meow1985

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The way I was trained, prescribing benzos or adderall to patients who have an active substance use disorder or high-risk use should be a "never" event.

But I'm increasingly realizing the real world is much more nuanced.

What about substance use disorder that's in remission? How long is long enough?

It's also quite possible to have a substance use disorder concurrently with a condition where stimulants or benzos are indicated, such as panic attacks or ADHD, and treating the ADHD can actually make the substance abuse less severe.

If I catch someone with a positive UDS for illicit or unprescribed drugs, we have a candid conversation about it and they are required to get a series of negative tests in order to get back their prescription. But a positive UDS also doesn't say anything about frequency, amount or reason, and everybody lies, particularly about substance use. And I've never worked in a facility that tests for EtG on UDS's, where that's even an *option*, whereas alcohol use is what I'd *really* want to know about when I'm prescribing, let's say, benzos.

I'm curious, do others here have mental algorithms as to how to think about this?
 
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Honestly I always viewed as a very cautious use, but not "never" event. I have seen benzos being used in substance abuse disorder as a damage control strategy. There is also studies that shows that a lot of addiction is related to ADHD, so it depends completely on the patient. I had a friend who is a addiction therapy that would use it pretty constantly. I personally don't like benzos (who does anyway? hateful meds), although sometimes we gotta use them.

I would say trust your best judgment.
 
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milesed

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I see kids with adhd and they sometimes violate our controlled substances contract. Depending on what they did, I often give a second chance. If they have abused the stimulant, sold, gave away or traded it then they are off stimulants forever with me. Same thing if the parent/guardian does something illegal with kid's meds. Sadly they can just go elsewhere if they are smart about it and continue the same behaviors.

Adults are tricky. If any history of abuse/dep on a similar substance (Ex. no benzo for patients with history of alcohol issues), I avoid prescribing it. I get burned on this by adults 100x more than kids. I also only prescribe long-acting benzos- no xanax. Once in practice for a while, they know not to even try.
 
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Benzos/stimulants should not be administered to individuals prone to drug abuse. The drugs may have abuse potential, especially in patients with a history of drug and/or alcohol abuse
 

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Benzos/stimulants should not be administered to individuals prone to drug abuse. The drugs may have abuse potential, especially in patients with a history of drug and/or alcohol abuse

Yeah, that's what some people used to preach to us too. Then I had an outpatient attending as a PGY 3 who opened my eyes to the evidence. Stimulants can be used cautiously in those prone to drug abuse and may even improve their inclination to use. Benzos are also used (though I'd avoid Xanax) if indicated. The punishing way many of us were taught to approach those with addiction disorders should really be revised.
 
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Yeah, that's what some people used to preach to us too. Then I had an outpatient attending as a PGY 3 who opened my eyes to the evidence. Stimulants can be used cautiously in those prone to drug abuse and may even improve their inclination to use. Benzos are also used (though I'd avoid Xanax) if indicated. The punishing way many of us were taught to approach those with addiction disorders should really be revised.

What are the indications for benzos? I'm with you on stimulants, but I've never had a patient with a substance abuse problem (other than tobacco) who was using them "appropriately". Unless it's for akathisia and propranolol failed, I don't start benzos for longer term use on anyone.
 
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What are the indications for benzos? I'm with you on stimulants, but I've never had a patient with a substance abuse problem (other than tobacco) who was using them "appropriately". Unless it's for akathisia and propranolol failed, I don't start benzos for longer term use on anyone.

I'm not really talking about long-term use in anyone. But if someone has a hx of substance use, that doesn't necessarily disqualify them from short-term benzo use that I'd prescribe for others under certain circumstances. One patient that immediately comes to mind is when I was a PGY 4 and I had a patient with opiate use disorder, clean for 4 years. He traveled quite a bit for his job and suffered from panic attacks on planes. I used to prescribe anywhere from 3-5 Klonopin tablets per month to be used only for plane travel. He never asked for early refills and never misused it that I know of. I was pretty clear about the risks and the reasons I would stop prescribing. He also found a CBT therapist in the community as I instructed. He was a good patient and the his history by itself shouldn't make me treat him differently than I do others. I was more cautious of his use, but it was clear he benefited from it without abusing it.
 
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clausewitz2

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I have had multiple patients on methadone or suboxone and stimulants. I also started stimulants in somebody who was using cocaine daily because if they didn't they couldn't stay awake for more than 3 hours at a time and were clocking 14+ hours of sleep daily. Had started right around when they hit their mid 30s. They were also finding evidence that they were smoking and rearranging clothes in their drawers during the night and having no memory of doing this. I emphasized multiple times that I was going to start stimulants because it sounded an awful lot like narcolepsy but I was not going to prescribe them again if they did not pursue a sleep study in earnest.

