Please Pass the Valium

In today's New York Times, I learned that Roche, the makers of Valium, will soon be closing the doors of their New Jersey plant.  In Valium's Contribution to our New Normal, Robin Marantz Henig writes:

Taking a pill to feel normal, even a pill sanctioned by the medical profession, led to a strange situation: it made people wonder what “normal” really was. What does it mean when people feel more like themselves with the drug than without it? Does the notion of “feeling like themselves” lose its meaning if they need a drug to get them there? 

Ah, we like to question What is Normal here at Shrink Rap.  Okay, time to pop my Xanax.

Shopping Spree

CNN recently had a story entitled How physicians try to prevent 'doctor shopping', about states' efforts to control and prevent prescription drug abuse. While it's a good story, it's unfortunate that we only tend to talk about this issue after the overdose death of a celebrity. Here at Shrink Rap we've talked before about our concerns and challenges related to this issue in a series of blog posts and one podcast which we've collectively referred to as "the Benzo Wars".

The Shrink Rappers have seen both sides of the prescription drug abuse issue and so we have different opinions about it. Neither opinion is all right or all wrong, we just differ on the degree of the problem and to some degree how it should be handled. Our opinions are shaped by the patients we treat: Dinah has a private practice and (I'm guessing here) probably doesn't have many patients with active addictions or legal problems related to this. I work in prison, and nearly 80% of my patients are locked up for crimes related to substance abuse.

First, the things we agree about (and that the CNN story also addresses): we agree that doctors can't be detectives and that we aren't lie detectors. We have no special ability to figure out who is or isn't lying to us about their pain and anxiety or exaggerating problems to obtain medication. We agree that most doctors have certain 'red flags' that raise a concern about abuse. We agree (although Dinah thinks I don't believe this) that patients with real pain and panic disorder deserve care that is delivered in an empathic, sensitive fashion and that questioning or doubting these patients can cause serious problems with the doctor-patient relationship.

That was the easy part.

What the CNN article doesn't address is this: what do you do when you find out that your patient is, in fact, receiving multiple controlled substances from more than one doctor? The CNN article implies that whenever this happens it means the patient must be "doctor-shopping" and that there's a problem.

This situation is going to be more of a challenge for Dinah than it is for me, because in correctional facilities controlled substances are rarely prescribed. When they are ordered, they are dispensed in a tightly supervised manner and generally for a limited time. If an inmate is caught with pills in his cell---whether or not they were prescribed for him---you know the medication is not being used as prescribed. Easy enough.

But what about free society? What if the patient tells you, "I have chronic pain and I get medication from Dr. So-and-So." Truthfulness is a good indicator that the patient probably isn't out to snooker you. True drug addicts rarely give you an avenue to check up on them easily. Nevertheless, physiologic dependence can happen even in the absence of abuse. If the patient is coming to see you for anxiety, I probably still wouldn't choose a benzodiazepine as a first-choice medication because I wouldn't want to cause yet one more dependency issue. There are non-habit-forming alternatives and SSRI's have been shown to have anxiolytic effects.

But what if the patient comes to you already on a benzodiazepine? This is where the benzo war started on the podcast, and where Dinah and I may differ. In this case I think you have to consider what the goal of treatment is going to be and physicians are going to differ with regard to their comfort levels in this situation. Presumably the patient has been referred to you because the previous prescriber either was unable or unwilling to continue the prescription. Unless the prescriber was dead or retiring, to me this could indicate a clinician's concern about the patient's pattern of use and I'd be reluctant to merely continue the status quo. A reasonable treatment goal would be to build coping skills to the extent that either the patient would no longer need medication, or could function with a non-controlled alternative. As strange as it may sound coming from a psychiatrist who mainly does medication-management, I do believe that psychotherapy can help with this.

What if you find out that the patient actually is selling, trading or giving away your controlled substances?

Most free society docs don't find out about this until the patient gets arrested. But say the patient is released on bail---do you accept them back in treatment? Do you continue to prescribe for them? Or what if the other doctor is prescribing unusual combinations of meds, or meds in doses that would raise the eyebrows of even the most liberal psychiatrist? Do you assume the doctor is over-prescribing or do you assume the patient must really 'need' the medication?

It's a complicated situation, made more complicated by the fact that even non-controlled psychiatric medications have street value. And don't even get me started on legalized marijuana.

I'm not trying to start Benzo War Part II, but it's an issue that doctors struggle with. I await your thoughts.

