even though it's where my extended family was for a long time. At least there was a Buddy's Pizza next door to where I was staying.
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Yeah, Southern Macomb has seen better days. Ah, Buddy's. Not a Jet's Pizza fan? Is the grease soaking through the pizza box too much of a deterrent? 😉
 
WisNeuro said:
Yeah, Southern Macomb has seen better days. Ah, Buddy's. Not a Jet's Pizza fan? Is the grease soaking through the pizza box too much of a deterrent? 😉
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A Jets actually opened in my old neighborhood like a month after I moved 40 blocks south. I was pissed.
 
WingedOx said:
@futuredo32

Where in Michigan are you practicing (and more importantly, where did you train)?, because as a Genesee County exile myself, I find your generalizing about the state the way you do to be really really weird.
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I'm not going to reveal any personal information. Physicians received an email from the Lt. Governor about prescribing both benzos and opiates and other emails. Don't love benzos, use them as a last resort and do try to get patients off of them, wow did this thread get derailed, I asking about how psychiatrists were handling patients on benzos and opiates not slamming you for not being a psychiatrist at all please don't take it that way but it is a real issue for those of us who prescribe . I got my answer. Carry on with your debate if you like.
 
In some patients it may be appropriate for them to be on both an opioid and benzo. If you are going to prescribe benzos to a patient on opioids, from a medico-legal perspective, you need to make sure that they are reliable; not abusing their meds, not taking extra, not diverting, that they are getting regular urine toxicology screens; that they have signed a benzo contract; that you have discussed and documented the risks, benefits, alternatives, and that you have documented a rationale of why the benefits of continuing outweigh risks; that you have discussed this with the patient; and that you continue to re-evaluate this every visit.
 
futuredo32 said:
I'm not going to reveal any personal information. Physicians received an email from the Lt. Governor about prescribing both benzos and opiates and other emails. Don't love benzos, use them as a last resort and do try to get patients off of them, wow did this thread get derailed, I asking about how psychiatrists were handling patients on benzos and opiates not slamming you for not being a psychiatrist at all please don't take it that way but it is a real issue for those of us who prescribe . I got my answer. Carry on with your debate if you like.
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Uhh, Where did you get the impression I'm not a psychiatrist??
 
WingedOx said:
Uhh, Where did you get the impression I'm not a psychiatrist??
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I apologize, a neuropsychologist has been posting. Just a lot of posts not related to my initial question, Michael Moore, Benzos are awful etc. and my question was about benzos with a patient on opiates and I was briefly glancing through the many posts. But as I said I have an answer I am comfortable with. So I'm good, and again sorry I made an error with your job title.
And I have no idea where Genessee county is.......
 
For as long as I've had my 02 checked, it's been low (it was a dentist who first discovered this when doing a twilight sedation procedure). Been to two pulmonologists with no explanation, except they see my mental health history so they make it about that (everyone loves anxiety because it's like a placeholder word for anything that can't be explained). But I really have a resting 02 of 90-92% and lower overnight. With conscious hyperventilation I can raise it but not for long. Never smoked, had CTPA, had PFT, echocardiogram, etc. Still not sure what it's about.

Anyhow, that's the premise--I'm not asking for advice on that. I know you can't give it nor would you have particular training in giving it.

When I had my appendectomy, I told them all of this about the low 02. I'm not sure if it was because of me saying that or them seeing my 02 sats were low but both before and after surgery they had an oxygen cannula in my nose, and my 02 hung out around 93-94% on their device, sometimes lower.

The night after the surgery, they wanted to give me Norco. I point out that they've been giving me Ativan and my 02 is low and I'm concerned about desatting further. They say it's fine and I take it. I desatted to 88-89% which they say is acceptable. After that when they come in I asked for just Tylenol--can't give it, not on my list (even though it's part of Norco). So I went without any pain meds except for the very first Norco.

So I get home, and I had the hardest time walking in the house. I used my own pulse ox and saw it drop to 84%. So based on that, I took no Norco (the had given me a script to take at home). I was in horrible weakness from what they called pathological exertion when I came out of the anesthesia--I wrestled around for about an hour and punched a nurse (unaware of it). It was so hard to move around for several days (I had to use my arms to pull on my sheet to get leverage to it up in bed) but never took a single Norco. And eventually my 02 returned to its normal (which is still not normal).

