Where’s the Buprenorphine asked Mr. Obvious? Thanks, CDC!

A quick note tonight, hopefully with a longer post to follow this weekend…
I’ve been frustrated by the people behind the Wisconsin PDMP, or Prescription Drug Monitoring Program, for their mistakes related to buprenorphine. Whoever came up with the numbers made a rookie error when calculating the equivalent morphine dose of patients taking buprenorphine products. The error is easy to notice by anyone who works with the drug, but apparently difficult to grasp by anyone with the power to correct the database figures.
Those people include, by the way, the folks at Brandeis University who give the numbers to Wisconsin, and the people at the CDC who give them to Brandeis. I’ve written to all of them; the bright folks at the CDC skimmed my explanation of their error and responded with a form-email that provides a link to where I can get ‘answers to my questions’.
Thanks, CDC!
In short, the people doing the calculation take a low dose of buprenorphine– say 200 micrograms– and extrapolate out in a straight line to 16 mg, ignoring the ceiling effect of partial agonists like buprenorphine. The calculation causes the PDMP to display a graph showing that people on buprenorphine are on the equivalent of 1200 mg of morphine. Any physician who sees that data (and all WI physicians are required by law to use the PDMP effective April 1) will think that the buprenorphine patient needing post-op pain is on THAT dose of opioids. Talk about an April Fool’s joke– nothing like hypoxia in the recovery room to brighten everyone’s mood! Don’t worry though– in their email they pointed out the disclaimer in fine print that the site shouldn’t actually be used to compare or convert opioid doses.
Then why make the calculation and show the graph, asks Mr. Obvious?!
This is getting longer than I intended… Another annoying State tidbit is the series of letters to Wisconsin physicians warning about the severe risk of harm from prescribing benzodiazepines to patients on buprenorphine. I’ve written to those folks as well, pointing out that combinations of benzodiazepines with opioid agonists are much, much, much more dangerous than with buprenorphine. I’ve explained how somehow, sometime long ago, the phrase ‘buprenorphine can only cause death in adults if given to someone without opioid tolerance AND combined with a second respiratory depressant, to which the person also lacks tolerance’ (a true statement) was changed to ‘buprenorphine is dangerous when combined with benzodiazepines’ (mostly ‘fake news’).
I haven’t written as many letters over this second issue because I’m no big fan of benzodiazepines. But both issues annoy me greatly, maybe because the errors of logic in both cases are SO obvious. Even for government work!!
Speaking of government work, the Milwaukee County Common Council released figures about the surge in overdose deaths, including a breakdown by ethnicity, age, county region, and drugs found at autopsy. Mr. Obvious has a question for the people writing to doctors to tell them about the SEVERE risks from buprenorphine: ‘What drug is NOT on the list of the 8 most-common drugs found in toxicology tests of overdose patients?’ A hint: It starts with a ‘B’!

Benzos and Buprenorphine

The high safety of buprenorphine, except when combined with a benzodiazepine, has been twisted in comments about the drug (and in the minds of regulators) to buprenorphine being uniquely dangerous when combined with benzodiazepines, which is not true.

I’ve heard more and more from insurers, regulators, and well-meaning agencies about the dangers of combining buprenorphine and benzodiazepines.   Some insurers protest paying for buprenorphine if patients are taking benzodiazepines.  Medicaid recently sent a letter that described a ‘severe risk’ of using benzodiazepines in patients on buprenorphine.  And the state drug database contains a graph for each patient of the morphine-equivalent narcotic dose over time, and shades the data in red if benzodiazepines are also prescribed.
Readers of my blog know I’m no big fan of benzodiazepines (read this for example).  But in an era of ‘fake news’, I’m even less of a fan of incorrect statements by doctors.   The drug database also ignores the ceiling effect of buprenorphine, and extrapolates the morphine equivalency of low doses of buprenorphine as if the dose response ‘curve’ was a straight line.  That ridiculous calculation leads the graph of opioid use to show buprenorphine patients as taking the equivalence of 900 mg of morphine per day.  The harm is minor I suppose by limitations on access to the database, but the error leads to misperceptions among doctors, and could potentially lead to mistakes in treatment decisions.
Benzodiazepines are respiratory depressants, especially when added to opioids.  The combination is dangerous when patients take doses of either class of drug that are higher than their tolerance levels.  The ceiling effect of buprenorphine eliminates that risk in patients who are stable on addiction-level doses of the drug, i.e. doses above the ceiling threshold.  A patient taking a maximal amount of buprenorphine CANNOT take a dose of buprenorphine that will cause respiratory depression.  Note the word ‘maximal’, not ‘maximum’.   By maximal, I mean a dose above about 8 mg per day, beyond which further doses will have no increase in mu receptor activity.
It is very difficult, and rare, to die from buprenorphine.  A person who lacks tolerance to opioids can die from buprenorphine, but deaths in that case are rare unless a second respiratory depressant is added– usually a benzodiazepine.  The high safety of buprenorphine, except when combined with a benzodiazepine, has been twisted in comments about the drug (and in the minds of regulators) to buprenorphine being uniquely dangerous when combined with benzodiazepines, which is not true.  Benzodiazepines are much, much more dangerous when combined with opioid agonists.  That risk is almost completely mitigated by buprenorphine, providing the person is tolerant to buprenorphine.
Buprenorphine rarely causes overdose unless combined with benzodiazepines in patients who are not tolerant to opioids.  Valid questions over benzo use should not be confounded by fears over buprenorphine.
Below, I will paste a letter I recently sent to one insurer who refused to cover buprenorphine in a patient on benzodiazepines.  Comments, of course, are welcome– and encouraged.
Re: XXX XXXX
XXX XXXX is treated with Suboxone for opioid dependence, and with a combination of medication for depression and anxiety that includes clonazepam and a shorter-acting benzodiazepine, currently lorazepam.    He has a history of (a significant anxiety disorder that I won’t disclose here).
The issue of benzodiazepine use in combination with opioids is complex, but fairly predictable in people who use benzodiazepines correctly (e.g. at regular intervals, rather than taking a month’s supply in three days and then going without for several weeks).
I am experienced in the use of medications that have respiratory depressant properties.  I am Board Certified in Anesthesiology and also in Psychiatry, and I worked as an anesthesiologist for over ten years before training in psychiatry.  I also have a PhD in neurochemistry, and I teach the section on opioids at the Medical College of Wisconsin.  I will take some time to explain the interaction of benzodiazepines and buprenorphine—so I hope you will read my comments and take them seriously.
Buprenorphine has been known to be a very safe medication for the past 3 decades.  Review of the pharmacology literature will show that deaths from buprenorphine are rare. While over 30,000 Americans die from overdose each year, only about 40 of those deaths occur in people who have buprenorphine detected in the bloodstream.  Of those 40 deaths, almost all were from opioid agonists, with buprenorphine NOT acting as a contributor to the death—and in most cases the death would have been prevented had MORE buprenorphine been present in the bloodstream.
The few deaths attributable to buprenorphine each year in adults require 1. An absent or low opioid tolerance, AND 2. the presence of second respiratory depressant that the person also lacks tolerance to.  Because of the ceiling effect, which caps the CO2 response-shift from mu-receptor activation,  deaths from buprenorphine alone are rare in adults.   Death is possible in adults naïve to opioids–  but only if a second respiratory depressant is present.
The fact that death from buprenorphine can only occur in the presence of benzodiazepines has been misinterpreted at times, in warnings about opioids, as the idea that benzodiazepines and buprenorphine are uniquely dangerous when combined.   Understand that patients tolerant to buprenorphine have a partial-pressure of carbon dioxide equal to 40 mm mercury (the normal level).  Because of the ceiling effect, additional doses or amounts of buprenorphine cannot shift the carbon dioxide response curve.  For that reason, patients who have been maintained on buprenorphine doses above the ‘ceiling threshold’ for over a couple weeks have no respiratory depression from the drug.  Such patients have similar respiratory responses to benzodiazepines as those of normal patients.
Mr XXXX is fully tolerant to the cap effect of buprenorphine, so he is not at risk of respiratory depression from the drug.  Frankly, he is in a much safer position than other patients contemplating benzodiazepines, because if he used opioid agonists their effects on respiratory function would be blocked.
I am not a big fan of benzodiazepines, and for that reason have tried to taper Mr. XXXX off of them in the past.  But when we have attempted to taper them, the insomnia and anxiety symptoms become more severe, causing him to isolate from others and miss work.  I am fearful- for good reason—that attempts to reduce benzodiazepines at this point would result in another significant depressive episode, resulting in hospital admission.  My goal has been to avoid any further increase in his dosage—something we have been able to do over the past two years.
Understand that the risk of respiratory depression comes down to tolerance, for both opioids and benzodiazepines.  Mr. XXXX uses the same amount of each medication every 24 hours, and does not stockpile medications or use medications impulsively.  His tolerance to BOTH medications, along with the cap on opioid effects intrinsic to buprenorphine, provides a significant margin of safety.

