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.

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

Getting Off Alprazolam (Xanax): The need for Recovery

A comment on my old blog referred to a discussion about the withdrawal from Xanax, or Alprazolam, a short half-life benzodiazepine:
Clonazepam (Klonopin) actually is not the drug of choice used in benzo withdrawal, rather it is diazepam (Valium). Clonazepam It is not a very long-acting drug, with a half-life of only 18-50 hours; diazepam’s half-life is 20-100 hours, with its metabolite hanging around for twice that long.

Absolutely the worst thing about benzo withdrawal (take it from me) is that it never ends. That is why I still take them.

Sadie

My Response:

The ‘drug of choice’ for benzo withdrawal depends on many factors beyond half-life. Diazepam (aka Valium) is absorbed very quickly and so the onset of action is as fast as 20 minutes; this is useful in some situations, but is also thought to contribute to the increased addictiveness of diazeapam over clonazepam (Klonopin). Both drugs stick around long enough to accumulate with repeated dosing; diazepam has active metabolites, making the effective half-life even longer than the pharmacologic half-life. But who cares? In either case the person coming off alprazolam (Xanax) can take the longer-acting benzo four, three, or two times per day– even once per day could be sufficient to prevent seizures with either drug, providing the dose is high enough.

It is very hard for most people to get off Xanax… or any benzo. For that reason, the best medication for alprazolam withdrawal may be a non-benzodiazepine anticonvulsant. I have used valproic acid (Depakote) or phenobarbital in patients for treatment of benzo withdrawal and/or alcohol withdrawal. Pretty much anything that works for alcohol withdrawal will work for benzo withdrawal– which is consistent with the fact that alcohol, benzos, phenobarb, and valproate all have actions at the GABA receptor. Other factors to consider when choosing a medication for benzo withdrawal include liver function– diazepam in particular lasts forever in patients with bad livers. Phenobarb affects the metabolism and plasma levels of many other medications. Valproic acid can cause liver damage and tends to stimulate appetite; is also causes heartburn and nausea in many patients.


The biggest problem with coming off benzos is losing the fuzzy haze that covers life and tolerating the harsh glare of reality. Patients complain of ‘anxiety’– many times they are simply feeling what everyone feels all of the time, but they have lost the ability to tolerate the normal stresses of life. This is where 12-step programs come in; working the steps provides everything that is needed for a person to learn to tolerate reality. After 15 years of going to meetings, I am still amazed at the value contained in the 12 steps. EVERYTHING is there! How to tolerate one’s self; how to deal with others; how to cope with rejection or loneliness; how to begin to understand a purpose for living… the answers to all of these questions– questions faced by most drug addicts on a daily basis– are contained in the steps. I strongly encourage, and invite, people learning to tolerate reality to come to recovery and join the others who are looking for the same thing– and finding it at AA or NA.

SD