i totally agree, and I never prescribed either of those drugs when I was in practice, or any other benzos, except for single doses for MRI's for claustrophobic people. When I posted about my sister, who is still trying to get off benzos, several psychs told me she needs them and should not try to get off of them, so it is not just the family docs you need to be talking to.
Thanks for that impressive and succinct advice. Sermo Doc 18 has also posted similar admonition in the past. This advice applies to lot of drugs doctors prescribe..It is a nightmare to get them off the medications once they are started as a "fix" for an ill-defined problem.
I don't have a favorite web site or CD and I realize it's a challenge for me too to get patients who want a quick fix to try relaxation/meditation but it's worth a try and if they insist on a pill you can give them Vistaril or Buspar or an SSRI. You could refer them to a cognitive behavioral therapist or another therapist who specializes in anxiety teaching some anxiety/relaxation techniques. If you recall Herbert Benson's Relaxation Response, you can teach a patient how to Breathe in, hold it for a few seconds, breathe out for a few seconds and say the word "Calm" or the word "One." I like to suggest they also put their hand over their stomach so they feel it rising and falling as they breathe and have them close their eyes. You can write on a prescription pad, Relax twice a day for 5 minutes. If they practice this or another form of relaxation they will be ready to use this tool when they're having a panic attack. The key is to get the patient to realize that what they're experiencing can be treated without medication but it takes practice. Firemen have to practice so they're ready when a fire comes along. They can google Progressive Muscle Relaxation or Guided Relaxation Imagery. They don't really need a CD just to have someone teach them about this. It takes an effort but it's worth it. Otherwise, they may be on Xanax for the next 20 years. The Xanax company thanks you.
Buspar doesn't always work great, I admit,but let the person work on controlling the problem. Give them a bit of encouragement that what they do or don't do will help. I know we live in a quick fix society but they have a role to play in reducing their anxiety. Maybe an analogy is if you have a wound, you don't want to just numb it up. You also have to heal it. Xanax etc. will get rid of their anxiety but when it wears off or the next time the panic attack comes or anxiety comes, they'll need the next dose.
<Can we add the same advice for opioids for chronic pain patients?>
Yes, please. If you don't know what to do with headache patients, I will gladly accept your e-mail.
And for the record, there is HUGE comorbidity between chronic headache patients and anxiety disorders. Can't speak for the numbers on other sorts of pain, but I'd imagine it might be similar.
As for anxiety/relaxation techniques--this stuff is widely available. Here is a selection of links:
How often is a patient willing to wait a week or two until the SSRI or Buspar kicks in to relieve their panic or anxiety attacks? You seem to suggest that we are all 3rd or 4th year medical students who really have no idea what we're doing with the anxiolytics. Now if you drop back to the 60's and 70's when all the docs had was short-acting barbiturates (Butisol, et.al.) and earlier benzodiazepines (Librium, Valium, Serax,etc.) and the thought of writing for a tricyclic rarely drew ink out of a GP's pen, then you are on target. But, of course, that's all they had in those days to calm everyone down and that's where the real problem that you describe occurred.
I noted that many primary care doctors dont realize that antidepressants like SSRIs are also indicated for anxiety... they focus immediately on addictive easy solution benzos.
There is absolutely no reason to ever use Xanax, I agree. Yes I realize I am using an extreme "ever".
Absolutely disagree. These meds, used VERY judiciously, can be an excellent bridge until the SSRI becomes effective and breakthroughs occur in cognitive therapy. The use of these medications, much like opiods, require a strong physician-patient relationship. In other words, KNOW YOUR PATIENTS and monitor use of all medications. This requires time but if you want them to be well and do no harm, this is essential. Monitor amounts, prescribe monthly to weekly, no refills, and develop a plan from day one to taper and stop AND share this with the patient at the first visit for this issue.
yes. people can use them and stop using them and not get addicted but here's two more bits of advice from a psychiatrist who sees the fallout (I don't often see the people who are using them judiciously because they don't come to me. I see people who are hooked on these meds.) of family doctor's and internists' decisions. If you're going to give them Klonopin tell them the research THAT MANY, MANY PEOPLE - I BELIEVE THE NUMBER IS OVER 90% CAN BE CURED OF PANIC ATTACKS BY COGNITIVE BEHAVIOR THERAPY AND THAT RELAXATION TECHNIQUES, BREATHING TECHNIQUES, EXERCISE WORK TO REDUCE PANIC AND ANXIETY. BUT PLEASE DON'T GIVE XANAX. THERE'S NO REASON.
I've been saying this for years and it seemed like no one listened...I hope this is the beginning of a grassroots effort on the part of us docs to stamp out these POISONS.....ditto the opiate!!!
Together, they are all responsible for far more pain and suffereing than they "cure".
Interesting....just yesterday I had a patient come in requesting a Xanax refill that a Gyn had given her for insomnia!
I've also inherited more than my share of patients from psychiatrists who think nothing of chronic TID dosing of benzodiazepams with refills aplenty.
I agree w/ Sermo Doc 7 and scharreramd1... we need to TALK to our pts establish a relationship and follow closely. It takes a few weeks for a SSRI or other to 'kick in' and hvae an effect. A benzo, prescribed judiciously (which includes explaining to the pt) is very helpful to give the pt some relief. I also agree that cognitive behavior tx is an important adjunct and key for long-term care but that also takes time and an investment for the patient both in time and, inmany cases, financially. We're here in the trenches with you psychiatristnj!
Yes SSRIs take a few weeks - how often does someone come in with an abrupt onset of a de novo anxiety/panic disorder? People have unrealistic expectations of instantaneous cures for chronic complaints....something I see in the ER nearly every single day.
Xanax and Klonopin are very different drugs. If you as a psychiatrist would prefer not to use them for the treatment of anxiety, so be it.
In neurological disorders, clonazepam is very helpful in the treatment of tremor, muscle spasms, myoclonus, and other conditions. To dismiss it as a bad drug is bad medicine. It is a drug to be used with caution by those who know how to use it.
Xanax, on the other hand, has, to my knowledge, no redeeming qualities. In fact, it is the ONLY benzodiazepine that causes seizures on withdrawal. The others do cause anxiety and restlessness on withdrawal, but no seizures. I would relegate Xanax to the same box as Demerol = unacceptable side effects when better drugs are available.
Buspar, however, is not particularly helpful for us neurologists. The few times that I have attempted to use it, it has been ineffective.
Xanax has no useful place in medicine at this time. Other than watching people practically snort it and go through withdrawls several times per day - which is not much fun after the first two or three every morning in your office. Agree, please stop using Xanax. Klonopin has occassionally but rarely been of much use, but it does not tend to have serious withdrawl sideeffects, though it can still be an very abused drug by "the Anxious".
Beware, even your great, reliable, professional patients have probably on occasion shared a Xanax or a klonopin with a loved one. It's not a huge problem but it's not great.
How quickly do SSRIs start to work? I like to tell my patients they can work in a few days or a few weeks. I'm not crazy about the give them a benzo for a couple of weeks until the SSRI kicks in. 2 years later, you're still trying to get them off the Benzo. That's my experience. Of course there are exceptions -- i.e. highly traumatic events that a Benzo may be helpful TEMPORARILY. Tell your patients the SSRI may work faster. Don't forget the placebo effect. We can make the placebo effect stronger and faster working depending on what we say. Yesterday's New York Times article about Depression research said the placebo effect is as good as an antidepressant for mild/moderate depression.
And by all means, Sermo Doc 14, use Klonopin for neurological disorders just think twice before you use it for anxiety.
the one good thing about this so called health care reform that is being shoved up our collective backsides, is simply that they will not have the money to pay for such nonsense in the future and thus these drugs, which have become drugs of abuse in my area, will die a belated death based solely upon the financial constraints that such a system will be forced to enact.................then, we will start seeing a lot of new allergies to vistaril!!!!!
Sermo Doc 17 - and how many patients were given UNECCESSARY antibiotics for viral infections by PCPs?
As long as CUSTOMERS demand and PROVIDERS provide, it will never be the way it's SUPPOSED to be - the correct and beneficial medication for the correct indication. First of all - do no harm......
"Even patients who begin taking benzodiazepines for legitimate reasons may end up abusing them. In one study of 2,600 patients prescribed diazepam, up to 60% had abused and/or become dependent on it." Current Psychiatry article from a 1975 study.
Since you have access to the article - please tell us how the patients were selected for inclusion in that study. From general practice? From psychiatry practice? From random pharmacy records? From specialty practices? Was it a very homogeneous group or quite heterogeneous? Are the data for diazepam generally applicable to all other benzodiazepines? How do you know?
Klonopin is a very good drug. It is almost impossible to get addicted to it because its effective half life is about 31 hours. (You will note the ridiculous recommendations to prescribe this at BID or TID, and using it for acute situations!)
Klonopin does get abused, crushed, and snorted.
It is an excellent drug for true panic disorder as a tonic to get in front of the panics instead of reacting to them. It is a good AED and muscle relaxant, although there are plenty of other choices.
It is a good idea that it be prescribed by specialists who can monitor it better than most. And I do mean specialists. I see plenty of irrational use of this drug by psychiatrists, not just PCPs.
As ti xanax, there is virtually no legitimate use of this medicine. It is irrational treatment to give it to someone to chance panic or anxiety symptoms, sleep, etc. The half life is so short, and the withdrawal mimics panic, so the risks of addiction are extremely high.
My unscientific survey here on Sermo revealed that an awful lot of doctors are prescribing it, not just NPs
Xanax should be removed from the market (along with several other bad drugs, like ambien)
vistar1, that same patient then went to yet another doctor to get a refill on what you gave her, and on and on.
Don't prescribe xanax. There is no legitimate use for it on primary care.
Learn about sleep, the harm of using hypnotics for anything but short to term, and then the need for "CBT" meaning, proper education of the patients to learn proper sleep hygiene and expectations.
I'd like every primary care doctor and Internist to read this post. It is an unvarnished review of effects of drugs thought to be "safe" because they are "short acting" Nurse practitioners and PAs must be banned from prescribing any narcotics or hypnotics.
""Even patients who begin taking benzodiazepines for legitimate reasons may end up abusing them. In one study of 2,600 patients prescribed diazepam, up to 60% had abused and/or become dependent on it." Current Psychiatry article from a 1975 study."
See my previous post - they didn't have any SSRIs, NERIs or Buspar in 1975. You can't build a case for current use on 1975 data!
As with EVERYTHING in medicine the prescriber has to use his/her head. I have exactly the opposite experience than psychiatristnj, but, of course, I'm not seeing other's patients.
Rarely is a patient simply depressed or anxious. Certainly treating patients with SSRIs will alleviate the anxiety because you've fixed the depression. But we all know it takes up to two weeks (maybe one, depending on the severity and length of time the patient has been afflicted) or more to achieve control. During that time, benzos or Xanax are helpful to calm the anxiety. IF the patient still needs Xanax at the two-week visit, the antidepressant dose - or maybe even the drug itself - needs a change. Most often I find the need for it decreases and eventually NONE is used. Thus, the concomitant use of these agents is a barometer to successful treatment with the antidepressants.
And the trash going around about 70% of patients don't need antidepressants in the first place is just that - TRASH. I've been treating these patients for 33 years, having used tricyclics extensively before Prozac arrived. Judicious use CHANGES LIVES. Elimination of antidepressants in those 70% will transfer them back to the 1960's when popular drugs were not only the barbs and benzos, but Seconal, Nembutal, Amytal, Tuinal, Doriden, Placidyl, Dalmane - all for people who couldn't sleep but had no generally appreciated antidepressants. I still see psychs ordering Ambien - how does that differ from using Xanax???
Actually, you are not correct and the efficacy of ssris due to their anxiolytic properties is a frequent confound leading people to see them as better antidepressants than they are. Most anxious people will tell you they are depressed before saying anything about anxiety. That is due to how troubling and depressing it is to be anxious.
In my practice, I have spent a considerable amount of time taking patients off medicines that were started by the referring PCP. One of the great confounds is that a huge number of people, also, are already on the mend by the time they first talk to anyone.
BOTH Xanax and Klonopin are overused and addictive. I agree with the SSRI method of controlling anxiety along with either therapy, biofeedback, meditation, and lifestyle modification.
A good way to lose anxious patients to therapy with an SSRI is to NOT cover them with an effective anxiolytic. A transient increase in anxiety is an expected SE of SSRIs. Pts will quit the SSRI and not be willing to retry it after it has made their symptoms worse. The anxiolytic can be tapered and stopped after treatment is initiated.
Sermo Doc 7: " Certainly treating patients with SSRIs will alleviate the anxiety because you've fixed the depression."
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Does anyone else but Sermo Doc 7 ACTUALLY believe that ANY medication "fixes" depression?????
And in our instant fix, fast food oriented culture - does anyone have many patients who actually TRY meditation, biofeedback, relaxation, etc, etc? I'd wager that there are VERY few - especially when a simple little pill can "fix" it.
I have a psychologist who comes to my office three days a week and yes he does offer my patients who I refer to him biofeedback, psychotherapy, and meditation techniques. Maybe there are a few patients who do utilize these techniques, but nevertheless I find them to be helpful and thus synergistic.
I think a large percentage of depression and anxiety can be helped or fixed with regular exercise and eating right or even halfway right.
Everyone wants a quick fix. As for Xanax, I have several patients on it, but I closely watch their refills and PMP reports and do not let them get early refills.
Sermo Doc 18-
From the moment they walk through the door, I am frank about what therapy is expected to produce, the limitations of medications and other modalities. In the chronic pain syndromes, depression/anxiety cases I advocate other treatment modalities like cognitive behavioral therapy, biofeedback - because even their placebo effect can be greater than that achieved by medications.
I saw this thread today and gave two patients a printout of a site listed by Sermo Doc 6. The sites look helpful. One patient was having severe frequent panic episodes, and she was given klonopin by me (ok, so kill me virtually now), but just a few, ok? I don't think she would have followed my suggestion for the SSRI and seeing a therapist without something to stop the panic.
By the way, my friends the psychiatrists, I have been prescribing SSRIs for anxiety disorders since I was an intern, and still do. And the patients don't even have major depression! Imagine that! 8- P
Sermo Doc 23, how have the SSRIs worked for anxiety. I have a patient with chronic anxiety and panic attacks and bipolar and PTSD who swears by Buspar 15 mg. He said to me today that it really has made a huge difference for his anxiety. Everyone's different. I gave him the medicine and I said, I think this may really help you, several months ago.
I was just responding to Sermo Doc 9's comment. Weird, I thought. SSRIs either decrease the rate of panic attacks or stop them, and have been helpful for GAD.
Buspar does work for some people, but I have found for many, it doesn't seem to work much. Yep, it was also available when I was an intern, too. That's just my experience.
I refer difficult to treat patients to psychiatrists, but sometimes it takes about a month or more to see one. My hands are tied. Do I treat with a benzo or no? It depends on how debilitating their symptoms are. I have had some panic attacks myself in the past, and during the first one, the shrink I was seeing offered to call in some....drum roll...Xanax. This was about 12 yrs ago, when I was in residency. I refused, he called in propanolol, I ran to the store, and took it, then paced and felt better. Maybe placebo?
My approach to patients who request xanax is strightforward. I tell them it is a street drug that I in good conscious cannot prescribe. I would say the majority of the patients I have seen come in for benzo's prefer xanax.
I only prescribe low dose klonopin in severe cases of anxiety and short term. There have been a few patients that I have felt truly do not respond to anything other than a benzo, but it is a rairity.
But like others have mentioned, besides SSRIs atarax, buspar and propranolol are a maintstay and they do work. I have had very good success with high dose vistaril for anxiety.
I don't think you can clump any meds or group of meds together. What I feel is more appropriate is that a physician should understand the meds they prescribe. I can't count the number of amazed looks I get when I advise a physician there pt OD'd on their Klonopin and that 0.5mgs of Klonopin is equal to 10mgs of Valium. I do emphasize that if a physician is going to prescribe BZ and opioids they need to MONITOR those pts. That includes random urine dips, tox screens, random pill counts, checking BOP sites etc. It's also important to know how to take your pts off these meds if you start them. Don't take off if you don't know how to land.
"Does anyone else but Sermo Doc 7 ACTUALLY believe that ANY medication "fixes" depression?????"
OklaERdoc, let me clarify my statement. Using the SSRIs or any antidepressant class without any discussion is not what I meant. I should have taken more time to elaborate. When I suspect depression, anxiety or both, I give the patient a mood disorder questionnaire which essentially covers the basics of sleep disturbance and quality, daytime fatigue, irritability, forgetfulness, lack of interest in usual tasks, sexual appetite, and misdirected anger. Based on the responses I discuss how these symptoms relate to anxiety and depression, bringing to their attention that we all have normal "ups and downs" but anxiety is really just an elevated level of alertness, produced by the need to identify the origin and identity of a perceived threat. If that level of alertness is higher than normal (for that patient) I characterize it as stress. Move higher and we have alertness equivalent to fear, but the patient has not identified what they fear. Go higher, we have panic. Higher again and we have what might be called a nervous breakdown, which is the brain's ultimate escape from its inability to identify the need for all this alertness. Now we simply can't exist in this altered state so the brain tries to compensate by DEPRESSING the level of alertness as a defensive and protective mechanism. Boredom is the first "level" of depression and this proceeds all the way down until one reaches the ultimate "escape, suicide. So any patient can now range, on any given day, between these various levels of anxiety and depression. I then point out that it has not been proven, but for discussion's sake, these ranges of uncontrolled emotion can be viewed as "burnout" - the brain's ability to manufacture enough of the neurotransmitters we call serotonin, norepinephrine and dopamine to function normally. There are probably more than 3, but let's just discuss these three. We all have them but not everyone has 1/3 of each. Just to clarify this picture I suggest that anyone's ratio of these three might reflect their personality, so that if you have 70% serotonin and 30% NE and I have 80-20, we might "think" alike, and get along with each other. If you have 90% dopamine while I have 90% serotonin we might rub each other the wrong way and not get along. This sets the stage for the patient's acceptance of the medication which I relate will replace the deficiency of neurotransmitters (recognizing this has not been proven) and once I get their chemistry back in balance, it's the patient's job to play psychologist and identify the stressor(s). reorganize their thinking, come to grips with what will be needed to alter lifestyle to fix the problems to their own satisfaction. I can usually get this introduction done in less than 25 minutes and often the patient feels better before I have written the Rx because they recognize someone understands how they feel. In two weeks I have the patient revisit and compare another mood questionnaire to the first, which directs the need for dose change, more discussion. During that first two weeks is where the need for an anxiolytic in addition to the antidepressant is useful. If the Xanax or whatever one might choose is still needed, it affirms the need for an antidepressant dose change or an addition of a NERI to the SSRI (or reverse, depending on how you started).The next visit is a month later and we repeat everything. If at any time I have not achieved control I opt for referral to a psychologist for more definitive cognitive therapy. Often the reverse is true - the psychologist starts the ball rolling and recognizes medication intervention is needed and refers the patient to me. I hope you now see what I meant by "fixing" the depression.
This post,not the poster,seems to assume that FPs 'abuse' their prescription privileges.Benzodiazepines have their specific indications in certain clinical situations,especially if you require immediate anxiolysis.Appropriately prescribed and monitored,short-term,for the right patient they are very valuable drugs.They are,afterall,scheduled substances.Besides,in most clinical situations,their ability to decrease the seizure threshhold may be more significant than their addictive potential.Physicians are patients too;some of them need benzos for various reasons.Benzodiazepines,in general,should of course not be prescribed to people with a history of ANY kind of addiction,family hx of same or even a perceived potential for addiction.There,lies the ART of medicine.
SSRIs invariably have to reach a steady state to be effective if at all;who knows where placebo effects end and true SSRI begins?Many psychiatrists I know will use these two classes of drugs concurrently,one ostensibly limiting the frequency of use of the other.The only useful indications I find for SSRIs are mild adjustment disorders and SAD.
Someone asked for the details of a 1975 article I cited on valium abuses. I don't have the article, I just have the quote I cited from a recent article in Current Psychiatry. My source isn't great but I guess most of us at least agree from what I can tell on the post that these meds are abusable and problematic even those who argue correctly that there is a place for these meds (maybe with the possible exception of Xanax) although I will personally try to dispense as few of them as possible, and I think a fair number of you agree that Xanax is the worst of the bunch. Maybe they should dispense Xanax only at Medical Marijuana clinics. As a psychiatrist who does some cognitive therapy I realize that Panic attacks can truly be cured -- that is either completely eliminated or reduced from hours to minutes so they don't control a person's life!!!! This can only happen by therapy not by benzos. Sometimes the period of anxiety passes if it's a life stressor.
Sermo Doc 7, a patient who's been on an antidepressant asked me the other day if she could come of her antidepressant. She had not been depressed for about a year or more. I said that yes she could try to lower it because a year is a good amount of time. She was worried that her serotonin might still be out of balance. I said that I did not really think of it as a chemical imbalance and that that was more the way the drug companies thought about it. I said that meds give you some extra serotonin or norepinephrine by blocking reuptake (i explained this) but that currently we cannot measure a depressed person's brain or a not depressed person's brain and find any difference in serotonin or chemicals. The meds work but why they work exactly is still not certain. I think, and there was some article on this week, that depression has more to do with negative thinking patterns than a chemical imbalance.
"PS - ANXIETY/PANIC and PAIN never killed anyone. "
except when it is misdiagnosed PTSD. Never given benzos is clearly a mistake and such absolutist thinking is contrary to proper medical management of anxiety and panic. Clearly, short term use and documentation and discussing with the patient that use will be short term can be a great benefit.
Also, no Valium...? Ever?? That's moronic. I'll tell that to the next parent I see whose kid was just killed or daughter was raped Come on, a couple of 5mg valium are appropriate in some cases.
Psychiatristnj said: " I said that I did not really think of it as a chemical imbalance and that that was more the way the drug companies thought about it. I said that meds give you some extra serotonin or norepinephrine by blocking reuptake"
What's the difference if you "give extra" neurotransmitters vs a chemical imbalance?
Sermo Doc 7, this is my own thinking based on my reading of the research, but I don't think of depressed people being deficient in serotonin or having an imbalance nor do I think of people with schizophrenia as simply having too much dopamine. My understanding is that the Serotonin theory came about from research on people in the 60s? who had committed suicide having less serotonin in their brains on autopsy than others but I believe that this research is far from clear cut. Frankly, I am not up on the exact research. If you google chemical imbalance you'll find that it's a controversial topic even among scientists.
I've read articles where people point out that an aspirin gets rid of headaches but that doesn't mean we have an imbalance of aspirin or a deficiency of aspirin. Increasing your serotonin or norepinephrine or dopamine (which are obviously different from aspirin because our bodies make them) gives you a boost in your mood but maybe I'm splitting hairs, but I'm not sure anyone has proven that that means the patient had a deficiency of these neurotransmiters in the first place compared to the nondepressed patient.
I can't remember a time on our addictions unit when a patient prefered ativan, klonopin, etc over xanax. They might have taken them when they were available, but invariably xanax was the prefered drug.
Society ?? I don't know what kind of a journal this is???
Jonathan Leo1 and Jeffrey R. Lacasse2
(1) Lincoln Memorial University, 6965 Cumberland Gap Parkway, Harrogate, 37752, USA
(2) Florida State University (FSU), Tallahassee, USA
Published online: 28 November 2007
Abstract The cause of mental disorders such as depression remains unknown. However, the idea that neurotransmitter imbalances cause depression is vigorously promoted by pharmaceutical companies and the psychiatric profession at large. We examine media reports referring to this chemical imbalance theory and ask reporters for evidence supporting their claims. We then report and critique the scientific papers and other confirming evidence offered in response to our questions. Responses were received from multiple sources, including practicing psychiatrists, clients, and a major pharmaceutical company. The evidence offered was not compelling, and several of the cited sources flatly stated that the proposed theory of serotonin imbalance was known to be incorrect. The media can play a positive role in mental health reporting by ensuring that the information reported is congruent with the peer-reviewed scientific literature.
Okay, it may not be the greatest source, it's from the same article...these guys are neuroscientists...I found it on Google but it seems to make a lot of sense to me.
"And, as Johnathan Leo argues, "low serotonin levels are no more the cause of depression than low aspirin levels are the cause of headaches." You can read the Leo and Lacasee article in the journal Public Library of Science Medicine, DOI: 10.1371/journal.pmed.002092.
Leo goes on to state that this myth involving a chemical imbalance "has become a mainstay of popular culture. But there's very little support for this. We really don't know what chemicals are involved." Moreover, if such a chemical imbalance exists, it has not yet been determined whether the imbalance is caused by the depression, or the depression causes the imbalance. Neither scenario has been scientifically established, but it is in the interest of multinational drug companies to propagate the myth.
More support for the chemical imbalance myth comes from the chairperson of the US Food and Drug Administration, Wayne Goodman. A "good man" indeed, he admits that the chemical imbalance story is a "useful metaphor" but claims that he would never tell his own patients that they were suffering from a chemical imbalance. "I can't get myself to say that," he stated.
The Irish Medicines Board, an equivalent body to the FDA in Ireland, has banned the drug company GlaxoSmithKline from making claims that depression is caused by a chemical imbalance. Such information is no longer permitted to be printed in patient information brochures. Leo and Lacasse want the US FDA to follow suit.
This is a great breakthrough for depression sufferers around the world. The myth of chemical imbalance effectively renders the sufferer a victim of circumstances seemingly beyond their control. Systematic deletion of this myth from popular folklore will hopefully encourage sufferers of depression to look for more effective ways of dealing with and eliminating their depression."
Clinical depression tends to run in families(read:seems to have a genetic basis),not quite as clearly as schizophrenia but most physicians in practice for a while will note on elaborate hx that clinically depressed patients invariably know someone in the family with a similar history.In my experience,after you obtain a negative family hx while interviewing depressed patients and kin,the answer may be different when you rephrase the question.My favourite alternative question is:do you know anyone in your family that suffered a 'nervous breakdown?History goes a long way in establishing diagnoses.I also interview spouses,siblings,etc. with pt's permission.Studies in mental health cannot really be empirical,strictly speaking,because answers on questioneers are invariably subjective.Environment and circumstances also play a role.
Occasionally,I would ask:has anyone in your family ever required hospitalization for mental health issues?Ever attempted suicide?Alcoholism or other substance abuse in the family(depressed patients may abuse substances to mask depression)?
"Clinical depression tends to run in families(read:seems to have a genetic basis)"
I'm not so sure you can jump to that conclusion. Could you say that a family with poor hygiene habits that all have B.O. have a genetic tendency for that? What if they all chew with their mouths open? Genetic? Miserable dispositions?
You may be correct but there may be other factors at play.
Women have cholelithiasis much more frequently than men - if a mother has it and her daughter gets it - is it genetic?
Okla,would you be more comfortable with that comment if I substitute 'genetic' with 'familial'?If so,you have it.:-)Yes indeed,chewing with mouth open,poor hygiene habits,cholelithiasis,you name it,may all be 'familial'.Ontogeny/phylogeny/physiognomy principles may apply here.Technically,we can only ascribe genetics to 'mapped-out' cases with the alleles isolated and identified.I did say that other factors may play a role.
Why in the world are you casting all the blame on family docs? I almost never prescribe them excepot very short term. Internists don't prescribe benzos???How about cardiologists? They're constantly putting my patients on Xanax. And frankly, every time I refer one of my patients to psychiatry they come back on Xanax or Klonopin, often Ambien or Lunesta, sometimes plus Ritalin!
