Thursday, September 15, 2011

No More Xanax

I'm posting this because Roy fell asleep at the wheel and missed the Xanax article on the front page of yesterday's  New York Times.  In "Abuse of Xanax Leads a Clinic to Halt Supply,"  Abby Goodnough writes about a clinic where they've stopped prescribing Xanax because to many people are abusing it.  Goodnough writes:

“It is such a drain on resources,” said Ms. Mink, whose employer, Seven Counties Services, serves some 30,000 patients in Louisville and the surrounding region. “You’re funneling a great deal of your energy into pacifying, educating, bumping heads with people over Xanax.”
Because of the clamor for the drug, and concern over the striking number of overdoses involving Xanax here and across the country, Seven Counties took an unusual step — its doctors stopped writing new prescriptions for Xanax and its generic version, alprazolam, in April and plan to wean patients off it completely by year’s end.

If you want to know how the Shrink Rappers feel about Xanax, do read Roy's post on Why Docs Don't like Xanax (Some of Us).  It's been our all-time most popular post.  

So I was a little (not a lot) surprised that this was "news."  I've worked in four public clinics-- I've never seen a prescription written for Xanax, and for the most part, the clinics where I've worked have had a sort of non-stated ban on prescribing controlled substances.  It's not that benzodiepines and stimulants are never helpful, but in the clinics, the issues concerning abuse, and the drain on the system gets to be very hard, plus we worry that the harm these medicines can do will be worse than the problems they 'cure.'   It's very rare that I've written for controlled substances, and I've never written for Xanax in a clinic, or seen a chart from another patient where Xanax was prescribed. I'd be shocked by the article, but during the two weeks I was in Louisiana after Katrina, I did see many patients who had been on high doses of long-standing Xanax that were prescribed by docs at community clinics, so I know it's done.  But you know, ClinkShrink doesn't like benzos at all, ever (per The Benzo Wars, if you'd like to hear us shriek at each other), and the rest of us Shrink Rappers don't like Xanax in particular.

Time to wake up, Roy.


SteveBMD said...

Roy's been hitting the Xanax again, apparently.

Carrie said...

About 90% of our moms in the methadone program are also on benzos - or taking benzos they get on the street or from other friends. Neonatal withdrawal from benzos is fast and horrible. If you see the kid jittering off the mattress, you can probably thank Klonopin, Xanax, or Ativan - those seem to be the big 3. In my mind, the benzos sort of defeat the purpose of being in the methadone program, since the combination of methadone and benzos can produce a high similar to that of heroin. They're pretty good at the "show me the bottle" way of picking up benzo abuse. A UDS+ for benzos does not necessarily mean they were prescribed - or even if they were prescribed, that they are taking them correctly or not getting them elsewhere on top of what they are already taking. That last bit is the hardest to pick up - but many of the moms will tell you about it.

All that being said, I think there is definitely a role for benzos - but it's got to be carefully monitored. Xanax is not one I'm very fond of, but my grandmother and my parents were prescribed that at different times - none of them ever took it - but physicians were all too willing to give it...

Panic attacks, sleep disorders, etc seem like a fair place to use benzos (outside of xanax) when other things fail or as a backup in an acute situation once in awhile versus regularly scheduled. I don't do adults, so I can't really speak to it except for the effects on babies. ;)

Oh and P.S. to shrinks everywhere - please don't ever tell a pregnant woman on benzos that the dose is so small the baby won't withdraw. That's really not fair to anyone - the mom when the baby does withdraw or the staff when the mom flips out because the psychiatrist promised the baby wouldn't withdraw.

Anonymous said...

I almost never prescribe xanax immediate release. I do use xanax extended release. This is only if we are into "cocktail time" with medications": the patient has been working with me for some time and has had some success with symptoms of depression, for example, but still has a severe anxiety symptoms that have not responded to an atypical or to topiramate 200mg Bid. The caveat: I am in private practice, I keep 10 drug urine screens in my office which I have patients agree in writing to cash pay for and be tested with or they can find another provider and I would never prescribe xanax xr to a patient on an opiate or with a history of sedative, barbituate or opiate addiction.
It is amazing what Carrie is saying abut the methadone programs and benzo use.
Here in Seattle, where a lot of agencies make a lot of Medicaid money from methadone "treatment" or distribution as I prefer to call it, the agencies are required to do state mandated urine screens and if a patient turns up positive for benzos or opiates the patient may get one violation warning warning , but on strike 2 is put on a taper and eject them from the methadone program system. How any of that is substance abuse treatment, don't ask me.
Also, sadly, jittering infants on the mattress can be caused by effexor XR among other things.
(I confess I made the same bizarre relational inference to the introduction that SteveBMD did: that Roy fell asleep driving because he was using Xanax! How weird! But I would never have posted that odd fleeting thought if Steve had not gone first! I would like to thank him and also my training analyst for helping me free associate with such ease!)

rob lindeman said...

