Thursday, January 10, 2008

Dose Dependent

Sometimes I wonder how much free society doctors know about what their patients are doing. Without going into detail about specific patients, I can tell you I see guys coming in to prison on Valium, Xanax, Klonopin and other medications (or claiming to be on them) from their family doctor or their neurologist or their surgeon. They get the meds for chronic pain, back spasms, anxiety, PTSD, sleeplessness and now (the latest trend) restless leg syndrome. Occasionally the meds get prescribed for panic disorder, but I'm amazed that these folks also seem to be able to tolerate daily amounts of cocaine while suffering from panic disorder.

I don't doubt each of these doctors is acting in good faith, with reasonable care and consideration, in the best interest of the patient. I'm sure each doctor has their own particular 'red flags' to watch for which would trigger concern about addiction or abuse. I would be surprised if they all knew about each other.

Good doctors can be deceived and manipulated just like any other human being. Manipulation and deception go hand-in-hand with addiction. (Just look at the number of times people find Shrink Rap by googling 'how to manipulate my psychiatrist' and 'how to get a shrink to prescribe Xanax'!) Sometimes the doctor only finds out about the substance abuse problem after the arrest. I imagine the hard part then is not getting really pissed off at the patient when you find out you've been deceived. Sometimes when I hear free society docs talk about their cases I suspect substance abuse and suggest that perhaps the patient may not be telling the entire story. Those docs get offended. "You just say that because you work with criminals," they say, "My patient isn't a criminal." Well, a lot of addicts have problems without getting caught.

So what can I do about substance abuse in prison? The key element is education. When I have a patient lobbying for benzodiazepines (Xanax, Valium, Klonopin or something like that), I teach them about the effects of substance abuse on mood or other psychiatric disorders. I teach them about the physical effects of controlled substances, the potential for dependence and addiction, and the legal consequences of using illicit drugs. Finally, I encourage abstinence.

To which the patient usually replies: "I know all that, doc. Stop bullshitting me. The only thing that works is Xanax."

At least I try.


Anonymous said...

"Claiming to be on them" may be a key phrase here. And in Free Society, we have telephones (I know, I know, I just ranted at you about my phone bill, it was all to verify xanax doses).

FooFoo5 said...

I once did the admitting assessment on a guy who had been on Xanax since Phase I clinical trials. It was so effective in reducing his GAD & panic for 30 years, he was now living in his car.

Easily, 50% of my evaluations include the statement "I/M did not believe a referral for chemical dependency treatment would be helpful at this time. I/M was informed by this provider that this belief was "shortsighted," and that a specific recommendation for CD tx would be included for the Parole Out-Patient Clinic." The research from my own university is clear: any chemical dependency treatment is better than no treatment, and "involuntary" treatment outcomes equal "voluntary" treatment outcomes. Restless Legs my ass.

Brava, Clink.

The Shrink said...

Still, through addressing manifest clinical need, rather than what they want, prescribing can be curtailed, no?

ClinkShrink said...

Dinah: In free society even 20% of the homeless have cell phones (I read that in the Sun, it must be true).

Foo: My legs would be restless too if I was locked up in an 8 foot square cell 22 hours a day. Oh, and I have tickets for the La Scala broadcast of Tristan and Isolde this month.

Shrink: Exactly.

Anonymous said...

As someone who has severe anxiety attacks and panic attacks, and has tried deep breathing techniques, meditation, relaxation, visualization everythying I can think of to stop or manage the anxiety and panic.

For me only thing that really works is either Lorazepam or Diazepam. Maybe your patients are telling you the truth.

Anonymous said...

I just hope you aren't saying that RLS isn't actually a true disease.... For awhile I was treated with Klonopin taken nightly. Now I don't actually take anything for it at the moment, but I also have problems with hypersomnia and fatigue these days, and RLS doesn't keep me up at night like it used to. My mom takes neurontin for it, and my grandma takes requip for it. My mom, grandma, brother, and I all have it. Today I was getting an EKG and even that was getting artifact because of my periodic limb movement and inability to hold still. No matter how hard I try, the more still I try to be, the worse those nerve signals are that causes the limb to twitch.