Amazingly enough, by the next week they had a sleep study appointment in our system!

They don't use cocaine any more. They also don't like IR stimulants because they tend to fall asleep when they offset but do really like their 30 mg BID of Vyvanse. It lets them wake up at 3:30 AM to take their first dose and go back to sleep so they can get up for real at 5. Now they manage to get away with only 11-12 hours of sleep per day! They can hold a job!

'SUD dx = nothing controlled ever' is just not a good policy.
 
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Stagg737

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I'm not really talking about long-term use in anyone. But if someone has a hx of substance use, that doesn't necessarily disqualify them from short-term benzo use that I'd prescribe for others under certain circumstances. One patient that immediately comes to mind is when I was a PGY 4 and I had a patient with opiate use disorder, clean for 4 years. He traveled quite a bit for his job and suffered from panic attacks on planes. I used to prescribe anywhere from 3-5 Klonopin tablets per month to be used only for plane travel. He never asked for early refills and never misused it that I know of. I was pretty clear about the risks and the reasons I would stop prescribing. He also found a CBT therapist in the community as I instructed. He was a good patient and the his history by itself shouldn't make me treat him differently than I do others. I was more cautious of his use, but it was clear he benefited from it without abusing it.

Right, that's a very specific example in someone who had been clean from a non-benzo related addiction for years. I'm talking about more common situations that aren't "that one patient I had in PGY-4" where benzos would be "indicated". Btw, the situation you described is the only reason I can think of where I'd actually write an Rx for Xanax willingly.
 

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Right, that's a very specific example in someone who had been clean from a non-benzo related addiction for years. I'm talking about more common situations that aren't "that one patient I had in PGY-4" where benzos would be "indicated". Btw, the situation you described is the only reason I can think of where I'd actually write an Rx for Xanax willingly.

That was just one example. There are certainly others. The point was just to show that having a policy where you automatically say no to controlled substances for anyone with a history of substance use disorder is bad medicine.
 
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Stagg737

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That was just one example. There are certainly others. The point was just to show that having a policy where you automatically say no to controlled substances for anyone with a history of substance use disorder is bad medicine.

Right, and I’m with you on that sentiment. I’m just curious as to what people think the proper indications for prescribing benzos are (other than those very rare patients like the example you gave) in someone with a substance use disorder. Especially if that use disorder was benzos or alcohol or they have not been sober for a significant period of time (less than a few years).
 

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I agree that this is a nuanced issue to which there is no one-size-fits-all solution. The "right" response, I think, is to not prescribe controlled substances in someone that you know is actively and regularly using illicit substances. Further, the DEA can theoretically yank your registration if you knowingly prescribe controlled substances to someone who is "abusing" or "diverting" controlled substances (and all illicit drugs are considered such). Obviously the liability to you in any one individual case is probably pretty low. Nevertheless, it's a theoretical risk.

I tend to focus on two things: 1) limiting risk from pharmacodynamic interactions (e.g., avoiding BZD use in someone who is drinking heavily, avoiding stimulant use in someone who is using cocaine/methamphetamine regularly, etc.) and 2) not being sucked into treating symptoms with controlled substances that are likely or potentially related to substance use (e.g., treating anxiety symptoms in someone using cannabis heavily and daily with a BZD). This is less an issue for me in my day-to-day work since I work in the inpatient and ED settings, so I don't tend to have long-term patients for which this is an issue. That said, I very rarely prescribe controlled substances in someone who has an ongoing, active substance use disorder.
 
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There are studies that show there can be some benefit of stimulants to some ADHD patients with past SUD. But I'm going to guess number needed to treat is probably quite high, but the risk for harm/relapse is quite high too.

Personally, I don't like playing parole officer, and it wouldn't be bad medicine to refer patients with SUD to addiction trained docs if the patient really, really believes they need stimulants or BZDs. Maybe even refer to Suboxone docs; they have the piss in a cup routine handled.
 
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meow1985

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There are studies that show there can be some benefit of stimulants to some ADHD patients with past SUD. But I'm going to guess number needed to treat is probably quite high, but the risk for harm/relapse is quite high too.