So, psychiatristnj, you are one of the few remaining in your specialty that actually does psychotherapy and counseling?
Practically ALL my patients who are under the care of a Psychiatrist complain that they are seen a mere 5-10 minutes, and visits are merely medications refills and adjustments. I asked 3 Psychiatrists in our area (at different times) why that is...the seemingly unanimous reply was..."Psychiatry now is mostly Psychopharmacology"- (including anxiety treatment.)
There is a declining number of psychiatrists who still do therapy, less than 10% for sure.
I am one, and I know only a handful of colleagues who still do.
The psychopharm psychiatry doesn't work because the medcheck doesn't allow the doctor to observe anything, but serves as a checklist. Think of an internist asking a person how his heart is, rather than listening to it and doing an ekg. In a therapy setting, I can interact with the patient over time and observe for myself what is really going on.
The typical PCP doesn't have the time to observe people either, so there is a lot of symptom focused prescribing,which is why a lot of people have medicines they don't need, and the drug abuser have such an easy time of it. Since no one values therapy, the insurance schemes will continue to discourage adequate face to face time with patients.
Sermo Doc 18 - there is also the "customer" phenomenon at play. Customer wants nerve pills, "provider" fails to provide - customer takes business elsewhere until customer gets what customer wants.
If I'm hellbent to get some Xanax and some yo-yo PCP starts yammering about "relaxation", "guided imagery" and all that crap - I'm going to Dr. Feelgood, who will be all too happy to take my cash in exchange for a script.
I'd like to see the results of a totally honest poll to find out how many PCPs give out antibiotics to patients who they know full well have the common cold - just so they'll keep coming back.........after all, businesses live or die on repeat customers.
Thank God I am in the ER setting and I couldn't care less if they come back or not for non-emergency stuff. I'm not so sure my CEO would agree with that sentiment but it's how I feel, nonetheless.
i agree with those who say klonopin prescribed judiciously, and followed carefully, can be an excellent medication for anxiety, so long as it can be discontinued when acute problem is resolved. Xanax has a multitude of problems, and if it were used only for airplane phobias it would b e fine with me. I just posted a comment on labdoc's thread about a patient with an acute panic attack who thought it was an MI, about the use of SSRI's plus a benzodiazepine during a state of acute panic. Here is the link md.sermo.com
There is a lot of irrational prescribing in psychiatry and in other branches of medicine that use psychiatric medicines. The "psychopharmacologists" in most residencies do not know anything. A few are true pharmacologists from whom you can learn valid principles. Some are outright dishonest people on the take from the industry. Most are self-styled blowhards who parrot the advertising glibly so pass themselves off as knowledgeable, which is why the teaching around prescribing and resulting practice is so poor.
I wonder how many people routinely follow updates such as this:
A big problem WE have at community health centers is that about one in five patients is Bipolar and THEY make a big stink and demand benzos. The Psychs at the mental health center give it for their "panic attacks" but probably also as a bribe to calm them down and keep them taking the other stuff that actually helps them.
Seroquel is not a benzo but is a BIG problem particularly amongst our prisoners
On another thread a family practitioner admits to prescribing narcotics he knows the patient doesn't need, then complains when the patient makes a public spectacle at his expense, then trashes those of us who call him for prescribing meds he knows a patient doesn't need! Go figure.
I agree with their use for a "bridge" to SSRI use. I've been in rural practice for 20 years now and feel I know how to use such meds. I also know my patients pretty darn well. And, I'd like to encourage you psych folks to bring a practice of two out here!! Not enough symphony orchestras, fitness clubs, major league teams, or what? Just kidding...., but it is a fact that getting behavioral therapy out here, 90 or more miles from help, is difficult.
I do agree that the use of these meds should not be done on a whim....and their use should be very short term. Also, your post has made me consider a few of my patients' usages. Thanks!
As a psychiatrist who does some work in corrections, I would also like to add that if your patient's social history includes a history of frequent arrests, you might seriously consider avoiding any controlled substance if they are at risk of being incarcerated in the future. These patients will not be maintained on benzos for long (they will almost certainly be tapered off if they remain incarcerated for any length of time). Better for them to be on something they might get a change of receiving (like an SSRI or Vistaril) I also see a lot of patients that come in, and are diverting their Xanax to get other drugs or money as well. And a lot of these patients have great stories about how they con doctors (often multiple doctors at once) to prescribe anything they want. I can't wait until there is some universal pharmacy reconciliation system.
Amen! Thank you psychiatristnj! I too must undo medication of this type in outpatients and those in forensic settings. Its' the ammunition that many persons who are incarcerated use: "I'll just leave here and get my ____(family doctor, psychiatrist, shrink...)____to give them to me!" Frustrating but I still dont prescribe these in the prisons where I work. When I switch long term patients to an SSRI they eventually begin to manage well. (After the withdrawl from the benzo's resolves)
three comments-- 1. in 1970, the number one and two prescribed medications at David Grant Medical Center (Travis AFB) were Valium and Librium--the hospital commander ordered that every patient who was taking this medication had to have a psychiatric consultation--I interviewed about 50 women and they all had chronic anxiety that was well controlled with low doses of these two medications, they were not abusing them and I did not find one case that did not warrant continued treatment with them. 2. There is no substitute for SHORT TERM use of benzos--good example a patient with a breast lump who is pending biopsy--while waiting two to four weeks, these medications can be very helpful 3. Panic attacks are best prevented with SSRI's, cognitive behavioral therapy, etc.
Hey it's not JUST THE FAMILY DOCS that shouldn't do this. It's all the other specialties as well ESPECIALLY the PSYCHIATRISTS. In my experience they usually start the supply going and refill it with no end in sight until I make a stink about it with the patient and with them as well. Family docs be brave hearts and confront the addictive nature of these 'band-aid' drugs with your patients. There are many more alternatives to them! Don't we all know.
With all due respect, Psychiatrists need to walk in our shoes and see what we have to do to treat the myriad of mental disorders we deal with as Family docs. Have you ever dealt with a distraught mother whose child was killed in a stupid accident? I don't think an SSRI would help.
I agree that benzos are not good long term, but to use judiciously in the right paiteints and with control, it can help. You can't generalize about one class of drug like that
Also, i have asked before WHY psychiatrists don't talk to their patients anymore and just prescribe mes. At least that's my experience .
Interesting. While I agree with the underlying premise about treating panic attacks, in my experience it is psychiatrists who are much more likely to jump quickly to medications without taking the time to try other therapies. It is psychiatrists who are much more likely to start these addicting medications and then the primary care physicians are left to deal with the ramifications. All the sanctimony from psychiatrists here about their expertise in managing these conditions doesn't match the reality that most of them only want to do "medication management." and not patient management. Most good primary care physicians at least do a thorough evaluation (including a physical examination, labs, etc) and consider other medical conditions before jumping onto the psychiatric med bandwagon. Most patients that I have sent to psychiatry for their expertise in managing these conditions end up coming back to me after a brief evaluation on the same medication that I would probably have started them on anyway (or a more addicting one).
This is a really, really great post. If you don't see the problem of massive addiction issues, illegal use and sale of these drugs, etc you are walking with you eyes closed. Every doctor who prescribes these has a tendency to think "Oh I do it right, my patients are well selected, I follow them, etc" but the stats simply don't support that.
I agree that if this isn't fixed, they SHOULD be taken off the market as numerically, they are causing far more suffering than they are treating. Prescribe exercise and follow up with patient, prescribe EFA's and nutritionals and follow up with the patient, etc etc. These things all work and don't cause addictions. Look at the number of children on these drugs-how can we defend this?. Perhaps we could create parenting tools that work instead. Might help the kids far more in the long run. We are doing something terribly wrong which is indefensible.
I used to prescribe benzos for patients regularly when I started private practice in 1995, now I don't. Perhaps it's because I work in a community mental health center where addiction and comorbidities abound. or perhaps it's due to the fact that there are better choices on the market. No one should need these medications daily, if you ask for them, you are telling me that your nervous system needs further stablization, for which I would use an atypical antipsychotic, and an anticonvulsant if necessary.
For the most part I couldn't agree more w/ most of you, esp/ re: xanax. However, our neurology colleague is right-on re: klonipin. When MY neurologist recommended klonipin to me for my REM sleep disorder and episodes of striking out w/ my body while "asleep",I protested (0.5 mg taken 3-4 nights per wk.). I didn't want any thing to do w/ THAT DRUG. Thankfully I listened, and now at least 3-4 nights per wk my wife is no longer beaten and I sleep restfully. I have Parkinson's disease........
Benzodiazepines are just alcohol in solid form acting on GABA receptors leading to Cl influx and hyperpolarization of a neuron. They do cause CNS inhibition which can lead to behavioral disinhibition especially in geriatric population. They can give courage to act on suicidal ideations. They are safer than barbiturates due to high therapeutic index.
They have limited role clinically like detox from alcohol and use in case of serious psychiatric emergencies similar to steroids i.e. quick taper off.
The difference between use and abuse is very difficult to recognize. They become very quickly 'life saver' or 'oxygen' for the patient who prefers to carry them all the time. They do have significant street value.
Long term use can lead to subtle changes in personality similar to BPD with interpersonal intolerence and impatience. It further can cause loss of job, marriage and family for the patient.
There are rare and few exceptions to all this with lack of tolerence. I have seen one patient of "Stiff man syndrome" being stable on Diazepam 60mg/day for many years.
But why to take chance or risk when there are several quick acting medications available as substitute to benzodiazepines like: Hydroxyzine, Diphenhydramine, Propranolol, Low dose Thorazine or Seroquel or any sedative type of medication acting on H1 receptor.
Ambien, Sonata and Lunesta have the similar potential like benzodiazepines thought they are technically non-benzodiazepines. (Tramadol/Ultram is similarly non-narcotic theorotically but not practically)
Unfortunately sometimes benzodiazepines are used by doctors to ensure compliance/adherence of the patient for regular follow-up and billing. A person on Xanax will avoid 'no-show' in spite of any weather or situational problems.
Stuff like this is never published in any peer reviewed journal with so many comments from practicing doctors. Good job psychiastrini..I really wish you had not singled out family doctors. I see all doctors including surgeons and psychiatrists casually prescribe these medications.
I agree with the posts (Sermo Doc 10 and the like) that state that you cannot AND SHOULD NOT categorically eliminate these from your repertoire if you are a PCP (family doc, etc) - these medications -- again agree with posts above -- like pain meds, can and should be used appropriately and like pain, anxiety tends to be undertreated by us as physicians.
ALL meds carry risks, the risks might be different and some more consequential than others, but the risks should always be weighed -- if YOU KNOW YOUR PATIENTS and you can seriously say you have a good grasp of their problems and the doc-pt relationship is there, PLEASE DO prescribe these (judiciously as you would rx an antibiotic judiciously and to only those who actually need it, you dont want resistance or a case of life-threatening cDiff etc).
I disagree with anyone who says ALWAYS and NEVER in medicine as these are NEVER right and likely ALWAYS wrong.
Of course whether they are seeing a therapist and managing coping skills (learning new ones if needed by way of yoga, exercise, therapy, CD's, web material etc) is ALSO VERY VERY IMPORTANT collateral and ADDITIVE treatment
I am flummoxed every time a patient shows me a Xanax bottle prescribed to them by another psychiatrist. As said by so many above: except for claustrophobia in MRIs and aerophobia (each of which require an rx quantity of #1 or #2), Xanax should never be prescribed. It is an outdated medication that should be Schedule I along with other historical medications such as cocaine and heroin.
Psychiatrist are not immune from being quacks either. Half of the kids diagnosed with ADHD do not have the condition, but many practitioners turn a blind eye towards the diversion that lies behind the self reports of "improvement" now that the psychiatrist is prescribing Adderall. Ultram? Z-packs? these have rare indications too, but they are grossly over prescribed by practitioners more interested in processing patients then doing the hard, difficult work of arguing with and educating patients.
Anyone remember the quack drug Darvon? Only quacks prescribed it.
I reiterate: there is NO reason for a PCP EVER to prescribe xanax (Klonopin is a different matter)
Withholding benzo's in panic is like withholding morphine to the patient writhing on the stretcher with a kidney stone or a broken leg.
I've prescribed them as a bridge-maybe 20 pills- until the SSRI's kick in and CBT can be arranged.
To do otherwise is mean or, at best, misguided.
To tell other docs what to do because they are not trained psychiatrists is ludicrous.
You guys are crazy.
Your AVATAR patient satisfaction scores will fall.
You will all get fired .
Come to think of it that sky is looking a tad unstable, too.
I disagree. There are more than rare indications for the short-term use of benzodiazepines. SSRI's do not work uniformly nor in everybody, and there are people who do not tolerate them. The vast majority of people who are prescribed benzos take them responsibly. Multiple papers have been written on this topic. There is clearly a group of people, most of whom have other chemical dependencies (esp opioid and alcohol) and some with personality disorders, who do very badly with benzos, and we need to ask the right questions of our patients, which we do not always do, to sort out these patients and keep benzos from them.
Even when SSRI's work, panic attacks still occur, and there the use of high potency benzos short-term is clearly indicated.
I work with chemically dependent patients, and have seen the devastation that benzo dependency can cause. However, I have to recognize this as a selection bias and also know that there are some people for whom very modest doses which remain stable have greatly improved their quality of life. For some of these folks, particularly those with severe trauma histories and PTSD, the level of psychotherapy available is not always adequate, affordable or effective.
Pot calling the kettle black: I find Sermo Doc 28's note to the point, and the proportion of psychiatrists in this thread who don't use BZDs out of sync with what I see. I think psychiatrists in general prescribe a ton of clonazepam and a fair amount of the short-acting BZDs as well. I continue to feel exasperated with my psychiatric colleagues in general with the amount of polypharmacy I see. I know few psychiatrist who can do much more than define CBT and are much more likely to simply write one more script than step back and look at how much stuff they're asking a patient to take. I can't tell you how many cases come to me with the patient on at least one of every family of psychotropics; and certainly a BZD or two is in the mix. They are typically difficult patients with lots of psychodynamics going unaddressed. I wonder how many of those docs would be willing to take the handful of pills they're asking their patients to take - even once.
You ARE misguided. If a cardiologist told you what to do with nitro, you would listen FPs are being put in a position to do what hey are not adequately trained to do.
You should NEVER prescribe xanax, ativan, serax, EVER! If you do, you are a drug pusher.
Did you know that most panic patients need nothing more than CO2 re breathing? Of course not. The poseur in your residency who claimed to be a psycho pharmacologist is, well, a poseur.
I agree with Sermo Doc 10
These meds, used VERY judiciously, can be an excellent bridge until the SSRI becomes effective and breakthroughs occur in cognitive therapy. This requires time but if you want them to be well and do no harm, this is essential. Monitor amounts, prescribe monthly to weekly, no refills. I prescribe klonapin only for a short time with SSRI, never xanax.
I think that it is important to make decisions based on each separate individual--that's where the 'art' of medicine comes in and it is, perhaps where intuition, true compassion, empathy, and the wisdom of experience come in. I, myself had a provider who prescribed these medicines to me during a particularly anxious-ridden time during my second year of medical school. They did wonders for me and I did not become addicted. Plenty of patients out there are just like me--they are aware of the addictive potential of these meds, but using them during a brief interval makes whatever they are going through much less painful. That is where these meds are helpful. Deciding to make an entire class of meds unavailable to all of our patients based on data from specific groups isn't fair to other groups. Though these medicines have addictive potential, they are not addictive for everyone. Some patients are more responsible than others, some have a higher tendency to toward addiction, and some are just trying to work the system. While it may be difficult at times to discern who fits into which category, part of our job as physicians is to ease symptoms of disease, while we work toward a diagnosis, cure, or some other more permanent fix. I don't think it is fair to our patients to discontinue prescribing these medicines entirely, however I do think that it is extremely important to make sure that every patient who takes these meds is aware of the potential for addiction and very regular follow-up should be required throughout the temporary interval that the patient is on these meds.
Due to the retirement, moving away or going "concierge" of a number of other docs in my community, I've inherited quite a few older patients in the past few years. Some of them are lovely ladies in their 60s through 80s who have been on stable doses of benzos (say lorazepam 0.5 tid) for decades, along with the usual antihypertensives and other old-lady meds. The mere mention of trying to wean them off their benzos gives them the vapors. Any wisdom from all of you out there?
What is very interesting is that in my experience the ONLY ones abusing Xanax are the psychiatrists! It is not unusual for a patient to be put on xanax 1 mg 4X daily as a starting dose. This is not a "family medicine" problem in my community.
Chose #19 (cf. "Comments") as the integral summation of agreements with propositions:
#4, BZDs useful in general;
#5. BZD possibly useful long-term;
#7. Agree, BZDs useful preferably short-term;
#11. Reasoned & reasonable empathy with the situation of many GPs/FPs at large with respect BZD & other vox populi Rxs (psychotropic & nonpsychotropic);
#17. CBT is more $/tx than relatively inexpensive BZDs.
lawdoc: Very cogent discussion (as usual).
njpsychiatrist: Thank you for raising an interesting & salient discussion on this matter of BZDs.
Sermo Doc 45: I have to agree most with this writer who warned against categorical, black-&-white thinking regarding BZDs. I don't think it would be very useful to "ban" Xanax or even Darvon (e.g. my internist late father described Darvon to me back in the late 1970s as "junk") because there's always the idiosyncratic & authentic beneficiary of the iatrogenic Rx of one or another demimonde or twilight zone meds. One wants to avoid artificial &/or avoidable inducements for the blackmarket production of Darvon or Xanax!
Here's a thought:
Clinical psychologists are lobbying (with some isolated successes) for Rx privileges (in order to tap into the lucrative psychopharm Rx practice, i.e. the worried-well, well-paying Prozac pt). Why not ask the "Prescribing Psychologist" why they ain't doin' what they they'z already best at?---Like PSYCHOTHERAPY?, like COGNITIVE BEHAVIORAL TX? If it's $, then why don't "Rx'ing Psychologists" lobby 3rd party payers for more $ for CBT & other therapies--instead litigating &/or lobbying against MD 'monopolies'?
[Apologies for the capitals letters--can't underline or italicize.]
I am so appreciative of that broad stroked advice. Last year I found myself prescribing too many drugs because I got a cool trinket or neat pen. I was thankful congress told me I was being too influenced by drug reps and now I don't have anybody telling me what and how to write medications. I have misplaced my cookbook for medicine, maybe I will find it soon. Thanks again.
So what does everyone think the best way to proceed is when you have new patients who come to you already on Xanax? I agree that this drug does more harm than good so I essentially never prescribe it. However, when we're undertaking new patients, should we just stick with that stance and say I never prescribe Xanax, or prescribe it temporarily to help wean them off of it, while adding SSRI's or other alternative treatments?
Some good comments. I think short term tightly controlled use cane be safely done and should be. Therapy and SSRIS take time and money and when the patient is actively hyperventilating you need to break the cycle immediately. Patient satisfaction-centered care causes us all to overuse meds we should not, including benzos, narcs and antibiotics. But saying no without the patient having a clear plan B- a therapist or additional support network can be dangerous. And we all know these resources are in short supply and not obtainable to the uninsured or poor patient who cannot take off from work to make the sessions.
I am completely behind Sermo Doc 18 on every single post he made. Including Xanax should be erased off the market and Klonopin used with way more caution.
I use xanax 0.25 mg acutely for anxiety, but never chronically. I Rx 30 of them, tell the patient I will never refill them and to make them last as long as possible. I also start them on a chronic meds as determined by the office interview.
On the first visit I spent 30 - 50 minutes with the patient if I feel they are reliable and will cooperate with treatment, otherwise I am through with them in 5 - 10 minutes if it is my opinion they are drug seeking or not willing to agree to try my way. If they ever get the meds somewhere else, I fire them from my practice.
In 35 years, I can truely say, I have not been the cause of a xanax addiction in a single patient.
I usually refuse to accept the patient who is already on xanax when they first try to schedule an appointment.
Xanax, a great acute - short term drug, a horrible, nightmare when used long term. 30 - 0.25 mg tabs one time in their life and not refilled.
NEVER use NEVER as an answer.
The nitro analogy seems a little boggus. There sure are some strong feelings about certain drugs here. I think there are rarely such absolutes in this world.
I wonder why the Klonopin manufacturer couldn't get JACHO to come up with an anxiety scale as the 6th vital sign. I find Percocets and Oxycontins being given to anyone with any pain. Then I have to convince patients these are addictive and restart at a lower level of pain med.
In doing both FP and Psych I see both sides of the issue which really comes down to time. FP docs (at least at our clinic) average about 7 minutes per patient which is hardly enough time to scratch the surface of the counseling needed. Psych doc's are usually at the top of the mental health food chain and therefore an expensive commodity that few insurers are willing to pay for except to do the thing only they can (as opposed to an LCSW/psychologist/LPC). Hopefully obamacare and parity laws will begin to fix this. As for all the finger pointing I find it unneccessary and counterproductive. The vast majority of all physicians are trying to do the right thing for thier patients in the circumstances they are dealt.
As for Xanax I agree with many of the posts. the problem primarily is a function of onset slope and area under the curve which looks like a high amplitude short duration sign wave. This is similar to the nicotine delivery found in cigarettes. providing the highest psychological addiction potential because the patients "feel" it's effects on and off. Overall benzo's with the exception of Xanax have thier place and I use them frequently. i keep a stack of cd's in my office with progressive muscle relaxation and deep breathing exersizes as well as a handout with basic CBT and a few homework assignments. I also frequently advise pt's to get a key chain pill holder to keep a benzo in; this provides a safety net for some that can be all they need to quell thier fear of being caught without; just the availability being enough and reducing overall usage; in fact some pt's need me to refill for them just because they "get old." I recommend the Anxiety and phobia workbook which the pt can buy or you can just zerox a few assignments for them.
SSRI's are an excellent prevention medication for anxiety and depression and I would caution getting too caught up in the popular antimedication movement. Many studies show us that therapy or medication will help the majority of people but htat the highest effective rate is seen when people do both.
It has been my experience that patients taking Xanax and Klonopin as well as hydrocodone fall in to two different groups. Those who can take them on a prn basis and never have addiction problems, and those who continue to need more and more.
It is the same problem with alcohol. Those who can drink responsibly and those who cannot put down the bottle after they take the first drink. Benzodiazepines are helpful in this first group, and harmful in the later.
In my practice, I usually try to find those who need long term treatment with these medications and have them sign a contract restricting them from early refills and taking more than prescribed. If this happens, they are not refilled anymore.
If these medicaitons were so dangerous, I am sure they would be taken off the market a long time ago. Look what happened to Vioxx and Bextra. Please don't blame the family physicians for this as many unethical generalists, family doctors, psychiatrist, and internal medicine as well as certified. pain specialists dole out these medications by the truckload every day. I had a patient who got all his abused drugs off the internet.
I thought you really weren't supposed to medicate grief. So, all of the "trauma" exceptions we have above really shouldn't be treated. Grief does not respond to medication the way garden variety depression does. If you daughter gets killed in a car collision, you are going to grieve, and you're going to feel it, and you shouldn't think a pill is going to take those feelings away. You are supposed to feel grief. It sucks, but c'mon.
And I know a lot of people here don't like zolpidem, but why oh why would you use a benzo for sleep over zolpidem? Benzos are never first line for sleep. At least zolpidem has some short-term SLEEP safety data. Benzos don't.
Xanax + soma + vicodin = flashback to residency hell, when my patients came in wanting refills of all three (they only work when all are taken together, don't you know), even though my clinic hadn't prescribed most of it. I'm glad soma's a controlled substance now, so I won't write for it.
I use a lot of SSRIs, an occasional TCA, a little effexor and wellbutrin--but never xanax. People with anxiety who have panic attacks can wait the 1-3 weeks for the SSRI to kick in, because they' ve already waited longer than that to call for an appointment anyway. And you have to get patients in to some form of counseling. Keeping 'em on a benzo forever is a failure. I just never start it and therefore it's never mine to refill.
Intense post. I'm for the drinking a beer solution. And before all the repsonses about promoting alcoholism, I jest. A single shot of whiskey takes effect much quicker and is less filling.
I work with patients in an intensive psychotherapy program and I often put them through "benzo boot camp". This is where I taper the medication and require them actually to TALK ABOUT THEIR FEARS AND PROBLEMS RATHER THAN AVOID THEM. This is how they get better, and I get very good results.
Need those FP's to keep prescribing to keep my business booming!
Speaking as a psychiatrist who "specializes" in anxiety disorders and whose practice is over 50% hourlong CBT sessions, I will agree-- please no xanax. It is especially addictogenic, given its "fast on, fast off" pharrmacology giving perfect negative reinforcement. I don't, however, agree with a prohibitive personal ban on benzos, as I prescribe them (I tend to stick with longer T1/2 like clonazepam or clorazepate) and they DO have their place. The main problem I see with klonopin is people not realizing how potent it is-- 2-4x more potent than lorazepam on a mg/mg basis, so you see people on ridiculous doses like 6-8mg/day. If you do a lot of CBT, you will see that it's not a panacea, and despite it being a preferred therapy, there are treatment failures, like with everything. Also, I think I help more people sometimes putting them on a low dose of a scheduled long-acting benzo and THEN doing exposure-based CBT with them while weaning them off, than if I had a hard and fast rule of "no benzos" and then expecting them to stick with a therapy that, when it's done right, sometimes involves getting a patient to make themselves more anxious. In the real world, you can't help a patient if they don't come back to see you. How 'bout we ask our primary care colleagues to prescribe long T1/2 benzos as clinically appropriate, but then to attempt to wean off after a month, with weaning failures being referred, sooner rather than later, to a psychiatrist? Using the band-aid analogy-- treating the root cause is great, but sometimes you have to stop the bleeding first. You don't put a band-aid on and leave it on forever, but you also won't get far if you are trying to get to the root cause and let them bleed out on your floor.
ABout time somebody said this! I've been seeing this problem all along.
What the GP's dont know is that all I do all day long is take people off drugs that well meaning docs put them on. I shudder at most of the discussion and reasons why practitioners do what they do. the answer is easy, you all are trained to give a script to fix a problem, when that may be the wrong thing to do. These are SEDATIVEs, people, so you need to look long and hard at the medical indication to SEDATE someone, especially when that pill is no longer under your control. I COMPLETELY disagree with Sermo Doc 18 that Klonopin is any better/safer than Xanax, just because it is more long acting...and even he admits people abuse it. The current epidemic is people abusing Benzos on Methadone and SUboxone...TO GET HIGH! because there is a some kind of synergistic effect of the two together which induces euphoria, energy and anxiolysis. It can also result in death.
WHO KILLED MICHAEL JACKSON???
I see in the answer discussion that someone justifies giving a sedative to a morning mother of someone who died...as if you'd do that with your own family? You can't prescribe something for someone because you feel BAD about what the preson is going through. That's NO indication for a medication!
Notes here ask 'what am i supposed to do?' well, refer a patient on, and sure, blame the other doc if you want to. I've seen hundreds of patients sent to psych to get Benzos, infact in the VA during my training the only patients who could get benzos had to have a psych doc, and the patients showing up complaining of suicidality tripled!!