Opioid Withdrawal Treatments

A post on the Forum asked about the best remedies for opioid withdrawal.   I will review the medications and other treatments for opioid withdrawal that I have heard discussed by physicians or by people on the internet.  Hopefully readers will leave comments about medications or approaches that they have found useful.  Likewise, if you are a physician, please weigh in with the approaches that you have found to be useful.
For readers, it is very important to understand a couple things about this post.  First, the medications listed here are not FDA approved for treating opioid withdrawal.  They have not been systematically tested for that purpose. Most of the medications that I will list are available only by prescription— and must be taken ONLY by prescription.  They all have interactions with other medications, and they all have toxicity in certain doses, and in people with certain conditions.  Do NOT take them other than through guidance by your doctor.  This post is intended to spark discussion with your doctor— and to help doctors learn about approaches that they have not heard about elsewhere.
I will encourage doctors or other contributors to this post to avoid discussion specific dosages.  These medications must be prescribed by physicians who understand them, or who know how to become knowledgeable about them.
One problem for doctors is that CME meetings generally discuss treatments that are FDA indicated.  I do not know of any medications that have been approved or marketed specifically for opioid withdrawal, and I do not have the sense that the field of medicine views opioid withdrawal as a pressing issue.  But I am aware that for buprenorphine patients, the treatment of withdrawal symptoms has the highest priority of any medical concern.
With those caveats, here are the medications that I have heard the most about, roughly in the order of what consider their usefulness:
– Clonidine:  Available by tablet or by patch.  The medication reduces CNS excitability, and relieves all opioid WD symptoms to some extent.  Side effects include sedation (which may be useful), dry mouth, and hypotension.
– Gabapentin:  An anticonvulsant that some people find relieves anxiety and perhaps the sweating during withdrawal.
– Benzodiazepines: A controversial topic.  They are potent sedatives, but they are also potent respiratory depressants when combined with opioids.  Most overdose victims have these drugs on board.  They relieve anxiety, insomnia, and muscle tension, and cause fatigue.  Should NEVER be combined with opioids unless under very careful supervision (i.e. ‘self treatment’ = NO treatment).
– Phenobarbital: A Forum participant wrote that his/her doc prescribed phenobarbital for opioid withdrawal with great success.  All barbiturates act similarly to benzodiazepines, and have potent respiratory depression, especially with opioids.  Again, must NOT be used except under close supervision.  Have effects similar to benzodiazepines.  Dangerous if combined with alcohol.
– Quetiapine: AKA Seroquel.  A potent sedative, used to treat psychosis, bipolar mania, depression… and off label, insomnia.  Side effects include dry mouth and sleepiness.
– Natural ‘remedies’: A variety of withdrawal remedies are advertised on opioid-related web sites.  I’ve had patients who tried most of them, and I’ve never heard anyone say they were useful. Some come in ‘daytime formula’ and ‘nighttime formula’.  Always read the ingredients– and if you see a long list of herbs and roots, realize that there is NO oversight of the claims that are made.  You could put bundles of dandelions into empty capsules and sell them over the internet, making the same claims.  How hard do you think it would be to find a people to write ‘testimonials’ for twenty bucks? Or you could just write them yourself! Buyer beware.
– Amino acids:  Again, advertised on the internet, and offered at steep cost by ‘select’ doctors.  One of the ‘pioneers’ of amino acid treatments for withdrawal was convicted of fraudulent practice in Texas, and now offers the same as he did in Texas, but safely across the border, in Mexico.  He has clinics in the US, run by other doctors, who boast of using his methods.  The appeal of buying into a treatment that was proven fraudulent in court escapes me.  But the treatment of opioid dependence is strongly influenced by perception, and so is strongly subject to placebo effects.  The appeal of snake-oil remedies has created a living for many, many charlatans over the years, and a sucker is born (at least) every minute.
– General sedatives:  Insomnia is such a big problem that anything that helps with sleep will help during opioid withdrawal.  Meds include diphenhydramine and hydroxyzine (antihistamines), zolpidem and zopiclone (short-term sleep meds), and trazodone and mirtazapine (sedating antidepressants).   Cyproheptadine is a sedating antihistamine that reduces nightmares, and stimulates the appetite.
– Stimulants:  I’ve read of people using them to fight the depression and fatigue during withdrawal.  That use of a schedule II medication may be illegal in some states, and is probably frowned-upon by agencies that regulate medical practice.  The energy and mood effects from stimulants are temporary, and must be ‘paid back’ with fatigue and depression when the stimulants are discontinued.
– Naltrexone: An opioid antagonist that has been used to speed the reduction of opioid tolerance.  Naloxone and naltrexone are used during rapid detox, under strong sedation or anesthesia, but I believe that some have used naltrexone in very low doses in awake patients.  If you are a doc who knows about this approach, I’m all ears…
– Antidepressants:  Depression is one of the worst aspects of opioid withdrawal.  Antidepressants would seem appropriate… but I know of no antidepressant medications that have a chance against the severe depression caused by opioid withdrawal.  I’ve used them for patients after the withdrawal ends, when depression lingers… but I see little use for them during acute withdrawal.
Gosh, I thought my list would be longer.  Given how many people suffer through discontinuation of opioids, our approach to easing misery is pretty limited.   I will remind readers–  most of the medications listed above will cause serious harm, if taken without doctor supervision.
If you are a doctor who has found success with other medications, or if you are a patient of such a doctor, leave a comment to help spread the knowledge.  If you are not comfortable with leaving a post, send me an email, or a message through LinkedIN.
 