Ditto on the "asleep at the wheel" misunderstanding.

wv = stelshes (Yiddish) the subjective feeling of having worried for so long that something bad would happen that one gets bored and stops worrying (see "shpilkes")

Anonymous said...

I used to be prescribed xanax and loved it so much I told my doctor to permanently never prescribe me any benzos. So for 4 years I have been off them and somehow I have managed to work through my panic attacks with the help of Cymbalta and Abilify. In my mind Benzos shouldn't be manufactured. But then again I have an addictive personality.

Roy said...

(Somehow, Dinah has time to actually read the New York Times daily and know when they write a psych piece. If she stopped giving me that Xanax, maybe I'd be awake to read, too.)

But seriously, a new free medical clinic opened up in our county this year. Posted in the waiting room is a notice that they will not prescribe controlled substance, including Xanax and Percocets.

@sidewaysshrink: Xanax XR (extended release) does reduce the rewarding rush patients get on taking the pill, but the risks of dangerous withdrawal from it are no different regular Xanax. The time-release part is about getting into the body, not out of it.

Carrie said...

Sideways Shrink,

I know about jittering from other meds, but the biggest two culprits in UDS+ and h/o use are methadone and benzos, so I've seen a lot of the tremoring from the benzos. There have been times when the mom was only on antidepressants where the babies have shown significant symptoms similar to withdrawal from opiates or benzos, but there's no treatment for that!

I honestly don't know how our system works here regarding the methadone programs. Because we've seen moms have +UDS for all sorts of things (cocaine, MJ, PCP, methadone+opiates, etc), but as long as they show a clean one (methadone only or methadone/benzos only if that's what they were prescribed), then DHS usually clears them to take their baby home.

Anonymous said...

Q for Sideways:

An extended release Xanax 'scrip is secondary to using an atypical for... anxiety? Really? There is just something sick and wrong there.

"Here, risk diabetes and play with your brain. We don't want to run the risk that you might enjoy the happy side effects of a benzo."

We are one sick-ass society.

Anonymous said...

From the Times Article:

"While the patients at Seven Counties are mostly poor, experts say the appeal of Xanax cuts across socioeconomic lines."

Uh-Huh. Are any rich patients getting cut off cold turkey and getting told to suck it up?

Yup. Best healthcare system in the world.

Alexis said...

I have never liked Xanax. I do have Ativan PRN for breakthrough anxiety and have for years. Interestingly, I have never had trouble getting it from a PCP, which I've heard nightmare stories about. I take 0.5mg, very sparingly (less than I could really use the help, but I don't want to develop a dependence or tolerance), which probably increases my internist's willingness to prescribe.

I am somewhat uneasy about a blanket ban on Xanax, as tricky as it is. There will be some innocent patients who get hard done by such a policy.

Sarebear said...

I was prescribed xanax initially by my first psychiatrist, and I was leery of it, but when used occasionally (at most, 2-3 times a week, often a 1/4 pill, sometimes a 1/2 pill) but more often average 1.5 times a week, it actually interrupted the anxiety cycle and even after it wore off I was noticeably less anxious. But I was so worried about the addictive potential I only took it this way for about a month, and then it became about 1-2 a month, then one a month, then one every few months . . . .spaced that far it didn't do what the doc said it would, which was help interrupt the anxiety cycle, if used as needed, carefully but not super afraid of it.

Of course, thank heavens for it when I had my two MRI's because I forgot to get the heavy tranquilizers (one pill for each MRI) before hand and I used a whole Xanax before each to help, and barely barely held it together; AND my head was at the open end. I can't ever go in those I think the other way, I'd die!

Anyway, there's been some difficult situations where it's been helpful; my 2nd psychiatrist continued the prescription my first one had started, but I only needed a refill once a year at the rate I was using it, if that.

My third will not, and responded with me needing behavior modification, which I get, but I've been in therapy for 6+ years and there's so many things to work on . . . my anxiety and panic are still a big problem, and some bad thinsg have happened because I've been too paralyzed with fear to deal with them.

Re: SS's mention of topirimate in association I'm assuming with treating anxiety? I was on that for 3+ years, and now that I think about it, my anxiety has been noticeably increased since being off of that. I'd kinda wondered from time to time why, in the last 8 months to a year, my anxiety hsa been higher; part of it was when I was on Risperdal it increased my anxieties, but even without that they are still more than I've been used to these last couple years.

The best I've ever been anxiety wise was taking some clonazepam at night, and a quarter pill in the morning so I wouldn't get too sleepy but so it'd as the doc said keep an almost constant some of it in my bloodstream. And since I'm on ADD med anyway that counters any sleepiness. Again this was the recommendation of my first psychiatrist.

It seems like some of the most effective stuff was prescribed by him, despitee our problems.

Anonymous said...