My psychiatrist says it's impossible for the benzos to cause my low 02. And I haven't seen much literature on 02 depression from just benzos alone--it's usually something more synergistic. I'm 6'2" 230 lbs, so right on the edge of obesity. But there are fatter people with normal gas exchange, so it's still a mystery. If I had to guess (which really is a guess because no one's told me), I would say OSA and OHS. But I have no idea.

But at least in my particular case, which is probably unusual, I will never take an opioid based on that experience. Too easy to slip over the edge.

And just to absolve anyone of saying I should seek care for these issues, I have and I am.
 
futuredo32 said:
I'm not going to reveal any personal information. Physicians received an email from the Lt. Governor about prescribing both benzos and opiates and other emails. Don't love benzos, use them as a last resort and do try to get patients off of them, wow did this thread get derailed, I asking about how psychiatrists were handling patients on benzos and opiates not slamming you for not being a psychiatrist at all please don't take it that way but it is a real issue for those of us who prescribe . I got my answer. Carry on with your debate if you like.
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I get it, but I don't think you quite get how it's also an issue for those of us who don't prescribe, but have to deal with the ramifications of inappropriate prescribing on a daily basis (e.g., huge anticholinergic load, benzos in general, massive doses of opiates, etc). I just wanted to be clear on the misconceptions on the literature and clinical practice that were asserted.
 
WisNeuro said:
I get it, but I don't think you quite get how it's also an issue for those of us who don't prescribe, but have to deal with the ramifications of inappropriate prescribing on a daily basis (e.g., huge anticholinergic load, benzos in general, massive doses of opiates, etc). I just wanted to be clear on the misconceptions on the literature and clinical practice that were asserted.
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As I stated earlier, I got a mess of patients from a "highly regarded psychiatrist" who left private practice, but prescribed benzos like candy and now I'm getting patients on benzos prescribed by their PCPs for years who are no longer willing to prescribe. I am guessing it's just Michigan, but the Lt. Governor finally decided there is an opiate crisis in 2018 and FP docs don't want to keep prescribing psychostimulants or benzos. Some Pcps are good with psych meds, some not.
 
Agreed with @WisNeuro

You cant bring this issue up and pretend it doesn't effect other fields, right?

Psychiatrist and PCP Rx habits (e.g., over prescribing) create problems for multiple physicians and allied health providers. You do alot of therapy, no? How can you not understand how this would significantly impact non-medical treatment...and that we would have an opinion about it in the face of contrary evidence of non-medication treatment effectiveness and options. Think whole health model, self efficacy, ultimate responsibility for treatment/improvement, stages of change/motivation for change, behavioral principles like escape conditioning, operant schedules of reinforcement, etc.[/QUOTE]
 
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futuredo32 said:
I apologize, a neuropsychologist has been posting. Just a lot of posts not related to my initial question, Michael Moore, Benzos are awful etc. and my question was about benzos with a patient on opiates and I was briefly glancing through the many posts. But as I said I have an answer I am comfortable with. So I'm good, and again sorry I made an error with your job title.
And I have no idea where Genessee county is.......
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Because neuropsychologists see alot of the following referral question: "Multiple treatment failures despite X number of years of treatment for his/her panic disorder/ptsd/depression/anxiety and now reports memory problems. Please eval and treat. Thanks."

Both Tx failure and "cognitive complaints" (in a 45/year-old chronic psychiatric patient) can be a result of long-term benzo maintenance for many psychiatric conditions. Not to mention adding in some opiates, right?

futuredo32 said:
I am guessing it's just Michigan,
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I doubt that.
 
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erg923 said:
Agreed with @WisNeuro

You cant bring this issue up and pretend it doesn't effect other fields, right?

Psychiatrist and PCP Rx habits (e.g., over prescribing) create problems for multiple physicians and allied health providers. You do alot of therapy, no? How can you not understand how this would significantly impact non-medical treatment...and that we would have an opinion about it in the face of contrary evidence of non-medication treatment effectiveness and options. Think whole health model, self efficacy, ultimate responsibility for treatment/improvement, stages of change/motivation for change, behavioral principles like escape conditioning, operant schedules of reinforcement, etc.
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[/QUOTE]
It has helped patients with severe anxiety and panic disorder and this is not JUST my experience but has been discussed at psych meetings locally initially in therapy- patients too scared to talk kinda thing. Sometimes they can taper off after sometimes not. I'm a D.O. and do think of mind body spirit. Anyway, I am outta this discussion. I wanted opinions from those who prescribe on how they are dealing with patients and opiates. Thanks for the those of you who contributed your thoughtful opinions on the matter.
 