Personally, I don't like playing parole officer, and it wouldn't be bad medicine to refer patients with SUD to addiction trained docs if the patient really, really believes they need stimulants or BZDs. Maybe even refer to Suboxone docs; they have the piss in a cup routine handled.
See, where I trained the substance use specialists' line was also "don't use benzos" except in emergency or inpatient settings. So I have not been exposed to any settings where patients with SUD were also on benzos or adderall, though I know it's theoretically possible based on studies I've seen with cocaine users and such.

What are the indications for benzos? I'm with you on stimulants, but I've never had a patient with a substance abuse problem (other than tobacco) who was using them "appropriately". Unless it's for akathisia and propranolol failed, I don't start benzos for longer term use on anyone.
Well, panic attacks for one. Bonafide, severe panic attacks are pretty terrible things to experience. I can see using clonazepam scheduled as a preventative measure. The APA guidelines say that benzos can be used in AUD if there's a co-occurring disorder where benzos are indicated. Of course, that would require establishing that the panic attacks exist independently from the alcohol use, and that's where things get murky because alcohol use is not going to make anxiety or panic attack tendencies any less. You also have to differentiate panic attack symptoms from withdrawal symptoms. That said, all of that is not impossible to do. You just have to be very thorough and precise with history taking and documentation.
 

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You'll definitely get hard line docs, even (I'd probably say especially) within addiction medicine who say no potentially abusable meds to anyone with problems with addiction. It's a large philosophical battle within the addiction community itself. They'll even extrapolate this out to stuff like gabapentin and get very conservative about this (although personally I find this pretty ridiculous...you can abuse anything if you take enough of it). That's also why you'll see so many people with OUD shamed for being on suboxone or methadone despite the extremely clear evidence of effectiveness and honestly low true abuse potential with suboxone. "Abuse" with suboxone is usually people buying it to stave off withdrawal until they can get their hands on more heroin/fentanyl...whichhhh you could argue if we had more suboxone access we would have less of this problem.

Anyway, I'd say there's also a difference between an active substance use disorder and a disorder being treated/in remission. I've inherited a few patients on suboxone and stimulants and they function very well on this. I also wouldn't be totally opposed to starting Vyvanse on someone who has a strong history of ADHD or presents very strongly as ADHD when the substance use disorder is under control. Stimulants are 1st line treatment and have the greatest effect size and can very literally change people's lives. You also have to remember that many people with substance use disorders are from low SES backgrounds/chaotic childhoods where they may not have received a proper evaluation or treatment trials for ADHD when they were under 18. I try to keep this in mind and try not to penalize people for just being poor when plenty of upper class high school kids have the opportunity to go to a private practice psychiatrist to get diagnosed with ADHD.

Benzos I don't love in general but there's already good examples above of when those might be considered.
 
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Stagg737

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Well, panic attacks for one. Bonafide, severe panic attacks are pretty terrible things to experience. I can see using clonazepam scheduled as a preventative measure. The APA guidelines say that benzos can be used in AUD if there's a co-occurring disorder where benzos are indicated. Of course, that would require establishing that the panic attacks exist independently from the alcohol use, and that's where things get murky because alcohol use is not going to make anxiety or panic attack tendencies any less. You also have to differentiate panic attack symptoms from withdrawal symptoms. That said, all of that is not impossible to do. You just have to be very thorough and precise with history taking and documentation.

I'm well aware of the general indications of benzos, I was just more curious about what people who prescribe benzos to those with an SUD on their chart feel the indications are and if they feel those indications change significantly if they see an SUD on the chart (especially benzos or alcohol UD). I'm actually surprised the APA would green-light the use of benzos in those with AUD though. Unless they have a very remote h/o it or are one of those people who never had a true chemical dependence and simply abused it, I wouldn't even consider continuing a patient with AUD on a benzo without first having a discussion on how we will be titrating off of it.

It's also interesting to me because from what I've seen the recommendation on uses for benzos in panic disorder are to use high potency benzos and not plan to have patients on them as a long-term treatment, which seems like a terrible idea for someone who has previously had significant problems with a substance.
 

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I educate patients on the possible risk of dementia with long-term benzo use as an entre to a slow taper. That grabs their attention.
 
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So benzos I am reluctant to prescribe, maybe a short run with a taper. Even if we consider panic disorder, panic attacks are relatively short in nature and benzos unless administered IV will take some time to work. So while it may have some benefit, likely it is limited.