Xanax Worsens Anxiety and Panic

First posted 12/13/2012
Anxiety is one of the most common presenting complaints for people who come to my psychiatric practice. By the time people with anxiety visit a psychiatrist, they have usually discussed their symptoms with friends and family members, and some have been to their family care physician. And as a result of these initial ‘consultations’, they often have been recommended or prescribed valium-type medications like Xanax or Klonopin— a class of chemicals known as ‘benzodiazepines.’
There have also been several highly publicized deaths from combining pain pills with benzodiazepines. The medications are commonly prescribed, and there are a number of misconceptions among laypeople about their proper use. I’ve written about this class of medications in the past, but given the frequency that they are prescribed and mis-prescribed, the topic deserves another visit.
Most experienced doctors have learned to cringe every time a patient says the word “anxiety,” knowing that in all likelihood they are in a lose/lose position. Why lose/lose? Because the experienced doctor knows that the options are to do the right thing and disappoint their patient, or do the wrong thing and struggle with the consequences of their actions for months or years.
A primary reason for the lose/lose proposition is that the non-medical community associates SSRI’s like Prozac or Zoloft with antidepressants, and believes that the proper treatments for anxiety disorders are sedatives like Valium or Xanax. But in reality, sedatives are useful in some situations, for example acute or short-term anxiety. But for chronic anxiety, the proper treatment consists of SSRIs or closely-related SNRIs.
Today a new patient requested treatment of her addiction to pain medications. When I asked about other symptoms, she said that she takes alprazolam and clonazepam for anxiety and panic attacks. I explained that those medications are dangerous for opioid addicts, and are intended for short-term use. She assured me that the milligram of alprazolam she is taking doesn’t even do anything, intending to inform me that her medications are not potent enough to worry about. But I took her assurances the opposite way—that she has taken benzodiazepines to the point where even very large doses of the medications have little effect because of ‘tolerance.’
She then said she also has attention deficit disorder and takes amphetamine. I explained that she is doing herself a disservice by taking both amphetamines and benzodiazepines, since benzodiazepines CAUSE attention problems; in fact, that is how they work! Anxiety essentially consists of too much attention to a problem or a fear. Benzodiazepines treat anxiety by preventing the brain from attending, attaching and remembering.
Anesthesiologists and dentists use the short-acting benzodiazepine midazolam during uncomfortable procedures to block memory. Most adults have had the experience of watching an anesthetic medication injected into the IV tubing, and next waking up to people saying “you’re OK—it’s all done.” For minor procedures they experience a loss of memory, not a loss of consciousness. They transfer to the OR table when asked, but have no recall of doing so because of the benzodiazepine’s effects. I repeatedly tell students in my university practice to avoid benzodiazepines, if nervous about an important exam. Amnesia and studying don’t mix!
The patient described above said that she takes stimulants for attention deficit disorder. Beyond amnesia, it is simply a bad idea to take two polar-opposite medications as this patient is doing. Stimulants cause wakefulness, attention, tight muscles, and anxiety. Benzos cause drowsiness, amnesia, relaxation, and the inability to remember what you were supposed to worry about. Instead of taking both, take neither.
A related question came to me by e-mail yesterday:
Hello, I found your website and see that you do phone consultations. I have been having anxiety problems and attacks for over a year. It has gotten worse and worse. I’ve been to the doctors in my area but no one wants to treat me for it…they just want to keep giving me Paxil, Zoloft, Prozac, Cymbalta and all these things I’ve tried and nothing seems to be helping me. I have anxiety attacks all the time where my heart beats out of my chest and I can’t breathe and go almost into this blackout stage. I have a lot of things that trigger it; one is my anxiousness all the time. I can’t focus, and any little dilemma sets me off. Everything is a crisis to me. And on top of that, I have the responsibility to take care of a 3 year old all by myself. I’m so scattered and anxious and upset all the time it is affecting me being a good mother. I cannot take it anymore and I am at the end of my rope. I don’t know what to do; no one will treat me with anything to calm me down along with the Paxil because of all the other people in this county that have abused it. I DO NOT know what else to do. I have no one to talk to or turn to. It’s affecting my job, my personal life and my life in general. If you can’t help me maybe you know someone who will.
The person doesn’t come right out and say it, but her comments about needing to be calmed down and about abuse of meds by others suggest that she is asking for a benzodiazepine.
Benzodiazepines include long-acting medications like clonazepam (Klonopin) and diazepam (Valium), intermediate-acting medications like lorazepam (Ativan) and alprazolam (Xanax), and the short-acting sleeping pills from my training years like triazolam (Halcion) and temazepam (Restoril). As an anesthesiologist, I gave patients midazolam (Versed) more than any other medication. All of these medications are appropriate in certain settings. Most have a street value. Some have active metabolites that accumulate in the body over time. All are sedating, all cause tolerance, and all have the potential to cause significant withdrawal symptoms. The longer-acting medications will self-taper to some extent, but the intermediate-acting agents in particular have the potential to cause withdrawal syndromes that are severe, and even fatal. The first patient I mentioned has been taking an anticonvulsant since presenting to the ER with a grand mal seizure while stopping Xanax “cold turkey.”
All of these medications have appropriate uses, almost always for short-term conditions. When given long-term, they cause problems. In fact, from the top of my head, I can think of 12 reasons to avoid prescribing benzos for “anxiety.” Let’s run through the list of 12 things, just in time for Christmas—and don’t forget to check it twice!

  1. Many anxious patients aren’t truly anxious. When a patient complains of anxiety, he or she is often complaining of something else. If I ask a patient to describe the symptoms without using the word anxiety, I often find that the patient is bored, restless, angry, depressed, overwhelmed, or appropriately frightened. Take a look at the second patient—the one who is “scattered,” “at the end of her rope,” and “caring for a 3-year-old boy all by herself.” Do you really think she will be a better mom if she is taking alprazolam or clonazepam? She is feeling overwhelmed, angry, tired, afraid, hopeless, depressed—feelings that when added together become ‘anxiety.’ Do we really want to give a person in this condition a medication that will make her sleepier, more forgetful, more scattered, and more disinhibited?
  2. Even if the medication is truly helpful, her relief will be short-lived due to tolerance. The human body quickly adjusts to benzodiazepines (and many other medications) so that a continued effect requires a higher and higher dose. Patients often escalate their dose at some point, no matter how many times they promise that they won’t. Dose escalation is not the patient’s fault; it is simply what these meds do. Dose escalation is difficult to control, once it has begun; patients will call two weeks into a month prescription to report that they are out of alprazolam, and the doctor feels pressured to issue a refill to prevent withdrawal.
  3. Benzodiazepines turn manageable anxiety into an anxiety disorder. Patients get a calming effect from the medication, but as the medication wears off, the anxiety returns, including extra anxiety from a rebound effect—a miniature form of withdrawal. Patients do not usually attribute that anxiety to rebound, but instead believe they have a horrible anxiety condition that appears as soon as the medication wears off. When I worked in a maximum security prison for women in Wisconsin, many inmates were taking benzodiazepines upon arrival. Several months later, the most amazing thing happened: the anxiety disorders went away!
  4. A problem specific to patients with addictions is that rather than take sedative medications to achieve the absence of anxiety, they take the medication until they feel relaxed. In other words, instead of seeking normalcy; they seek relaxation. There is a difference between the two states! The mistaken goal is simply a consequence of the conditioning process during addiction. People with addictions don’t often realize that they are seeking ‘fuzziness’— a feeling that people without addictive histories often find uncomfortable.
  5. Again specific to people with addictions, benzodiazepines (like other medications that have an immediate psychotropic effect) direct the person’s attention inward. People with addictions are overly aware of how they feel; a goal in treatment is to get the addict out of his or her own head to experience life on life’s terms. Benzodiazepines encourage the opposite effect, encouraging the addict to focus on internal feelings and sensations.
  6. People with addictions who favor one class of drugs, for example opiates, will often move to a different substance when the first drug of choice is removed. This phenomenon is called “cross addiction.”
  7. A final concern for people with addictions is that benzodiazepines help preserve the mistaken thought that the person cannot function without taking something.
  8. Benzodiazepines impair driving and working with dangerous machinery. And patients get anxious at work too—making the medications a poor choice. They also make a person appear intoxicated by causing slurred speech, forgetfulness, and sometimes loopy behavior, risking the person’s job and having other unforeseen consequences. Some people have completely different personalities when disinhibited by benzodiazepines.
  9. Benzodiazepines have been linked to fetal anomalies and early miscarriage.
  10. They destroy sleep in the long run through tolerance and through rebound effects. If the patient takes a benzodiazepine during the day, he or she will go to bed just as the sedation is wearing off. The alternative is to take the medication at bedtime, defeating the goal of finding relief for daytime anxiety. If the person takes benzodiazepines both day and night, tolerance increases even more quickly.
  11. I have already mentioned the need to taper off benzodiazepines and the risk of seizures (and worse) during withdrawal.
  12. Benzodiazepines may calm an anxious person, but they do not generally increase function. A person who can’t get out of bed becomes less likely to get out of bed. Bills that are unpaid become even less likely to be paid. Relationships do not generally improve when one partner is nodding off as the other talks about feelings!