futuredo32 said:
It has helped patients with severe anxiety and panic disorder and this is not JUST my experience but has been discussed at psych meetings locally initially in therapy- patients too scared to talk kinda thing..
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Yes, I'm sure it has/does. But this isnt IM or FP. The harm reduction model functions different here as standard of care (or least it should). Diabetes and cholesterol kills. Acute anxiety/panic attacks don't, right? Getting the patient to work the problem is your job in this field, and if it fails, it fails. No blame to you (it generally falls on them). Therapeutic script writing in conjunction with appropriate treatment is different than script writing that presents as treat on its own.

But, the (over) drugging of America shouldn't come down to 'well they don't want to do anything else???"So, What am I to do?"

Some psychiatrists really seem to think that their patients are as weak and incapable as they claim they are. We didn't get here by having 30% of the populous unable to function due to "anxiety" and/or depression. This is a societal problem that is aided/enabled by "psychiatric medicine."
 
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futuredo32 said:
It has helped patients with severe anxiety and panic disorder and this is not JUST my experience but has been discussed at psych meetings locally initially in therapy- patients too scared to talk kinda thing.
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I attend many conferences, lectures and the last time I heard someone espousing the virtues of benzos for anxiety was at least 5 years ago by a psychiatrist who was older than dirt.

The comments here from those who don't prescribe speaking out about the detriments of this class of medications indicate knowledgeable, skilled clinicians who are motivated to guide patients toward growth rather than punting to the prescriber for a magic pill. It would be my pleasure to work with any of you.

futuredo32 said:
Laws about benzos opiates etc seem to be Mi only based on the posts here.
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Not unique. I believe there are about 37 states with a mandated PDMP database and I have received notices from the state, CDC and FDA regarding appropriate prescribing for several years.
 
Jules A said:
I attend many conferences, lectures and the last time I heard someone espousing the virtues of benzos for anxiety was at least 5 years ago by a psychiatrist who was older than dirt.



Not unique. I believe there are about 37 states with a mandated PDMP database and I have received notices from the state, CDC and FDA regarding appropriate prescribing for several years.
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I'm studying for the psych board right now and benzos are often the right answer and no it's not just directed to the ABPN certification, but for practice too. Physicians in Mi just started receiving these emails. Thanks all again for the thoughtful answers . I'm not going to reply, no disrespect but as stated I got the info needed.
 
erg923 said:
Yes, I'm sure it has/does. But this isnt IM or FP. The harm reduction model functions different here as standard of care (or least it should). Diabetes and cholesterol kills. Acute anxiety/panic attacks don't, right? Getting the patient to work the problem is your job in this field, and if it fails, it fails. No blame to you (it generally falls on them). Therapeutic script writing in conjunction with appropriate treatment is different than script writing that presents as treat on its own.

But, the (over) drugging of America shouldn't come down to 'well they don't want to do anything else???"So, What am I to do?"

Some psychiatrists really seem to think that their patients are as weak and incapable as they claim they are. We didn't get here by having 30% of the populous unable to function due to "anxiety" and/or depression. This is a societal problem that is aided/enabled by "psychiatric medicine."
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Actually one patient had a myocardial infarction during a panic attack, could have been fatal. There are neurochemical imbalances in the brain in people with major depressive disorder, panic disorder and generalized anxiety disorder which are helped by psychiatric medications.
 
futuredo32 said:
There are neurochemical imbalances in the brain in people with major depressive disorder, panic disorder and generalized anxiety disorder which are helped by psychiatric medications.
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Is that so...
 
futuredo32 said:
I apologize, a neuropsychologist has been posting. Just a lot of posts not related to my initial question, Michael Moore, Benzos are awful etc. and my question was about benzos with a patient on opiates and I was briefly glancing through the many posts. But as I said I have an answer I am comfortable with. So I'm good, and again sorry I made an error with your job title.
And I have no idea where Genessee county is.......
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I posted what I did because you said that a lot of your patients have tried or are trying therapy, and it didn't work so the benzo must be the answer. I'm saying that it may be that the patients aren't doing the right type of therapy (exposure) and, if they are, taking a benzo at the same time is probably going to make exposure therapy not work.