ALL OF US have to develop a mentality to challenge the patients believe that the FIX to everything in life comes in a pill form. I dont do surgery for sleep apnea so I refer on when the study says obstructive for CPAP or scalpel. I Don't put my finger down the patients throat and see what I can muck with. Just admit you cant fix evrything and send the patient on! I feel bad for the docs who didnt get adequate training to handle these issues, but you have to find a way to do no harm.
Second the Anxiety and Phobia Workbook by Bourne! Every primary care doc and psychiatrist should have this book in the office to show to people who turn up with anxiety.
I agree. Even the use of them as short term adjuncts to SSRIs is problematic. I DO use Xanax as my MRI sedative of choice, but that's a single dose. I DO use klonopin for Restless Legs syndrome, and have escaped nearly all "dosage creep" with that as a bedtime only med. Of course, I'm referring the failures to Neurology.
Sermo Doc 67 I like the advice of that doc who wrote "kill as Few Pts as Possible" that valium is safer for our livers and he takes (maybe joking) and we should take one every ngiht instead of a martini. It was fine for me for a few weeks in college with back ache (even took finals on it) but I quit as soon as I figured out it was one of Mother's Little Helpers the Stones sing about.
And I have the alcoholism curse on my family and have seen how Lortab and Xanax are for many patients so I'll never take chronic opiates or benzos (I do have a drink every few months) and give me codeine for bad outpt pain; I'll be vomiting before I use too much. I just go through life a lot more anxious than those who have a drink or three or a valium every night. I might take up regular alcohol in my old age- wonder how old the oldest new alcoholic has been so far? I am taking up exercise, yoga, and regular doses of fukitol starting with quitting any job where I am wishing for a martini most nights when I get home.
Tons of BS here of course but everyone is entitled to their opinion.Just be very,very careful to weed out the chaff from the grain,especially if you are still in Residency or fresh in clinical practice.The most frivolous use of benzos I see without adequate follow-up or counseling is among psychiatrists.
As I remember: It was the evening of the first American attack on Iraq January 2001? The drug company then responsible for Xanex (Upjohn ?) invited all the practicing psychiatrists in Wichita Falls, Texas to a dinner at one of the best hotels that evening. The subject was how to educate the primary care providers to prescribe Xanex! We all received a check for $300!
It may just be that I reside and practice on the moon or even a different dimension but I've seen ridiculous escalations in dosages of these sedatives and anxiolytics with refills written by psychiatrists.The patients come in 'ZOMBIFIED'.The entire admonition on this post should ideally be directed at psychiatrists.Just my personal opinion.
I am a psychiatrist and I believe that there is a place for most medications. I have prescribed Xanax to patients before; but only a few out of hundreds. And those were primarily for phobias related to flying that had been on other benzos and haven't tolerated them well. As a note, many of the psychiatrists who perform 10 min med checks are accepting insurace, or as someone said before, consider themselves more as a psychopharmacologist. The business of insurance makes it difficult to profit if you take more time. I can testify because I spend 20-30mins with each of my medication management patients and my profit is slim. As far as therapy goes, sometimes, it just depends on the training they received. There are many psychiatrists like myself who still do therapy and don't prescribe medications to all their patients. But, many times we do get patients who have more severe conditions that have already been treated to no avail by other specialists and their conditions indicate pharmacological intervention.
Separate out who is doing the prescribing from what prescribing tey are doing. Factory, managed care psychiatry is a joke. Prescribing xanax, atavan, etc more than about once per decade is a bad sign unless you have a very special practice.
The only people prescribing it a lot, in single doses, should be radiologists.
Here is a quick little technique that I teach patients with panic attacks. I've used it on patients in the midst of panic attack and it worked well. You have them say 5 things they see, 5 things they hear, and 5 things they feel (physically, ie "my feet on the floor". Then 4 of each, 3 of each, 2 of each, 1 of each. I explain it, then demonstrate it, then have them do it. Most anxiety is fear about the future or worries about the past. This exercise brings people back to the present, where not much is happening! It focuses their attention, slows their breathing and eventually gets boring. I use it for myself if I have trouble getting to sleep.
Re: benzos: I only give a few xanax for people with phobia of flying. I have found clonazepam 1 mg hs to be very effective for some people with panic disorder, social phobia that couldn't tolerate SSRI's. Also for severe insomnia. Very rarely have I had anyone need to increase their dose and the quality of their lives is much better.
I disagree that pain and anxiety don't kill people. Many people have killed themselves because they can no longer tolerate the anguish that these cause.
As mentioned by many, there is a place in Medicine for benzo use. Caution should be used w/these meds as with all others--pretty sure that's why we all had to take the Steps and board exams. There are several FP docs that know how to use them and do so appropriately. I am the only psychiatrist at my military clinic among many NPs, PAs, and FP MDs. The vast majority are doing a great job using SSRIs, appropriate sleep meds (not seroquel), and yes--benzos on occasion.
To make a generalized statement about use of this class of medications is just, well, interesting. I have been serving the military for several years now and you will shudder to know that--yes--I have even deployed rare individuals on low dose prn benzos. And they have done fantastically out in the field as well as on return to home.
I don't prescribe benzos to people addicted to alcohol or benzos (unless they are in active withdrawal) and I am cautious about counseling on risk of sedation. I also look for disinhibition but at the doses I prescribe, I really don't see it. The majority of my patients and the ones who have come to me after getting benzos from an FP have not presented with addiction. I must tell you, however, I just don't give benzos to people unless they are really anxious.
My last comment about meds....
1) SSRIs are for many but not for everyone (have seen too many severe cases of bruxism, intolerable headaches, and sexual side effects...etc.)
2) When you treat symptoms with appropriate doses of meds people usu do not get addicted (we are finally learning this when treating pain, this can also be applied to treating anxiety).
3) Buspar sucks. Sorry, it just doesn't work. The literature will support me on this. The only use I have for buspar is that it sometimes reverses the bruxism that a few of my patients get from the SSRI.
Hmm. Interesting thread. Geriatric patients with mild dementia and depression/anxiety are hard to treat. Usually can't take propranolol, H1 antagonists or TCAs. Antipsychotics (a post earlier mentioned thorazine and quetiapine) have a black box warning with dementia, and CBT is difficult to initiate and maintain since they often need help with cognitive tasks. In the cases where SSRIs are ineffective or contraindicated, I prefer clonazepam in very low doses, but some patients cannot even tolerate 0.125 mg, and it's hard to split the pills smaller than that.
I understand the concern, but am worried about all the absolutes: "never" "illegal" etc. See, I would say "never" prescribe chronic low-dose neuroleptics for anxiety, but that was mentioned above as a perfectly legitimate option.
I like the fact that we are thinking about this and keeping each other honest. BTW--on the subject of unnecessary antibiotics, my mother called to ask about antibiotics for her cold. (Don't know when she'll learn. I never prescribe for family/friends!) Told her no, won't work, wait it out, etc. She went to "her" doctor who promptly put her on an antibiotic and she felt "so much better the next day!!" Some patients we can't educate.
If they are not intellectually equipped to do CBT, and too wired to do relaxation techniques (Andrew Weil, MD has some good CDs, have used them myself and given to pts.), I've gone to Tranxene. An oldy but goody, never had anyone addicted, all have come off within about 6 months when the the SSRI kicks in.
Thanks, Sermo Doc 81. That's actually my point. There are some good uses for most medications. Of course, I only have one patient who is so boxed in a corner medically and cognitively that our options seem to be limited to benzos, but still, to be so dogmatic about never prescribing something seems wrong to me. In residency, we were taught NEVER to use tranxene, but there are times when you judiciously weigh the options.
If I want to keep my job unfortunately I'm required to "fulfill the patients needs". If I don't they go to my boss who acts like he respects my decision but then prescribes it to them anyway and therefore I am making his job harder and me the soon to be outested family doc. Jobs are scarce in my area. I'm a single mom of 2 with a mortgage, student loans, house repairs...I cannot afford to be out of a job. I do add in Buspar, SSRIs, antipsychotics, anticonvulsants and Visteril for those patients that come back seeking more quantities of the benzos but these patients are street smart...they know what they want. One good thing.... my limit is that patients must return qmonth for refills, I never prescribe Xanax "Bars" and I only in really rare extreme
circumstances RX quantities of 120. Benzo do have a place in medicine ie. the little old lady with CLL or the wife who's husband suddenly past away...yes they need something to get them thru the difficult time but then need to taper off as things settle down if possible. I try to get the patient interested in other modalities...meditation, yoga, exercise...we in the medical community need to stress to our patients that not everything is cured with an RX...but the insurance and pharmaceutical industries make it too easy for the wrong choice for the patient....benzos are cheap, other meds may not be so and hardly any insurance companies pay for meditation, acupuncture, descent cognitive therapy...it is sad, very sad..times I wish I hadn't become the FP...maybe oneday when I'm a grandmom I can hope to get back into a Residentcy program where I would be able to pass the buck and not prescribe these meds. Or may seriously just quit medicine all together and become a chef...LOL
Perhaps one should first do an evaluation of the patient to find out the cause of his/her anxiety and prescribe for the underlying condition rather than the symptom. Even a Family Physician can do that . . . though it may take several 20 minute sessions to get it right. The assessment itself with perhaps a few sessions of psychotherapy will often solve the problem. If one decides to medicate, buspirone does work very well, but there is a very long period before the therapeutic effect kicks in. Aspirin in a dose of 1 gram (3 regular or 2 arthritis size pills) also works very well. Why? It is a muscle relaxant.
In my experience, about 5% of the population has an endogenous benzodiazepine deficiency, and about 5% has an endogenous opioid deficiency. For every neurotransmitter known to man, some people have an endogenous deficiency. When is medical science going to acknowledge this simple, obvious facts, and stop labeling everyone who has to take benzos or narcotics on a regular basis to feel normal as addicts? Sure, there are plenty of addicts and abusers out there. There are also plenty of people who simply have an endogenous deficiency and need their Xanax or hydrocodone to feel normal.
A number of years, but not that far in the past, were several articles in reputable and widely distributed "throw away" journals that were written by psychiatrists. The advice was to avoid alprazolam but for a short time, specifically no more than 3 weeks, do not avoid using clonazepam in small doses for many cases of significant anxiety. Simultaneously, begin a prescription of BuSpar or an SSRI. Instruct the patient to take both meds as prescribed. When the clonazepam was gone, that was it. No refill. If not under control by the time the treatment was solo, BuSpar or the SSRI, return for re-assessment (covertly meaning a referral to a psychiatrist or therapist or in the tiniest number of cases, a yoga class or a source for any of the relaxation methods that so rarely get a nod from a patient). I'd prescribed BuSpar with 100% lack-of-sucess and in those cases, the majority felt their treatment was not up to par with the overwhelming majority of other physicians in the area, including 6 psychistrists, locked and loaded for rapid fire Xana-script writing. From another community physician there was never pause about the treatment he was initiating- excepting a few moments at my expense to mention my reluctance to use any benzo as monotherapy or long-term was perhaps some of the best "advertising" for directing patients his way for the inevitable alprazolam prescription (one for 30-days to have filled locally and another for 90-days to fill through their mail pharmacy...WITH a refill on each). Heavily pessimistic, I decided to give this 3 week benzo simultaneous with BuSpar thing a try. Amazingly, it worked and not just once. Not every time prescribed but more than half of them. Quite an accomplishment for treatment of acute anxiety in my population. Half of the anxiety cases in a practice actually reporting improvement was freakish but also did wonders for a personal burn-out phase. It was even a better record than neighboring Xana-colleagues who insisted their Xana-doo monotherapy was the "gold standard". I was slow on the uptake but later clued in that their terminology was more aptly about their satisfaction over the steady revenue stream and the repeat business than any improvement in a patient. It really wasn't a surprise to learn many of the half of those in my practice reporting absolutely no benefit (much like 100% of those who I gave BuSpar alone) had only picked-up one of the two prescribed meds from the pharmacy and it sure wasn't the BuSpar... Lastly, for the record, it has always been my principle and practice to be considerate of the colleagues to which I refer the patients who happen to be my (and most physician's) "bread and butter". Burning such bridges is the mark of utter stupidity and punting a patient who could have been made worse by overuse of benzos, to a psychiatrist, is exactly that and much worse. There is really no justification to make up for lopping off a hand of a friend that has one's back unless the owner of the adjacent ass was hoping contact applied up it by a swift kick from a large shoe might enlighten him.
In my experience ambien does not promote tolerance. It has a place. Xanx, never-clonazepam, judiciously. I work in a Student Health Service, and patients can't afford CBT. Much of medicine now is about money. Psychiatrists are being forced into becoming givers of medication, and psychotherapy, although I love to use it and am good (40 years experience), I don't get to do it much, and I don't even take insurance. And yes, SSRIs work for many people, certainly not all. Best is combining it with psychotherapy or CBT. How long to use an SSRI depends on duration of symptoms . I see patients all the time whose lives are dramatically changed for the better by using SSRIs.
Most legitimate anxiety patients who require benzodiazepines are easy to recognize. They do not escalate doses, do not ask for extra refills, do not lose them, and use the minimum amount necessary. The benzodiazepine receptor is there for a reason. Some people have understimulation of this receptor and are naturally anxious. Most prefer not being anxious and want the brakes put on. Benzodiazepines do this safely and effectively. Regarding impairment, I would rather be driven around by a calm driver able to recognize threats than an angry anxious agressive driver. The same analogy holds for anxiety the disease. A chronically anxious person is like a truck running downhill without brakes. Benzodiazepines, when properly used, apply the brakes. For the chronically anxious they are miracle drugs. They are CIV for a reason, low abuse potential . They are necessary weapons in our armamentarium of drugs useful against rage, anxiety attacks, and generalized anxiety disorders. CBT, Relaxation tecniques, SSRI's, TCA's, buspirone and many other drugs and techniques help. However, nothing is as fast and safely effective for anxiety than the benzodiazepine class of drugs. The pendulum swings; in the 1970's diazepam was the most prescribed drug in both dollars and quantity. Some physicians got away from using it when other benzo's came out. Then came SSRI's and Buspar. Anxiety is psychological pain, and benzodiazepines relieve it. My advice to anyone who believes these drugs should not be prescribed because they are "addictive" is to change your attitude. Your job as a physician is to relieve suffering. Do not allow the anxious patient to suffer needlessly. Perhaps we should add anxiety as the sixth vital sign and create a visual analog scale for it. This might enlighten some healthcare providers.
Benzos have done much more harm, they are rarely helpful in the long run. I strongly disagree with Sermo Doc 88. There are safe effective ways to treat anxiety without benzos. Would the same argument for pain encourage use of opiates that are fast and effective?
i think the opening editorial is stating obvious medicine.. it disturbs me that someone has to inform FP's not to practice medicine this way.. i mean, come on, t his is basic medicine 101 stuff... having said that, i see patients all the time who are prescribed these meds completely inappropriately and their underlying issues are not addressed.. I always address them, and it doesn't take that much time.. .but I'm most disturbed by the fact that this isn't obvious to FP docs and has to become an editorial... I expect more from doctors and from FP's in particular.
My guess is that psychiatrists see a particular subset of patients that have a higher prevalence of addiction issues and treatment failure of common psychiatric conditions. I agree with the poster that BZDs have a risk of abuse. Many things we rx have potential downsides. As with anything, I assess risks and benefits, and individualize treatment decisions, and feel that there is an appropriate time and place for these drugs. I can say with confidence that my net creation of BZD addicts is a negative number. I will rx BZDs for short-term conditions like death in the family or pre-airline flight anxiety or for claustrophobia during MRIs. I will rx chronic anxiety with behavioral methods and occasional BZD use. If the problem is that severe, the pt will be on buspirone or SSRI or SNRI, and if those don't work the pt gets a psych referral. Oh, and I do take offense that the author singles out family docs as being the only docs who inappropriately rx BZDs. Go write the FDA if you want these drugs banned. I could inappropriately accuse psychiatrists of not talking to pts anymore and being rx factories putting my pts on all these atypical antipsychotics which make them fat, diabetic, and give them worsening cholesterol profiles, making pts walk around like zombies, and being lazy with inpt consults (usually occur over 24 hrs after requested, unlike the timely service provided by other specialty disciplines). Don't generalize! And don't tell me what medications I'm allowed to rx. PCPs can quite appropriately rx BZDs as long as caution is used. I am quite pleased with my ability to not attract drug seekers and their requests for BZDs, opiates, tramadol, Soma, ...
I find myself in the opposite position. I, as an FP, will send pt's to a psychatrist and more often then not, if they have any anxiety, they leave the psychiatrist's office with a prescription for Xanax, QD, BID or TID, depending upon how bad their anxiety is. I have seen them give it often for insomnia. They prescribe Xanax as often as I tell my patients to exercise. It has made me hesitate to refer to any local psychiatrists here. (I didn't have this problem when I practiced in WA state). Unfortunately, I have patients that aren't doing well with an SSRI, Buspar, exercise relaxation techniques, and counseling. That leaves me up a creak without a paddle. It's not just one psychiatrist here in So Oregon either, it seems to be most of them, and I know that it's a BIG problem with at least 4 of them.
I wholeheartedly agree with your recommendations!! Now, if you could only get your own specialists on board with this, it would help me out a lot.
Well, I knew doctors were silly, uncontemplative creatures psychiatristnj, but you take the cake. Here is your injunction to your minions: " PLEASE don't prescribe Xanax or Klonopin (or Valium or ativan)! The next time someone comes to you and tells you they have anxiety or panic attacks give them an SSRI or give them vistaril." Right. OK. Clever lad. "When you give them Xanax or Klonopin, you're essentially telling them they should not work on their problems." Alternatively, when you give them an SSRI or vistaril, presumably you are telling them something altogether different--that the universe is a complex space of vagrantly competing higher dimensions in which moral concerns drift alternatively into spaces that challenge our oft-beset self-understanding. Got it. Right. Vistaril rules.
I don't know about this.. life is not so cut and dry.. I have had patients taking 0.5 mg xanax to sleep for 5 years without a single problem... they had been through the whole cocktail of drugs and "nothing worked" Never say never in medicine, never say always!
Soma, Demerol, serax, dalmane and afrin should all be banned, probably!
I have treated many highly anxious patients with Buspar - totally UNSUCCESSFULLY. I did not know it worked on ANYBODY!
Effexor in am with neurontin in evening is not a bad non-addictive treatment..
The VAST number of patients of mine on regular Xanax and Klonopin got them from a psychiatrist at some point, and I am just doing refills.
Anxiety is very poorly treated pharmacologically...
Depression responds pretty well to SSRI's for quite a few patients in my experience.
I believe my wife to have GAD. I asked her to talk to her doctor about it. He gave her some Xanax 0.25mg. She took 2 of them in a month. He said therefore, she doesn't have GAD and doesn't need an SSRI. It was basically she didn't like it and didn't feel it helped any.
"Thank God I am in the ER setting and I couldn't care less "
That is part of the problem with people who work in the ER.
They just don't care about the patients that suffer from chronic pain or anixety.
Those patients really should stay out of the ER. They don't care about these problems
there, and they don't know how to manage them.
Patients come back to family practioners because most do care. They know or get to
know each of their patients. They are good at spotting the patients that are risk for
abuse and no how to identify the patient that is abusing.
So pain or anxiety doesn't kill anyone. I remember that you have a drug that you use
for migraine. Just relax and take it--or is your pain greater than others.
No the practice of medicine is not easy. The chronic problems are frequently the
worst. Too bad some physicians can't deal with them
I have to chime in now that this is becoming "blame THAT psychiatrist". Your IM, FP, Neuro, ER or Psych individual experiences should not be extrapolated to an entire population; i.e., you have your patient population, and I have mine. Maybe they need to be treated differently, and perhaps some or even a few of the other specialists (or generalists) in our respective regions tend to create the problems each of us needs to "fix". An FP may have one or two patients improperly hooked on BZDs; a psychiatrist may have the saem problem in 1/4 of his patient population (that is not going to be the psychiatrist who hands out Xanax like candy). It has been my experience that when BZDs have been used as the first line anxiolytic therapy, it inevitably becomes MY problem, sent down from FP or IM because they have finally become tired of calling in early refills, or they accidentally discover from the pharmacist that their now very calm patient has 3 other doctors (and maybe even a pain specialist) and uses 5 separate pharmacies to get their 2mg TID of Xanax. It's a bad drug. You can use Klonopin to wean people off of Xanax, but it is a long and tedious road, with extensive counseling. Most have "refused SSRI therapy" for one reason or another; they start one or find another doctor, barring adverse side effects or other contraindications. Once down to klonopin, they start weaning that, too. Xanax is not the answer to anxiety. Note, I did not say panic DO, and I did not say BZDs. I said Xanax. If you can take the time to monitor your prescribed meds, go for it. Just clean up your own messes.
Sermo Doc 44 Psychiatry Edited Jan 11, 2010 at 2:53 PM
Benzodiazepines are just alcohol in solid form acting on GABA receptors leading to Cl influx and hyperpolarization of a neuron.
So, do any of you out there drink alcohol, but refuse to use benzos?
I have never seen anyone die from benzos. I have seen plenty dead
from alcohol.
If you drink alcohol - stop. It is very addicting and very dangerous.
I do not use alcohol, and I have never recommended it.
Sermo Doc 88 Family Medicine Edited Jan 11, 2010 at 9:07 PM
Most legitimate anxiety patients who require benzodiazepines are easy to recognize. They do not escalate doses, do not ask for extra refills, do not lose them, and use the minimum amount necessary. The benzodiazepine receptor is there for a reason. Some people have understimulation of this receptor and are naturally anxious. Most prefer not being anxious and want the brakes put on. Benzodiazepines do this safely and effectively
WJD I agree 100%. If a patient escalates or losses prescriptions or uses any of the other manipulative methods; the problem can be corrected. DC the Rx.
'DC the Rx'?Just like that?If the patient suffers a partial/complex or other seizure while leaving your office after his/her 2nd or 3rd attempt to get alprazolam from you,behind the wheel,how will you plead?
i'm a bit surprised by some of the hyperbole here. i mean, is anything really all bad or all good? i don't write it, but know more than a few people who have used xanax to avoid panic while flying, and not become addicted. klonopin can be really helpful, especially for getting someone off a shorter acting benzo.
yeah, when abused, they're bad, and probably are written way too frequently (agree, too, about the bizarre notion of writing klonopin tid). we could assail the virtue of vicodin, or oxycontin, or soma, or whatever, but they all can have some use. maybe they just need to be used more judiciously..
the problem isn't fp's, or internists, or shrinks, or whatever (there are some pretty wild generalizations in some of the posts above). medicine is complicated, and people are weird animals. it might be a sign of hubris for a doc to say "i've never used a medicine inappropriately," b/c it does happen, sometimes totally inadvertently, and sometimes maybe less than innocently. in the end, we're all in this together, and should try to find a way to help people that are addicted to these get off 'em. so they might develop strategies for coping, find ways to feel good about who they are, and then go create their life. i reckon pointin' fingers isn't probably going to do a lot of good.
Hello I am an ER doctor and a board certified Addiction Medicine doctor. Must partially disagree with Sermo Doc 18, but agree benzos are very overprescribed and xanax and klonopin are frequently the benzos that are specifically desired by the addicts I see in my addiction practice. I have successfully gotten benzo addicts off them with phenobarbital, but I generally have to treat the GAD with the right version of an antidepressant to succeed.
I think everybody who gets a chronic benzo of any kind should have a psychiatrist who sees them longitudinally. If the patient resists this, there is a problem that needs to be investigated. The patient is actively degrading the patient-physician relationship by refusing referral. If they persist there will come a point where the benzo in my opinion will have to stop despite their wishes. Interestingly when the provider terminates the benzo supply some patients will give up and go to the psychiatrist and actually start getting better.
I do have an office patient with panic disorder who seems to be doing very well on xanax. However, I demand that she see another doctor to write that medication for her if she feels she simply must have that particular med.
It is certainly NOT impossible for people to get klonopin addiction - they just jack the dose way way up to make up for its latency. I have had hundreds of patients using > 10 mg of klonopin a day, most of them opioid dependent patients, frequently on methadone, trying to augment the methadone so that they can continue to dissociate from their lives. The two benzos that one rarely sees problems with, in part because of their low lipophilicity and long latency are chlordiazepoxide and oxazepam. They have a low street value (but some value because benzo dependent patients who can't find their drug of choice will use any benzo in a pinch), but will work as well as any other.
I will try to find that paper on a 60% abuse rate - have never seen anything that high. Don't know how they were defining "abuse." There have been other papers with thousands of patients showing misuse/abuse/dependence rates in the low single digits. This is more in line with my own experience.
As long as it takes 4 months to get a psychiatric appointment, and the stigma persists with many patients regarding seeing a shrink, generalists are going to continue prescribing for anxiety and depression. Finding psychologists or LICSWs to do CBT is also not easy, and often insurance constraints make it too expensive to attract many people.
Certainly agree that most patients can be managed with an SSRI or SNRI with occasional use of short-acting benzos for breakthrough, but nonetheless there are many who cannot, and who safely take stable doses of benzos for the very long-term.
While xanax and other benzo's are clearly overprescribed and abused by some, they are not abused by everyone and should have a place in the pharmacologic armamentarium. For people who have had true panic attacks, the panic is extremely dibilitating. Most of my patients who are on xanax will carry one or two with them, and the security of knowing they have a quick acting medicine as a safety blanket reduces their reliance on needing to acutally use it. They go through maybe 10 pills every 3 months. Then again, I tend to work with highly motivated patients who are trying to minimize their use of medications. When I used to work in community mental health, most of my patient abused the benzo's so I stopped using them there. I think the key is getting to know your patient and close monitoring, and choosing the right medicine for that INDIVIDUAL patient.
Maybe the psychiatrists in the house should walk a mile in our shoes. I WAS trained properly. I dont use benzos unless they are on an SSRI and still not controlled. They have to sign a controlled substance contract and I adhere to strict refill counts. And for the congnitive therapy....when there is one psych clinic, which is overcrowded and understaffed, that accepts MA, the patients dont get much out of it. I work in a rural, low socio-economic area, and the patients have to understand the therapy to get anything out of it. Not everyone gets to treat middle class suburbanites. These poeple have hard lives, and the prevelance of inherited bipolar and anxiety is through the roof, and yes their coping skills are poor, BUT I dont see any of you working around here! We do our best, but when they are in YOUR office every week crying, you just have to get off your high horse.
I think it is important for everyone to step back and think. Everyone here can attest to rational prescribing, individual examples of actual cases from the practice, etc. Yet xanax is one of the most widely prescribed and abused medicines out there. You will note that I have posted elsewhere that there is a serious deficiency in how prescribing is taught throughout medical school, residencies, and across specialties. Those of you posting here for a while know I trash psychiatry more than others. We are going in the wrong direction allowing Pas to prescribe and psychologists. I expect pastoral counselors will get prescribing privileges next.
Rather we need to tighten prescribing and narrow who can prescribe what. There is too much over reach and not enough respect for boundaries and limits.
and Sermo Doc 101, why don't you teach your panic patients to use re-breathing? It is still the most effective way to break most acute attacks.