I do prescribe benzodiazepines, usually for short-term or intermittent use. Some patients do fine with them, but for others, benzodiazepines are a Pandora’s Box that is best not opened. As a psychiatrist, I often see treatment plans that lead to a mess that I must try to clean up—such as the case with the first patient I mentioned. I think most doctors who read this will understand what I am saying, and many will have similar thoughts about benzodiazepines. Perhaps others will find the use of benzodiazepine much more beneficial than harmful; comments are welcome!
Addendum:  Since the original post, a large British study showed a higher death rate in patients who have been on chronic benzodiazepine therapy, and a more recent study showed a link between benzodiazepine treatment and the later development of Alzheimer’s disease.

Bathtub Tragedy

I was never a huge Whitney fan, but nobody can debate the beauty and power of her voice.  Also beyond debate is that she deserved a better ending than the one she found, alone in a bathtub, while ‘friends’ were partying a few floors away.  Xanax and other benzodiazepines, combined with alcohol, are suspected of contributing to her death.


Fonda and a Kardashian
Grief-Stricken Friends

In fact, my primary reaction to reading about her death has been disgust over the way things play out in star circles– similar to how they played out after the death of Michael Jackson.  We have the parade of the business confidants– Simon, the Idol/X-Factor guy, saying that he could tell something was amiss.  Producers who say she looked great the last time they met.  Friends who say they tried to reach out.  Even Jesse Jackson somehow got his picture taken as part of the tragedy.
The picture that summarizes that world best shows Jane Fonda and one of the Kardashians (I don’t know one from the other) taking a break from grief to pose for a photo.
Hollywood, as I think about it, is the perfect setting for addiction– a place where everyone is acting and pretending, where relationships are fake but ‘useful,’ where rage occasionally makes headlines but bad behavior is mostly ignored.
I would LOVE to be a part of it.  But I wouldn’t last five minutes.

The Problem with Benzodiazepines

Last night I came across a medical student web site that included a link to a post of mine from a couple years ago, that described my feelings about Xanax, Valium, Klonopin, and other benzodiazepines.   The people commenting at that site appreciated my comments, and my comments were ‘seconded’ by other physicians.  Here’s the post again, for those who missed it the first time:
Twelve Things I Hate About Benzodiazepines
Author: J Junig MD PhD


Because of several highly publicized deaths from combining Suboxone with benzodiazepines or “benzos”—a class of sedative medications that includes Xanax and Valium—I am frequently asked about the safety of combining Suboxone with those medications. The risk of life-threatening respiratory depression can be mitigated fairly easily, but that does not mean that benzos are safe or appropriate medications for people with or without addictions. They are commonly prescribed medications, and there are a number of misconceptions among laypeople about their proper use, so they deserve a thorough discussion. Most doctors with a bit of experience have learned to cringe every time a patient says the word “anxiety,” knowing that in all likelihood they are about to be placed in a difficult position. They will either do the right thing and disappoint their patient, or do the wrong thing and struggle with the consequences of their actions for months or years.
The problem is that the non-medical community sees SSRI’s as “antidepressants,” and believes that the proper treatments for anxiety disorders are sedatives like Valium or Xanax. Whereas the sedatives are appropriate for acute or short-term anxiety, chronic anxiety disorders are more appropriately treated using SSRI’s or SNRI’s.
Today, I saw a new patient who asked for treatment of her addiction to pain medications. When I asked about other psychiatric symptoms, she said that she takes alprazolam and clonazepam for anxiety and panic attacks. I explained that those medications are very dangerous for addicts and are intended for short-term use, and the primary treatments for anxiety disorders are SSRIs or SNRIs. I asked her dose and wasn’t surprised to hear that her tolerance was quite high. A milligram of alprazolam doesn’t do anything, she said—intending to mean that the meds are not potent enough to worry about. I of course took it the opposite way—she has taken benzos to the point that a very large dose has no effect due to her high tolerance. She then said she also has ADD and takes Adderall (ie, amphetamine). I explained that it makes no sense to take both amphetamines and benzos, particularly a long-acting benzo like clonazepam, which has a half-life of around 30 hours. Benzos CAUSE deficient attention; that is how they work! Worry consists of too much attention to a problem or a fear, and benzos prevent the brain from attending, attaching and remembering. In fact, anesthesiologists and dentists use the short-acting benzodiazepine midazolam during uncomfortable procedures to block the patient’s memory. Most adults have had the experience of watching the medication injected into the IV tubing, and next waking up to people saying “you’re OK—it’s all done.” Don’t take a benzodiazepine if you are nervous about an exam the next day! Beyond the amnesia, it is simply a bad idea to take two polar-opposite medications as this patient is doing. Stimulants cause wakefulness, attention, tight muscles, and anxiety. Benzos cause drowsiness, amnesia, relaxation, and the inability to remember what you were supposed to worry about. Instead of taking both, take neither.
A related question came to me by e-mail yesterday:
Hello, I found your website and see that you do phone consultations. I have been having anxiety problems and attacks for over a year. It has gotten worse and worse. I’ve been to the doctors in my area but no one wants to treat me for it…they just want to keep giving me Paxil, Zoloft, Prozac, Cymbalta and all these things I’ve tried and nothing seems to be helping me. I have anxiety attacks all the time where my heart beats out of my chest and I can’t breathe and go almost into this blackout stage. I have a lot of things that trigger it; one is my anxiousness all the time. I can’t focus, and any little dilemma sets me off. Everything is a crisis to me. And on top of that, I have the responsibility to take care of a 3 year old all by myself. I’m so scattered and anxious and upset all the time it is affecting me being a good mother. I cannot take it anymore and I am at the end of my rope. I don’t know what to do; no one will treat me with anything to calm me down along with the Paxil because of all the other people in this county that have abused it.. I DO NOT know what else to do. I have no one to talk to or turn to. It’s affecting my job, my personal life and my life in general. If you can’t help me maybe you know someone who will.
The person doesn’t come right out and say it, but her comments about needing to be calmed down and about abuse of the meds by others suggest that she is asking for a benzodiazepine.
Benzodiazepines include long-acting medications like clonazepam (Klonopin) and diazepam (Valium), intermediate-acting medications like lorazepam (Ativan) and alprazolam (Xanax), and the short-acting sleeping pills from my training years like triazolam (Halcion) and temazepam (Restoril). As an anesthesiologist, I gave patients midazolam (Versed) more than any other medication. All of these medications are appropriate in certain settings. Most have a street value. Some have active metabolites that accumulate in the body over time. All are sedating, all cause tolerance, and all have the potential to cause significant withdrawal symptoms. The longer-acting medications will self-taper to some extent, but the intermediate-acting agents in particular have the potential to cause withdrawal syndromes that are severe, and even fatal. The first patient I mentioned has been taking an anticonvulsant since presenting to the ER with a grand mal seizure while stopping Xanax “cold turkey.”
All of these medications have appropriate uses, almost always for short-term conditions. When given long-term, they cause problems. In fact, from the top of my head, I can think of 12 reasons to avoid prescribing benzos for “anxiety.”
1. Many anxious patients aren’t truly anxious. When a patient complains of anxiety, he or she is often complaining of something else. If I ask a patient to describe the symptoms without using the word anxiety, I often find that the patient is bored, restless, angry, depressed, overwhelmed, or appropriately frightened. Take a look at the second patient—the one who is “scattered,” “at the end of her rope,” and “caring for a 3-year-old boy all by herself.” Do you really think she will be a better mom if she is taking alprazolam or clonazepam? She is feeling overwhelmed, angry, tired, afraid, hopeless, depressed—feelings that when added together become anxiety. Do we really want to give a person in this condition a medication that will make her sleepier, more forgetful, more scattered, and more disinhibited?
2. Even if we get it right, her relief will be short-lived due to tolerance. Patients often escalate their dose at some point—no matter how many times they promise that they won’t. Dose escalation is not the patient’s fault—it is simply what these meds do. Once a pattern of dose escalation begins, it is difficult to control; patients will call after two weeks, reporting that they are out of alprazolam, and the doctor feels pressured to issue a refill to prevent withdrawal.
3. Benzos turn manageable anxiety into an anxiety disorder. Patients get a calming effect from the medication, but as the medication wears off, the anxiety returns, including extra anxiety from a rebound effect—a miniature form of withdrawal. Patients do not usually attribute that anxiety to rebound, but instead believe they have a horrible anxiety condition that appears as soon as the medication wears off. When I worked in a maximum security prison for women in Wisconsin, many inmates were taking benzos upon arrival; several months after the benzos were discontinued, the most amazing thing happened: the anxiety disorders went away!
4. A problem specific to addicts is that they don’t take sedative medications to achieve the absence of anxiety, but rather until they feel relaxed. They are not seeking normalcy; they are seeking relaxation. There is a difference between the two states: one is feeling normal without feeling excessive worry or panic; the other is feeling relaxed, something other than feeling normal. This doesn’t make addicts bad people; it is simply a consequence of the conditioning process during addiction. Addicts are not aware that they are seeking a fuzziness that non-addicts often find to be uncomfortable.
5. Again specific to addicts, benzos (like other medications that have an immediate psychotropic effect) direct the person’s attention inward. An addict becomes obsessed with how they feel; a goal in treatment is to get the addict out of his or her own head to experience life on life’s terms. Benzodiazepines encourage the opposite effect, encouraging the addict to focus on internal feelings and sensations.
6. Addicts with one favored class of drugs, for example opiates, will often move to a different substance when the first drug of choice is removed, for example using Suboxone. This phenomenon is called “cross addiction.”
7. A final concern for addicts is that benzos help preserve the mistaken thought that the person cannot function without taking something.
8. Benzos impair driving and have the potential to impair a person working with dangerous machinery. After all, patients get anxious at work too. They also make a person appear intoxicated by causing slurred speech, forgetfulness, and sometimes loopy behavior, risking the person’s job and having other unforeseen consequences. Some people have completely different personalities when disinhibited by benzos.
9. Benzos have been linked to fetal anomalies and early miscarriage.
10. They destroy sleep in the long run through tolerance and through rebound effects. If the patient takes the benzo during the day, he or she will be trying to sleep just as the sedation is wearing off. The alternative is to take the medication at bedtime, defeating the goal of finding relief for daytime anxiety. If the person takes benzos both day and night, tolerance increases even more quickly.
11. I have already mentioned the need to taper off benzodiazepines and the risk of seizures and worse during withdrawal.
12. Benzodiazepines may calm a truly anxious patient, but they do not generally increase the patient’s function. A person who can’t get out of bed becomes less likely to get out of bed. Bills that are unpaid become even less likely to be paid. Relationships do not generally improve when one partner is nodding off as the other talks about feelings.
I do prescribe benzodiazepines, usually for the short-term or while recommending they be taken no more than every other day. Some patients do fine with them, but for others, benzos are a Pandora’s Box that should never be opened. As a psychiatrist, I often resent the treatment that led to the mess that I try my best to clean up—such as the case with the first patient I mentioned. I think most doctors who read this will understand what I am saying, and many will have similar thoughts about benzodiazepines. Perhaps others will find the use of benzodiazepine much more beneficial than harmful. Comments anyone?