In terms of benzos, however, I agree that they are generally overprescribed. My 85 year old grandmother has bottles of xanax and ativan labeled "for anxiety", but does not truly understand what they are or what they do. She was given ativan to take before an MRI a few days ago due to her RLS (they can't even read her films if she doesn't take something), and she decided she would just take 2 because she hadn't taken one before going, as she was supposed to. I was infuriated as she was then drugged up for like a couple of days. She frustrates me because she doesn't pay attention to her meds and doesn't realize what they can do. Her doctor frustrates me because he just throws pills at her, without following up, and never tells her to stop things - if she didn't just stop taking pills on her own, she would easily be on 90 different drugs about now. All in all, it is a maddening situation, and I believe the doctor is largely at fault for prescribing these things on what seems like a whim and then not following up on it. It's something we hope to put an end to if my grandparents move up here as they are planning.

Take care,

Anonymous said...

I'm tired of the benzo bashing. If you hate it so much than maybe you should lobby to get it off the market.

I too have tried deep breathing, a $200 StressErasor and relaxation CDs.

I HATE taking what I am taking. I have been developing tolerance and DON'T KNOW WHAT TO DO! Does doc have any recommendations, No. Suggestions, No.

I take 1mg clonazepam at night. It seems to help with anxiety the next day. I have, thank goodness, cut down on my use of alprazolam at .5mg at a time during the day, because my anxiety seems better. I was even able to shop at Christmas without Xanax!!!!! Yeah!!

I DON"T WANT TO TAKE SO MANY MEDS! I recently tried to cut down my lithium in half and I had so much more energy for a couple of days before I started sobbing all day so I had to go back to it.

Now I get up 2 to 4 times a night. I am exhausted by Wednesdays. Now I take Xanax at bedtime too and I'm only getting up once.

I have a challenge to you guys.

Come up with a list of *alternative* stress relievers and sleep helpers instead of bashing the benzos again.

I am not talking about the following which we ALL know about:

*going to bed at the same time and waking up at the same time every night/day

*creating a relaxing nightime routine

*take a bubble bath

*don't do anything too stimulating before bed such as exercise, television or reading Stephen King's IT

*only use your bed for sleep or sex


Anonymous said...

The problem is with your colleagues, NOT with the patients.

ClinkShrink said...

For those of you who are new to the blog, I work in a maximum security prison. Nearly 80% of my clinic patients have active substance abuse problems and were using at the time of arrest. I'm not just talking about benzodiazepines; they're also on opiates, cocaine, heroin, PCP, LSD, "mushrooms", Ecstacy, you name it. The pills may or may not have been prescribed by a doctor. Regardless, the first step in rehabilitation is abstinence. It's hard to convince someone to be abstinent when they feel entitled to a prescription. But until they're abstinent you can't really tell what prescription (if any) they actually need. Sometimes a period of observation in a correctional facility is the best way to sort that out. Sometimes I find that what they really need is an antidepressant rather than a benzodiazepine. I don't fault free society docs for this; active substance abuse problems are truly difficult to treat on an outpatient basis, particularly if someone is intent on hiding the problem or using the doctor to get meds.

Anonymous said...


I am not a doctor even though I play one on TV. All jokes aside, because you wanted suggestions on alternatve sleep helpers, I thought I would share my experience.

Currently, I am tapering off of Remeron, which I have been taking for sleep. Before I started, I anticipated having some rebound insomnia. Well, taking a 3/4 teaspoon of the powered form of magnesium has given me the best sleep I have had in years.

If you or anybody decide to go this route, start very slowly. And don't make the mistake of thinking more is better as one day, I tried taking a teaspoon. It was a big mistake.

I know people will say this is unproven. But when you think about it, it is no more unproven than alot of things that occur in mainstream medicine.

As far as the topic being discussed, I don't understand the concern about benzos being addictive since most psych meds will cause withdrawal symptoms when you try to taper off of them. Some of the antidepressants that have short half lives like Cymbalta sound like they are very hard to withdraw from.

In spite of tapering slowly off of Remeron, I still had withdrawal symptoms.

Good luck with your sleeping problems. I can sympathize as I went through a horrible stretch of insomnia two years ago. I wish I had known about the magesium then.


Anonymous said...

"I teach them about the physical effects of controlled substances, the potential for dependence and addiction, and the legal consequences of using illicit drugs. Finally, I encourage abstinence."
Sorry, but I found this highly comical.
Aren't your sessions with these people 5 to 10 mintues long?

ClinkShrink said...