There are a host of issues swirling around in the comments posted here, and the facts are getting lost in everyone's personal biases. One should avoid speaking in absolutes in most medical situations, such as making statements like, "One should never prescribe benzodiazepines for any reason," or, "Antidepressants don't really cure depression." I would like to ask my colleagues in primary care how many patients they have "cured" of diabetes, hypertension, coronary artery disease, degenerative joint disease, asthma, etc. Sure, most psychiatric illness tends to be chronic; well, guess what? So does most medical illness! Would primary care even exist if all you treated were infected fingers and sore throats? Does the fact that most diseases are incurable mean that patients don't need both medication and education to help them manage their conditions? Which brings me to the benzodiazepine vs. SSRI vs. anticonvulsant vs. antipsychotic question when it comes to managing anxiety disorders, which happen to be my specialty. What I have found is that too many primary care docs give a short-duration benzo prescription to an anxious patient "to get him out of the office," and when he inevitably comes back needing more, they send him to the psychiatrist, who now must deal with both treating the anxiety disorder and managing the benzo dependency. Or, the primary care doc who thinks he knows how to use SSRIs (but really doesn't) starts the anxiety patient on the same dose of SSRI he uses for depression, and the patient gets far worse and then refuses to take another SSRI when he finally finds his way to the psychiatrist. I also see way too much use of low-dose Seroquel prescribed by primary care docs for simple anxiety; this to me is a case of trying to kill a fly with one swing of a sledge hammer. Basically, what you're doing in this instance is using a subtherapeutic dose of a powerful antipsychotic for a problem for which it is not indicated. It harkens back to the days when every anxious or depressed patient left his primary care doc's office with a prescription for Triavil. In 25 years of psychiatric practice, I have rarely found a primary care physician who knew what he was doing when he prescribed an antidepressant, sorry to say -- not that that ever stopped him/her! Let me ask you: what would you think if one of my psychiatric patients came to your primary care practice having been started on antihypertensive or antiasthmatic treatment by me? Would you report me for "practicing outside of scope," which most states consider to be medical misconduct? Yet I'll wager that I know more about managing hypertension or asthma than most primary care docs know about managing depression or anxiety! As for benzodiazepines themselves, they can be very useful medications when prescribed for the right reasons and monitored properly. They are certainly not drugs of choice as monotherapy for chronic anxiety disorders, yet can have wonderful "PRN value" in specific instances, such as helping "air-travel-phobics" fly in comfort when they absolutely must travel by air. To make a statement such as, "One should never prescribe any benodiazepine for any reason" strikes me as one born out of ignorance or fear, or both.
One of my suggestions for doctors who prescribe these (or any psych) medications on a chronic basis is to look at the patient through a functional lens...ask the question "is the patient better able to function in their daily lives on the medication or off the medication?" and "are their activities revolving around their medication use?" These questions may help to differentiate between an effective use of benzo's (even effective long-term use) versus abuse of a medication. BTW, my dad has "shot up" a medicine twice a day, every day, for 50 years...he has withdrawal symptoms of sweating, hallucinations, and seizures if he misses a dose. He does not constantly crave the medication, it helps make him more functional. It's insulin.
To psychiatristnj. Your posting is one of the most short-sighted and ridiculous things I have read in a long time. Who made you the overseer of rx meds? I am offended that you have the gall to dictate to my profession what we should or shouldn't rx. Certainly benzos can be abused and are overused, but would you tell a sugeon not to use narcotics post op because of the same concerns? I am not a major fan of these meds and have lost patients from my practice when I refused to order them, OR continue them when they were sent back to me from their psychiatrist on them. I probably use these meds in well less than 1% of my anxious or depressed patients, often as an adjunct while waiting for SSRI's or SNRI's to kick in, but they do have their place in the right situation. If you dared send this same message to psychiatrists, I'm fairly sure you would b a laughingstock. Congratulations, in my eyes, you already are.
Agree wholeheartedly with kristaciv, lulittman & drhoelhaf & Sermo Doc 103......I'm thankful for the professionals who practice their profession responsibly, with Individuals known as patients...
I think Klonopin and Xanax are traded more than chronically abused around here. The less pills "in circulation" the smaller the problem for everyone. A few psychiatrists write the 100 pill Rxs and make it hard on everyone, but they are not reading this.
What an arrogant post. I agree that there is a lot of truth behind this and I believe they are overprescribed. But,
1) Don't single out "Family Docs". There are other primary care docs out there and other non-psychiatrists that are significant offenders in this regard.
2) Psychiatrists, as mentioned, above, push pills as bad any specialty I know. These people that have the most complex problems are often given a 5 min med check and more scripts.
3) There are legitamate uses for the meds (particularly klonopin) as mentioned above. Any "absolute" statement should always be taken as fairly pompous. i.e. "never prescribe benzos for anxiety". Shoot, they do this in the psych ward all the time.
Thanks Dragon: A thoughtful and reasonable respone. Possibly you don't realize how often family practioners have to deal with anxiety and depression. Most patients with
serious chronic medical problems suffer from a and d issues also. I have mostly practiced in rural situations, and finding a psychiatrist was difficult at best. It is possible and important for a FP to learn how to use antianxiety medications and
antidepressants.
Part of the problem is the "anti-drug" bias that many physicians develop because we all see abusers at one time or another. It is unfair when we start suspecting every patient that presents with pain or mental suffering. I know that I can't cure or fix many of my patients; but is feel strongly that as physicians it is incumbent on us to comfort and care about those who present with suffering. Yes, you do have to look at the entire situation. Yes, you have to look for signs of abuse and potential abuse.
I know treating these problems are not easy; but it is very important.
Possibly I was too hard on the ER doctors. The ER isn't a good place to deal with
this type of problem. Follow-up is essential. I also suspect that the ER is more likely to see abusers than am I in the quiet of my office.
Relief of pain, anxiety and depression is important.
Sir William Osler: "To test a doctor's mettle, have him treat a headache."
Certainly, SSRI's are a mainstay of treatment in anxiety/depression but benzos can and do have a role in many circumstances. Xanax is horrendously misused and I refuse to prescribe it. I call it legalized crack, which is probably an overstatement but not far off. However, Klonopin is long acting, much cleaner and a much better drug. In general, if they are prescribed, give small amounts and no refills and they should be seen in the vast majority of cases as short-term only meds. But, to think that PCP's should not prescribe benzos is completely unrealistic. In the right circumstances, they can be extremely helpful, albeit used with caution.
Whereas I totally agree that BZDs are overused and CBT underused, from an ER point of view, the number of chest pain, PE work ups are staggering economically and logistically...and inevitably patients with a catastrophic panic attack will end up getting over-tested in an emergency setting. I've known patients who have done quite well on a variety of benzodiazepines. It would be great if all patients responded likewise to SSRIs and the like, but they don't.
I totally agree with this! Thank you for bringing it to the attention of the community! There is no good evidence that supports the use of benzodiazepines, and studies conclusively show that they prevent recovery with respect to anxiety. I have come across too many patients who were perscribed benzos by well meaning doctors who ended up worse off in the end. I don't start anyone on benzos - there are plenty of other medications that are clinically indicated for the treatment of anxiety that work a lot better!
If I may add, I would also like that General Practitioners, Family Physicians, Orthopedic Surgeons AND Dental MD's would also consider prescribing less Opiates for the treatment of pain.
I don't intend to suggest that pain should not be addressed aggressively - but after a tooth extraction or uncompliated forearm fracture, is it really necessary to take opiates for three to ten days in a row? Would Tylenol or Ibuprofen relief at least 60 % of the pain and be less likely to produce so much Opiate misuse among our younger crowds?
In monitoring those children that are given Opiates for three days, I find that the toughest day is the first (stating the obvious), but the second and third days they are willing and able to manage their pain with Tylenol and Ibuprofen in an alternated schedule.
Issues with Opiate abuse may not touch home for many, but knowing that the greatest expanding use of drugs is at the expense of cabinet medicines is pretty telling.
For those of us that work at Colleges and Universities, would it be possible to consider starting a policy in which we seriously weigh risk/benefit ratios when considering prescribing pain medications that dope people up and predispose them to misuse?
I think it is amusing that people considered as "Trolls" on the internet such as the OP and folks such as Sermo Doc 18 end up flourishing in Sermo. And you guys eat it up.
I have been in practice about 30 years. Here is where I am on this issue:
addictive? -- damn right. Tolerance, withdrawal, craving: benzos have them all.
effective alternatives available? -- sure, if you can lock patients up, prevent dr shopping, get funding for psychotherapy, adjust everyone's IQ and personality so they can benefit from meditation, psychotherapy, feedback, etc. But in the real world, the only thing that works as fast and effectively as those NSAIDs in the commercials are the benzos. Most people won't do the work in non-drug treatments and the TV is blaring at them every day saying they don't have to (or have they taken those NSAID commercials off the air? The ones that show orgasm, not pain relief?)
safety? -- even abused, benzos have one of the widest tx windows of any drug around. The SSRIs are MUCH more likely to do people harm as a direct consequence of use.
Ban benzos? -- Does that include all the neuro patients on Tranxene? How about my patients who have tried everything including MAOIs? Get real.
Conclusion: these are very safe and effective drugs with TERRIBLE side effects. They are going to be used and abused, and they are needed (damn it!).
I carry a bottle of NTG with me always, as do many people. If you proposed to take it away from me without a truly effective replacement, I might show a lot of "addictive" and "drug seeking" behavior myself...
I agree with trying to avoid benzos. However, adding an SSRI is basically the same thing. These drugs are worthless and never address the underlying issues. In the long run, they make things worse by depleting neurotransmitter levels. In addition to psych approaches, anxiety can be a symptom of nutritional or toxic problems, which are rarely considered.
Chronic benzos for anxiety is the exact same as chronic opioids for pain patients - you are treating a "chemical-coper" who is usually unwilling to use alternative methods of treating their symptoms. They've learned 1) I have an unpleasant feeling. 2) I took a pill and that feeling went away. 3) I want more of those pills. 4) Nothing else is gonna work for me, so I don't even want to try, just gimme more pills.
These are the patients (anxiety and/or pain) that go to pieces when you merely suggest trying alternatives and/or lower dose: "Oh God, no! Please don't take my pills away! Please, I'm begging you! They're the only thing that helps me. Oh God!"
Wow, I trust all that seem so VERY AGGRESSIVELY against ANY USE of benzos.....are as consistently adamant against the sale / use of alcohol! Central nervous system acting drug, ...addictive potential, ...risk factor for abuse / broken homes / job place issues, treatments = big $$$$$ bucks,....50% of automobile accidents directly linked to its use, is often used 'medicinally' / and wrongly so (to drown sorrows, calm anxieties, relax tension, etc), fetal alcohol syndrome, liver toxicity and failure, gout attack increase, metabolic disorders worsened, etc.etc.etc....
Benzos have been around for multiple decades and haven't, to my knowledge, been as clearly problematic as alcohol...or perhaps are on the same level with it's risk potential,....but it's a "recreational drug"...and bezos aren't supposed to be.
So, I should perhaps prepare myself for a fierce defense of the use of alcohol as I close this blog piece,....from those who so fiercely oppose the medicinal use of benzos. I do not drink....but I do prescribe the short term use of bezos.
Hmmm.....am I confused! Perhaps I should be prescribing a shot or two of vodka q AM , and up to q 8 hours, for those anxious moments..., at least until the Celexa has kicked in!
Re: Sermo Doc 110: "Conclusion: these are very safe and effective drugs with TERRIBLE side effects."
To add to the "safety" profile: The LD50 in rats, translated to humans on the LOW end of the toxicity range. A 125 pound patient would have to swallow 18,800 tablets to kill him/her self 50% of the time. It could go as high as 123,313 tablets if we get nervous about making the comparison to rats.
It is remarkable and admirable that this long heated discussion is almost free of name calling! Only one name calling out of three whole columns! Way to go colleagues. we can keep it that way.
From the link provided by Sermo Doc 33:
Application of the term troll is highly subjective. Some readers may characterize a post as trolling, while others may regard the same post as a legitimate contribution to the discussion, even if controversial. The term is often used as an ad hominem strategy to discredit an opposing position by attacking its proponent.
Often, calling someone a troll makes assumptions about a writer's motives. Regardless of the circumstances, controversial posts may attract a particularly strong response from those unfamiliar with the robust dialogue found in some online, rather than physical, communities
Frankly, you would all do better to spend a little more time with the patient before the ssri kicks in. The antianxiety effects of ssris are almost immediate, so you have been sold some bill of goods. patients these days. And I direct these comments at the psychiatrist too, who also tend to spend too little time with
I'm glad this sparked a discussion. I definitely didn't mean to single out Family Practice Doctors. I should have addressed it to all docs. I'm sorry if I insulted anyone. I am also not trying to dictate prescribing to anyone. I was just expressing my opinion and of course I also see exceptions, however, I haven't found a compelling reason to give Xanax other than that the patient was already on it. I didn't mean to insult anyone. I'm glad we can have an open discussion on Sermo without too much name calling. The less name calling the better. Thanks.
It is really easy to touch a raw nerve on the internet because of the lack of inflection. Most people understand that and react to the subject matter. A tiny number of people will go berserk, and it is best to keep your head down a focus on the topic.
I still remember the first drug rep in 1984 who detailed me on the non-addictive advantage of Xanax over Valium.. And thinking how much revenue this drug detailer and his company would gain from the LIE.
I would like to add that NSAID's cause more deaths and serious side effects than
any other class of medication that I know of. I have never seen death or even an allergic reaction to a benzodiazapine. I have seen deaths and many G-I bleeds secondary to NSAID's.
I will agree that Xanax (alprazolam) seems to generate more problems than any of the others in that class. I also like chlordiazdepoxide. It is relatively long acting, it works, and it is dirt cheap. Lexapro is a great drug, but it is very expensive. Generic celexa is a real $$ saver; but you just have to use twice as much.
I will also restate my objection to alcohol as recently mentioned by another writer.
Far too addictive and dangerous but most in the US including physicians continue
to drink. Why? Maybe a benzo would be safer; I've never seen cirrhosis from a benzo.
I realize that making alcohol illegal was a Disaster for the country. Don't vaccum up
and out-law a sometimes useful, effective medication with minimal side effects.
I use a simple rule for this class of meds. If it has a street value and is found in the local dope house I should not write a script for it.
I volunteer at a local rehab.
Here is the street stuff. Meth addicts love xanax the Best to come down from a Meth run. One guy says his dealer sells the "High" the Meth and the "net" the xanax to catch you on the way down.
I also see loads of people on Oxy's most from local dope houses.
For Dragon and others with similar views:
A) At least half of the patients we see daily are anxious and/or depressed, especially in more rural or poverty stricken areas.
B) Many people with chronic diseases, including diabetes and heart disease, are depressed and frequently anxious
C) Psychiatrists are very unavailable in many places, with wait times of one to three months.
D) Psychologists or other therapists are difficult to see on a timely basis, even if they "take the patient's insurance"
Please follow me around my office, just for a day. What would you like me to do? Meditate and pray with the patient? Give them an SSRI when "I'm really not educated enough to dispense SSRIs?"* Give them a benzo when "I can addict the patient then end up dumping them on the poor psychiatrist?" Give them a sticker and a lollipop?
*By the way, I do know that anxiety disorders require less of a dose of SSRI.. 'Think I learned that in residency from a psychiatrist.
I do a lot of "therapy" myself although i am "untrained" for CBT and psychoanalysis.
For example: I was seeing a patient for diabetes and foot pain. I asked him..."You seem to be upset or perhaps depressed."
The patient tells me about the horrible things happening: "Well doc, my son was arrested for drugs the other day, and I can't sleep and I cry all the time." The patient then cries and opens up. We talk. I mostly listen. i discuss things he can do to help themselves besides meds. I prescribe a med (usually no benzo) if indicated. He feels better. He is told to come back soon.
Another example: A chronic pain patient is very anxious. I ask about her childhood and her marriage (even though I have maybe 20 min at the most). She tells me about the time her stepfather raped her from age 8 to 14. We talk. I mostly listen. She finally tells me she rarely talks about this stuff. She is seeing a psychiatrist already. I reassure her it's ok to talk about her feelings. She cries and thanks me.
Sermo Doc 112 It is the METH that is the problem in this case-- not the Xanax.
Yes, substance abusers will use benzodiazepines to treat the side effects of the
drugs that the prefer. I worked in a psychiatric hospital for 6 years doing the medical
part. We frequently used benzodiazapines to blunt serious CNS side effects of
alcohol withdrawal. They work for that; and they are darn safe!
I saw all kinds of abusers in that hospital. Patients whose primaryt problem was
substance abuse and mentally ill with co-morbid addiction/abuse. I saw patients that abused alcohol (most common), metamphetamine, cannabis, crack, crank, Ectasy,
PCP, steroids, oxycontin, all opioids, tobacco, LSD, other hallucinogens, glue, gasoline
and spray paint. I probable left out a few. These guys would take a benzo if they
couldn't get anything else. However; they are just not most of them want.
If you have a patient with cataplexy would you refuse to use amphetamines? They
do have a street value; but they also work for cataplexy.
Sermo Doc 95... It was ICE( a form of Meth) produced by the Hells Angels in Arizona that kept the trucks rolling from the East Coast to the West Coast from the 60's through the 90's... now every "cow-boy" in a shack is cooking meth, in the south
I agree with everyone who defends the use of benzodiazepines, whether prescribed by psychiatrists, neurosurgeons, nephrologists, obgyns, and everyone except pediatricians. I think anyone who has ever personally suffered an anxiety attack knows what a boon klonopin or even xanax can be. And yes, I have used these meds personally, prior to giving a public presentation. ( Self disclosure athough I have no financial investment in these pharma companies, more's the pity. )
Maybe Sermo Doc 18, you never get anxious. Maybe you have such excellent self-control, and self-confidence that you have never had a panic attack. Maybe it seems to those of you people who are so sure that benzos are Satan's medicine, that one can never touch a benzodiazepine type medication without an immediate addiction, similar to an injection of heroin. The invective on this post reminds me of what people used to say about masturbation: if you touch yourself "down there" it'll just shrivel up and fall off.
I work with a lot of people who have panic attacks. I see young people, hard working, stressed, trying hard to make it at IT, financial services, sales, even law who have crises and show up with somatic symptoms--tightness in the chest, shortness of breath, dizziness, tingling in extremities. Some have come to my practice from the ER, when they called 911 thinking they had an MI, only to have all cardiac pathology ruled out. Guess what!!! They do really well on Klonopin 1mg PRN, and/or hs during this acute crisis, no more in my practice than 1 mg BID, for the first week, and then 1 mg hs which, with its long half life, can work to calm them during the day. Often these symptoms are precipitated by the loss of a significant other plus increasing demands at work. Starting an SSRI shortly AFTER the panic is calmed by the benzo is the way I prefer to do it, as I have seen a few patients react to an SSRI with an immediate increase in anxiety and agitation. I treat these patients with a thorough psychiatric evaluation to determine the current stresses and losses, their current medical condition, substance use or lack therof, and history of family of origin. I see them at first twice a week if possible, during the time of crisis, then once a week. I perform psychotherapy, not even CBT, but psychotherapy to tease out the stressors, and to help the patient by mobilizing the patients relatives and friends to offer support, problem solving what issues at work may be amenable to change, reminding the patient of his/her current strengths and talents which are forgotten during a crisis. I find that looking into their interpersonal skills, finding who can support them now, plus knowing that the psychiatrist has the patients back during this crisis, plus the damnable BENZO often lead to recovery within 2 months. Starting an SSRI at the beginning, such as Lexapro, Celexa, Cymbalta, Zoloft while still using the benzos I find a very effective treatment. (I posted this on another thread, in slightly more detail) I think if a family medicine doctor, or any doctor, has the time, he/she can be a caring person and does not need the training of a neurosurgeon to help people at a time of crisis. My patients are reassured to carry around the klonopin knowing that if the panic should strike, they have a quick remedy. They rarely abuse this. Have I been duped by my patients? Yes, of course. But my effectiveness rate is fairly good.
Sermo Doc 30, go back and read what I said about using klonopin for panics, but not xanax, And then go back and read my actual comments, universally ignored about re-breathing, ignored because no one seems familiar with the physiology of panic.
Please do not say something I didn't say and then attack me for saying what I didn't say.
My success rate for treating panic is 100% for decades. But so what.
Xanax prn is a great way to get a person addicted. Xanax withdrawal feel like panic, so many people addicted think they have panics!
Klonopin prn is placebo. Have you any idea how slowly it rises in its active plasma metabolites?
Rebreathing is a great gimmick that physiologically works better than a bet a blocker.
But you'll never get detailed on rebreathing.
See, I actually care enough about my patients to sympaethize but with their anxiety but also don't want to get them addicted or harmed by irrational treatments that are laced with placebo.
Now think about the pharacokinetics of klonopin. For a typical individual, peak plasma can take up to 8 hours, though usually 1 - 2 hours. Typical panic is a few minutes and ends within a few minutes.
So how does Klonopin break a panic attack that is already under way? It doesn't. The panic remits because of placebo.
What you must remember is that the typical residency "psychopharmacologist" is not. There are a few programs with actual researchers who know a lot and teach a lot. A larger number of programs have researcher s on the take from pharma. These are outright frauds. The large majority of programs have self styled experts who have learned the pharma propaganda and mouth it to pose as experts. These are the ones who go one at length about cytochromes and use lots of abbreviations
It is funny to ask these poseurs about an MK constant (Michaelis-Menten) or to tell you the difference between pharmacodynamics and pharmacokinetics.
vo = v max S / Km + [S]
This is why most psychiatrists also have no idea what rational prescribing is.
Xanax addicts at the 10 10 range. Only placadyl would be worse.
Sermo Doc 18, i am sorry if i misunderstood your previous posts. I am not familiar with the typical residency Psychopharmacologist these days, as I used to teach residents, but do not do so at this time. I am glad that you find that rebreathing works well for your patients, and that you have such a good success rate. Nevertheless that does not give you the right to trash methods that can work well in the hands of others. I would not discount your results either. I would not call rebreathing a placebo effect, although others might.
By the way, nobody details anyone on klonopin or xanax these days either. I do not use xanax for anything except an immediate, one time problem such as an airplane phobia. I am fully aware that there is a rebound anxiety after a few hours of taking xanax, when it starts to wear off, if someone takes it more than once a day for a few days at a time. I never recommend xanax, except for a one time use, and I said as much previously.
but, as you yourself have said, klonopin has a longer half life, and using it hs can lead to a much more restful sleep and add to calmness during the day. It is also useful to carry around knowing that it can help with a panic attack. If a patient has a phobia of driving across a bridge, he can take the klonopin either 1/2 hr prior to the drive, or carry it knowing that it will start to work within 20-30 minutes. Maybe the peak level takes longer than twenty minutes, but a soothing effect starts within about 20-30 minutes, and that can be enough to take the edge off the anxiety.
As I posted above, I did have one patient with a severe panic attack, that he thought was a heart attack, who turned out to be in excellent physical health. I started him first on an SSRI, perhaps Celexa, and he became so agitated that he thought of suicide. He then was given Buspar, to which, to my great surprise, he responded well. Then he took another SSRI, with the caveat that he could add klonopin if his anxiety rose again. This worked well. Within two months he no longer needed any klonopin, later reduced the buspar, and now has stopped his SSRI. I do not know if you respect any anecdotal reports. I have a number of patients who use benzos PRN unusual work challenges.
I also think that exercise helps a lot, and I prescribe that. I am happy to use whatever modalities work so long as they are not harmful to the patients. I try not to be too judgmental of my colleagues who may use other modalities. I think tolerance is a sign of world experience and of having made enough mistakes in life that you think twice before throwing the first stone.
Wow! WAY TOO MUCH HYSTERIA on this thread! Just use your medical judgment: anytime anyone says "always" or "never" you can be assured that hysteria is driving the bus, not judgment. YES!! Some patients "need" and do very well on daily benzodiazepine dosing. For example, some people seem to have a "hyperactive cortex" that causes initial insomnia. Some try and fail relaxation. Non-BZD's can help, such as trazodone, Rozerem, Seroquel, etc. can help - - - - but there ARE those who do best on a benzodiazepine. There are several studies demonstrating that people who need these meds do NOT abuse them. Of course, still monitor for overuse or non-compliance and deal with these. I have noticed that more patients reduce or discontinue their benzodiazepines than accelerate their dose and begin abusing. But that may be because the latter are thumped from my practice and referred to an addictions specialist as soon as their behaviors are spotted. I remember when I was an intern little old ladies with terminal cancer were taken off their self-controlled morphine pumps if they dosed themselves more than the chief resident thought appropriate. I suspected they were rapid metabolizers - they never showed signs of toxicity. Nonetheless they were cut off. On the bell curve of life, there are always outliers.
Yes, sometimes, Benzos are needed for short-term, "emergency" use, for symptom-control. How many more E.R. visits do these patients need? Often, just carrying them in a pocket is enough for most patients....
I agree that rebreathing is VERY successful if you have the time to "handhold' through it since these folks are most often severely CLAUSTROPHOBIC at the same time.
Sermo Doc 21 - please don't be too harsh on the drug reps...I was one well before med school. they have very little pharmacological knowledge beyond what they are fed by the company - and of course, all they get is the propaganda. When I was selling, i was not ALLOWED to give the negative aspects of the drug - cost, side effects, etc.
Okay, here's 3 questions.
Is there any rationale for Klonopin more than once a day? It doesn't make sense from a half life point of view. Half life is 18-50 hours.
How about Ativan once a day? half life 10-20 hours.
Is Ativan better than Xanax, less addictive?
I'd feel a bit better about these meds if they were given just once a day.
Useful post and discussion. Though I agree with psdoc that I have seen many psychiatrists advise or prescribe these short acting benzos, so by no means is it a problem of restricted to family doctors and internists. I think the original posting psychiatrist sees the world from his/her perspective but that is not the full story and the opportunity to fix this problem requires more than one lens.
Sermo Doc 18 wrote: "Now think about the pharacokinetics of klonopin. For a typical individual, peak plasma can take up to 8 hours, though usually 1 - 2 hours. Typical panic is a few minutes and ends within a few minutes."
Sorry if I missed a post somewhere. What Sermo Doc 18 wrote holds true for Xanax too, no? I.e., the onset of action of Xanax (20 minutes) is longer than the length of the panic attack itself. Of all my panic patients, the longest reported attack was 18 minutes. Pt's describing "panic attacks" of 1-8 hours in duration are mislabeling their symptoms. So any effect from any benzo taken during an actual panic attack is simply placebo effect. I'm beginning to like the rebreathing solution more and more.
I hate Xanax. My mom was addicted to it, and have wrote a rx for it one time only (someone with MRI claustrophobia and it was a one time dose). Thankfully, most of the people on this post aren't crazy about it either. It should never be prescribed as daily therapy, if at all.
I am in full agreement that benzos are not a good long-term treatment or solution for mood disorders. When working from the ED with patients who frequently have little or no access to a PMD, it is a very tricky situation. Given that there is risk of suicide after initiation of SSRI, I will not start these on patients from the ED. I will selectively provide short courses of benzos to bridge them (20 pills of 0.5 or 1 mg lorazepam) until they can get the propper assessment and therapeutic interventions (meds, cognitive tx, etc.). I always emphasize that these medications are not for long term use and that they are potentially habit forming.
I think that benzos may serve for a month bridging for SSRIs and/or psychological stherapies (if covered) - the risks of abuse are minimal in my experience.
I was trained with the concept of using Benzos to bridge for SSRIs (although I really never did it much) but I'm afraid that in many cases, the bridge becomes a highway that doesn't end.