I get that you're a compassionate person and you want to help your patients. I'm encouraging you to think of long term versus short term here. Our most effective treatments for anxiety involve actually feeling your anxiety, tolerating it, and learning that it's okay. Benzos are pretty counter to this idea and, as erg mentioned, they reinforce avoidance of anxiety.
 
cara susanna said:
I posted what I did because you said that a lot of your patients have tried or are trying therapy, and it didn't work so the benzo must be the answer. I'm saying that it may be that the patients aren't doing the right type of therapy (exposure) and, if they are, taking a benzo at the same time is probably going to make exposure therapy not work.

I get that you're a compassionate person and you want to help your patients. I'm encouraging you to think of long term versus short term here. Our most effective treatments for anxiety involve actually feeling your anxiety, tolerating it, and learning that it's okay. Benzos are pretty counter to this idea and, as erg mentioned, they reinforce avoidance of anxiety.
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NOT all patients are willing to do exposure therapy or even CBT, many of them prefer psychodynamic therapy. And a lot have tried and failed CBT/exposure therapy. Personally I have major performance anxiety and was in CBT for 16 months DID the homework, and made zero progress, and this started with the MCAT, having taken countless tests, my performance anxiety wrt exams should be extinguished, it's not. I suggest therapy to ALL of my patients and most are in or have tried and failed.
 
You can be sure that Xanax causes chemical imbalance.

I guess to the extent that any drug causes the body to attempt to reach the homeostasis it was previously at, could you say it causes a chemical imbalance (e.g., excess glutamate production in benzodiazepine use or increased stress hormone production in the presence of beta blockers—basically the body trying to use the opposing lever to get back to where it was)?
 
ersonally I have major performance anxiety and was in CBT for 16 months DID the homework, and made zero progress, and this started with the MCAT, having taken countless tests
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Given that most people only take the MCAT 1-2x, CBT isn't exactly a great way to approach this problem. Of course it could work with some people, but CBT's strength is often times exposure based.

Kind of hard to get that type of exposure when one only takes it 1-2x.

And take into consideration that I don't know your specific situation. I'm just talking about someone that has a fear of the MCAT in general but not so much other academic things.
 
whopper said:
Given that most people only take the MCAT 1-2x, CBT isn't exactly a great way to approach this problem. Of course it could work with some people, but CBT's strength is often times exposure based.

Kind of hard to get that type of exposure when one only takes it 1-2x.

And take into consideration that I don't know your specific situation. I'm just talking about someone that has a fear of the MCAT in general but not so much other academic things.
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The performance anxiety for exams remains. And I have taken countless exams in med school. CBT works for some people just not me. It should have extinguished itself long ago. It's worse for the one time exams but it was there for all exams and still is.
 
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futuredo32 said:
UM read. Read.
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This is something you should do instead of perpetuating - and basing your practice on - an outdated and not well supported hypothesis. Our current understanding of mental illness is well past the simplistic model of chemical imbalance.
 
Amygdarya said:
This is something you should do instead of perpetuating - and basing your practice on - an outdated and not well supported hypothesis. Our current understanding of mental illness is well past the simplistic model of chemical imbalance.
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You are a med student? I and a lot of psychiatrists must be " bad" then. I don't find your posts helpful and I am opting to ignore you as your comment on another thread was cruel and incorrect. Post away on any of my comments but don't expect a response.
As stated a few times thanks to those of you who posted thoughtful responses. I'm all set.
 
futuredo32 said:
You are a med student? I and a lot of psychiatrists must be " bad" then. I don't find your posts helpful and I am opting to ignore you as your comment on another thread was cruel and incorrect. Post away on any of my comments but don't expect a response.
As stated a few times thanks to those of you who posted thoughtful responses. I'm all set.
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I can't speak to you personally, but a lot of psychiatrists ARE bad. Same with every field in medicine.
 
VA Hopeful Dr said:
I can't speak to you personally, but a lot of psychiatrists ARE bad. Same with every field in medicine.
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Amen, and yet, in an effort to mechanize a patient's understanding of the pathophysiology of mental illness, the whole "chemical imbalance" thing often does get patient's buy in about as deep as their understanding needs to be to see their need for treatment as not a failing.
"Look, your dopamine receptors in your prefrontal cortex are either hyper sensitized, or overly stimulated by an inappropriate amount of dopamine...." (eye roll). "Let me know when you have heard enough to just do what I say without question and I will stop."
 
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