Things We Argue About

Sometimes, especially on the podcasts, we get heated and go at it. Oh, sometimes on the blog, too. Among ourselves, we refer to these discussions as "The Benzo Wars" --the posts where we've argued about what role benzodiazepines and addictive medications have in psychiatry, and "Who Deserves Care" cause Clink thinks her patients need help more than mine (..if you see me walking around with bruises, you'll know it's me......)

So what else do Shrinks argue about? We've got a colorful history here. Took us decades to decided if homosexuality was a disorder (yes, maybe, no). Is psychosurgery with knitting needles good? Should our patients get special accommodations? What if I'm allergic to your support dog?

Ah, we're writing a chapter and I like the input you all give!

And please listen to our podcast. We're back...probably monthly for now, but weekly once we finish the book and they teach me how to edit them.

For The Sake Of Argument

[Subtitle: Clink Takes The Bait]

But first, Good News for those following the HBO In Treatment Sub-Blog: Post on Sophie below this: Click Here.

If I were a trout I'd be three feet out of the water by now. Dinah's post "When A Shrink Picks A Benzodiazepine" is like a bright colorful feathered fly with a tantalizing spin. I tried resisting, but I just had to leap for it.

In my clinic today two patients had benzodiazepine issues. Patient One had been taking his mother's Xanax. Patient Two had his parole violated for a dirty urine. He said he had been getting his psychiatric care through a local program, but that they had only prescribed Xanax "to help me with my marijuana problem". I asked him what they were giving him for his bipolar disorder, and he said, "Oh nothing. Between the marijuana and the Xanax I was alright." Right.

I'd like to think the outpatient doctors for both Patient One and Patient Two were both as careful as Dinah. Hopefully they both took good substance abuse histories and knew their patients well. I'm sure they were well-intentioned. Right. The problem with the approach Dinah suggests is that people with active addictions aren't going to tell you about them. They're going to conceal their substance abuse histories and lie about the pharmacies they go to. Taking a history isn't going to help too much.

So for the sake of argument (and we do like to argue here at Shrink Rap!) let's say Patient One's mother has, as Dinah suggests, a fear of flying that necessitates occasional benzodiazepine use. So nervous flying mom also has a pot-smoking son who also drinks a bit (but is smart enough to hide the empties), a son who also snorts his Ritalin. Patient One's doctor takes a history and learns nervous flying mom has never abused alcohol or been dependent on drugs. He doesn't find out about snorting, pot-smoking son because nervous flying mom is clueless. He writes a prescription for a benzodiazepine and now pot-smoking son mentally blesses him whenever he opens his mom's medicine cabinet. And I have a new parole-violating patient. And mom's doctor never has a clue this is going on.

So when I hear about free society docs who never have a problem with patients on benzodiazepines, I can't help but wonder if the problems are truly that rare or if they just never find out about them. The patients disappear when the med gets tapered (or they get arrested) and the doc never hears the end of the story.

And I wonder why, when working in a public clinic, it is "very rare" that Dinah will start benzodiazepines in that setting. I suspect it's because with those patient the substance abuse issues are a little harder to conceal, especially when they come to her freshly released from jail. Thus, addicts from low socioeconomic classes are pretty much stuck buying their stuff off the street.

So I agree with Dinah that prescribing involves a risk-benefit assessment. I just don't get the part where the risk of temporary nervousness while flying outweighs the risk of diversion, misuse, abuse and dependence. I'm still working on that part.

(Dinah and I could keep this up until people beg for more In Treatment posts. I'll try to contain myself.)

When A Shrink Picks A Benzodiazepine

I'm still talking about our not-so-favorite shrink medications, those calming, addictive benzodiazepines: valium, librium, ativan, klonopin, and everyone's favorite: Xanax.

If you listened to our podcast The Benzo Wars, you know this is a heated topic among the three Shrink Rappers, and then ClinkShrink had to go post again in Sober Thoughts. Okay, it finally happened, I finally agreed with something Clink said about benzos. She writes:

Doctors aren't soothsayers or mind readers, and taking a good history or talking to relatives won't always turn up the problem prior to writing a prescription. We want to care for people and relieve distress and a prescription is one way to do that. Unfortunately, it is also possible to create a new addiction in a person who never had one before and we have no way of knowing ahead of time which patient this will happen to.