That being said, in the case of ADHD, if we look at the neuroscience behind it, there are some theroies regarding dopamine response being low secondary to a low tonic (basal) level of dopamine and therefore phasic firing is decreased (pleasure response from doing rewarding activities like completing homework or cleaning their room). What a large study ~26,000 patients has found is that if you treat ADHD symptoms, their rate of substance use decreases 31%. Stimulant ADHD medication and risk for substance abuse

Here is how I approach stimulants, choose ones that are either not an amphetamines, i.e methlyphenidate or a prodrug such as lysdexamfetamine.
Reason: amphetamines in higher doses have a secondary action on VMAT transporters essentially amplifying the dopamine response which methylphendidate doesn't do. Vyvanse (lysdexamfetamine) has a lysine that is cleaved on red blood cells and is thus rate limited and cannot be snorted, injected, etc to increase peak concentrations.

Basically, we should treat ADHD sx to decrease substance use but do it in a safe way. Benzos, I'm not really convinced because they can be dangerous if combined with other depressants and they prevent forming good coping mechanisms.
 
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I’m still in residency but I really saw any benefit to using a benzo other than what essentially amounts to shutting someone up. Aside from alcohol withdrawal and catatonia what practical use does prescribing benzos have, other than giving you extremely needy, drug seeking people in your life?
 
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See, where I trained the substance use specialists' line was also "don't use benzos" except in emergency or inpatient settings. So I have not been exposed to any settings where patients with SUD were also on benzos or adderall, though I know it's theoretically possible based on studies I've seen with cocaine users and such.


Well, panic attacks for one. Bonafide, severe panic attacks are pretty terrible things to experience. I can see using clonazepam scheduled as a preventative measure. The APA guidelines say that benzos can be used in AUD if there's a co-occurring disorder where benzos are indicated. Of course, that would require establishing that the panic attacks exist independently from the alcohol use, and that's where things get murky because alcohol use is not going to make anxiety or panic attack tendencies any less. You also have to differentiate panic attack symptoms from withdrawal symptoms. That said, all of that is not impossible to do. You just have to be very thorough and precise with history taking and documentation.
You’re saying ingesting a benzo tablet that takes at least half hour to take any effect is useful in a panic attack?
 
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I’m still in residency but I really saw any benefit to using a benzo other than what essentially amounts to shutting someone up. Aside from alcohol withdrawal and catatonia what practical use does prescribing benzos have, other than giving you extremely needy, drug seeking people in your life?
People with known but rare anxiety triggers?

MRIs in people with claustrophobia. People anxious about flying who don't fly regularly. My dog being terrified of fireworks.
 
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People with known but rare anxiety triggers?

MRIs in people with claustrophobia. People anxious about flying who don't fly regularly. My dog being terrified of fireworks.
True. I’ve used on inpatient medicine quite a bit, but for psychiatry I don’t think many are prescribing for those indications. I’m 100% behind the dog getting them though.
 
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True. I’ve used on inpatient medicine quite a bit, but for psychiatry I don’t think many are prescribing for those indications. I’m 100% behind the dog getting them though.
Oh no question, and my part of medicine is even worse about it.
 
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Candidate2017

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People with known but rare anxiety triggers?

MRIs in people with claustrophobia. People anxious about flying who don't fly regularly. My dog being terrified of fireworks.

The MRI people can get 1-2 tablets from their ordering doctor or surgeon, or even radiologist. The rare flying people just need a few tablets a year. If they fly so rarely, they can utilize therapy. If they fly a lot for work, even more reason for therapy. When psychiatrists hand out BZDs for short term relief, it becomes somewhat normalized and reinforces a pill for every ill.

Dogs... beer works just as well and cheaper than the vet.
 
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VA Hopeful Dr

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The MRI people can get 1-2 tablets from their ordering doctor or surgeon, or even radiologist. The rare flying people just need a few tablets a year. If they fly so rarely, they can utilize therapy. If they fly a lot for work, even more reason for therapy. When psychiatrists hand out BZDs for short term relief, it becomes somewhat normalized and reinforces a pill for every ill.

Dogs... beer works just as well and cheaper than the vet.
Yes, I think everyone here is aware that therapy is preferable in most cases. But what do you do when patients can't/won't do it? Is it worth fighting over 20 lorazepam/year?
 

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Yes, I think everyone here is aware that therapy is preferable in most cases. But what do you do when patients can't/won't do it? Is it worth fighting over 20 lorazepam/year?

Not worth fighting over, but definitely worth a firm, constant, gentle push toward therapy if they have a fear of flying.

It is different for you as a PCP, but psychiatrists who prescribe BZDs have a greater responsibility as it somehow becomes a seal of approval coming from a psychiatrist. Psychiatrists have a duty to function as psychiatrists -- to utilize more than just medications and not be complicit in helping patients avoid improvement. If we are not doing that, the patient should see someone else who happens to have a DEA license.
 