Humana Sneak Attack– Lawsuit Anyone?

I have written about the sleazy actions of health insurer Humana.  Today I filed a formal complaint with the Wisconsin Commisioner of Insurance regarding their practices.  I’ll copy my letter below, rather than take the time to write everything over again.  If there is an attorney willing to work the case on contingency, please contact me.  Likewise, if other patients or physicians are having similar problems with Humana, send me an e-mail through my website at www.fdlpsych.com.
The complaint:
My patient, XXXXXX, has been treated for opioid dependence for two years, using maintenance treatment with Suboxone.  He has maintained sobriety from opioids.  He also suffers from panic attacks and takes Effexor daily.  He uses lorazepam, a sedative, several times per month, and takes a sleeping medication, Ambien, most nights.
The standard of care for treating opioid dependence with Suboxone includes long-term use of Suboxone, particularly in young people (Mr. XXXXXX is in his early 20’s).  Mr. XXXXXX was fully compliant with treatment, including attending weekly psychotherapy and avoiding illicit substances.
In December of 2010, Humana stopped covering Suboxone for XXXXXX.  When I wrote to the company and asked for an explanation, I was told that he was denied because he did not meet the criteria of the company’s ‘buprenorphine coverage policy’.  This new policy was introduced without warning, and stated that people would not be covered if they were prescribed ‘benzodiazepines’ like lorazepam.
I appealed the decision by Humana, stating that the lorazepam was important for treating Mr. XXXXXX’s panic disorder.  But I wrote that his life depended on buprenorphine (Suboxone)– so we would stop the lorazepam immediately so that he would fit their ‘buprenorphine coverage policy’. 
The company continued to deny coverage.  I wrote again, asking for an explanation, and they wrote that Mr. XXXXXX was not eligible because ‘he was taking the benzodiazepine Ambien.’  I noted that Ambien is NOT a benzodiazepine, and does not therefore violate their policy.  But again, I wrote that I would not debate whether Ambien was or was not a benzodiazepine, but instead we would stop the Ambien, given the importance of Suboxone to the patient’s life and health.
The company again denied coverage through the appeal process, writing that ‘maintenance treatment for addiction was not indicated.’  Humana did not explain WHY his addiction treatment was not indicated.  I note that many patients receive buprenorphine for years, and the death rate from untreated opioid dependence is significant and well established.  I appealed the decision, asking for the name of their medical director.  Humana refused to provide the name, even after I called their offices repeatedly.  They continue to deny coverage, and today Mr. XXXXXX received notice that his final appeal was denied.
In summary, Humana was covering maintenance treatment for Mr. XXXXXX’s opioid dependence using Suboxone.  They then abruptly stopped coverage.  Mr. XXXXXX was forced to go through withdrawal without any warning–to him or to his physician–placing him at great risk of relapse and death.  When I attempted to re-establish his coverage, Humana wrote that they had instituted a ‘buprenorphine coverage policy’ without any prior warning. The policy is arbitrary and discriminatory, essentially stating that patients who are treated for opioid dependence are not eligible for treatment of other mental disorders, including panic disorder.
Finally, Mr. XXXXXX was willing to give up treatment of panic disorder in order to receive Suboxone—a medication that is vital to his continued sobriety.  I have repeated notified Humana that Mr. XXXXXX now complies with their arbitrary coverage policy– yet they continue to deny his claim.
This is a very dangerous situation.  Patients who are taking buprenorphine can do very well when compliant with treatment using Suboxone.  Humana pulled the rug out from under Mr. XXXXXX without warning, suddenly denying the medication, and then refusing coverage even when the patient clearly met all criteria according to Humana’s own unfair, arbitrary coverage policy. 
At minimum, Mr. XXXXXX should have his coverage for buprenorphine resumed.  Humana should be punished to prevent this dangerous, discriminatory behavior from hurting other patients.

Are you ANXIOUS? Are you SURE?