ClinkShrink is right here: some patients take a medicine and it gathers a life of it's own, an addiction forms. And there's not a way of knowing if that post-operative Percocet will start an addiction or make the patient vomit or simply relieve the pain. Clink has made the point that it's never worth the risk in the case of benzodiazepines: take them and your life could dissolve and you could end up being her inmate.

While she's right about the unknown risk, I'll make the point that life is full of uncertainties. With her thinking, one should never try a drink-- it could (oh, and it often does) lead to alcoholism. I don't know when I prescribe any medication who will get diabetes from it, who will have a bad side effect, whose kidneys and thyroid will be compromised, who will become suicidal from that SSRI, or who will have a horrible time with withdrawal symptoms when they decide to stop it. I don't know who will become addicted, I do my best to take a guess.

I do prescribe benzodiazepines for short-term use for acute anxiety. I don't see a problem with giving someone a tablet of Ativan for an MRI or a few to deal with post-9/11 flying anxiety. And if someone is having panic attacks, they are a good temporary measure until a prophylactic agent kicks in. I've seen plenty of patients on benzodiazepines (yes, even Xanax) where I tell them to stop the medicine, and they do so without arguing, bargaining, complaining, or insisting it's the only thing that helps. I only prescribe them in my private practice where I follow the patients very closely and know them well. In the clinics where I've worked, very few doctors have used these medications, and it is very rare that I'll start them in that setting.

So what helps me feel a little more comfortable prescribing a benzodiazepine?

1) If a patient has been on them in the past and stopped them without difficulty. I don't hesitate to check with old docs and pharmacies.
2) If the patient has never had a problem with alcohol-- benzodiazepines bind to the same receptors and there is cross-tolerance.
3) If there is no personal history of substance abuse or addiction
4) If there is no family history of substance abuse or addiction
5) If the patient understands that it's a short-term solution, not a permanent thing.
6) And yes, I've had patients come to me already on these medications where I just can't get them to taper off and I can't really pinpoint how exactly the medication is hurting them. I will continue such a patient on a low dose. It's been just a handful of people over the years, most people don't seem to need or want chronic benzodiazepines.

Funny, but ClinkShink writes:

I say: "Respect your gut." If you think it may be a problem for you, it could be. If your loved ones or doctor is encouraging you to take more and you're not comfortable with that, say so. Repeatedly if necessary.

My experience-- and I have no data to support this, it's just my "gut"-- is that when I tell patients that the medication can be addictive, the people who express concern are the ones I worry least about-- you're supposed to worry about getting addicted, you're supposed to watch out for a craving for the drug. It's the people who immediately say, "Oh, I won't get addicted," that I worry about the most.

Life is full of risks-- I'll give you a list if you'd like, but they'll include the heart attack you can have when you get on the treadmill and the concussion you can get when you fly off your bicycle.

At this point, I feel a little anxious when I write a new prescription for almost any medication.

Sober Thoughts

[I'd like to thank Clinking By Proxy for helping me post while my Comcast was down. I owe you chocolate. And yes, Dinah, I'll babysit Max. He's adorable.]

I used to think that I wouldn't write about substance abuse because I wasn't an "official" substance abuse expert, at least not on paper. I didn't do an addictions fellowship and addiction per se was not usually the primary focus of treatment in my outpatient clinic. Then came my Dose Dependent post and the Benzo Wars podcast and all the subsequent comments, positive and negative, about the issue. I discovered I had a lot to say, mainly as a result of several years of direct practical experience.

Many doctors, as a rule, do not like patients with substance abuse problems. They fill up the emergency room, they suck down psychiatric resources, they fill up the psychiatric inpatient beds looking for detox or housing, they fill up the inpatient medical wards with conditions resulting from their lifestyles. They take a lot of time and work and they're not always nice people to deal with.

Those are the folks with the severe addictions, the ones that result in arrest and incarceration or homelessness and poverty. There are lots of other addicts out there whom I never see, the middle-class non-criminal addicts whose addiction touches the lives of their families and loved ones but never quite sinks to the level of the streets. These addictions are no less serious. I think I get vocal about these folks (and about things like prescription controlled substances) because I can see where things are headed. I know how bad they can get and the human wreckage that will be left along the way. I can tell you story after story about people who have never done a thing wrong in their lives until that on-the-job accident and the first opiate prescription, or that first hit of cocaine (or the first benzo prescription) and the next thing you know the wife is gone, the job is gone, the house is gone, and they're in prison. It does happen, more often than you think.