Sermo Doc 121, you're baaack!!! Yay!!! I loved your comments two years ago, so insightful and thoughtful. You made me think a lot then and the discussion ranged back to evolution and the survival value of anxiety,
I hope everyone goes back and reads that thread about benzos, it was very informational. Seeker was there, and Galaxy, Stu Gitlow,Maxwell Edison and many other very thoughtful and sincere doctors commented. Lawdoc was even in favor of Klonopin two years ago.
I have seen specialists/subspecialists start folks on addicting medications (ambien, Klonopin, ativan) - and then return the patient to a PCM who continues the medication...and when they come to my office, they have been on it for a couple years... when they arrive to me as their new PCM and I challenge the use - I am not considered satisfactory in terms of the "customer care representative" that doc's are considered to be these days... my question is that are psychiatric comorbities and personality disorders as frequent in less-developed countries as they are in America? Has our environment of entitlement fostered the right for patients to dictate their own care? There are many similarities between this discussion and the discussion of the appropriate use of antibiotics... (I understand physical addictions are separate) - but a lot revolves around patient demand for a fast cure and enough knowledge to know/feel that they can self-diagnose but rely on a provider to aid in the treatment - and with folks being cramped for time and a desire to please their customers - that the faster wrong becomes the easier and happier solution... I am not saying I agree with it or that it is a correct response - but it is what it is and I expect it will continue. I do believe that most family physicians, internests, PCMs, psychiatrists, etc understand the potential problems with these medications, but make the conscious decision to use them - and will likely continue to do so despite any begging, pleading, or attempted education... just as antiobiotics continue to be given (AND USED) by health care providers for viral illnesses/common colds
I am shocked to discover that this is obviously not taught routinely, or at all.
Here is the Classic Comic Book version of what I learned from one of the true great psychopharmacology researchers of the mid 20th century who always said that if you give someone a pill, you rob him of dignity and convince him he cannot do it without a pill. (Interesting insight from someone who's business was researching the use of pills!)
Do you remember that if you infuse lactic acid in someone with panic attacks that it triggers a panic attack? That people with panic attacks spend more time with anticipatory anxiety than they do in panic attacks?
Anxious people are seldom aware of their rate and breathing capacity?
Simple behavior modification to raise awareness of breathing, use paper bag, holding breath, cupped hands, to EMPOWER a person to modify his own acid base/ O2 CO2 balance.
In so doing, person learns that can control panic if has one, relaxes, has fewer.
The physiology is spot on.
If you do enough behavioral mumbo jumbo around teaching and practicing the technique, with empowerment language mixed with a little education on physiology, you should get 100% success without use of medication at all in simple panic disorder.
Panicky people are fearful of losing control, right?
So tellem "you don't want to become more helpless by being dependent of pills? My God! You could lose the pills. Then WHAT!"
"So I'll teach you how to take charge of yourself ..."
It is fun because there is so much showmanship.
If you are dealing with a character disorder, then you need to do more therapy around the technique.
Besides the physiology, there IS a certain amount of placebo effect going on.
A lecturer once demonstrated a "technique" to eliminate the gag reflex - on a med student in front of the rest of the class - it worked perfectly. Just involved tapping around the side of the head while delivering the patter and then using the tongue blade again with remarkable results.
It's good to bring up issues like this from time to time. I'm so over the b.s. of one specialty "dissing" another on this forum. Give me a break will ya. We've all seen our share of patients come from another specialist hooked on one drug or another. I've seen my fair share of patients coming from Psychiatry on crap loads of Xanax. A drug I prescribe to patients because the patient came to me on it. On top of the number of folks on benzos for sleep.
On the other hand, how many out there go home after a really crappy day, or on a weekend sitting back watching a ball game and have a beer? A lot of people in this country utilize GABA receptor substances to make life a little less stressful and don't over do it. Telling us to forget about using benzos would be like bringing prohibition back. That worked well! NOT. Come on folks use common sense when prescribing these drugs, understand what you are doing, make sure the patient understands and do your darndest not to get them hooked on the stuff. Will it happen you bet. Have we all seen nightmare cases, you bet. Universal proclamations on the other hand are worthless. That's why it's called the art of medicine.
When insurance and the government start paying for people to see counselors and therapists is when we will see a decrease in the use of addictive substances, until then get off your High Horse and let's start talking about Reality instead of Utopia.
Now I think I need a beer after that tyrade. Breathe in, hold, breathe out, breathe in, hold, breath out, etc. Hey yea that works.
The problem is that we're not willing to differentiate between feeling better and feeling high, between withdrawal and symptom re-emergence. When a patient feels better on a drug we don't like we simply demagogue it by saying, "Oh, sure, you feel better, but you'd feel better on cocaine, too!!!" Why can't I equally say that about SSRIs when they work? When we have trouble getting patients off benzodiazepines because it's the first time in their life they've ever felt "normal", we call the abrupt return of their previous problem "withdrawal". When they stop drinking we say, "Oh, yeah, that drug's no better because it made you feel the same", even if you now feel the same without falling down in a stupor and don't pickle your liver.
My opinion is that anxiety IS the problem, and treating it is not "putting a band-aid on an amputated limb" or whatever flippant irrelevant comparison someone previously used. Anxiety and mood problems cause issues, not the other way around. Mood is genetic, and no amount of fear or guilt mongering lecturing by a physician is going to change that; it likely will make it worse. As a patient once said to me, "I've had a LOT of therapy, and I know why I drink too much." When I put her on alprazolam she said, "Now I not only know why I drink, but I actually stopped." Oh, right, she really didn't, nor did any of the rest of the patients that have told me that, they (and their family and friends) have all lied to me and I'm too naïve to know that.
Here's a possibility - genetic mood disorders are the problem, and issue centered counseling is what is nothing more than band-aid therapy, offering little more than a temporary solution that addresses the predominant issue du jour in their life, the manifestation of that mood disorder, rather than addressing the real underlying problem. And, meanwhile, specialists of various sorts go on blithely evaluating and diagnosing one somatic symptom after another, shoving scopes and scans at anxious people over and over as they circle the drain, anxiety leading to more physical, interpersonal, and economic problems, leading to still more anxiety, while we tell them, "You just need to learn to relax." How about people just learn to lower their BP and cholesterol, too?
We need to get past the idea that a patient feeling better is evidentiary of a drug being abused rather than used effectively.
Sermo Doc 123: "A drug I prescribe to patients because the patient came to me on it. "
Sermo Doc 123: "Come on folks use common sense when prescribing these drugs, understand what you are doing, make sure the patient understands and do your darndest not to get them hooked on the stuff."
Come on, Sermo Doc 123, use some common sense and don't prescribe it just because someone else did!
Anxiety and mood problems cause issues, not the other way around. Mood is genetic, and no amount of fear or guilt mongering lecturing by a physician is going to change that; it likely will make it worse.
So you mean that my now ex-wife spending MY money on her boyfriend's trailer renovation, Lortab addiction, cheating on me with half the town INCLUDING our sons' high school friends, etc was NOT the cause of my acute anxiety and depression? Dammit, now I'm pissed.....even though we got divorced ten years ago and I got better, I suppose now I'm still anxious and depressed???
Not sure what Sermo Doc 18 has against serax. It actually has almost no street value, is very slowly absorbed and poorly crosses blood/brain barrier. It, and librium, are the two least-valued benzos on the street, which is why they are my most prescribed when needed.
Agree with Sermo Doc 50 regarding oxazepam;if I recall correctly,it is also the only benzodiazepine that is not predominantly metabolized by the liver,therefore,may be more useful in cirrhotic patients and others with significant liver disease or poor hepatic function.Many,many years ago when I worked at a VA detox. and addiction unit,the protocol for ETOH withdrawal utilized serax,tapered as appropriate from 30mg several times/day to 15mg QD,DEPENDING ON THE PATIENT.They were mostly repeat patients with known alcoholism and persistent drinking behaviour.
Operative word is "least." And you would be amazed at what can be done with it for a high.
Not sure what Sermo Doc 18 has against serax. It actually has almost no street value, is very slowly absorbed and poorly crosses blood/brain barrier. It, and librium, are the two least-valued benzos on the street, which is why they are my most prescribed when needed.
"So you mean that my now ex-wife spending MY money on her boyfriend's trailer renovation, Lortab addiction, cheating on me with half the town INCLUDING our sons' high school friends, etc was NOT the cause of my acute anxiety and depression? Dammit, now I'm pissed.....even though we got divorced ten years ago and I got better, I suppose now I'm still anxious and depressed???"
I'll make 2 points before I go back into seclusion:
(1) No, I'm saying YOU weren't the cause of HER problems. (2) And "dammit" you seem easily "pissed" by nature. I'm saying THAT'S genetic/endogenous.
Now I remember why I stopped visiting here and posting. Perhaps I should tell you what I'd read all too often here, what we should tell patients who are "problems" to us - "AMF YOYO". Not fighting with you has given me more time to try to help those patients.
Green, >I'll make 2 points before I go back into seclusion:
(1) No, I'm saying YOU weren't the cause of HER problems. (2) And "dammit" you seem easily "pissed" by nature. I'm saying THAT'S genetic/endogenous.
Now I remember why I stopped visiting here and posting. Perhaps I should tell you what I'd read all too often here, what we should tell patients who are "problems" to us - "AMF YOYO". Not fighting with you has given me more time to try to help those patients. <
Bravo!!
Don't leave. You've more wisdom in your little finger than some have in their whole brain.
Well I can personally attest that benzo's help suppress the vestibular system for vertigo attacks due to AIED and Meniere's. I have used the same dose for 9 years. So not all of us that take benzo's are freaked out addicts; and yes, I exercise daily. Maybe some drugs are used for things beyond anxiety and depression
Dr Sermo Doc 121: Thank you for posting, and like Ebola I wish you would stay. I truly appreciate your comments on benzos and mood, and genetic, endogenous predispositions. Following your comment here, and your good example we have had a much more civilized discussion, IMHO, and I was able to learn something about Serax that I did not know before. Plus you are funny.
It would be so much better on Sermo if we could discuss anecdotal uses of meds, some that have worked well for us individually, some off label, without fear of being insulted contemptuously by those who disagree.
Just one more point about benzos. They are extremely safe and rarely result in fatal OD unless combined with alcohol. If you are worried about suicide potential when sending a patient out of the ER a small Rx of benzo would be the safest thing to use.
Nothing beats rebreathing for breaking an acute panic attack or hyperventilation.
Ebola, I totally agree about the safety of benzos, and when you compare them to the other drugs in our armamentarium: Elavil, abilify, seroquel, Maoi's -- Elavil can cause qt lengthening, and is quite lethal in OD. Abilify, Seroquel cause metabolic syndrome and significant weight gain, MAOI's hypertensive crisis. I'll stop beating this dead horse.
Never say never, but I generally agree that there is a rare need for any Benzo. They can be used in short acute situations, but almost never chronically. Klonipin HS is probably the only rare exception because of it's long half life and anticonvulsant activity. Still it can be abused and should be used judiciously.
I'm not sure why I came back to re-read this post-I guess it's like slowing down to watch car accidents. Some of the comments are ridiculously inflammatory and make you question an ability to practice psychiatry of all fields with so little personal insight or interpersonal skill. e.g. "I'll wager I know more abut how to manage hypertension ...than FPs know how to manage depression..." The ignorance of the statement---much hypertension is actually quite complex to manage so I'll take you up on that wager any day-is only outweighed by its narcissism. The topic is important and many of the comments thoughtful so I guess I've gotten a little out of it, still...... There was an interesting article about blogging and mob-rule and how even some of the developers of the internet now feel it's led to the devolution of intelligent conversation and that anonymity has been actually an overall negative. I tend to agree. (not that I plan to sign my name when no one else is, of course.)
I actually used to use my own name, but it was on the aforementioned thread a few years ago that I started to fear for my professional career and appealed to the moderator to let me change to a pseudonym lest some of the more self-righteous here feel a need to "put a stop to" my contrarian way of managing patients by pointing out to my SMB that they thought I was "a drug pusher" for my position on anxiety vs. depression and the usefulness of benzodiazepines vs. antidepressants or CBT. Sometimes people see little difference between "practicing bad medicine" and "not doing what I would do". The threat of loss of licensure is often profoundly persuasive and tends to end a lot of meaningful discussion.....
It is too hard for too many people simply to acknowledge a lack of true knowledge and admit that maybe one has made a mistake.
Psychiatric residencies do a terrible job in teaching psychopharmacology, but other fields do even worse. Sermo Doc 28's comments gell with mine, because I would never think of treating HTN in a patient on anything but an emergency basis and there was no alternative whatsoever. I see it as a duty to seek out and respect my limits.
That is not to disown my medical background, and I have made some pretty good diagnostic pickups in my time, but then I refer.
For some reason, we do not teach doctors to respect one's own limits.
PCPs have vast knowledge, but they cannot function as specialists; their knowledge is not deep.. Specialists have vast knowledge, but it is narrow. We have to know when and how to work together.
With all due respect, and at the risk of being back-handedly diagnosed as narcissistic for presuming to know something, I disagree.
Using your rationale, I'm not supposed to do anything at all. It's reminiscent of my alma mater's dismissal of FP as unnecessary and insufficient in expertise, since every problem it presumed to treat was already "owned" by a specialty that was more "qualified" to treat it. Obs delivered babies (and presumably even did Paps) better, nephrologists claimed to know more about treating hypertension, ophthalmologists could more thoroughly evaluate corneal abrasions, and so on down the line. Heck, some problems like hypertension even had 2 different specialties fighting with each other over who should be treating it. As I resident I witnessed a medical staff war over who shouldn't have the "privileges" to do colonoscopy - GI said they had it first, GS said they invented it, GI told them to go do a GI residency if they wanted to do it, and GS ultimately found out the GI who was doing the most had learned to do it from the rep who sold him the scope. And who couldn't enjoy the manage (pun there) a trois between ophth, ENT, and plastics over a blow out (pun there, too) fracture of the orbit. In the end we're probably left fighting for the right to do rectal exams without someone to give us a hand.....
If I took the advice of NYU, and many specialists, and "respected my own limits" the way they think I should, I'd have left FP decades ago and retrained for a real specialty. But the way I see it, you should instead be asking me why, some years ago now, 24/25 FPs at a focus group meeting thought that promoting a drug as "the #1 antidepressant used by psychiatrists in the US today" was such a profoundly negative statement that they would have left it off the advertising piece. Today that would likely be 25/25, since, after further experience in practice, I'd like to change my vote.
Psychiatry has a lot more limits than it realizes, and it's close-mindedness that's the biggest one. The biggest problems in medicine is not narcissism, it's arrogance.
BTW, if you look around here at some of my posts, you will see I am all for limiting who practices in my specialty also. And arrogance is an outgrowth of narcissism which you would know, if you asked, instead of presuming and exceeding your limits.
If any of you have ever experienced situational anxiety, such as a prolonged illness of a loved one, or a personal chronic illness that required enormous life changes, I think you may be more sensitive to situations where benzos may be very important for a patient's treatment. The same applies for chronic pain and the use of narcotics. Until you have lived through some of these experiences I understand why you have a "just say no" approach. I, unfortunately have had some bad experiences. I don't think I could have made it through without the use of these medications. I am also a big believer in SSRIs, stress management, relaxation etc... but these things take a while to work.
"And arrogance is an outgrowth of narcissism which you would know, if you asked, instead of presuming and exceeding your limits. "
Let's try again, in case I wasn't clear/direct enough - I exceed my limits every time I see a patient in the mind of someone in another specialty. Sometimes I exceed my limits 3, 4, or even more times in a single visit.
"I am all for limiting who practices in my specialty also"
Let's try again, in case you weren't clear/direct enough - but first you're for limiting who practices in your specialty from outside your specialty, no? It's never a "turf" war when it's your specialty, when it's always about ensuring "quality of care".
Not at all. There is unifying knowledge, there is specialty knowledge, there is even the specialist knowledge of knowing that ans what that difference is, which is what primary care is supposed to be about. Unfortunately, there is not only too little respect for understanding of these boundaries, there is common to all of medicine some rather ubiquitous irrational prescribing,
Perhaps it can be best summed by realizing that wisdom comes from the capacity to say "I didn't know that" more than it tends to get said.
Sermo Doc 18,alprazolam remains the drug of choice,the gold standard if you will,for the acute management of panic attacks.This is really the only approved indication for this drug which,among benzodiazepines,has minimal sedative and maximal anxiolytic properties(approx. 15% and 85% respectively),depending of course,on the patient.Therefore,I really cannot understand how you can persist with your use of the word 'NEVER'.If you retract that categorical absolute,your position makes more sense.
See, you prove my point. It cannot be the gold standard due to the fundamental irrationality of breaking a panic with a drug that takes so long to work.
The ONLY benzo that can break a panic pharmacologically is halcion because it works so fast.
Most benzo treat the inter panic anticipatory anxiety, not the panic.
Either you learned your lesson from the detail rep, or the poseur who taught you psychopharmacology in residency learned that form the detail reps.
Alpazolam doesn't reach significant plasma levels in time to have even a marginal impact on an acute panic.
So, you do not recognize a PLACEBO when you see it.
I reiterate the word m NEVER because if a large number of specialists can't get it right, why should a generalist?
While an infinite improbability may remain a finite possibility, somethings are impossible,
Sermo Doc 18.... thanks for the article .....the pharmacokinetics explain why so many people were titrated to 5 mg doses with a redosing interval of 8-12 hrs... in order to
treat/ manage panic disorder,...outside of the placebo affect, and why acute exacerbations did not result in symptom relief until 42-108 mins after dosing..
(add the placebo effect and the patients saw 10-30 min onset of symptom relief)
Sermo Doc 18,now you are being rather ridiculous;using equations you certainly do not understand to try and butress your untenable stance.Alprazolam's anxiolytic activity has a lot to do with 'onset of action' and almost nothing to do with T1/2.You should also know that studies in pharmacokinetics are invariably more population-dependent and akin to transliterating in-vitro studies as in-vivo.I really do not want to continue this Sermo Doc 18,but if you insist,you might just lose some of the credibility you EARNED over the years.
The onset of action for alprazolam,in practice NOT theory,is 3 - 30 MINUTES;placebo effects are indeed considered 'therapeutic' and indeed,the 'anticipatory anxiety', to borrow your phrase,does not occur in patients managed appropriately for true panic attacks with alprazolam.You may ask Rod Steiger(well-known actor who was virtually home-bound for several years,crippled by panic and other phobias).
My last bit Sermo Doc 18,stick to what you know for sure;this should not be about winning arguements;and never say never:~) We are not all residents here;again,I humbly request that you be 'nicer' to your colleaques;consider limiting yourself to psychotherapy and 'rebreathing'.
A cursory search of pharmacology literature shows: Following oral administration, alprazolam is readily absorbed. Peak concentrations in the plasma occur in 1 to 2 hours following administration.
I think 3 minutes onset is a little optimistic...clinical effect would probably be present by 30 minutes. Useful in an ACUTE panic attack? Doubtful.
"We are not all residents here;again,I humbly request that you be 'nicer' to your colleaques;consider limiting yourself to psychotherapy and 'rebreathing'. ""I'm sorry Sermo Doc 18,I forgot to mention your primary occupation when I suggested you adhere to what you know.That would be Law. "
.
.
Do as I say, not do as I do?
OklaERdoc,it is ok to look up data but you also have to know 'how' to interpret data.When you did your 'cursory' googling and found that alprazolam is easily absorbed and 'PEAKS' in 1 to 2 hours,did you also note the binding percentages and propensity;the tiny amounts and individual variability for therapeutic effects;the carefully stated indications and repeated reminders to individualize its use;the completely lack of absolutes in its pharmacokinetics?You kinda disappoint me,for all your philosophical brilliance on other threads eg 'do you believe in eternal life'?;that turned out to be simple plagiarism did it not?Sermo Doc 18 can speak for himself.
Sermo Doc 18,you and I know that there is unquestionable duelism in the simultaneous practice of medicine and law.I know several physicians that also have law degrees;they invariably practice medicine.You have chosen to practice law;nothing wrong with that but you need to be true to yourself and sermo.Sorry,I have no links or studies to site;like I've said before,we should try our best to stick to what we know.
BTW,I will never pretend to practice or even understand the practice of law.As you know,there is 'LAW' AND 'THE PRACTICE OF LAW';two different things entirely,from my very limited understanding.
How do you do a rebreathing exercise while driving accross the San-Fransisco bridge AT THE ONSET OF A PANIC ATTACK?You would be better off if you had taken your duely prescribed dose of alprazolam before embarking on the trip.
See if the person is properly treated, the person uses klonopin for maintenance, then the person has ceased having breakthrough panics. Furthermore the anticipatory anxiety has been treated, and rebreathing can be done while driving.
So why don't you just give us the citations that show xanax working in 3 minutes?
Of course re-breathing can be done while driving but should it?Wearing a neck-collar while driving gets you a $200 ticket in my state.Regarding the 3 minutes,what I actually wrote was 3 to 30 minutes,a rather wide range very similar to the absorption and systemic availability of various forms of alcohol and THC.The oral absorption of benzodiazepines in general is erratic at best but even more so IM due to their highly lipophilic nature.The onset of action depends on several variables even in the same individual at different times.
If you occasionally or frequently have an alcoholic beverage or two,you might be able to attest to the fact that your tolerance may be different EACH time,depending on your general physical AND psychological state.Your last meal,fatigue,affect,state of hydration,metabolic rate and therefore thyroid function,gastric pH,etc.all significantly affect absorption.Medicine remains more art than science as I have said several times elsewhere.The placebo effect you kept harping on,is considered a part of a drug's therapeutic effect.
The cumulative kinetics of benzodiazepines, mosly due to their lipophilicity, deserves mention because subsequent dosing may increase the levels above what can be predicted by pharmacokinetics;again,this invariably depends on the patient's fat content,especially 'brown fat'.Above all,their complex interractions with GABA and other receptors in the brain are to date not completely understood.Sermo Doc 18,never say never;otherwise,you are OK.
Furthermore,can you explain the paradoxical effects of these sedative/hypnotic/anxiolytics?Even benadryl can cause elation and hyperactivity in some individuals,especially children.So-called pure hypnotics,such as ambien,rozerem,lunesta,etc. all manifest paradoxical effects in several patients.Idiosyncratic reactions and interactions are rife in therapeutics as any experienced clinician will tell you.Really don't want to keep repeating myself AND will not quote the studies you look at in pharmacokinetics that have an average 'n' of 86.I will continue to enjoy your perspectives on various relevant issues and learn from them.Thanks.
a few more comments on this thread of eternal life, or is it eternal anxiety........
Xanax can be bitten and held under the tongue, and absorbed sublingually, resulting in somewhat quicker effect. There is a new formulation of klonopin that is dissolvable under the tongue, klonopin IR probably. I wonder if anyone would agree that that is useful? Could someone provide the proper mathematical constants for that?
I do like the image of holding a paper bag over ones mouth, while hyperventilating into it, driving one-handed, possibly even talking on a cell phone? while assuming that your panic will immediately subside because of the "rebreathing" treatment while driving across the Golden Gate Bridge. It sounds perfectly conceptualized and therapeutic to me. I don't know why we don't all use this technique. I do think that the size and capacity of the paper bag would need to be taken into account, however.
ak - how about googling or otherwise convincing us - rather than just simply stating - that xanax can give EFFECTIVE results in THREE MINUTES? Surely you must have a source for the three minute claim - or did you just make it up?
And if I choose to "defend" Sermo Doc 18 or anyone else, I will feel free to do so - I don't require your permission to speak freely here. What are you - some kind of moderator or something?
Sermo Doc 30,BRAVO.You are pretty smart,and probably quite pretty.I enjoy your intelligent snippets of knowledge.I call them as I see them.The 'quite pretty' part will of course apply only if you are XX:-)
want to make the point once more that oxazepam should not be on the same list as alprazolam. It has low abuse potential, hardly any street value, and its not what most benzo abusers would even accept unless nothing else was available. It has the disadvantage of enormous latency (takes 2 hours to peak) combined with very short-halflife and a quick exit, as well as slow entry into brain.
In a way this reminds me of the post saying that FPs should leave the prescribing of Provigil to the psychiatrists when there are no approved psychiatric indications for Provigil.
Ebola - just because you're sore that I proved you wrong on the other post - you don't have to stalk me over here and jump into this little discussion.
And besides - as Sermo Doc 26 has suggested - he can speak for himself.
Sermo Doc 18,you can actually demonstrate this for yourself since you still claim to practice medicine.The next time you encounter a patient in panic,administer 0.25mg of alprazolam orally;instruct the patient to chew this and swallow,then start your stop-watch.Sometimes you can abort an attack by talking,nasal O2 or by face mask,rebreathing actually just increases oxygen by using the central effect of hypercapnea,exercise,etc.A panic attack may be considered a psychosomatic event and can be aborted in different patients by different things.I can teach you a lot of things you may not find in texts and citations;but now,I guess I'll let the wanking continue and get back to more progressive activity.
ak - so, in other words - you have no citation but have just made up the three minute timeframe and are basically now claiming that - using a combination of chewed up pill and misdirection - you can treat an acute panic attack successfully in three minutes?
When you mentioned the three minute onset - you didn't say anything about other modalities.
And BTW - a hyperventilating patient has a HIGHER pO2 and a LOWER pCO2 than a normally ventilating person. By rebreathing, you actually DECREASE the pO2 and INCREASE the pCO2 which normalizes the pH - exactly the OPPOSITE of what you said.
And that is why a properly educated patient with practice can drive the bridge without a paper bag, just regulated breath holding coupled with regulated breath.
There is not cite. I am soooo bitterly disappointed!
You are dead wrong about the indications and appropriate use of Provigil. I don't disagree with you about the use of Xanax being rare but in the case of Provigil you should follow your own advice and leave it to the doctors who are experienced at using it.
Okla, >Ebola - just because you're sore that I proved you wrong on the other post - you don't have to stalk me over here and jump into this little discussion. <
You didn't (prove me wrong). I didn't (stalk you).
Please tell me the documented uses of provigil, and not the garbage submitted to fda for the erroneous approval of this junk.
Its approval was another abomination of fda.
But I am open to reading actual cites that give me information I don't have. Please cite.
And, as a doctor experienced in using it, please tell us what follow criteria you use to make sure that the positive results you see are not placebo? Not due to diversion?
I said nothing about street value for provigil, I don't know where you got that idea.
It would actually have to have some pharmacologic impact before it had street value. It is high priced caffeine, should not be on the market, and never prescribed.
This is one place I agree with the insurance companies that no one should pay for this junk.
Remember that the cites are only the starting point. I have yet to see a single well designed study that has shown to provigil as anything more than caffeine. So I am always happy to see if there are others that say otherwise.
Well, it was looking good, but once again, we have proved that no discussion on Sermo can go on more than 2 pages without breaking down into name calling, accusations, sarcasm and anger.
I don't know about accusations, but I do think some have misunderstood what I was driving at about provigil. I doubt there is much street value to this junk, but people do share it, like ambien. You guys don't seem to realize that your patients view prescription meds differently that you do.
That said, my point is that provigil is nothing but expensive caffiene, and the insurance companies are correct in making you do a lot of work to justify prescribing a medicne that has no reason ever to have even been approved.