I’ve been posting more lately, but I’m hoping to slow down by the end of the holidays to let everyone catch up.   I’ve also mentioned ‘my book’ several times in the past year, promising to myself and to others deadline that comes and go.  I wish I could take a month and work on it full-time, but I don’t see much chance of that happening… so I’ll have to just keep chipping away at it.  I can be a perfectionist and everything can be worded just a little better…  I’m the same way some mornings with my electric razor, until  my wife gets sick of watching me ‘make it perfect’ and takes the razor from me.  I came across an article the other day that described a form of OCD that involves exactly that behavior– so at least I know the nature of my problem! 
I want to thank those of you who responded to the ‘here to help’ post, and please, if anyone else has had positive or negative experiences with the Here to Help program run by Reckitt-Benckiser,  let me know.  You don’t have to report anything ‘profound’– just a general comment or two whether it was helpful, whether you stuck with it, etc.
I have written about benzos a number of times and I still have more to say.  I would hope that everyone is familiar with the danger of respiratory depression when combining benzos and opiates.  Most of the deaths involving buprenorphine that I have reviewed or read about had two things in common.  First, the person took buprenorphine along with a second respiratory depressant– often a benzodiazepine, but alcohol acts at the same receptor sites as benzos and so alcohol has similar dangers.  The other commonality is that the person who died was not ‘tolerant’ to high doses of opiates, benzos, or both.    I do not want to say anything that puts addicts at risk, and I am NOT condoning benzo use, particularly the use of medications that are not prescribed by your addiction doc.  Doing so will eventually destroy you– but for the opiate/benzo combination to kill someone quickly generally requires that the person is not tolerant to one or the other chemical.  THIS IS NOT SOMETHING TO RELY ON TO AVOID DEATH!  Did I make myself clear?   Understand that the danger of combining opiates and benzos is not greater than the risk of combining benzos with opiate agonists.  There is nothing ‘more dangerous’ about buprenorphine EXCEPT the false sense of safety that users may have about buprenorphine.  But other than that false sense of safety, combining a pure opiate agonist with a benzo is MORE dangerous than combining similar potencies of buprenorphine with the same benzo.
I wanted to get that issue out of the way so that I could get to the main danger for addicts on buprenorphine when taking benzos, i.e the long-term effects on sobriety.  Opiate addicts will become actively addicted to other drugs when opiate addiction is prevented if no efforts are made to change.    I have written about my opinion that ‘standard AODA counseling’ is not the best fit for many people.  But that does NOT mean that change is not required.   At the very least the addict must find a way to fill the time spent using, and find a way to tolerate the harsh glare of reality when the mind is not constantly occupied with using, coming down, craving, or regretting the use of opiates.   I have had many patiens go through an initial ‘happy honemoon’ stage, and several months later struggle with all of the feelings that were being held at bay by preoccupation with opiates.   That preoccupation burns off a great deal of emotional energy, and suddenly our minds have plenty of time to worry about OTHER things!   There is also the fact that many of us used to dull our feelings and our reactions to life’s challenges.  So opiate addicts often compain of ‘anxiety’ early in buprenorphine maintenance, as they experience unpleasant feelings that should really be considered plain old cravings rather than an anxiety disorder.  I’ve written about what people say when I ask them to describe their ‘anxiety– they feel edgy, there is nothing to do, they are pacing, restless– they sound more bored than ‘anxious!’   But right now, for the sake of  the argument I will accept that some addicts are having real ‘anxiety.’  This is a big thing to accept, since anxiety is fear, and the people with anxiety are generally not the ones taking on new challenges, but rather tend to be the people who are doing nothing but playing video games all day… so I’m not sure where the ‘fear’ is coming from.  But even so– if that person was in residential treatment (before the days of buprenorphine) and complained of anxiety, every counselor would say ‘poor baby…. how HORRIBLE that you feel so ANXIOUS!  And so UNIQUE–  why, nobody has EVER felt like THAT before!!’
Do you get my point?  Sorry to be such an ass about it, but we are dealing with a fatal illness here.  Before buprenorphine, addicts would avoid narcotics after surgery in efforts to avoid risking relapse– now with buprenorphine, some people want to take the easiest way that they can find.  I will tell you straight up– if you are on the verge of finding stability on buprenorphine, you are extremely blessed.  Many people have died before you from opiate dependence, without the opportunity to improve their odds with buprenorphine.  You must do SOME tough things— and one is to learn to deal with life on life’s terms.  If you cannot do that, your chances for avoiding using–even with buprenorphine– are low.   Yes, for a time you are going to be ‘anxious’, or dysphoric, or whatever you want to call it.  You haven’t dealt with life lately, so of course it will be a tough adjustment!  But what do you expect– that you can just be numb and relaxed the whole time, and everything will just fall into place?
People with cancer deal with extreme pain, nausea, surgeries, deformity of body parts…  YOU must deal with your ‘anxiety.’   Why?  It is hard to explain to people who have not been through residential treatment, where a person at least learns some things about what addiction is all about.  Addiction is complicated, and occurs for many reasons– there is not ‘one reason’ for being and staying an actively using addict.  One reason relevant to the benzo issue, though, is that addicts become very aware of their own physical discomfort– we become ‘big babies’, basically.  Benzos only make this worse;  the addict in early recovery feels uncomfortable about many things, and having a pill to take when things get bad enough only makes the addict look inward even more often to decide whether things are  bad enough to deserve a Klonopin.   Another reason people stay addicted is because of distortions of insight, specifically losing the ability to predict what they will do in the future.  The addict says ‘I will take it only for severe anxiety’, but after a few days the addict finds that there is ALWAYS a reason to take another dose of a benzos.  Addicts didn’t know life was so tough until benzos became available, when suddenly EVERYTHING seems like a severe situation–  snowed in, new coworker, lost job, getting a new job, a first date, a break-up, an NA meeting… ALL of these things are great reasons for Klonopin!!
Another problem for addicts taking benzos is that when addicts take a benzo for ‘anxiety’, they don’t focus on the disappearance of their anxiety– they focus on the appearance of the ‘buzz’ from the benzo.  ‘Normal’ people hate that feeling, and so they find benzos to be too sedating or too impairing.   But addicts LOVE that feeling– any feeling– and so they dose until they feel it– not until the anxiety is gone.  And that extra ‘dosing for feeling,’ combined with the fast tolerance  characteristic of benzos, leads to rapid escalation of dose.  And what a surprise– that dose escalation even occurs in people who say ‘don’t worry doc– I don’t plan to raise the dose.’
I realize I’m expressing anger with this post, but hey, I have to express it somewhere!  Part of my anger comes from the repeated behavior of addicts– behaviors that I resent that will always remain within myself as well.  I realize my anger is for the addiction, not for the person suffering from the addiction… but sometimes I am frustrated by the unwillingness of addicts who are at the edge of relapse to ‘step up’ and face the challenges, and to fight for their lives.  I was also angry at what happened on a TV show this AM as I was getting dressed.   I shouldn’t admit this… but I was watching MTV, the show about the teens who became pregnant and had babies, which is now a show about teen moms… and one of the teen moms went to the doctor and complained of her ‘anxiety’.  She is young, bored, stuck at home with a crying baby… and she has ‘anxiety.’ Some mornings she ‘just lays in bed and doesn’t want to get up.’   What a surprise that she isn’t just thrilled to get up every morning!  She sees a doc (who could pass for a beetle if he had the right markings on his back) and the doc prescribes… Klonopin.  The next morning the baby is fussing and the teen mom holds the baby at arms’ length, passes him to her BF, and says ‘I have to take my Klonopins.’   A close shot of the bottle shows instructions to take ‘one tab twice per day’ (clonazepam has a half-life of about 24 hours, so the level in her body will increase over several days to a high steady-state level).  The next camera shot the next day shows her laying on the couch, yawning, saying that the medication seems to be working.  Her one-yr-old, meanwhile, is… somewhere….  not sure where I left him… 
But at least she isn’t ‘anxious’!
I went off on something that I was only going to mention in passing… so I guess I’ll finish the story I intended to write in a few days.  I want to write about a couple studies that looked at the cognitive effects of buprenorphine, methadone, and benzos.  Thanks for letting me vent…    good luck returning to work tomorrow for those of us lucky enough to be working, and I hope those who are looking find somethng soon.
JJ

Brittany Murphy's medications and their interactions

A note of follow up:  According to TMZ, a variety of medications were found in Brittany Murphy’s apartment under her name and under the name of her husband and mother.  Of course it is possible that the medications actually belonged to her husband and to her mother– but as you read in my last post, I am not surprised that opiates were included on the list.  THe medication list:

Brittany Murphy used dangerous medication combinations
Was her death related to dangerous medication combinations?