Doctors can't always tell who is or isn't an addict among these nice, educated, relatively well-heeled genteel non-criminal folks. Addiction is a hidden disease, a disease of denial, a thing that's carried in secret and buried away even from the addict. Addicts can hide their problems even from people living in the same household. Shame is a powerful motivation for secrecy. Doctors aren't soothsayers or mind readers, and taking a good history or talking to relatives won't always turn up the problem prior to writing a prescription. We want to care for people and relieve distress and a prescription is one way to do that. Unfortunately, it is also possible to create a new addiction in a person who never had one before and we have no way of knowing ahead of time which patient this will happen to. Giving a warning about addiction potential or cautions about continuous use is one way of approaching this problem, thus leaving the responsibility for the addiction back with the patient ("I warned you this could happen, I have it documented in the informed consent section of my progress note.") but this would be little comfort to me when I see these folks in prison.

When I read comments from people who say they're reluctant to take more of their prescribed controlled substance, I say: "Respect your gut." If you think it may be a problem for you, it could be. If your loved ones or doctor is encouraging you to take more and you're not comfortable with that, say so. Repeatedly if necessary. You're the one carrying both the symptoms and the addiction risk. As one of our anonymous commenters said:

"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?"

That's exactly why we're blogging and podcasting about this. Thank you.

My Three Shrinks Podcast 42: The Benzo Wars (or, Xanax Reloaded)

[41] . . . [42] . . . [43] . . . [All]

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Dinah, Clink and I get into a podcast brawl about the use of benzodiazepines (such as Xanax/alprazolam, Ativan/lorazepam, and Valium/diazepam) in the practice of psychiatry. See how many rounds we go, and who is left standing at the end.

---

February 16, 2008: #42 The Benzo Wars

Topics include:

• Round 1: Why Docs Don't Like Xanax (or, Xanax Reloaded). This is what started it. Then there was Xanax Blues in Podcast 19. Also, this one from Oct 10.
  
  
• Round 2: Dose Dependence. Our blog commenters dissent.
  
  
• Round 3: Just Say No! Clink offers sage advise to fellow prescribers.
  
  
• Round 4: The Trouble with Tapering. How slow can you go? See Perchance to Dream.
  
  
• Round 5: Need It Versus Want It. Is there a difference?
  
  
• Final Round: Last Shrink Standing. What are the situations where you feel very uncomfortable prescribing benzodiazepines? Roy wraps things up by quoting from his Jan 12 comments from Dose Dependent.
  

[Ed: I forgot that I had transcribed a few comments from the podcast when I was on a plane recently. I've added them below, including the time in the podcast where they occur]

15:06 Dinah: "So, shut up a minute!"

17:20 Roy: "Benzo's modulate GABA receptors... You've got glutamate, which is an excitatory amino acid, and you've got GABA, which is an inhibitory amino acid. So, they kinda balance each other. If you have too much glutamate, that's bad, you can have ... seizures... If you have too much GABA, that's bad because then your brain is s-o s-l-o-w-e-d d-o-w-n that you can't do anything."
17:45 Dinah: "What's his point?"
18:00 Roy: "So, benzo's effectively increase the role that GABA plays in the brain. So does alcohol. In fact, for the most part, your brain can't tell the difference between alcohol and a benzo."

20:20 Roy: "You can be dependent but not addicted."
21:00 Clink: "Why is it that this [coming off Xanax] is so bothersome to you?"
21:22 Clink: "When you start hearing that 'this is the only thing that works', then the red flags should go up."
22:20 Clink: "I see the addictions that are started by physicians, and we need to address this as a reality."
24:00 Dinah: "We have this dilemma... is this a medicine that this person needs versus is this somebody who's addicted?"

24:20 Dinah: "There are circumstances where I encourage people to take benzos, and I'll tell you what they are..."
24:27 Roy: "Like now!"

Feel free to add your favorite quotes in the comments.

The background music is from the mash-up I made for podcast #24, Dr. Phil on Skype.

---

Find show notes with links at: http://mythreeshrinks.com/. The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom). This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

Everybody Doesn't Need Psychotherapy

There, I said it. And primary care docs do just fine at treating many cases of depression. Everybody doesn't need a psychiatrist. There, I said that, too.

So, with my years of experience with my psychotherapy practice, here is my bullet-point formula for who needs psychotherapy:

• Oops, I don't have one.