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You’re saying ingesting a benzo tablet that takes at least half hour to take any effect is useful in a panic attack?

It's pretty well established that they're helpful in an acute panic attack. It's the overall long-term benefit that's controversial.
 
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Mass Effect

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Not worth fighting over, but definitely worth a firm, constant, gentle push toward therapy if they have a fear of flying.

It is different for you as a PCP, but psychiatrists who prescribe BZDs have a greater responsibility as it somehow becomes a seal of approval coming from a psychiatrist. Psychiatrists have a duty to function as psychiatrists -- to utilize more than just medications and not be complicit in helping patients avoid improvement. If we are not doing that, the patient should see someone else who happens to have a DEA license.

Of course therapy is preferred, but benzos are not all-evil-all-the-time. When I was an intern, I was convinced benzos weren't good for anyone and I wanted to be the person who tells all other non-psych prescribers they should never be prescribed to anyone for any reason. Then I worked in the real world. Like everything else in medicine, benzos have their place. I'm sure we wouldn't tell a chronic pain person we won't prescribe opiates, you need to use therapy to overcome the pain. We wouldn't not prescribe insulin to a diabetic who refuses to follow dietary recommendations. We wouldn't refuse statins for the guy still eating 10 cheeseburgers for breakfast. But somehow when the problem is emotional instead of physical, there's no place for a med that, despite risks, actually can help people when used properly.

Benzos should not be used daily/long-term and if someone is actively abusing substances (including alcohol), then certainly don't give them benzos. But I'm also not going to withhold benzos from my guy who flies for his job and is terrified of planes or my lady who takes an Ativan for chemo-related anxiety/nausea/vomiting (no-go to Zyprexa) or my lady with panic disorder who is prescribed only 15 Klonopin per calendar year because just knowing she has them if she needs them is enough.

Like all drugs, benzos come with risks and should be prescribed and used responsibly. But they definitely have their place and can be a savior for some.
 
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I’m still in residency but I really saw any benefit to using a benzo other than what essentially amounts to shutting someone up. Aside from alcohol withdrawal and catatonia what practical use does prescribing benzos have, other than giving you extremely needy, drug seeking people in your life?
giphy.gif
 
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It's pretty well established that they're helpful in an acute panic attack. It's the overall long-term benefit that's controversial.

How much of that help is the actual benzo vs. the panic attack running it's course though? Realistically, if we want the benzo to actually have an effect before the attack is subsiding then Xanax isn't even fast enough work most of the time, you'd have to go with Niravam. If anything, I feel like the benzos are just helping them get back to a lower level of anxiety after the attack is over, and I feel like there are more benign options to achieve this.
 
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It's pretty well established that they're helpful in an acute panic attack. It's the overall long-term benefit that's controversial.
Yea I think it has strong efficacy as a placebo in people with benzo use disorder.
 
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clausewitz2

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Yea I think it has strong efficacy as a placebo in people with benzo use disorder.

Placebo-controlled studies have been the standard for research since the 80s, so I think you'll find the evidence shows an effect above and beyond placebo ipso facto.

Whether it is harnessing more general non-specific effects is a different question, but that applies to easily 90% of the situations in which we prescribe medicatons
 
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NontradCA

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Placebo-controlled studies have been the standard for research since the 80s, so I think you'll find the evidence shows an effect above and beyond placebo ipso facto.

Whether it is harnessing more general non-specific effects is a different question, but that applies to easily 90% of the situations in which we prescribe medicatons
And how many of those studies looks at full remission and successful taper of BZD?
 

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And how many of those studies looks at full remission and successful taper of BZD?

There's a reason I don't use them for this purpose like, ever. But 'not great long term' is a far cry from 'placebo only right now during a panic attack'
 
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NontradCA

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There's a reason I don't use them for this purpose like, ever. But 'not great long term' is a far cry from 'placebo only right now during a panic attack'
Yea see my original post...we’re in agreement. If you can’t get a joke I dunno.
 

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To get back to the original post, what are the goals of treatment? Like let’s say I have someone who did meth, has ADHD Dx as a kid.

What is this person trying to achieve by being on a stimulant? Treating addiction? Yea, no.

They have trouble concentrating watching TV? Talking with their meth friends? You really need a stimulant to do these things? That’s how I’d approach it.

But I’m a mean ol’ doctor who’s just in big pharmas pocket and I never give the patients what they really need.
 

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