Jacob: I don't have "sessions" because I'm not doing therapy. I'm doing medication management. And yes, even in a med management appointment you can insert useful information about health (I've taught inmates what a BMI is, I've calculated them, I've given information about the health consequences of obesity), about medication side effects (especially now that we're doing PEG treatment for hepatitis), and yes, about substance abuse. I don't limit myself to just the psych med stuff.

And no, I don't think there's anything "highly comical" about doing that. I think it's important information for my patients to have.

Roy said...

Lily, those are actually many of the ones I often suggest. I find that they often don't work... mostly because people often don't actually DO them. A pill is much more convenient.

Carrie, have no fear. I know I have seen many people with very clear RLS. I think there is an upsurge of folks with RLS due to the marketing of ?Requip for RLS (thus an increase in public awareness and some self-diagnosis).

the shrink, you're right.

Clink, a fair number of homeless folks who I see in the ER have cell phones... I'd say more like half. Keep in mind that the majority of people who are "homeless" are temporarily so, getting situated after a month or two. Not sure where they plug in the chargers, but when you really start looking for free electricity, it is not too hard to find.

As for benzo-bashing, i think in my original post on Xanax, I made it clear that it has appropriate uses (as do the other benzos). That post was focused on the negatives, however. I don't hate them nor do I think they should be taken off the market. Keep in mind that barb-bashing was all the rage in the 60s & 70s, and now barbiturates have mostly vanished. I expect that we will eventually have safer (if not more effective) alternatives to benzos, and then they will also wind up in the box on the top shelf with the Seconals and Miltowns.

Jacob, I get what you are saying... how can one do all that teaching in a very brief visit? However, I find that some of my most effective interventions have come from one or two well-worded and well-placed comments during a patient interaction. I have had pts come back to me some time down the road telling me "Remember when you told me ..." and how powerful that statement was (and, no, I usually don't remember).

a psychiatrist who learned from veterans said...

Privacy rights keep doctors from seeing what is prescribed in narcotics by others. I do electronic prescribing and was told the legal problem would be settled with the appropriate government department by now to allow seeng what my patients are on. I'll tell you whether I see that happen or the tooth fairy first (Well maybe I won't cover that last it being kind of ho-hum).

Anonymous said...

I've never had a pharmacy refuse to tell me what meds a patient is taking, though I have to say there is nothing there that keeps a patient from going to 8 different pharmacies and not telling me Oh, if you call Walgreens, they'll tell you about my oxycodone, but Rite Aid does my benzos and an independent chain does my psych meds.
But if someone new wants me to prescribe a benzo that they're already on (or someone I'm covering for), I like to be able to at least verify the prescription and get a little pharmacy history (yup, Klonopin twice a day, same dose for a long time, doesn't ask for refills too early.)

Sarebear said...

Clink has a rather different population.

I've actually been getting the best sleep I've had in a looooooong time, and there's been a gradual and definite increase in mental health benefits because of it, as I recovered from not resting well.

Actually, the Klonopin I was prescribed in December that I take is actually for my husband's health.

My sleep-punches had been going AWAY from him, but one morning, I woke up at the end of a punch and it was fast, hard, and smack dab in the middle of his pillow, right where his face would have been had he still been in bed.

So I joke that it is for his health too, lol!

Parasomnia, although that's not the only thing I did/do in that category. It also helps a HEAP with the vicious, vicious nightmares Effexor gives me. And lest one think hey, perhaps the Effexor causes the nightmare and thus the punching, yelling, screaming, kicking, other stuff, etc., no, I've been doing stuff in my sleep my whole life. Although the discovery in the last two years of the punching was a bit unnerving (perhaps more so for my husband? lol . . .) Hey, dear, I'm feeling a bit punchy this morning . . . .

Yethb, huddey, I dow (he says, holding a washcloth to his bloody nose and lip). Totally fictional, but coulda happened, glad it won't now. So it's a funny punny since I never "landed" one on him.

Anonymous said...

I love how doctors get all high and mighty on the benzo heads.
We didn't wake up one day addicted.
It was one or more of your colleagues with an MD after their name who started all of this for the vast majority of us so as someone else said, why don't you take it up with them at your conferences or in professional writings or wherever it is that you all gather to talk down about us and the problem your crew created?

And for Christ's sake, if you do nothing else, can you all get on the same page please? One primary will, another won't. One psych will, another won't.