I have no idea. Some people find that psychotherapy is essential to dealing with mental illness. Some people find it helps them sort out their maladaptive behavioral patterns and enables them to stop doing the same things over and over. Some people...oh I could go on and on. I touched on this in my post You're Supposed To Get Better, back in July, when I did go on and on (so what else is new?). The bottom line: there are people who come willing and readily to therapy, they talk openly about their problems, they do the work of therapy, and they don't get better, they don't change, but if they get comfort from it and it helps sustain them through their suffering, that's good. Only some people don't even find therapy comforting. Other people resist coming, "My primary care doc's been telling me to call you for two years now." They come in begrudgingly and filled with skepticism, talk about their problems, often for not all that long (a few weeks, a few months, maybe less) and they get a lot out of it. "I wish I'd come sooner."
Some people come, don't say much of anything, but still get better, feel comforted, or find that it's helped them to change.

My next post will be When To Refer. Maybe later? It's a holiday, so we'll see.

And finally, the Shrink Rappers met yesterday to do a couple of podcasts. They were both themed, though apparently Roy plans to post the second one first, so we had the pleasure of talking about the "last podcast" before it was done. So, if I have this right, Dr. Chris Kraft joined us for the "first" show and we talked about the Sexual Re-Orientation treatments. If ClinkShrink is our walking encyclopedia of Prison History, well Chris knows an awful lot about the history of Sex! The 'second' podcast is a discussion about the appropriate and inappropriate uses of Benzodiazepines. Essentially, the show consists of the three of us Screaming at each other. So I promised a series of posts on benzos, perhaps I do short ones as a prelude to the My Three Shrinks bloodiest podcast ever.

The best part was going out for Indian food after. I am the type of person who always enjoys eating a good meal with friends.

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.

Perchance to Dream

I've been having trouble sleeping sometimes lately. Oh, who am I kidding? I've always had intermittent insomnia, lately it's bothering me more for some reason. I'm lucky: if I don't sleep well, I don't feel it the next day, and so I've learned not to worry so much about it. If I go a few days with restless nights, I start getting irritable, and then I usually sleep well for a bit until the cycle repeats. A friend insists I'd sleep better if I turned off the computer and TV by 10 or 11 pm. I'm usually IN bed by 11:30, and I'm not much of a TV watcher, so I don't think that's it-- I sometimes get on the computer after that if I can't sleep, but I've tried first. Then she said it's the Diet Coke I have with dinner. Fine, I've given up caffeine after 9 am. I've had no Diet Coke in almost two weeks. I don't miss it, but it's not making much difference. Some nights I sleep well, others I don't. Last night, by the way, Roy was in my dreams....

So with that as a prelude, the New York Times has an interesting piece on sleep medications. I prescribe sleep medications sometimes, and I really don't think they're a problem for short term issues-- someone who sleeps poorly because of an acute stressor. And SSRI's often disrupt sleep, for some people the combination of an SSRI with trazodone seems to be helpful for both sleep and depression. Getting back to the New York Times article, "Sleep drugs found mildly effective but wildly popular"-- Stephanie Saul writes,

But if the unusual pitch makes you want to try Rozerem, consider that it costs about $3.50 a pill; gets you to sleep 7 to 16 minutes faster than a placebo, or fake pill; and increases total sleep time 11 to 19 minutes, according to an analysis last year. If those numbers send you out to buy another brand, consider this, as well: Sleeping pills in general do not greatly improve sleep for the average person.

The article goes on to say that while total time asleep is increased by 25 minutes or so, that sleep satisfaction amongst insomniacs is greatly increased. The article goes on to theorize why that is, to talk about some specific problems with certain hypnotics, and to say that the perfect sleep agent hasn't been found.

And with this thought, I've changed the sidebar poll-- Please vote for your favorite sleep medication. In Roy's honor, I've tried to be a bit more complete. And once again, in my pursuit of useless data, I don't care who you are, if you take or prescribe it, or if you merely like the idea, just tell us your favorite.

Oh, and finally, I should have put this on my last post about the Red Sox, but if you didn't know it, Red Sox pitcher Curt Schilling is a blogger-- do check out 38pitches.com . Funny, but his posts get more comments than our Shrink Rap posts get. I wonder why.

More On Everyone's Favorite Medication: Xanax

First, check out Roy's post below from earlier today; he tells us how to cure alcoholism! Click Here.
[I do nothing of the kind, don't listen to her.]