Study in JAMA on effects of Dopamine suggesting potential for abuse. jama.ama-assn.org
Study in Journal of Pediatrics showing effect in ADHD children. www.jpeds.com
Study Published in Annals of Clinical Psychiatry showing effectiveness of modifinil in augmentation of SSRIs in the treatment of MDD. www.informaworld.com
There are many articles out there attesting to the effectiveness of modifinil in the approved indications as well as off label use. Yes, some of these are sponsored by Cephalon.
I have some other things to do today but I'll get back to tell you how I use it.
Okla,do you seriously think that a panic attack is an acid/base disorder?I have ignored you so far but apparently you need to interract.If so,go right ahead 'cos I've looked you up.Lets go then.
What is truly funny or sad about all the citations listed by Ebola are that they demonstrate nothing about clinical superiority, nor have clinical relevance in some instances.
These cites, such as they are, do demonstrate how many people who prescribe drugs have no idea what hey are doing, but if the detail reps give you a mug, whell you are bought.
Prescribing provigil causes no harm other than unneccessary cost.
Prescribing xanax is harmful as it is addictive, poses harm of dangerous withdrawal, and there are better alternatives. I guess it is is useful to the bottom line to keep your waiting room full of junkies?
Okla, is it possible for any doctor not to know about acid base balance and 02 CO2 balance? Is it actually possible? Don't you have to know about that in internal medicine residencies and for the boards?
Oh - and then please tell me where I state that panic attacks are acid/base disorders. I simply corrected your notion about the physiology of rebreathing.
Let me clarify - panic attacks often are accompanied by HYPERVENTILATION. Hyperventilation causes an DECREASE in the pCO2 and a concomitant INCREASE in the pO2, RAISING the pH , thus being classified as a respiratory alkalosis. Rebreathing corrects this alkalosis.
Sermo Doc 18, You will have to excuse me as I am at work today and don't have the time to fully support my position. I just want you to know that I'm not avoiding the question and can support the its appropriate use and will.
I haven't seen any studies comparing it to caffeine, however most with the serious indications have already tried coffee to no avail. It certainly has less side effects than caffeine.
Please don't point to my hastily acquired cites as evidence of my ignorance of the med. I would put my knowledge of the correct prescribing and the pharmacology of Provigil against yours any day.
I don't say that about the meds you speak of in your specialty. I just feel you should stick to your own specialty when advising docs what meds do and do not work. You are way off base on this one.
Do you have OSA or Narcolepsy. If so do you just drink extra coffee as a treatment?
Okla,please read what I wrote.You just told us that rebreathing corrects acid/base balance and panic attacks are OFTEN accompanied by hyperventilation.How about those NOT accompanied by hyperventilation?Will rebreathing still abort them?I stated clearly that panic attacks may be aborted in different patients by various techniques.Strictly speaking,rebreathing treats 'hyperventillation' and its effects;oxygen by inhalation,talking to the person and other 'distractions have been known to abort episodes of panic.You don't have to go to med school to know the machanism of rebreathing;is it THAT which treats panic attack?Or is it the very act in itself,the forced and controlled breathing,or that it just burns out while you do all that you do.
Yes,I did look you up.Your background clearly shows that you are incapable of independent thought.All you have done to date is commit information to memory and regurgitate;quote and insist on words written by others;cite this,cite that;not once have you 'cited' something you did;not once have you 'cited' something you know.ANYONE can memorize text and regurgitate,hence I previously said to you that looking at data is one thing,interpreting data correctly is another.
1.Give us a citation or ANY proof that xanax is effective BY ITSELF in as little as 3 minutes - as you repeatedly claim.
2. Please tell me that your comment "...rebreathing actually just increases oxygen by using the central effect of hypercapnea..." was simply WRONG.
Quit trying to avoid the 2 simple questions by throwing up irrelevant information. YOU have demonstrated a clear misunderstanding of the physiology of hyperventilation. Something a first year medical student should know.
"Strictly speaking,rebreathing treats 'hyperventillation' and its effects" - this is the only thing that you and I agree on.
As to Sermo Doc 18's "hidden motives" and "secondary gain" - I have no idea. Are you suggesting that he has stock in some competetive drug or something????
But I digress - please address the two questions or points that I have made - so far you haven't......
"All you have done to date is commit information to memory..." Thank you.
"ANYONE can memorize text and regurgitate..." with the possible exception of YOU when it comes to acid-base chemistry - since you are wrong in your understanding of rebreathing.
Does it have anything to do with that little machine that THEY planted in your head?
Sermo Doc 26 Internal Medicine Posted Jan 21, 2010 at 8:57 AM Lawdoc has his agenda on this board;he has secondary gains for the positions he takes on some issues but you can't even see that,can you???
Okla,you need to attend a real medical school.You are actually an impostor practicing medicine by force of legislation.You claim your primary specialty is ER BUT YOU ARE REALLY A DO,TRAINED IN FP,WORKING IN AN ER.On other topics you have been guilty of plagiarism,a true crime.You quote people out of context just to 'win' an arguement.You have NO credibility here.You should really crawl into a hole whence you can continue following MENUs written by others.
Oh - I see - now, instead of admitting that you are ignorant of acid-base theory and have NO idea what the physiology of hyperventilation is - you now choose to attack Osteopaths as real doctors? Real professional.
1.Give us a citation or ANY proof that xanax is effective BY ITSELF in as little as 3 minutes - as you repeatedly claim.
2. Please tell me that your comment "...rebreathing actually just increases oxygen by using the central effect of hypercapnea..." was simply WRONG.
You guys need to back away. No one gains anything from insults. I think AK's problems with your sort of logic (no logic) Okla doesn't stem from this post but from chronic interaction with you and your inability to be civil and eagerness to be caustic and to get down and personal. It may not be right but you bring this kind of personal attack on yourself by attacking others personally and badgering them until they reply, sometimes having lost their patience with you (imagine that).
You can consult Sermo Doc 18 about legal recourse but I doubt you have a case. It is my understanding that AK's statements about you would only be actionable if they weren't true.
Ummm....I think that impugning the legitimacy of Osteopathic physicians and Osteopathic medical schools sinks below ANY measure of civility.
Furthermore - if I was a graduate of ANY school of medicine and didn't understand the BASICS of hyperventilation and acid-base chemistry, I wouldn't be so quick to cast stones.
And speaking of losing patience - as I recall - AK was the FIRST to question Sermo Doc 18's knowledge yet he is too obstinate to simply ADMIT that he was just making up the 3 minute comment AND too afraid to ADMIT that he doesn't understand hyperventilation.
You should really be in conference with your bankers by now.You must learn a few facts of life.NEVER threaten people,especially those you do not know.I often use the example of a man that pulls out a gun during a verbal altercation.Be ABSOLUTELY certain you are willing AND able to use it.
I hesitate to write anything in the middle of a duel. AK4700 do you need a second? Is there going to be a dawn appointment? I am available, although I am XX.
Nevertheless, screwing up my courage I am adding some references to the usage of rebreathing for hyperventilation. I do hesitate to add anything here, so feel free to ignore me and just keep punching guys. But I did look up rebreathing, and these articles may be in support of AK4700. (gasp) Also, if this is long enough and boring enough, maybe the above elevated adrenaline and testosterone will subside for a bit?
Paper bag rebreathing Many panic attack sufferers as well as doctors recommend breathing into a paper bag as an effective short-term treatment of an acute panic attack.[13] However, this treatment has been criticised by others as ineffective and possibly hazardous to the patient, even potentially worsening the panic attack.[14] They say it can fatally lower oxygen levels in the blood stream,[15] and increase carbon dioxide levels, which in turn has been found to be a major cause of panic attacks.[16] It is therefore important to discover whether hyperventilation is truly involved in each case. If it is, then rebalancing the oxygen/CO2 levels in the blood and/or re-establishing an even, measured breathing pattern is an appropriate treatment which may be also achieved by extending the outbreath either by counting or even humming.[17]
But, breathing into a paper bag restricts the fresh air you are able to get. Without fresh air, too little oxygen is in the air you're inhaling. So, breathing into a paper bag dangerously lowers the amount of oxygen in your bloodstream. There have been several documented cases of heart attack patients incorrectly thinking they had hyperventilation syndrome and fatally worsening their heart attacks by breathing into a paper bag. ...... To make matters worse, several studies now show a link between high concentrations of CO2 and panic attacks, which means that artificially increasing CO2 in inhaled air is likely to trigger more feelings of panic in patients who suffer from anxiety. The best treatment of hyperventilation syndrome is to stay calm and practice breathing slowly and not too deeply. Calmness and breathing exercises have just as much success as paper bag breathing, and no one is going to die from staying calm.
Sources: Callaham, M. "Hypoxic hazards of traditional paper bag rebreathing in hyperventilating patients." Annals of Emergency Medicine. Jun 1989 PMID: 2499228 van den Hout, M.A., et al."Rebreathing to cope with hyperventilation: experimental tests of the paper bag method." Journal of Behavioral Medicine. Jun 1988 PMID: 3139884 Ohi, M., et al."Oxygen desaturation following voluntary hyperventilation in normal subjects." American Journal of Respiratory and Critical Care Medicine. Mar 1994 PMID: 8118644
Griez, Eric J., et al. "Carbon Dioxide Inhalation Induces Dose-Dependent and Age-Related Negative Affectivity." PLoS ONE. 3 Oct 2007 PMID: 17912364
That is WIKIPEADEIA article so obviously written by a paranoid nut job that it begns with this disclaimer:
"This article is in need of attention from an expert on the subject. WikiProject Psychology or the Psychology Portal may be able to help recruit one. (January 2009)"
Why are you Xanax prescribers so afraid to challenge the junkies in your waiting rooms? Are you afraid you will lose too much income if you practice rational medicine?
Even in the paranoid wiki article it says:
The best treatment of hyperventilation syndrome is to stay calm and practice breathing slowly and not too deeply. Calmness and breathing exercises have just as much success as paper bag breathing, and no one is going to die from staying calm.
And that demonstrates the point in the first place about training a person to maintain self control, which is undermined by the use of xanax.
Cutting out all of the obfuscation - AK claimed - ERRONEOUSLY - that hyperventilating patient had LOWER oxygen in their blood than normoventilating people - this is just plain WRONG.
I will stipulate that there MAY be disagreement as to the efficacy of rebreathing and its role in panic attacks - but that is all beside the point.
Here we have a (presumably) MD person who is berating me because I am a supposedly inferior DO - yet he makes a major blunder in discussing blood gases - and then refuses to just step up and admit he was wrong.
And also refuses to - again - just simply admit that he made up the 3 minute claim regarding xanax onset of action.
And finally - AK - please show me where I THREATENED you. If you are refering to my coment about seeking legal redress - I don't really believe that is considered a threat, more like discussing a perfectly reasonable legal option available to someone who is being slandered.
They say it can fatally lower oxygen levels in the blood stream,[15] and increase carbon dioxide levels.....
"They" are quite correct when "they" say that rebreathing increases the CO2 - that's the WHOLE POINT! As for it fatally lowering oxygen levls - one would have to imagine that long before someone became FATALLY hypoxic, they would drop the paper bag away from their face.
Nice citation, though, from WIKIPEDIA. At least it's more than AK can offer regarding the 3 minute claim.
Ak and everyone, we are all doctors and colleagues. Please stop the fighting.
You all have valid points.
DOs are the same as MDs, we know that. I refer to a surgeon who is a DO all the time because he is one of the best. One of the FPs in my office is a DO and he was named the best primary doctor in No. County (and he didn't have to pay for that). My relative in CA is an interventional radiologist and a DO.
Paper bag breathing probably would work for some, but not all, panic victims.
I don't initiate xanax, but have some pts who were already initiated by someone else, and it's sometimes hard to get them off.
Thank you Sermo Doc 23 - for your vote of confidence in DOs. Quite honestly, I believe that AK doesn't REALLY mean that we DOs are inferior. I believe that he is just SO pissed that I called him on two errors that he made that he is just grasping at straws to misdirect others from the points I made.
Maybe he'll do the right thing and apologize. Then again, maybe he won't.
Although I am not an internist, I find it impossible to believe that a true internist could have completed a residency and not know that hyperventilation lowers CO2. Would it be possible in California to have a medical license without internship and residency?
Sermo Doc 23, you see the problem with xanax is getting them off it. Try initiating Klonopin in slow increments alternating with slow reductions in the xanax. Over several weeks you should at least be able to transition the person to klonopin. Later it will be easier to wean from the klonopin. Many people who think they have panics actually have withdrawal from xanax, so they are thinking the drug is controlling their panics when they really are addicted.
DOs and MDs pretty much receive the same training now days as far as I can tell. We had some DOs in my FP residency I think they still have training in manipulation and some in this area do a lot of it. I have referred patients for manipulation before.
I talked with a pain specialist a while back and he had a 7 day regimen for tapering pts off Xanax! I'll try to ask him again. It might have something to do with the fact that they are starting the patient on other addicting substances?
I'm going to hold any discussion of Provigil for now in view of the present situational morass. Perhaps I'll do another post on it myself.
Okla, I wasn't trying to stick my nose into your fight, just calm things down but I didn't expect much from you and you lived up to my expectations. So just continue your useless, childish, shadow boxing.
As far as I'm concerned - a simple apology from AK will end it all from my perspective. And an admission of being wrong about the blood gases wouldn't hurt either.
I'm ready to "kiss and make up" as long as a sincere apology is offered.
I've not been wrong in those cases that you are referring to - those issues were matters of OPINION not medical or scientific FACTS, Ebola. Big, HUGE difference. This person insulted my school, my professional and by extension ALL Osteopaths.
You continue to quote me out of context.Yes,in the treatment of panic attacks,the so-called 're-breathing',WHICH NO ONE DOES CORRECTLY,may only be effective by increasing oxygenation(one of the various options I mentioned).A panic attack is not an acid-base disorder;it is psychosomatic.Anyone interested should go back and read what I wrote,in its correct context.I wrote 3-30 minutes,NOT 3 MINUTES.At no time did I say what you claim I said.If you continue to insult me,I will be forced to tell you a few more TRUTHS.BTW,I am still waiting to hear from your lawyers.
Yup, fully boarded in Psychiatry and Neurology, as well as a member in good standing of the bar..
Now, notice that you never answer questions but just make attacks.
Do YOU have boards in anything?
California lets lots of fake professionals practice due to phony license tracks. I realize for the first time that California might have a fake license track for medicine too?
AK you make mistakes that a mediocre 2nd year med student shouldn't make. Do you actually have boards in anything?
Sermo Doc 18,would you care to enumerate a few of these 'mistakes'?I am interested in correcting them.And,what does 'fully boarded in Psychiatry and Neurology' really mean?
Your question clearly indicates that you do not have boards, perhaps no residency, perhaps have snuck onto Sermo with a degree from an unaccredited institution and a California license.
Sermo Doc 18,you utterly lack honor;you have no integrity;these are my personal opinions having observed your general conduct on sermo over the last 2 years.Somebody should have told you this a long time ago.You ought to be ashamed of yourself.Do you really think anyone,let alone a clinician,will take anything you say seriously?Most of your comments are written after you 'research' GOOGLE;same goes for your red poodle.
Who's the felon now?And while we're at it,let sermo look up your red poodle too.I'll wait for as long as you want.One thing is certain,more physicians will participate in these discussions if these verifications are published here.You are yet to enumerate my 'mistakes'.You think this is grade school(statement,not a question).
AK - "...,the so-called 're-breathing',WHICH NO ONE DOES CORRECTLY,may only be effective by increasing oxygenation(one of the various options I mentioned)."
Okay - there you have it - AGAIN.....rebreathing INCREASES pCO2 and DECREASES pO2.......despite all of the fuss - you STILL don't know what you're talking about!! Incredible.
And no one evr said that panic attacks were acid-base disorders - talk about misquoting!
Saying that Xanax can be effective in 3-30 minutes means that it can be effective in AS LITTLE AS 3 minutes. You were NOT misquoted - that was your EXACT statement. And you know it.
What happened to your Sermo Doc 19?I desperately hope he is not in perpetual slumber.Have you ever administered 'rebreathing' to anyone?Ever?For anything?Tell us how the 'self-induced suffucation' turned out.At the end of the manuevre,even if for a mere 30 seconds,do they not display 'air-hunger' and 'gulp air'?CO2 is the most powerful central stimulant for breathing.A good medical education teaches you to think for yourself.Okla,you lack that propensity;so does your Sermo Doc 19.
I tried to be gentle;tried to teach you that re-breathing may only treat the effects of 'hyperventillation' and since you agree that a panic attack is NOT an acid-base disorder..........do you follow now?The irrational 'feeling of impending doom',tachycardia,sweating,confusion and a few other symptoms occur much more commonly than SOB/tachypnoea/hyperventillation in panic sufferers.I've told you before,I try my best to only write what I know;no 'googling' here;especially not without acknowledgement,as is your wont.Plagiarist!
Oh yes.Did you note where I suggested you start a 'stop-watch' after administering the drug?Who knows?It might even be less than a minute in some instances,depending on severity of the event,even in the same patient who may have required IV diazepam or lorazepam to successfully abort a previous episode.
BTW,do you know how the famous 'Kung-Fu' actor,David Carradine, died in Bangkok?He may have listened to you or the one 'fuuuuully boarded in psychiatry and neurology;and law'.
Okla,at the end of this 'slumming',I intend to block you and your Sermo Doc 19;I suggest you block me too.Plagiarist.Don't want you sending me any more private e-mails.Whatever you have to say,stay transparent,say it here.
hyperventilating people have HIGHER pO2 than normoventilating people - contrary to what you believe.
You might want to try GOOGLING that - you might learn something Mr. Internist.
As for your false accusations of plagiarism - the quotes I used on another post were used with explicit permission....you might want to GOOGLE the defintion of plagiarism.
DIDDLING myself? What are you - an elementary school student??
Incidently - David Carradine supposedly died from autoerotic asphyxiation.....what's that got to do with hyperventilation?
Oh - so NOW (oral) xanax may be effective in LESS THAN A MINUTE??
You're out of control, pal......
Just admit you don't understand hyperventilation.......you made up the 3 minute claim on xanax and you apologize to the DOs - and it'll be over - or aren't you man enough to just "fess up?
On the topic authored by Wonposet,'Do you believe in life after death',you were seemingly on the ball,until someone pointed out that your writings,for days,were lifted,literally cut and pasted from someone else's theories and ideas.You made absolutely no acknowledgement before you got caught.Yes,you e-mailed me that the original author,whose ideas you reproduced,wrote an index permitting people to use her/his words,you plagiarized her/him nonetheless BECAUSE you only stopped AND acknowledged it AFTER THE FACT.I'll slum for a while longer,waiting for your Sermo Doc 19 to point out my mistakes(so I can correct them) and for him to give sermo permission to publish the results of their investigation here.
hyperventilating people have HIGHER pO2 than normoventilating people - contrary to what you believe.
Incidently - David Carradine supposedly died from autoerotic asphyxiation.....what's that got to do with hyperventilation?
Oh - so NOW (oral) xanax may be effective in LESS THAN A MINUTE??
Just admit you don't understand hyperventilation.......you made up the 3 minute claim on xanax and you apologize to the DOs - and it'll be over - or aren't you man enough to just "fess up?
Sermo Doc 12 Emergency Medicine Edited Jan 06, 2010 at 4:16 PM
My posts here - while i would like to take full credit aren't my own - they are from Godisimaginary and whywontgodhealamputees (which, BTW, the author gives free permission to share with others in an attempt to bring reason to humankind).
This is from the whywontgodhealamputees AND godisimaginary websites:
Would you like to help?
Here are four simple things that you can do today:
Add links to this web site in forums, blogs and newsgroups. Anywhere you see people discussing religion, add a link to this web site and quote specific sections that you think are relevant.
Link to this site in your own profiles, personal pages and blogs.
Email a link to this web site to your friends.
Encourage discussion and help others to start thinking rationally about religion.
pla⋅gia⋅rism
-noun 1. the unauthorized use or close imitation of the language and thoughts of another author and the representation of them as one's own original work.
2. something used and represented in this manner.
So - smart guy - care to persist in accusing me of plagiarism? Also not copied but MANY posts before I actually used any quotes - I referenced these websites.
You are still lying.You only 'fessed-up' after you were caught.I said you ARE guilty of plagiarism NOT copyright infringement;that would be an entirely different matter.Anyone that followed that post can go back and check exactly when you acknowledged the author.It was AFTER you were called on it,soon after I wrote,'what if you are wrong'?And in the lexicographic book of reference,your picture should be inserted to represent your definition #1.
At last,I have something to 'cite';ANYONE INTERESTED CAN LOOK UP YACHADHOO'S comment posted January 07 at 12.20pm on the thread "Do you believe in eternal life?",authored by Wonposet.Soon,you will hit the bottom of the abyss.Continue.....plagiarist.
OklaERdoc Emergency Medicine
Posted Dec 30, 2009 at 5:59 PM
I would encourage folks to browse through www.whywontgodhealamputees.com
for some thought provoking stuff.
OklaERdoc Emergency Medicine
Posted Dec 30, 2009 at 10:46 PM
will YOU check out whywontgodhealamputees with an open mind as well? It's an easy read (no flowery mumbo-jumbo) and a REAL eye opener.
OklaERdoc Emergency Medicine
Posted Dec 31, 2009 at 2:02 PM
I really, really hope that OPEN MINDED people that are following this post thoroughly peruse the whywontgodhealamputees website....please do yourself a favor. I will say no more as I have said enough.
jmh4kids Pediatrics
Edited Jan 07, 2010 at 2:27 PM
OklaERdoc, I have visited your referenced websites, as have others I'm sure. They offer interesting arguments, but no proof and certainly no indisputable facts. I just didn't want you to think that no one was following-up.
chilicat Pathology
Posted Jan 07, 2010 at 4:03 PM
When I said Bravo to OklaERdoc, I was well aware that he was using arguments from various sources. I was commending him for putting those arguments together in the fashion he did.
Sermo Doc 95 Internal Medicine
Posted Jan 07, 2010 at 5:45 PM
I had looked at the sites by Okla and understood that he had used them in his explanations. I was not confused,
No I certainly do not;those words were not yours and you never said you were lifting them.You were revelling in your much-estolled 'debating skills' until yachadoo called you on it.
the USE was authorized, website was repeatedly posted...in fact others visited the website - as is the intention and desire of the author, at least two readers were not confused nor did they believe I misrepresented anything.......
You have NO CASE, pal.
BUT - of course, all of this is simply a smokescreen to misdirect everybody from the original issue which revolves around YOUR evasion of these questions:
1.Why do you continually REFUSE to simply admit that you are confused about the physiology of hyperventilation (LOW pCO2 and HIGH pO2)?
2. Why won't you simply admit that you completely MADE UP the 3 minute onset of action claim about xanax (now amended to a ONE MINUTE claim)?
3. Why won't you apologize for your disparaging and unprofessional remarks about the legitimacy of DOs?
Are you referring to the yachadoo that presented a cartoon as his own work - and NEVER once refuted that implication? Is that the yachadhoo that you are using as a source?
What happened to your threat of legal action?I bet your Sermo Doc 19 can give you a discount if your finances are inadequate to back up your big mouth;after he takes you to the Vet.He is yet to give sermo permission to publish their findings here after a thorough investigation of our unrestricted priviledge to practice medicine and surgery.
Are you all OK? Although I haven't seen much cursing, you all have been SO mean to each other. I don't think I've ever seen it this heated. There are so many posts I can't remember who said what against anybody.
Please take a deep breath, all of you and calm down. I run the risk of being insulted but this should be a debate based on facts and not opinionated insults.
DOs, MDs, psychiatrics, internists, ED docs, family med docs - I like all of you. Please show just the facts and quit the infighting. You all are frequent posters and all have good things to contribute.
Okla, I think in California, the land where people think that Pelosi and Waxman are sane.. naturopaths can do surgery, and are licensed as equivalent to real physicians. Real physicians meaning DOs and MDs
At the risk of being accused of trying to interject something.......well, never mind..
When you consider that this is the way physicians (yes, even DOs!) with over 23 years of education behave, do you understand why I don't think very many of my patients with half as much schooling and often even less brainpower and capacity for insight are going to benefit form counseling? When you look at the amount of anger and irritability, which I believe to be innate, do you understand why I like drugs that are potent enough actually to work?
As I've said before, alprazolam is hard to stop for one simple reason - it really works. Anti-depressants are easy to stop because - they don't (or people aren't depressed). If alprazolam doesn't actually do anything, then why do people, in your opinion, like to abuse it? What some people see as abuse, I see as effectiveness.
" As I've said before, alprazolam is hard to stop for one simple reason - it really works. "
No, you see, it has withdrawal that mimics panic. After 10 days, most people are physiologically addicted. You try to wean them, and they cannot be weaned.
Here is the challeng: if klonpin works just as well, and it is hard to become addicted to klonopin, and klonopin is cheaper, and withdrawal from xanax can kill, but withdrawal from klonpin doesn't, why would you use xanax?
Many doctors, eyes wide shut, prescribe xanax, opioids, adderral, and thus keep their waiting rooms filled.
There is nothing harder to do than to say this and elicit the response: Reall? I hadn't thought about that. I will consider doing something different.
>Add links to this web site in forums, blogs and newsgroups. Anywhere you see people discussing religion, add a link to this web site and quote specific sections that you think are relevant. Link to this site in your own profiles, personal pages and blogs. Email a link to this web site to your friends. Encourage discussion and help others to start thinking rationally about religion. <
This is an excellent example of an atheist proselytizing!
Sermo Doc 18 = HOT AIR.Who is the felon now?You stated you contacted sermo to look up the status of our unrestricted licenses to practice medicine and surgery.Will you give sermo permission to publish their findings here,like I have done?Physicians who distrust you on this board might just participate more if things were more transparent.What have you got to lose IF you are legit?How about it Sermo Doc 18?If not,I have nothing more to say.
Exactly what does that mean? Are you telling me I'm essentially just selling drugs to keep busy and for profit?
There is no substantive difference between alprazolam and clonazepam. To say that alprazolam has all manner of problems associated with it and clonazepam is totally different is just hair-splitting nonsense. The same nonsense has been said about diazepam and lorazepam for the past 30 years - diazepam was bad, but lorazepam was okay. The only significant difference is the time of onset and duration of action, which makes clonazepam useless as a prn; I'm just stunned by the frequency with which patients have been given prn clonazepam for panic attacks. If anyone can claim alprazolam doesn't work fast enough, then clonazepam for damn sure doesn't. And the objection to alprazolam seems to be that it DOES work quickly, which is why is can be diverted and misused while clonazepam much less so. How can it work quickly when misused, but not when properly used? Everything else is rhetoric, although I generally find alprazolam to be more effective. Some people do better with one, some with another.
I think we simply disagree, I'm sorry you have to frame that as a matter of competence and credentials. I think people are anxious, and I think benzodiazepines work far, far better than SSRIs, and you don't. I think people are better, you think they're just high. We just disagree. But, again, thanks for the personal attack on my professional character.
This thread has become pointless and should be closed despite the importance of the topic. I figure in the end those who work in psychiatry inpatient and the ER will see lawdoc's side vs. those who work in primary care and primary psychiatry will see Sermo Doc 121's side. This is probably cause both sides don't see the same patients, well not in the same emotional state at least.
jcp - thank you....I am done with this. I think I have made my points - not adequately answered by the one in question for reasons that should be clear to everyone.