Never taken xanax but I experienced Valium the other day and I wasn't the least bit impressed. I'm a complete child when it comes to going to the dentist. I break out into a sweat, get tachycardic, and generally act a fool, and that's just during a routine cleaning. So, when it came time for real work to be done the dentist asked if I needed to take something first. I said yes, please, I'll take double. They asked if I wanted to Valium or Xanax. I didn't know the difference so I said whatever you recommend.

They gave me 10 mg of valium and I couldn't tell a bit of difference in my anxiety level. The dentist asked if I was mellow, and I said nope. I guess my anxiety is > anti-anxiety meds. Later I read about the differences in the half life between the two meds, so I guess I might have done better with Xanax.

I hate going to the dentist. It ranks right up there with torture.

Anonymous said...

I have been very upset about this story but unfortunately, couldn't articulate my thoughts very well. Finally, I found this blog entry on the Beyond Meds blog which beautifully expresses my feelings.

The blog owner as an FYI has given permission for the whole blog entry to be copied. So the post isn't horribly long (ok, it obviously isn't short), I will copy certain parts of it.

At Seven Counties, some of the roughly 3,000 patients who were on Xanax have been switched to clonazepam, a longer-acting benzodiazepine that does not kick in as quickly and is thought to pose less risk of addiction.

“They don’t get the high that’s associated with Xanax,” Dr. Hedges said, “nor the withdrawal associated with it.” (read the article)

Unfortunately that last bolded section is complete and utter bullshit. The withdrawal from clonazepam is potentially just as ugly, debilitating and serious as it is for Xanax.

You know what is going to happen to this mostly poor and uneducated population when they start weaning people too quickly? Because they’re poor, they’re going to be labeled DRUG SEEKING. They’re going to be blamed for their DOCTOR CREATED AND PRESCRIBED addiction. And they’re going to be disbelieved when they present so sick they can hardly stand or do anything at all. They will be told they are crazy drug addicts. It will be thought that it’s a psychiatric issue and not a serious physical illness caused by medical iatrogenesis. And in fact, there will be great resistance to see the truth because the people treating them in withdrawal will be at fault for their condition.

The withdrawal syndrome creates so many odd and terrible symptoms that for some of us last YEARS. It is much worse than opiate withdrawal from all accounts. Without great sensitivity from caretakers to the extreme nature of these symptoms some of these people will be lost to the system forever. It’s really horrifying to me. I know what social service mental health care is like. I worked in these systems the entire time I was a social worker.

In Overcoming Prescription Drug Addiction: A Guide to Coping and Understanding Rod Colvin quotes Ronald Gershman MD who says:

"I have treated ten thousand patients for alcohol and drug problems and have detoxed approximately 1,500 patients for benzodiazepines – the detox for the benzodiazepines is one of the hardest detoxes we do. It can take an extremely long time, about half the length of time they have been addicted – the ongoing relentless withdrawals can be so incapacitating it can cause total destruction to one’s life – marriages break up, businesses are lost, bankruptcy, hospitalization, and of course suicide is probably the most single serious side effect."


Anonymous said...

Why would physicians put patients on Xanax long term knowing it's addictive? I'm sure some patients are doctor shopping to get their drugs, but when I was in the hospital there were patients detoxing from benzos that other psychiatrists prescibed. I felt for those patients, they were miserable.

When patients are being detoxed off of benzos like Xanax does it help to move the patient to a different benzo with a longer half life or an extended release version to ease the withdrawal or does that make any difference?

wv = acking. The sound a cat makes before depositing a wet lump of semi-digested fur on your carpet.

Anonymous said...

To the last anonymous,

On the Benzo withdrawal boards, they constantly recommend that people ask their doctors to be switched over to Valium from the benzo they are currently on. The reasoning is it has the longest half life and is easier to taper.

By the way, when many people have asked their doctors to be allowed to switch to Valium, they have encountered complete resistance. They were deemed as drug seeking addicts which is the same theme I am hearing regarding Xanax users even though it is my understanding that the drugs have different chemical properties.

It all seems to depend on the doctor's biases. Before anybody flames me, I am not claiming that all doctors are like this. I realize many do care about doing what is best for the patients.

Back to the point you raised - The competing theory is that you should taper off of the drug you are on as many people have had a horrendous time cross tapering over to another med.

In my opinion, all the options need to be presented to the patient and then he/she should be completely supported regarding the method for tapering that they want to chose.

Whether that actually happens is another issue.


Anonymous said...

He most likely fell asleep driving because he was abusing the drug. I am so tired of everyone saying we should stop prescribing every drug that can be abused as if there is, no medical benefit to any of these drugs. The addicts who die from a legal drug by abusing it will continue to hurt themselves even if we stop all controlled subtances. They are addicts and will buy illegal drugs on the street. I know this because one of my children is an addict.

Anonymous said...

wait till you try to stop cymbalta and get horrible shakes ( worse thing i ever came off of). Or wait till you get tardive dyscanisia ( look it up ) from the abilify. You will sido you were taking xanax responsibly