So the New York Times has a health blog, and if you ask me, today it's trying to be Shrink Rap. In today's Post, For Some Bereaved, Pain Pills Without End,
the unnamed author talks about the ease with which physicians ( primary care docs) prescribe benzodiazepines for acute grief, the ease with which they refill these scripts-- often for years at a time--, the ease with which these patients become addicted and suffer from side effects:

Powerful benzodiazepines such as Xanax, Valium and Ativan are widely overused in older patients, many experts fear, leading to serious health worries, including sleep troubles, cognitive difficulties, car crashes and falls. Yet doctors in the survey seemed willing to offer unlimited amounts of these addictive drugs to help patients cope with death.

The study is small-- it consists of 33 primary care docs in Philadelphia, and interviews with 50 older patients who've taken benzodiazepines for years: 20% said they began taking benzodiazepines during a period of grieving. Want details? Read the original article HERE.

As always, the reader comments are as enlightening as the blog post itself (ah, that's true here at Shrink Rap as well).

Interesting stuff, but I guess I think the sample here is so small as to be useless. Half the docs said they'd prescribed benzos for grief (so at least 16.5 primary care docs) and 10 patients started chronic benzodiapine use after a death. I'm not surprised, I'm not commenting on anyone's practice, I guess I just don't like the tone of the blog post which somehow paints the docs as ignorant, perhaps lazy, may be even negligent or sinister.

Finally, please note that I stole my "grief" graphic from a Red Sox blog: http://redsoxdiary.blogspot.com/

Why Docs Don't Like Xanax (some of us)

[BTW, you might also be interested in checking out our related podcast, #19: Xanax Blues.]

This is in response to JW's question below about the "rules" docs use about prescribing Xanax/alprazolam. Not all docs feel this way, but here's how I think about it. Of course, I am not suggesting that, if you are taking this anti-anxiety drug, you should stop it. I'M NOT. Talk to your doctor if you have concerns.

The half-life for Xanax is short... on the order of 6-20 hours. Halcion is the only similar sedative that has a shorter half-life (and that one has even more problems). Thus, it doesn't stick around long. It is also quite lipophilic, meaning that it quickly gets into the brain. So, it has a quick on, quick off way of working. Sounds great, right?

The quicker a drug works, especially one which makes you feel good in some way, the more addicting it is, as the cause (taking it) and effect (feeling it) are close in time, making it very reinforcing. This is fine if you just take it on those rare anxious moments where you need something to get through it. However, since it works so quickly, many folks start taking it more and more often, until it gets to the point that they are taking it daily. Then they start taking it as soon as they feel it wear off. Before you know it, you are taking it 3-4 times per day. Now, that's not the big problem.

The big problem is all because of your brain's laziness. See, your brain makes it's own natural Xanax-like substance, called GABA. GABA works by inhibiting the brain's natural tendency to speed up. It's like a brake pedal, where the accelerator is stuck in the pedal-to-the-metal mode. GABA keeps your brain from over-working. Xanax (and other sedatives, and alcohol) works by acting like GABA in the brain (sort of). If you start taking it daily, your brain starts thinking "I guess I don't need to make so much GABA because this Xanax stuff is here, so I'll only make 20% of what I usually make." It takes a week or more for your brain to stop making the GABA (which is why just a few days on Xanax won't lead to much trouble), and a week or more for it to start making it again when you stop taking the Xanax.

Here's where the trouble begins. If Xanax wears off in just a few hours, but it takes a week for your brain's natural Xanax to kick back in, what happens in the interim? Withdrawal. What does that feel like? It feels like a panic attack, but worse. High blood pressure, rapid heart beat, tremors, confusion, delirium, hallucinations, seizures. What do folks do when they feel a panic attack coming on? Take another Xanax.

As a hospital-based physician, I see lots of folks, often older, who wind up with severe withdrawal problems from Xanax. It's usually because they run out of the drug, decide to cut back or stop taking it, or something else happens (eg, stroke, get sick) and they forget to take it. Or they don't tell their surgeon they are on it, and 2 days after their hip surgery I get called because they are hallucinating.

Some prescribers think it is a good antidepressant (it's not). Or that, because of the short half-life, it's not as addictive (it is).

So, here are my rules of thumb about Xanax:

1. Avoid it.
2. Keep the doses small.
3. Do not use in older folks or forgetful folks (more likely to forget it, thus more likely to have problems).
4. Do not use in anyone with a history of alcoholism or addiction (yes, that means you have to ask).
   
5. Tell folks to avoid from daily use.
6. If they are on it, warn them that stopping it suddenly, even for a day or two, can result in confusion, hallucinations, seizures, and even death.