1.  Topamax.  Topamax is an anticonvulsant that is also used to treat migraine headaches, and sometimes prescribed as a mild ‘mood stabilizer’–  say for someone who has symptoms of bipolar disorder but who instead has borderline personality or just ‘mood swings’ that don’t quite qualify as full blown bipolar disorder.  The medication is favored by some patients, particularly women with eating disorders, because unlike more effective mood stabilizers like Depakote (valproic acid), Topamax (generic name topiramate) causes weight loss instead of weight gain.  It has the nickname ‘dopamax’ because it can reduce cognitive function to a mild extent.
2.  Methylprednisolone.  This is a steroid anti-inflammatory medication, and I have no idea why she may have been taking it, if she was at all.  It is used to treat severe asthma, rheumatoid arthritis, and a wide range of autoimmune or allergic disorders.  It will create a brief euphoria in some people, and can also cause depression, mania, and even psychosis in others.  It tends to cause significant weight gain if taken for a long period of time.
3.  Fluoxetine.  Also known as Prozac, the well-known SSRI used to treat depression and anxiety (and to a lesser extent mood symptoms and irritability related to ‘periods’ in women).  Tends to decrease appetite slightly;  there is an ‘internet fad diet’ called ‘phen-pro’ which is a combination of phentermine (one of the phen-fen drugs from the heart-damaging diet of a few years ago) with fluoxetine.  Fluoxetine and other SSRIs are generally safe medications, but fluoxetine in particular can reduce the liver’s ability to metabolize some other medications, making the other medications more potent.
4.  Klonopin.   AKA clonazepam, a long-acting benzodiazepine (meds in the Valium or Xanax family).  These medications almost always start out small and become big problems in people with addictive tendencies, as I write here in my psychiatry blog.  They are great for short-term anxiety– say for a couple weeks for a death in the family.  But the person quickly becomes tolerant to the medication and then needs to take it to feel ‘normal’, eventually needing it all the time.  Benzos turn managable anxiety into an ‘anxiety disorder’.  They are also potent respiratory depressants when combined with opiates, and are often half of the equation in the case of overdoses.  They work at brain receptors that are also affected by alcohol, making them essentially ‘brandy in pill form.’  Do yourself a favor, and just say ‘no’ to benzos.  One last thing– the way that they block ‘anxiety’ is through their action as ‘amnestics’– they block the formation of memories.  A drug called ‘versed’ is widely used for dental work or colonoscopies to block memory;  that is what clonazepam and alprazolam (Xanax) do.  You can’t worry about what you cannot remember!
5.  Carbamazepine.  Also known as Tegretol, this medication is an anticonvulsant similar to Topamax but one that is potent enough to actually work for bipolar disorder and seizure disorders.  It is also prescribed for some chronic pain conditions, including a very painful facial condition called trigeminal neuralgia.   Not particularly dangerous with opiates except for effects at the liver where it also blocks or increases the metabolism of other medications in an unpredictable fashion.  It can have other uncommon but serious side effects on blood components.
6.  Ativan.  Also known as lorazepam, this is another benzodiazepine.  Works just like clonazepam but with a shorter duration of action– the half-life of lorazepam is about 12 hours and the half-life of clonazepam is 2-3 times longer.  Again, a lousy, addictive medication that is a disaster in people with addictions.
7.  Vicoprofen.  Ibuprofen combined with the opiate hydrocodone, which is a moderate-strength narcotic.  People who take opiates long term become used to them, and have to keep taking them to avoid withdrawal– as all readers here probably know!
8.  Propranolol.  This is an old, cheap medication used to treat a number of things.  It is a ‘beta blocker’, meaning it blocks the actions of adrenaline at ‘beta receptors’ at the heart and other brain regions.  It used to be used commonly for high blood pressure, but now many better medications are available.  It is used to prevent migraines, and to block the feeling of adrenaline in a person’s body– so it will be used in prisons as a non-narcotic medication to treat panic attacks or anxiety.  It is commonly used by musicians, politicians, and public speakers to help them feel calm during presentations or public appearances.  For example it will stop that ‘rush’ in a person’s chest, stop the hands from shaking, stop the heart from racing or pounding, and reduce the husky voice some people get when nervous.
9. Biaxin.  An antibiotic also known as Clarithromycin, used to treat a wide range of bacterial infections including acne, sinus infections, bladder infections… again, an old medication with many better modern substitutes.  The use of the medication is limited by the fact that similar to many of the other medications in this list, it interacts with many other medications, making the other medications more or less potent than intended.  The medication can also cause potentially fatal heart arrhythmias, particulary in combination with STEROIDS, such as the methylprednisolone on the list.
10.  Hydrocodone.  Not needing much explanation for readers of this web site, hydrocodone is a moderate-strength opiate narcotic.  It is a component of the Vicoprofen described above.  Like all opiates, it initially works very well to relieve pain.  Some people, though, find that it ‘fits’ very well;  it makes them feel whole, loved, happy, content, warm… at least for a little while.  It works just like heroin, but has a lower potency so more hydrocodone is required– but if enough is taken the same effects will occur.  The person becomes tolerant to hydrocodone fairly quickly, resulting in withdrawal if the medication is discontinued.
All in all, the medications, if they were all taken by Brittany Murphy, would be consistent with someone being treated for migraine headaches, anxiety or panic, and a mood disorder.  Just guessing, of course… and this would NOT  be the ideal way to treat these conditions.  For example, opiates are lousy ways to treat headaches, especially long-term, probably causing far more headaches than they get rid of.  Propranolol is a relatively harmless med for anxiety (providing the person doesn’t have asthma, which propranolol would aggravate).  If the carbemazepine, fluoxetine, and topamax were being used for a mood disorder like bipolar or a personality disorder like borderline personality, then taking the steroid methylprednisolone would be a risky thing to do, as steroids can cause pretty severe mood effects.
These medications have a number of dangeroud interactions, besides the addictive dangers of several of them both alone and in combination.  For those interested in a more detailed list of the dangerous interactions, I have prepared a list of the med/ med interactions in pdf format using the interactions checker provided by epocrates.
JJ
Suboxone Talk Zone