Green Lantern - you are correct - learned physicians have many of the same traits as "normal human beings" - we get angry, we fight, we antagonize, we're obstinate and some of us are very much on the edge......
"...this is the way physicians (yes, even DOs!) ..." - see? even YOU can't resist being a little "human" from time to time, can you?
"...this is the way physicians (yes, even DOs!) ..." - see? even YOU can't resist being a little "human" from time to time, can you?
Uh, that was meant to be humorous. I just finished precepting a DO student over the last 2 weeks of December, a student at PCOM-Atlanta who was home over the holidays and needed a quick low-impact elective to make up some time. We chatted a lot about where medicine was before her and where it is today from both my and her perspective, particularly the changes in the way MDs and DOs see each other and the way both concepts have changed.
Not to go off topic, but it's interesting that apparently osteopathy is now aiming to "take over" or "take back" primary care, re-affirming their commitment having physicians provide primary care while the allopathic world has all but ceded it to NP/PAs as though it were beneath them. That's the message she's been getting; and, if she wants to go into surgery, they're recommending general surgery rather than the other sub-specialties. Osteopathy wants to "own" primary care medicine and (primary care) surgery. But that's another discussion.
"This is probably cause both sides don't see the same patients, well not in the same emotional state at least. "
Unquestionably true. I take care of a psychiatrist and his family; he does primarily drug rehab/substance abuse. At the outset it was clear to he didn't like alprazolam, but he's come to realize that he's not seeing the patients whom I treat who do well, but rather an entirely different group who have often never done well with anything, including antidepressants, and, if alprazolam isn't their answer, it certainly isn't their problem. Finally one day I asked, "Have you EVER seen a patient abusing alprazolam or another benzodiazepine who wasn't also previously, repeatedly, and currently abusing all sorts of other drugs?" and he said, "Well, now that you mention, it, no." Conversely, I would hope that in those patients who would otherwise wind up under his care I've stopped alprazolam and moved on to other treatments or referred them, vs. just dumping them (aka AMF YOYO), continuing to try to find them some sort of answer (presuming they want one). BTW, I also love Symbyax for treatment resistant anxiety, although that, also, is another discussion.
Green Lantern - when I was in school ('83-'87), the given stats at that time put DOs at 90% primary care and 10% specialty areas - so, I don't think it's a matter of DOs "taking back" primary care - we have ALWAYS had stronger representation in primary care areas.....now, please consider that - at least when I trained - we only represented about 10% of practicing physicians in the country.
Interesting bit of DO history......in 1962...the State of Claifornia took over the DO schools that were in existencwe then and offered the DOs trained there an opportunity to CONVERT their DO degrees into MD degrees for a fee of $65....about one-half took them up on their offer and , to the DO community, they became traitors and referred to as "md's" (small case letters intentional).
The last state to accept DOs as unrestricted practitioners of medicine and surgery was Louisiana in 1971 - interstingly, the "birthplace" of Chiropractic.
In 1968 - well into the VietNam War - MDs had been drafted and forced to serve. DOs had not been recognized at that time and were ignored by the military and left to conduct their respective practices. The story goes that MDs who had been drafted - and previously sneered at the inclusion of DOs into the "brotherhood" all of a sudden decided that we really WERE equal to them and then, in 1968, the military accepted DOs. Henceforth - in the Armed Services - we were ALL known as "MC" Medical Corps...there is no special military distinction between DOs and MDs.
As you all may well know - some states have separate DO and MD Boards while others have combined Boards. The distinction these days is less and less obvious.
I will admit that, in the early days, DO training WAS inferior. These days - not so. I did my residency in the Air Force alongside MDs - and I did quite well comparatively speaking. We can all cite instances of MD colleagues and DO colleagues who have no business practicing medicine and we can probably all cite individual physicians - both MD and DO - who we would trust with our own lives.
I take great offense at the suggestion that we DOs are somehow "pretenders" or "poseurs" and would suggest that those who believe that nshould re-examine the facts and offer apologies where appropriate.
Ebola - I have never pretended to be anything other than "human" - prior to my elevation to the lofty position of PHYSICIAN, I was an orderly (remember those), EMT,Army medic and pharmaceutical salesman.
My shit stinks just like everybody else's, I fart and I belch and I'm not above a dirty joke. This has always served me well, because I think I can talk to ANYONE on their own terms. I can relate to people from all walks of life. I have even received FOOD STAMPS after college and before my job in pharmaceutical sales. I even used to be that scared stiff parent of a feverish kid long BEFORE becoming a doctor.
I've made plenty of mistakes - a very few of which ever caused anyone harm - thank God......I also should've made it MORE CLEAR that I was quoting whywontgodhealamputees and godisimaginary on the other post that Sermo Doc 26 has made such a fuss about - but I still adamantly deny that I committed any crime in doing so at the invitation of the author.
I wonder if others in this discussion can be so honest?
It is a pity that you want to continue this charade;that you have been trying your best to escalate and extrapolate an opinion directed at YOU unto others.I would advise you let it go now,without bias and without significant sequelae,as I have.
>I wonder if others in this discussion can be so honest? <
Honest about what?
Before I became a doctor, I worked in the East Texas Oilfield Summers and Holidays while going to school, laying pipes, cleaning tanks, swamping for heavy equipment. During college I worked in the work-study program. During medical school I worked nights and weekends cross matching emergency blood at Charity Hospital NOLA. This doesn't make me particularly special but I try to acknowledge when I have made a mistake and apologize if appropriate.
You, OTOH, are always demanding or waiting for an apology from someone yet never apologizing for your frequent mistakes, even refusing to support your own position while DEMANDING that others meticulously document their comments. You hold others to a much higher standard than yourself.
I take great offense at the suggestion that we DOs are somehow "pretenders" or "poseurs" and would suggest that those who believe that should re-examine the facts and offer apologies where appropriate
Sermo Doc 26 Internal Medicine Posted Jan 21, 2010 at 4:58 PM Okla,you need to attend a real medical school.You are actually an impostor practicing medicine by force of legislation.You claim your primary specialty is ER BUT YOU ARE REALLY A DO,TRAINED IN FP,WORKING IN AN ER
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I will let others interpret your own words......but I certainly do not take these words as directed at only ME but at ALL DOs.....an apology is in order.
Well,let's see.Are you not a D.O.?Do you not work in an ER?Do you not claim ER as your PRIMARY SPECIALTY?My opinion regarding your medical training in the '70s emanated from my interpretation of your emphasis on other people's works,lack of originality and a decisive conclusion that you follow a MENU in your evaluation and management of patients,as if patients were clones of the same mold.
If you disagree with me that your particular medical school at the period you were enrolled was not less than exemplary,we will just have to hold our independent opinions.The fact that you are 'carrying on' so, with this issue, seems to speak volumes.What exactly do you have against the truth?Especially if it is verifiable.
"Each time I think I'm out,they pull me right back in"........or something like that.......culled from one of the Mafia-themed movies and repeated on The Sopranos as a joke.
2. your statement: "...you need to attend a real medical school.You are actually an impostor practicing medicine by force of legislation..." is an insult to ANY DO - whenever they trained and wherever they trained. You have accused me and "my kind" of being "impostors" (sic). This calls for an apology.
3. The fact that you REFUSE to offer a proper apology for your unprofessional attacks SPEAKS VOLUMES - to use an overused cliche.
4. The fact is that I PRACTICE Emergency Medicine and have done so for nearly twenty years. Nowhere have I EVER claimed to ANYONE at ANYTIME that I am residency trained in EM. In fact, I missed the opportunity to "grandfather" in the Osteopathic realm by one year. Otherwise, I could claim to be Boarded without a residency at all! My Board was taken in FP. Many FPs gravitated to EM and have practiced as such for many years.
ACEP has a term for us - we are called "legacy physicians" by them and, in fact, are eligible to become members. So, I suggest if you have a problem with this - you could complain to the ACEP. But I suspect that they really could not care less about what YOU think.
Finally - as per YOUR statement: "...If you disagree with me that your particular medical school at the period you were enrolled was not less than exemplary..."
I actually agree 100% - my school was NOT LESS THAN EXEMPLARY...in fact, it WAS exemplary!! Thank you for the nice compliment!! Although it would seem to fly in the face of your other unprofessional comments.
Not that I really need to further justify myself to the likes of you, but for the edification of anyone else who cares to know more:
Practice Resources > ACEP Policy Statements
The Role of the Legacy Emergency Physician in the 21st Century
Approved by the ACEP Board of Directors June 2006
ACEP believes that physicians who begin the practice of emergency medicine in the 21st century must have completed an accredited emergency medicine residency training program and be eligible for certification by the American Board of Emergency Medicine (ABEM) or American Osteopathic Board of Emergency Medicine (AOBEM).
ACEP acknowledges that emergency medicine's rapid growth resulted in a workforce that includes physicians who are not eligible for ABEM or AOBEM specialty certification. These legacy emergency physicians, many of whom are residency trained and/or board certified in other specialties, began the practice of emergency medicine prior to the 21st century.
Many legacy emergency physicians have demonstrated their commitment to the specialty through membership in ACEP. ACEP supports its members who are legacy emergency physicians.
ACEP acknowledges that legacy emergency physicians, by virtue of their primary training and emergency medicine practice experience, play an important role in the current emergency medicine workforce and patient care safety net.
ACEP supports the efforts of legacy emergency physicians who seek additional training and continuing medical education to enhance their ability to provide high quality patient care.
ACEP believes that the quality of care delivered by legacy emergency physicians should be a primary determinant of their hospital privileges and credentialing. Legacy emergency physicians should be subject to the same quality standards as ABEM/AOBEM certified emergency physicians. Legacy emergency physicians should not be forced out of the workforce solely on the basis of their board certification status.
Your comments and the policy statement you posted merely seem to support my position.Your primary specialty is FP;ER may be regarded as your 'self-proclaimed specialty', or even secondary specialty.I can't say I knew exactly when you trained but I doubt if it will make any difference '70s or 80s.
"the State of Claifornia took over the DO schools that were in existencwe then and offered the DOs trained there an opportunity to CONVERT their DO degrees into MD degrees for a fee of $65"
At the rate things are going, I might be looking to convert my MD degree into a DO. Wouldn't that be a kick in the pants for NYU, my malma mater which still doesn't recognize the existence of FP - trading up their degree for a DO. FYI, I discussed this with my student last month and she told me it's $1000 now. I suppose California needs the cash, since in Orange County "the average pay and benefits package for firefighters was $175,000 per year" according to Steven Greenhut ( liberty.pacificresearch.org ) of the Pacific Research Institute (again, another discussion, but read the link for fun).
I worked ER for several years myself,doing locums initially but subsequently as an employee,including secondary and tertiary centers in the early '90s.I have not questioned your right or qualification to function as an ER physian but I still argue that your primary specialty is FP not ER.In any case,let it be whatever you say it is because it would not affect me or mine in any way I can imagine.
BTW,you should change your primary specialty to FP on formal documents,forms and sermo;you never know when a 'witch-hunt' might arise and they'll spin it in such a way that it'll make your head rotate on its axis/fulcrum..
Okla,if you go back and read my comments from the begining,it will be quite clear that I did not intend to cause you pain.Why do you carry on so?Perhaps I should have left immediately after my first couple of comments,or even third,which pretty much summarized my entire view,regarding the original topic of this post.
Where you practice, the setting, and your patient population must be taken into consideration. It's not possible to withhold benzos for anxiety if you practice in a dying industrial city, and you have a lot of unhealthy, undereducated Appalachian-types with 'bad nerves' (a result of centuries of inbreeding?) most out of work now on medicaid-like health plans (with timely referrals to specialists a luxury they do not have), choking your local clinic or urgent care to the breaking point...leaving you with no time to practice good medicine?... and then the corporate types give them a 'comment card' rating the Doctor's 'concern and proper treatment' for their illness after each visit, with your job/pay on the line if you don't do what they demand. With no support from management, since they drank the Kool Aid long ago and their entire raison d'etre is just to have a lot of happy 'customers' to make them bigger bonuses.
If i didn't prescribe the benzos, I would have to be on them myself.
For my own education, where do you send people to purchase relaxation materials, is there a good internet site you can suggest?
Sermo Doc 18 has also posted similar admonition in the past.
This advice applies to lot of drugs doctors prescribe..It is a nightmare to get them off the medications once they are started as a "fix" for an ill-defined problem.
Come on.
Same animal, different face.
Soma, too. It's just a benzo in sheep's clothing.
Yes, please. If you don't know what to do with headache patients, I will gladly accept your e-mail.
And for the record, there is HUGE comorbidity between chronic headache patients and anxiety disorders. Can't speak for the numbers on other sorts of pain, but I'd imagine it might be similar.
As for anxiety/relaxation techniques--this stuff is widely available. Here is a selection of links:
www.healthy.net
www.anxietyhelp.org
helpguide.org
www.relaxationtechniquescd.com
Caveat: I have not listened to this particular CD, so cannot vouch for it, but most of them are pretty similar.
Oh com'on
I have quit them in a heart beat at least a hundred times.
There is absolutely no reason to ever use Xanax, I agree. Yes I realize I am using an extreme "ever".
Together, they are all responsible for far more pain and suffereing than they "cure".
I've also inherited more than my share of patients from psychiatrists who think nothing of chronic TID dosing of benzodiazepams with refills aplenty.
I agree w/ Sermo Doc 7 and scharreramd1... we need to TALK to our pts establish a relationship and follow closely. It takes a few weeks for a SSRI or other to 'kick in' and hvae an effect. A benzo, prescribed judiciously (which includes explaining to the pt) is very helpful to give the pt some relief. I also agree that cognitive behavior tx is an important adjunct and key for long-term care but that also takes time and an investment for the patient both in time and, inmany cases, financially. We're here in the trenches with you psychiatristnj!
Xanax and Klonopin are very different drugs. If you as a psychiatrist would prefer not to use them for the treatment of anxiety, so be it.
In neurological disorders, clonazepam is very helpful in the treatment of tremor, muscle spasms, myoclonus, and other conditions. To dismiss it as a bad drug is bad medicine. It is a drug to be used with caution by those who know how to use it.
Xanax, on the other hand, has, to my knowledge, no redeeming qualities. In fact, it is the ONLY benzodiazepine that causes seizures on withdrawal. The others do cause anxiety and restlessness on withdrawal, but no seizures. I would relegate Xanax to the same box as Demerol = unacceptable side effects when better drugs are available.
Buspar, however, is not particularly helpful for us neurologists. The few times that I have attempted to use it, it has been ineffective.
How quickly do SSRIs start to work? I like to tell my patients they can work in a few days or a few weeks. I'm not crazy about the give them a benzo for a couple of weeks until the SSRI kicks in. 2 years later, you're still trying to get them off the Benzo. That's my experience. Of course there are exceptions -- i.e. highly traumatic events that a Benzo may be helpful TEMPORARILY. Tell your patients the SSRI may work faster. Don't forget the placebo effect. We can make the placebo effect stronger and faster working depending on what we say. Yesterday's New York Times article about Depression research said the placebo effect is as good as an antidepressant for mild/moderate depression.
And by all means, Sermo Doc 14, use Klonopin for neurological disorders just think twice before you use it for anxiety.
As long as CUSTOMERS demand and PROVIDERS provide, it will never be the way it's SUPPOSED to be - the correct and beneficial medication for the correct indication. First of all - do no harm......
Klonopin does get abused, crushed, and snorted.
It is an excellent drug for true panic disorder as a tonic to get in front of the panics instead of reacting to them. It is a good AED and muscle relaxant, although there are plenty of other choices.
It is a good idea that it be prescribed by specialists who can monitor it better than most. And I do mean specialists. I see plenty of irrational use of this drug by psychiatrists, not just PCPs.
As ti xanax, there is virtually no legitimate use of this medicine. It is irrational treatment to give it to someone to chance panic or anxiety symptoms, sleep, etc. The half life is so short, and the withdrawal mimics panic, so the risks of addiction are extremely high.
My unscientific survey here on Sermo revealed that an awful lot of doctors are prescribing it, not just NPs
Xanax should be removed from the market (along with several other bad drugs, like ambien)
Don't prescribe xanax. There is no legitimate use for it on primary care.
Learn about sleep, the harm of using hypnotics for anything but short to term, and then the need for "CBT" meaning, proper education of the patients to learn proper sleep hygiene and expectations.
www.ncbi.nlm.nih.gov
Nurse practitioners and PAs must be banned from prescribing any narcotics or hypnotics.
See my previous post - they didn't have any SSRIs, NERIs or Buspar in 1975. You can't build a case for current use on 1975 data!
As with EVERYTHING in medicine the prescriber has to use his/her head. I have exactly the opposite experience than psychiatristnj, but, of course, I'm not seeing other's patients.
Rarely is a patient simply depressed or anxious. Certainly treating patients with SSRIs will alleviate the anxiety because you've fixed the depression. But we all know it takes up to two weeks (maybe one, depending on the severity and length of time the patient has been afflicted) or more to achieve control. During that time, benzos or Xanax are helpful to calm the anxiety. IF the patient still needs Xanax at the two-week visit, the antidepressant dose - or maybe even the drug itself - needs a change. Most often I find the need for it decreases and eventually NONE is used. Thus, the concomitant use of these agents is a barometer to successful treatment with the antidepressants.
And the trash going around about 70% of patients don't need antidepressants in the first place is just that - TRASH. I've been treating these patients for 33 years, having used tricyclics extensively before Prozac arrived. Judicious use CHANGES LIVES. Elimination of antidepressants in those 70% will transfer them back to the 1960's when popular drugs were not only the barbs and benzos, but Seconal, Nembutal, Amytal, Tuinal, Doriden, Placidyl, Dalmane - all for people who couldn't sleep but had no generally appreciated antidepressants. I still see psychs ordering Ambien - how does that differ from using Xanax???
In my practice, I have spent a considerable amount of time taking patients off medicines that were started by the referring PCP. One of the great confounds is that a huge number of people, also, are already on the mend by the time they first talk to anyone.
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Does anyone else but Sermo Doc 7 ACTUALLY believe that ANY medication "fixes" depression?????
Everyone wants a quick fix. As for Xanax, I have several patients on it, but I closely watch their refills and PMP reports and do not let them get early refills.
From the moment they walk through the door, I am frank about what therapy is expected to produce, the limitations of medications and other modalities. In the chronic pain syndromes, depression/anxiety cases I advocate other treatment modalities like cognitive behavioral therapy, biofeedback - because even their placebo effect can be greater than that achieved by medications.
By the way, my friends the psychiatrists, I have been prescribing SSRIs for anxiety disorders since I was an intern, and still do. And the patients don't even have major depression! Imagine that! 8- P
Buspar does work for some people, but I have found for many, it doesn't seem to work much. Yep, it was also available when I was an intern, too. That's just my experience.
I refer difficult to treat patients to psychiatrists, but sometimes it takes about a month or more to see one. My hands are tied. Do I treat with a benzo or no? It depends on how debilitating their symptoms are. I have had some panic attacks myself in the past, and during the first one, the shrink I was seeing offered to call in some....drum roll...Xanax. This was about 12 yrs ago, when I was in residency. I refused, he called in propanolol, I ran to the store, and took it, then paced and felt better. Maybe placebo?
I only prescribe low dose klonopin in severe cases of anxiety and short term. There have been a few patients that I have felt truly do not respond to anything other than a benzo, but it is a rairity.
But like others have mentioned, besides SSRIs atarax, buspar and propranolol are a maintstay and they do work. I have had very good success with high dose vistaril for anxiety.
OklaERdoc, let me clarify my statement. Using the SSRIs or any antidepressant class without any discussion is not what I meant. I should have taken more time to elaborate. When I suspect depression, anxiety or both, I give the patient a mood disorder questionnaire which essentially covers the basics of sleep disturbance and quality, daytime fatigue, irritability, forgetfulness, lack of interest in usual tasks, sexual appetite, and misdirected anger. Based on the responses I discuss how these symptoms relate to anxiety and depression, bringing to their attention that we all have normal "ups and downs" but anxiety is really just an elevated level of alertness, produced by the need to identify the origin and identity of a perceived threat. If that level of alertness is higher than normal (for that patient) I characterize it as stress. Move higher and we have alertness equivalent to fear, but the patient has not identified what they fear. Go higher, we have panic. Higher again and we have what might be called a nervous breakdown, which is the brain's ultimate escape from its inability to identify the need for all this alertness. Now we simply can't exist in this altered state so the brain tries to compensate by DEPRESSING the level of alertness as a defensive and protective mechanism. Boredom is the first "level" of depression and this proceeds all the way down until one reaches the ultimate "escape, suicide. So any patient can now range, on any given day, between these various levels of anxiety and depression. I then point out that it has not been proven, but for discussion's sake, these ranges of uncontrolled emotion can be viewed as "burnout" - the brain's ability to manufacture enough of the neurotransmitters we call serotonin, norepinephrine and dopamine to function normally. There are probably more than 3, but let's just discuss these three. We all have them but not everyone has 1/3 of each. Just to clarify this picture I suggest that anyone's ratio of these three might reflect their personality, so that if you have 70% serotonin and 30% NE and I have 80-20, we might "think" alike, and get along with each other. If you have 90% dopamine while I have 90% serotonin we might rub each other the wrong way and not get along. This sets the stage for the patient's acceptance of the medication which I relate will replace the deficiency of neurotransmitters (recognizing this has not been proven) and once I get their chemistry back in balance, it's the patient's job to play psychologist and identify the stressor(s). reorganize their thinking, come to grips with what will be needed to alter lifestyle to fix the problems to their own satisfaction. I can usually get this introduction done in less than 25 minutes and often the patient feels better before I have written the Rx because they recognize someone understands how they feel. In two weeks I have the patient revisit and compare another mood questionnaire to the first, which directs the need for dose change, more discussion. During that first two weeks is where the need for an anxiolytic in addition to the antidepressant is useful. If the Xanax or whatever one might choose is still needed, it affirms the need for an antidepressant dose change or an addition of a NERI to the SSRI (or reverse, depending on how you started).The next visit is a month later and we repeat everything. If at any time I have not achieved control I opt for referral to a psychologist for more definitive cognitive therapy. Often the reverse is true - the psychologist starts the ball rolling and recognizes medication intervention is needed and refers the patient to me. I hope you now see what I meant by "fixing" the depression.
except when it is misdiagnosed PTSD. Never given benzos is clearly a mistake and such absolutist thinking is contrary to proper medical management of anxiety and panic. Clearly, short term use and documentation and discussing with the patient that use will be short term can be a great benefit.
Also, no Valium...? Ever?? That's moronic. I'll tell that to the next parent I see whose kid was just killed or daughter was raped Come on, a couple of 5mg valium are appropriate in some cases.
It does not seem right to issue such a blanket condemantion of these drugs, in particular clonazepam.
Have you explored your phobias with your therapist? Are your phobias a source of anxiety that remains untreated?
I haven't explored my phobias but I do take Xanax tid.
and Sermo Doc 27,
for recent trauma, sure, give klonopin or valium but Xanax?
What's the difference if you "give extra" neurotransmitters vs a chemical imbalance?
I've read articles where people point out that an aspirin gets rid of headaches but that doesn't mean we have an imbalance of aspirin or a deficiency of aspirin. Increasing your serotonin or norepinephrine or dopamine (which are obviously different from aspirin because our bodies make them) gives you a boost in your mood but maybe I'm splitting hairs, but I'm not sure anyone has proven that that means the patient had a deficiency of these neurotransmiters in the first place compared to the nondepressed patient.
Xanax + devil in my opinion.
Jonathan Leo1 and Jeffrey R. Lacasse2
(1) Lincoln Memorial University, 6965 Cumberland Gap Parkway, Harrogate, 37752, USA
(2) Florida State University (FSU), Tallahassee, USA
Published online: 28 November 2007
Abstract The cause of mental disorders such as depression remains unknown. However, the idea that neurotransmitter imbalances cause depression is vigorously promoted by pharmaceutical companies and the psychiatric profession at large. We examine media reports referring to this chemical imbalance theory and ask reporters for evidence supporting their claims. We then report and critique the scientific papers and other confirming evidence offered in response to our questions. Responses were received from multiple sources, including practicing psychiatrists, clients, and a major pharmaceutical company. The evidence offered was not compelling, and several of the cited sources flatly stated that the proposed theory of serotonin imbalance was known to be incorrect. The media can play a positive role in mental health reporting by ensuring that the information reported is congruent with the peer-reviewed scientific literature.
"And, as Johnathan Leo argues, "low serotonin levels are no more the cause of depression than low aspirin levels are the cause of headaches." You can read the Leo and Lacasee article in the journal Public Library of Science Medicine, DOI: 10.1371/journal.pmed.002092.
Leo goes on to state that this myth involving a chemical imbalance "has become a mainstay of popular culture. But there's very little support for this. We really don't know what chemicals are involved." Moreover, if such a chemical imbalance exists, it has not yet been determined whether the imbalance is caused by the depression, or the depression causes the imbalance. Neither scenario has been scientifically established, but it is in the interest of multinational drug companies to propagate the myth.
More support for the chemical imbalance myth comes from the chairperson of the US Food and Drug Administration, Wayne Goodman. A "good man" indeed, he admits that the chemical imbalance story is a "useful metaphor" but claims that he would never tell his own patients that they were suffering from a chemical imbalance. "I can't get myself to say that," he stated.
The Irish Medicines Board, an equivalent body to the FDA in Ireland, has banned the drug company GlaxoSmithKline from making claims that depression is caused by a chemical imbalance. Such information is no longer permitted to be printed in patient information brochures. Leo and Lacasse want the US FDA to follow suit.
This is a great breakthrough for depression sufferers around the world. The myth of chemical imbalance effectively renders the sufferer a victim of circumstances seemingly beyond their control. Systematic deletion of this myth from popular folklore will hopefully encourage sufferers of depression to look for more effective ways of dealing with and eliminating their depression."
I'm not so sure you can jump to that conclusion. Could you say that a family with poor hygiene habits that all have B.O. have a genetic tendency for that? What if they all chew with their mouths open? Genetic? Miserable dispositions?
You may be correct but there may be other factors at play.
Women have cholelithiasis much more frequently than men - if a mother has it and her daughter gets it - is it genetic?
Practically ALL my patients who are under the care of a Psychiatrist complain that they are seen a mere 5-10 minutes, and visits are merely medications refills and adjustments. I asked 3 Psychiatrists in our area (at different times) why that is...the seemingly unanimous reply was..."Psychiatry now is mostly Psychopharmacology"- (including anxiety treatment.)
I am one, and I know only a handful of colleagues who still do.
The psychopharm psychiatry doesn't work because the medcheck doesn't allow the doctor to observe anything, but serves as a checklist. Think of an internist asking a person how his heart is, rather than listening to it and doing an ekg. In a therapy setting, I can interact with the patient over time and observe for myself what is really going on.
The typical PCP doesn't have the time to observe people either, so there is a lot of symptom focused prescribing,which is why a lot of people have medicines they don't need, and the drug abuser have such an easy time of it. Since no one values therapy, the insurance schemes will continue to discourage adequate face to face time with patients.
Sic transit gloria mundi.
If I'm hellbent to get some Xanax and some yo-yo PCP starts yammering about "relaxation", "guided imagery" and all that crap - I'm going to Dr. Feelgood, who will be all too happy to take my cash in exchange for a script.
md.sermo.com
I wonder how many people routinely follow updates such as this:
www.fda.gov
Seroquel is not a benzo but is a BIG problem particularly amongst our prisoners
I do agree that the use of these meds should not be done on a whim....and their use should be very short term. Also, your post has made me consider a few of my patients' usages. Thanks!