Get this.
I was declared to have a problem with a benzo and the psych who originally wanted me locked up in rehab now has me back on them!
So you tell me what's going on.
And there was ZEROOOOOOOO deception on my part. In fact, when he mentioned this drug, I realized he didn't review the chart and suggested he do so before we go any further. He did and he STILL prescribed them.

What's wrong with you people?

lephee said...

I wish all posts looking negatively at benzodiazepine in general or a specific 1 had disclaimers. i came across this site searching for info on the generic manufacturer of my most recent prescription for Klonopin 2mg tablets & i like to do my research & be my own advocate. I take both Clonazepam & Alprazolam, prescribed from the same doctor, one of the most selfless dr.'s I've ever met. Anyway i say all that because i am very proud of him and very honored to be his patient and have his help.
I have been on Benzos ( i hate using this short slang term but for my joints sake i will ) since first being prescribed Valuim in 6th grade at a low dose of 2.5-5mg for my back pain that was giving me problems in school and had me actually getting in trouble with some teachers thinking i was fidgeting for fun?!?! Then it was taken over by my neurologist to serve both muscular & anxiety issues as i suffer from severe migraines and have always had anxiety which evolved into severe panic attacks and GAD w/agorophobia as of late. Anyway i have a huge issue with shame and self hatred for needing all the medications i need, and the more stigma a med carries the more i am ashamed, I'm tired of the looks from family,society,pharmacists. Anyway some blogs and articles forget to mention that there are people who actually do NEED the med of topic and that thats ok and that there are cases where long-term treatment is acceptable. I myself after a dosage adjustment following a breakdown post Katrina don't ever need medication adjustments or dosage raises and i rarely take the amount of medication that I'm allowed to take in a day, in fact I'm often criticized and encouraged to take more because i get myself in trouble trying to take so little that once i get out of control and wind up in the ER or needing rescue dosages. Anyway my biggest point/wish after stumbling upon the previous article about "why we don't like Xanax" was that people use the words "addiction" carefully, and that quoted "definition" of addiction was and is ludicrous. This caused me great pain and confusion in my life and appropriately differentiating dependance from addiction is crucial and does only good. For the longest time i hated myself because i thought i was an addict for needing certain meds. I lost what most consider their prime years to depression and self hatred thinking i was an addict because i had a physical dependance and tolerance. Addiction and addicts medicate in an attempt to get high or achieve some intoxication/altered mental state. Calling it addiction simply because of the medication being discussed is cruel and ridiculous, no one calls it addiction when referring to blood pressure, diabetes or any other such treatment that the body may build up a tolerance and a physical dependance on, yet when it comes to pain management or psychiatry, or more conveniently to medications used in treatments of said conditions that people also abuse, then dependance becomes addiction somehow, when its not an abused med, its dependance if even and usually even more politely phrased as simply requiring no abrupt discontinuation in the event of stopping treatment with the med. I have family that to this day have no relationship w/ me because of the ridiculous crapp they once read & now see some of the meds i take as being inherently evil & that anyone who takes them on a prolonged basis are by definition addicts. Help me spare future patients such pain by just speaking clearly and using facts-not throwing words around at least not without clarifying other words that could be mistaken for them. thanks for everyones time and to all the doctors thanks for helping us and to the Dr. with the inpatient population, i greatly respect what you do, no one is too low to be deprived of mental health treatment.

lePhee said...

the opposite goes for people who blame doctors or psychiatry for their addiction to benzos, again, addiction doesn't come without misuse, simple dependance occurring and being something unappealing to you requires nothing but you being honest and telling your doctor you aren't comfortable with the degree to which you've come to depend on the medication at which point why will gladly slowly lower your dose to prevent any withdrawal effects, your decision to continue on and go against actors instructions was your own, this also would be much clearer to all from addict to family members if the words addiction and dependance weren't so often misused and used in place of each other

lePhee said...

the opposite goes for people who blame doctors or psychiatry for their addiction to benzos, again, addiction doesn't come without misuse, simple dependance occurring and being something unappealing to you requires nothing but you being honest and telling your doctor you aren't comfortable with the degree to which you've come to depend on the medication at which point why will gladly slowly lower your dose to prevent any withdrawal effects, your decision to continue on and go against actors instructions was your own, this also would be much clearer to all from addict to family members if the words addiction and dependance weren't so often misused and used in place of each other