Anxiety, step-work, and gratitude

One of the primary insights that I want addicts to gain from reading this blog is the similarity between their own thoughts, feelings, and pattern of use and the thoughts and patterns of use of other opiate addicts.  We are all dealing with the same beast, we have all felt the same desperation, and we have all experienced the same distorted thinking.  I hope that reading the desperate stories of others will help the reader understand that he or she is not alone, and will help readers identify their own distorted thinking.  But tonight I finished the final performance of a Holiday play with Community Theater (I played the psychiatrist who interviews Santa in a take-off on Miracle on 34th Street) and so I want to tell a happy story related to something that I heard from a patient last week.
The treatment of opiate dependence is in a state of flux;  regular readers know all of this very well, but some of the new readers from my last post (!) may not know my ‘philosophy’ on treatment.  I have an article out there somewhere called ‘Suboxone’s complicated relationship with traditional recovery’ that sums things up pretty well for those who want to see how one person (i.e. me) has come to terms with buprenorphine and the twelve steps.  I find the two approaches to be difficult to combine, since ‘getting’ recovery through the steps requires personality change, which requires desperation.  And once on buprenorphine, addicts quickly lose that desperation.  One could say, then, that buprenorphine is ‘bad’ because it gets in the way of ‘stone cold sober’ recovery.  But I would NOT say that myself, because I know that the success rate for treating opiate dependence using the steps is lousy.  The steps have remained as the mainstream treatment for opiate dependence for one reason:  They were all that we had!  The steps saved my life not once, but twice– but they fail for most others.  I got lucky–  maybe having my medical license hanging over my head made the difference.  It is impossible to predict who the lucky ones will be.  All I know is that I am grateful to be one of them.
At the same time I am haunted by the faces of the people I knew who died from opiate dependence.  And I find the current attitude toward opiate dependence to be heartless– the attitude that leads to discharge of patients from treatment for one ‘dirty’ urine.  I personally know of several people who died after forced discharge from treatment centers.  Who benefits from that approach to ‘treatment’?  Sometimes I am tempted to write to the treatment centers that discharged the dead teenager after his or her ‘dirty urine’, to ask if they are satisfied with the ‘care’ they provided!  Before buprenorphine, we had to accept the fact that 80-90% of young opiate addicts would fail treatment over and over, losing everything– losing dreams of attending college, losing family relationships, and sometimes losing their lives.
New readers are now asking, ‘this is a ‘happy story’?’
Sorry.  I tend to wander a bit.  The point I am leading up to is that I became a fan of buprenorphine treatment because the idea that we can simply ‘treat’ opiate addiction has been mostly myth.  Opiate dependence has been treated successfully in a small fraction of addicts.  Yes, the steps CAN work in those who ‘keep coming back’.  But the truth is that people in their 20’s do NOT ‘keep coming back’.  Instead they relapse over and over until everything is gone, and they have become shadows of their former selves.  But then buprenorphine came along.  Buprenorphine is NOT a panacea;  many people fail treatment with buprenorphine as well.  But in a fatal disease with no real effective treatments, buprenorphine is an exciting step in the right direction.
If you are new to buprenorphine, you will likely have a few months of excitement at the feeling that you have been delivered from opiate dependence.  But then reality will set in, and the work will begin– or at least SHOULD begin if you expect to remain free from active using.   After a few years of treating patients with buprenorphine I have learned that THIS is the point where traditional step work can be helpful to understand what is happening in the mind of the addict, and to guide further treatment.  For example, many (MANY) opiate addicts complain of ‘anxiety’.  I used to worry that the ‘anxiety’ would increase the risk that the patient would use, and I would go to great steps to treat the anxiety- including the judicious use of benzos (the respiratory depressant effect of benzos can be dealt with if they are used properly, but people must NOT combine benzos and buprenorphine without guidance by their doctor).  I found that universally, patients who took benzos did WORSE.  They thought they needed them, and even thought they benefited from them.   But the patients who did the best were the ones who accepted the fact that the ‘anxiety’ was nothing but a craving to be ‘numb’, who then worked on reducing the cravings in HEALTHY ways, without taking benzos.  The patients who eventually wore me down and got me to prescribe a small dose of a benzo only ended up wanting more, and then needing more… until they eventually became people who couldn’t do anything without a benzo on board.  I now realize that the ‘anxiety’ that addicts feel is nothing but the cravings that they taught me about when I was in residential treatment.  When I was in treatment, I felt physically horrible much of the time– nervous, tense, trouble sleeping, etc.  But if I went to a counselor and complained of ‘anxiety’, they would have had a great laugh!   People taking buprenorphine are no different than I was;  they are trying to make HUGE changes in how they deal with their feelings.   Of COURSE they will feel all messed up inside!  But the answer is NOT to find another subsstance to reduce those uncomfortable feelings.  The answer can be found instead in many of the principles that make up the twelve steps.  If a person in ‘sober recovery’ has anxiety, the universal recommendation is to go to a meeting.  I think the same is the case for those taking buprenorphine– not so much for the personality change that is needed to ward off the most severe cravings, but rather to help deal with the more minor cravings that are disguised as anxiety.  Other remedies that are used by twelve steppers include meditation, prayer, reflection, readings, step work, and acting ‘as if’.  All of these techniques will work– if the addict works them.
Gratitude is another major part of twelve step programs.  And again, I find that the people on buprenorphine who find gratitude are the ones who tend to stay clean.   The patient from last week that I referred to a moment ago is a patient who has done well on buprenorphine who NOT coincidentally, I believe, uses lessons from the steps in her day to day life.  During our appointment she talked about how grateful she was for where she is today in comparison to where she was a few years ago.  She talked about looking around her home at the material things she can now afford, like a TV set (two 80’s of oxycontin), nice furniture (four 80’s), the microwave (one 80), etc.  She was grateful for the positive changes in her relationships as well.  No, things were not perfect– they never are.  But they sure tend to be better when OC and ‘junk’ are taken from the equation.
She may or may not realize how everything ties together.  Not being broke and sick all the time allows a person to start to feel like a contributing member of society.   Being able to go all day without telling her friends or partner a lie has improved her relationships.  Realizing that she is not ‘anxious’, but instead is having normal consequences of positive change, allows her to feel a sense of personal empowerment and self esteem for dealing with the feelings without taking pills.  And feeling grateful is a great antidote to resentments, and resentments are common triggers for relapse.  As I mentioned earlier, those recovering addicts who are grateful tend to do well.
The experience of speaking with her during her appointment helped me understand one more ‘piece of the puzzle’ for how buprenorphine and the steps are best combined.  No, I do not FORCE patients get into the steps, because I see buprenorphine as something that is more effective at blocking the intense desire to use.  But addicts who are past the honeymoon stage of buprenorphine and who are starting to drag a bit would do themselves a favor by checking out a program that has been around for almost 100 years.  As always, your personal health history is YOUR business;  if people at a meeting are asking which meds you are taking I recommend finding a healthier meeting– after telling the person that it is none of his/her business!  If you are experiencing ‘anxiety’, realize that we ALL struggle with those feelings, particularly early in recovery.  You will feel better in every way if you see that anxiety as a form of craving, and learn to deal with it in a non-benzo way.  If you have anxiety or panic that does warrant medication, the proper medication is an SSRI– NOT Xanax.
And as the Holidays approach, take time every day to notice what you are grateful for.  If you cannot find anything, be grateful for being alive, as many opiate addicts have lost even that gift.  With all of the Holiday activities I may be absent for awhile.  My kids– the ones who saw me in a locked psych ward 9 years ago, sick from withdrawal– are coming home from college for a couple weeks.  Back then I thought my life was over– no job, license suspended, anesthesia career effectively over.  I couldn’t imagine going back to do a whole new residency in a new field– but it turned out to be an entirely new calling, and has included experiences that I wouldn’t trade for anything.
One last thing.  I was incredibly self-conscious throughout life up to that point in 2001, even needing to enter from the back of the med school auditorium to avoid feeling like everyone was staring at me– what everyone in AA calls ‘being an egomaniac with an inferiority complex’.  I learned through meetings that EVERYONE with addictions felt that exact same way.  After years of watching Community Theater productions from the seats and wishing I had the guts to get up on stage, I used the two years that I was out of work to act in four productions– including two with major solo singing parts (and I had never even been in choir).    Until the play that ended today, I’ve been too busy to participate.  But today I was on the exact same stage where I stood 9 years ago.  Today I reflected on all that has happened since feeling so hopeless back then.  I am grateful that back then I KNEW that I didn’t know anything about how to stay clean.  I am grateful that I somehow stopped listening to myself, and started listening to those who had the clean time that I wanted so desperately for myself.  Had I continued to insist that I knew what I needed, I would not be here today.
I wish you all a very special Holiday season.
JJ