1. in 1970, the number one and two prescribed medications at
David Grant Medical Center (Travis AFB) were Valium and Librium--the hospital commander ordered that every patient who was taking this medication had to have a psychiatric consultation--I interviewed about 50 women and they all had chronic anxiety that was well controlled with low doses of these two medications, they were not abusing them and I did not find one case that did not warrant continued treatment with them.
2. There is no substitute for SHORT TERM use of benzos--good example a patient with a breast lump who is pending biopsy--while waiting two to four weeks, these medications can be very helpful
3. Panic attacks are best prevented with SSRI's, cognitive behavioral therapy, etc.
I agree that benzos are not good long term, but to use judiciously in the right paiteints and with control, it can help. You can't generalize about one class of drug like that
Also, i have asked before WHY psychiatrists don't talk to their patients anymore and just prescribe mes. At least that's my experience .
I agree that if this isn't fixed, they SHOULD be taken off the market as numerically, they are causing far more suffering than they are treating. Prescribe exercise and follow up with patient, prescribe EFA's and nutritionals and follow up with the patient, etc etc. These things all work and don't cause addictions. Look at the number of children on these drugs-how can we defend this?. Perhaps we could create parenting tools that work instead. Might help the kids far more in the long run. We are doing something terribly wrong which is indefensible.
Bottom line, there are some rare indications for short acting benzos, but almost 100% of the prescriptions are irrational and unwarranted.
PCPs should NEVER prescribe short acting benzos and Psychiatrists should virtually never prescribe them.
Do not prescribe xanax. Do not prescribe ambien, do not prescribe serax.
The risks far outweigh the putative benefits.
I am shocked to find, due to these discussions that I have to add restoril to this list, next I'll have to add Dalmane!
Look at this p ost by someone trying to justify prescribing narcotics to a patient he knew didn't need them.
For the most part I couldn't agree more w/ most of you, esp/ re: xanax. However, our neurology colleague is right-on re: klonipin. When MY neurologist recommended klonipin to me for my REM sleep disorder and episodes of striking out w/ my body while "asleep",I protested (0.5 mg taken 3-4 nights per wk.). I didn't want any thing to do w/ THAT DRUG. Thankfully I listened, and now at least 3-4 nights per wk my wife is no longer beaten and I sleep restfully. I have Parkinson's disease........
They have limited role clinically like detox from alcohol and use in case of serious psychiatric emergencies similar to steroids i.e. quick taper off.
The difference between use and abuse is very difficult to recognize. They become very quickly 'life saver' or 'oxygen' for the patient who prefers to carry them all the time. They do have significant street value.
Long term use can lead to subtle changes in personality similar to BPD with interpersonal intolerence and impatience. It further can cause loss of job, marriage and family for the patient.
There are rare and few exceptions to all this with lack of tolerence. I have seen one patient of "Stiff man syndrome" being stable on Diazepam 60mg/day for many years.
But why to take chance or risk when there are several quick acting medications available as substitute to benzodiazepines like: Hydroxyzine, Diphenhydramine, Propranolol, Low dose Thorazine or Seroquel or any sedative type of medication acting on H1 receptor.
Ambien, Sonata and Lunesta have the similar potential like benzodiazepines thought they are technically non-benzodiazepines. (Tramadol/Ultram is similarly non-narcotic theorotically but not practically)
Unfortunately sometimes benzodiazepines are used by doctors to ensure compliance/adherence of the patient for regular follow-up and billing. A person on Xanax will avoid 'no-show' in spite of any weather or situational problems.
ALL meds carry risks, the risks might be different and some more consequential than others, but the risks should always be weighed -- if YOU KNOW YOUR PATIENTS and you can seriously say you have a good grasp of their problems and the doc-pt relationship is there, PLEASE DO prescribe these (judiciously as you would rx an antibiotic judiciously and to only those who actually need it, you dont want resistance or a case of life-threatening cDiff etc).
I disagree with anyone who says ALWAYS and NEVER in medicine as these are NEVER right and likely ALWAYS wrong.
Of course whether they are seeing a therapist and managing coping skills (learning new ones if needed by way of yoga, exercise, therapy, CD's, web material etc) is ALSO VERY VERY IMPORTANT collateral and ADDITIVE treatment
Anyone remember the quack drug Darvon? Only quacks prescribed it.
I reiterate: there is NO reason for a PCP EVER to prescribe xanax (Klonopin is a different matter)
I've prescribed them as a bridge-maybe 20 pills- until the SSRI's kick in and CBT can be arranged.
To do otherwise is mean or, at best, misguided.
To tell other docs what to do because they are not trained psychiatrists is ludicrous.
Your AVATAR patient satisfaction scores will fall.
You will all get fired .
Come to think of it that sky is looking a tad unstable, too.
Even when SSRI's work, panic attacks still occur, and there the use of high potency benzos short-term is clearly indicated.
I work with chemically dependent patients, and have seen the devastation that benzo dependency can cause. However, I have to recognize this as a selection bias and also know that there are some people for whom very modest doses which remain stable have greatly improved their quality of life. For some of these folks, particularly those with severe trauma histories and PTSD, the level of psychotherapy available is not always adequate, affordable or effective.
You should NEVER prescribe xanax, ativan, serax, EVER! If you do, you are a drug pusher.
Did you know that most panic patients need nothing more than CO2 re breathing? Of course not. The poseur in your residency who claimed to be a psycho pharmacologist is, well, a poseur.
Time to listen and learn.
2 different issues are conflated and confused here.
These meds, used VERY judiciously, can be an excellent bridge until the SSRI becomes effective and breakthroughs occur in cognitive therapy. This requires time but if you want them to be well and do no harm, this is essential. Monitor amounts, prescribe monthly to weekly, no refills. I prescribe klonapin only for a short time with SSRI, never xanax.
#4, BZDs useful in general;
#5. BZD possibly useful long-term;
#7. Agree, BZDs useful preferably short-term;
#11. Reasoned & reasonable empathy with the situation of many GPs/FPs at large with respect BZD & other vox populi Rxs (psychotropic & nonpsychotropic);
#17. CBT is more $/tx than relatively inexpensive BZDs.
lawdoc: Very cogent discussion (as usual).
njpsychiatrist: Thank you for raising an interesting & salient discussion on this matter of BZDs.
Sermo Doc 45: I have to agree most with this writer who warned against categorical, black-&-white thinking regarding BZDs. I don't think it would be very useful to "ban" Xanax or even Darvon (e.g. my internist late father described Darvon to me back in the late 1970s as "junk") because there's always the idiosyncratic & authentic beneficiary of the iatrogenic Rx of one or another demimonde or twilight zone meds. One wants to avoid artificial &/or avoidable inducements for the blackmarket production of Darvon or Xanax!
Here's a thought:
Clinical psychologists are lobbying (with some isolated successes) for Rx privileges (in order to tap into the lucrative psychopharm Rx practice, i.e. the worried-well, well-paying Prozac pt). Why not ask the "Prescribing Psychologist" why they ain't doin' what they they'z already best at?---Like PSYCHOTHERAPY?, like COGNITIVE BEHAVIORAL TX? If it's $, then why don't "Rx'ing Psychologists" lobby 3rd party payers for more $ for CBT & other therapies--instead litigating &/or lobbying against MD 'monopolies'?
[Apologies for the capitals letters--can't underline or italicize.]
Patient satisfaction-centered care causes us all to overuse meds we should not, including benzos, narcs and antibiotics. But saying no without the patient having a clear plan B- a therapist or additional support network can be dangerous. And we all know these resources are in short supply and not obtainable to the uninsured or poor patient who cannot take off from work to make the sessions.
On the first visit I spent 30 - 50 minutes with the patient if I feel they are reliable and will cooperate with treatment, otherwise I am through with them in 5 - 10 minutes if it is my opinion they are drug seeking or not willing to agree to try my way. If they ever get the meds somewhere else, I fire them from my practice.
In 35 years, I can truely say, I have not been the cause of a xanax addiction in a single patient.
I usually refuse to accept the patient who is already on xanax when they first try to schedule an appointment.
Xanax, a great acute - short term drug, a horrible, nightmare when used long term. 30 - 0.25 mg tabs one time in their life and not refilled.
NEVER use NEVER as an answer.
As for Xanax I agree with many of the posts. the problem primarily is a function of onset slope and area under the curve which looks like a high amplitude short duration sign wave. This is similar to the nicotine delivery found in cigarettes. providing the highest psychological addiction potential because the patients "feel" it's effects on and off. Overall benzo's with the exception of Xanax have thier place and I use them frequently. i keep a stack of cd's in my office with progressive muscle relaxation and deep breathing exersizes as well as a handout with basic CBT and a few homework assignments. I also frequently advise pt's to get a key chain pill holder to keep a benzo in; this provides a safety net for some that can be all they need to quell thier fear of being caught without; just the availability being enough and reducing overall usage; in fact some pt's need me to refill for them just because they "get old." I recommend the Anxiety and phobia workbook which the pt can buy or you can just zerox a few assignments for them.
SSRI's are an excellent prevention medication for anxiety and depression and I would caution getting too caught up in the popular antimedication movement. Many studies show us that therapy or medication will help the majority of people but htat the highest effective rate is seen when people do both.
~ Edmund J. Bourne
It is the same problem with alcohol. Those who can drink responsibly and those who cannot put down the bottle after they take the first drink. Benzodiazepines are helpful in this first group, and harmful in the later.
In my practice, I usually try to find those who need long term treatment with these medications and have them sign a contract restricting them from early refills and taking more than prescribed. If this happens, they are not refilled anymore.
If these medicaitons were so dangerous, I am sure they would be taken off the market a long time ago. Look what happened to Vioxx and Bextra. Please don't blame the family physicians for this as many unethical generalists, family doctors, psychiatrist, and internal medicine as well as certified. pain specialists dole out these medications by the truckload every day. I had a patient who got all his abused drugs off the internet.
And I know a lot of people here don't like zolpidem, but why oh why would you use a benzo for sleep over zolpidem? Benzos are never first line for sleep. At least zolpidem has some short-term SLEEP safety data. Benzos don't.
Xanax + soma + vicodin = flashback to residency hell, when my patients came in wanting refills of all three (they only work when all are taken together, don't you know), even though my clinic hadn't prescribed most of it. I'm glad soma's a controlled substance now, so I won't write for it.
I use a lot of SSRIs, an occasional TCA, a little effexor and wellbutrin--but never xanax. People with anxiety who have panic attacks can wait the 1-3 weeks for the SSRI to kick in, because they' ve already waited longer than that to call for an appointment anyway. And you have to get patients in to some form of counseling. Keeping 'em on a benzo forever is a failure. I just never start it and therefore it's never mine to refill.
I won't prescribe it today; I'll just get through today without prescribing xanax...
Need those FP's to keep prescribing to keep my business booming!
I don't, however, agree with a prohibitive personal ban on benzos, as I prescribe them (I tend to stick with longer T1/2 like clonazepam or clorazepate) and they DO have their place. The main problem I see with klonopin is people not realizing how potent it is-- 2-4x more potent than lorazepam on a mg/mg basis, so you see people on ridiculous doses like 6-8mg/day.
If you do a lot of CBT, you will see that it's not a panacea, and despite it being a preferred therapy, there are treatment failures, like with everything. Also, I think I help more people sometimes putting them on a low dose of a scheduled long-acting benzo and THEN doing exposure-based CBT with them while weaning them off, than if I had a hard and fast rule of "no benzos" and then expecting them to stick with a therapy that, when it's done right, sometimes involves getting a patient to make themselves more anxious. In the real world, you can't help a patient if they don't come back to see you.
How 'bout we ask our primary care colleagues to prescribe long T1/2 benzos as clinically appropriate, but then to attempt to wean off after a month, with weaning failures being referred, sooner rather than later, to a psychiatrist? Using the band-aid analogy-- treating the root cause is great, but sometimes you have to stop the bleeding first. You don't put a band-aid on and leave it on forever, but you also won't get far if you are trying to get to the root cause and let them bleed out on your floor.
What the GP's dont know is that all I do all day long is take people off drugs that well meaning docs put them on. I shudder at most of the discussion and reasons why practitioners do what they do. the answer is easy, you all are trained to give a script to fix a problem, when that may be the wrong thing to do. These are SEDATIVEs, people, so you need to look long and hard at the medical indication to SEDATE someone, especially when that pill is no longer under your control. I COMPLETELY disagree with Sermo Doc 18 that Klonopin is any better/safer than Xanax, just because it is more long acting...and even he admits people abuse it. The current epidemic is people abusing Benzos on Methadone and SUboxone...TO GET HIGH! because there is a some kind of synergistic effect of the two together which induces euphoria, energy and anxiolysis. It can also result in death.
WHO KILLED MICHAEL JACKSON???
I see in the answer discussion that someone justifies giving a sedative to a morning mother of someone who died...as if you'd do that with your own family? You can't prescribe something for someone because you feel BAD about what the preson is going through. That's NO indication for a medication!
Notes here ask 'what am i supposed to do?' well, refer a patient on, and sure, blame the other doc if you want to. I've seen hundreds of patients sent to psych to get Benzos, infact in the VA during my training the only patients who could get benzos had to have a psych doc, and the patients showing up complaining of suicidality tripled!!
ALL OF US have to develop a mentality to challenge the patients believe that the FIX to everything in life comes in a pill form. I dont do surgery for sleep apnea so I refer on when the study says obstructive for CPAP or scalpel. I Don't put my finger down the patients throat and see what I can muck with. Just admit you cant fix evrything and send the patient on! I feel bad for the docs who didnt get adequate training to handle these issues, but you have to find a way to do no harm.
And I have the alcoholism curse on my family and have seen how Lortab and Xanax are for many patients so I'll never take chronic opiates or benzos (I do have a drink every few months) and give me codeine for bad outpt pain; I'll be vomiting before I use too much. I just go through life a lot more anxious than those who have a drink or three or a valium every night. I might take up regular alcohol in my old age- wonder how old the oldest new alcoholic has been so far? I am taking up exercise, yoga, and regular doses of fukitol starting with quitting any job where I am wishing for a martini most nights when I get home.
The only people prescribing it a lot, in single doses, should be radiologists.
Re: benzos: I only give a few xanax for people with phobia of flying. I have found clonazepam 1 mg hs to be very effective for some people with panic disorder, social phobia that couldn't tolerate SSRI's. Also for severe insomnia. Very rarely have I had anyone need to increase their dose and the quality of their lives is much better.
I disagree that pain and anxiety don't kill people. Many people have killed themselves because they can no longer tolerate the anguish that these cause.
To make a generalized statement about use of this class of medications is just, well, interesting. I have been serving the military for several years now and you will shudder to know that--yes--I have even deployed rare individuals on low dose prn benzos. And they have done fantastically out in the field as well as on return to home.
I don't prescribe benzos to people addicted to alcohol or benzos (unless they are in active withdrawal) and I am cautious about counseling on risk of sedation. I also look for disinhibition but at the doses I prescribe, I really don't see it. The majority of my patients and the ones who have come to me after getting benzos from an FP have not presented with addiction. I must tell you, however, I just don't give benzos to people unless they are really anxious.
My last comment about meds....
1) SSRIs are for many but not for everyone (have seen too many severe cases of bruxism, intolerable headaches, and sexual side effects...etc.)
2) When you treat symptoms with appropriate doses of meds people usu do not get addicted (we are finally learning this when treating pain, this can also be applied to treating anxiety).
3) Buspar sucks. Sorry, it just doesn't work. The literature will support me on this. The only use I have for buspar is that it sometimes reverses the bruxism that a few of my patients get from the SSRI.
I understand the concern, but am worried about all the absolutes: "never" "illegal" etc. See, I would say "never" prescribe chronic low-dose neuroleptics for anxiety, but that was mentioned above as a perfectly legitimate option.
I like the fact that we are thinking about this and keeping each other honest. BTW--on the subject of unnecessary antibiotics, my mother called to ask about antibiotics for her cold. (Don't know when she'll learn. I never prescribe for family/friends!) Told her no, won't work, wait it out, etc. She went to "her" doctor who promptly put her on an antibiotic and she felt "so much better the next day!!" Some patients we can't educate.
circumstances RX quantities of 120. Benzo do have a place in medicine ie. the little old lady with CLL or the wife who's husband suddenly past away...yes they need something to get them thru the difficult time but then need to taper off as things settle down if possible. I try to get the patient interested in other modalities...meditation, yoga, exercise...we in the medical community need to stress to our patients that not everything is cured with an RX...but the insurance and pharmaceutical industries make it too easy for the wrong choice for the patient....benzos are cheap, other meds may not be so and hardly any insurance companies pay for meditation, acupuncture, descent cognitive therapy...it is sad, very sad..times I wish I hadn't become the FP...maybe oneday when I'm a grandmom I can hope to get back into a Residentcy program where I would be able to pass the buck and not prescribe these meds. Or may seriously just quit medicine all together and become a chef...LOL
I work in a Student Health Service, and patients can't afford CBT. Much of medicine now is about money. Psychiatrists are being forced into becoming givers of medication, and psychotherapy, although I love to use it and am good (40 years experience), I don't get to do it much, and I don't even take insurance.
And yes, SSRIs work for many people, certainly not all. Best is combining it with psychotherapy or CBT. How long to use an SSRI depends on duration of symptoms . I see patients all the time whose lives are dramatically changed for the better by using SSRIs.
www.arkansasbusiness.com
I wholeheartedly agree with your recommendations!! Now, if you could only get your own specialists on board with this, it would help me out a lot.
Soma, Demerol, serax, dalmane and afrin should all be banned, probably!
I have treated many highly anxious patients with Buspar - totally UNSUCCESSFULLY.
I did not know it worked on ANYBODY!
Effexor in am with neurontin in evening is not a bad non-addictive treatment..
The VAST number of patients of mine on regular Xanax and Klonopin got them from a psychiatrist at some point, and I am just doing refills.
Anxiety is very poorly treated pharmacologically...
Depression responds pretty well to SSRI's for quite a few patients in my experience.
Good luck to all on this one!
That is part of the problem with people who work in the ER.
They just don't care about the patients that suffer from chronic pain or anixety.
Those patients really should stay out of the ER. They don't care about these problems
there, and they don't know how to manage them.
Patients come back to family practioners because most do care. They know or get to
know each of their patients. They are good at spotting the patients that are risk for
abuse and no how to identify the patient that is abusing.
So pain or anxiety doesn't kill anyone. I remember that you have a drug that you use
for migraine. Just relax and take it--or is your pain greater than others.
No the practice of medicine is not easy. The chronic problems are frequently the
worst. Too bad some physicians can't deal with them
Benzodiazepines are just alcohol in solid form acting on GABA receptors leading to Cl influx and hyperpolarization of a neuron.
So, do any of you out there drink alcohol, but refuse to use benzos?
I have never seen anyone die from benzos. I have seen plenty dead
from alcohol.
If you drink alcohol - stop. It is very addicting and very dangerous.
I do not use alcohol, and I have never recommended it.
Most legitimate anxiety patients who require benzodiazepines are easy to recognize. They do not escalate doses, do not ask for extra refills, do not lose them, and use the minimum amount necessary. The benzodiazepine receptor is there for a reason. Some people have understimulation of this receptor and are naturally anxious. Most prefer not being anxious and want the brakes put on. Benzodiazepines do this safely and effectively
WJD I agree 100%. If a patient escalates or losses prescriptions or uses any of the other manipulative methods; the problem can be corrected. DC the Rx.
yeah, when abused, they're bad, and probably are written way too frequently (agree, too, about the bizarre notion of writing klonopin tid). we could assail the virtue of vicodin, or oxycontin, or soma, or whatever, but they all can have some use. maybe they just need to be used more judiciously..
the problem isn't fp's, or internists, or shrinks, or whatever (there are some pretty wild generalizations in some of the posts above). medicine is complicated, and people are weird animals. it might be a sign of hubris for a doc to say "i've never used a medicine inappropriately," b/c it does happen, sometimes totally inadvertently, and sometimes maybe less than innocently. in the end, we're all in this together, and should try to find a way to help people that are addicted to these get off 'em. so they might develop strategies for coping, find ways to feel good about who they are, and then go create their life. i reckon pointin' fingers isn't probably going to do a lot of good.
I concur. Why not vacuum up the dirt (CBT/SSRI), rather than sweep it under the rug (BZD)?
I think everybody who gets a chronic benzo of any kind should have a psychiatrist who sees them longitudinally. If the patient resists this, there is a problem that needs to be investigated. The patient is actively degrading the patient-physician relationship by refusing referral. If they persist there will come a point where the benzo in my opinion will have to stop despite their wishes. Interestingly when the provider terminates the benzo supply some patients will give up and go to the psychiatrist and actually start getting better.
I do have an office patient with panic disorder who seems to be doing very well on xanax. However, I demand that she see another doctor to write that medication for her if she feels she simply must have that particular med.
I will try to find that paper on a 60% abuse rate - have never seen anything that high. Don't know how they were defining "abuse." There have been other papers with thousands of patients showing misuse/abuse/dependence rates in the low single digits. This is more in line with my own experience.
As long as it takes 4 months to get a psychiatric appointment, and the stigma persists with many patients regarding seeing a shrink, generalists are going to continue prescribing for anxiety and depression. Finding psychologists or LICSWs to do CBT is also not easy, and often insurance constraints make it too expensive to attract many people.
Certainly agree that most patients can be managed with an SSRI or SNRI with occasional use of short-acting benzos for breakthrough, but nonetheless there are many who cannot, and who safely take stable doses of benzos for the very long-term.
Rather we need to tighten prescribing and narrow who can prescribe what. There is too much over reach and not enough respect for boundaries and limits.
and Sermo Doc 101, why don't you teach your panic patients to use re-breathing? It is still the most effective way to break most acute attacks.
Which brings me to the benzodiazepine vs. SSRI vs. anticonvulsant vs. antipsychotic question when it comes to managing anxiety disorders, which happen to be my specialty. What I have found is that too many primary care docs give a short-duration benzo prescription to an anxious patient "to get him out of the office," and when he inevitably comes back needing more, they send him to the psychiatrist, who now must deal with both treating the anxiety disorder and managing the benzo dependency. Or, the primary care doc who thinks he knows how to use SSRIs (but really doesn't) starts the anxiety patient on the same dose of SSRI he uses for depression, and the patient gets far worse and then refuses to take another SSRI when he finally finds his way to the psychiatrist. I also see way too much use of low-dose Seroquel prescribed by primary care docs for simple anxiety; this to me is a case of trying to kill a fly with one swing of a sledge hammer. Basically, what you're doing in this instance is using a subtherapeutic dose of a powerful antipsychotic for a problem for which it is not indicated. It harkens back to the days when every anxious or depressed patient left his primary care doc's office with a prescription for Triavil.
In 25 years of psychiatric practice, I have rarely found a primary care physician who knew what he was doing when he prescribed an antidepressant, sorry to say -- not that that ever stopped him/her! Let me ask you: what would you think if one of my psychiatric patients came to your primary care practice having been started on antihypertensive or antiasthmatic treatment by me? Would you report me for "practicing outside of scope," which most states consider to be medical misconduct? Yet I'll wager that I know more about managing hypertension or asthma than most primary care docs know about managing depression or anxiety!
As for benzodiazepines themselves, they can be very useful medications when prescribed for the right reasons and monitored properly. They are certainly not drugs of choice as monotherapy for chronic anxiety disorders, yet can have wonderful "PRN value" in specific instances, such as helping "air-travel-phobics" fly in comfort when they absolutely must travel by air. To make a statement such as, "One should never prescribe any benodiazepine for any reason" strikes me as one born out of ignorance or fear, or both.
1) Don't single out "Family Docs". There are other primary care docs out there and other non-psychiatrists that are significant offenders in this regard.
2) Psychiatrists, as mentioned, above, push pills as bad any specialty I know. These people that have the most complex problems are often given a 5 min med check and more scripts.
3) There are legitamate uses for the meds (particularly klonopin) as mentioned above. Any "absolute" statement should always be taken as fairly pompous. i.e. "never prescribe benzos for anxiety". Shoot, they do this in the psych ward all the time.
serious chronic medical problems suffer from a and d issues also. I have mostly practiced in rural situations, and finding a psychiatrist was difficult at best. It is possible and important for a FP to learn how to use antianxiety medications and
antidepressants.
Part of the problem is the "anti-drug" bias that many physicians develop because we all see abusers at one time or another. It is unfair when we start suspecting every patient that presents with pain or mental suffering. I know that I can't cure or fix many of my patients; but is feel strongly that as physicians it is incumbent on us to comfort and care about those who present with suffering. Yes, you do have to look at the entire situation. Yes, you have to look for signs of abuse and potential abuse.
I know treating these problems are not easy; but it is very important.
Possibly I was too hard on the ER doctors. The ER isn't a good place to deal with
this type of problem. Follow-up is essential. I also suspect that the ER is more likely to see abusers than am I in the quiet of my office.
Relief of pain, anxiety and depression is important.
Sir William Osler: "To test a doctor's mettle, have him treat a headache."
If I may add, I would also like that General Practitioners, Family Physicians, Orthopedic Surgeons AND Dental MD's would also consider prescribing less Opiates for the treatment of pain.
I don't intend to suggest that pain should not be addressed aggressively - but after a tooth extraction or uncompliated forearm fracture, is it really necessary to take opiates for three to ten days in a row? Would Tylenol or Ibuprofen relief at least 60 % of the pain and be less likely to produce so much Opiate misuse among our younger crowds?
In monitoring those children that are given Opiates for three days, I find that the toughest day is the first (stating the obvious), but the second and third days they are willing and able to manage their pain with Tylenol and Ibuprofen in an alternated schedule.
Issues with Opiate abuse may not touch home for many, but knowing that the greatest expanding use of drugs is at the expense of cabinet medicines is pretty telling.
For those of us that work at Colleges and Universities, would it be possible to consider starting a policy in which we seriously weigh risk/benefit ratios when considering prescribing pain medications that dope people up and predispose them to misuse?
en.wikipedia.org
addictive? -- damn right. Tolerance, withdrawal, craving: benzos have them all.
effective alternatives available? -- sure, if you can lock patients up, prevent dr shopping, get funding for psychotherapy, adjust everyone's IQ and personality so they can benefit from meditation, psychotherapy, feedback, etc. But in the real world, the only thing that works as fast and effectively as those NSAIDs in the commercials are the benzos. Most people won't do the work in non-drug treatments and the TV is blaring at them every day saying they don't have to (or have they taken those NSAID commercials off the air? The ones that show orgasm, not pain relief?)
safety? -- even abused, benzos have one of the widest tx windows of any drug around. The SSRIs are MUCH more likely to do people harm as a direct consequence of use.
Ban benzos? -- Does that include all the neuro patients on Tranxene? How about my patients who have tried everything including MAOIs? Get real.
Conclusion: these are very safe and effective drugs with TERRIBLE side effects. They are going to be used and abused, and they are needed (damn it!).
I carry a bottle of NTG with me always, as do many people. If you proposed to take it away from me without a truly effective replacement, I might show a lot of "addictive" and "drug seeking" behavior myself...
These are the patients (anxiety and/or pain) that go to pieces when you merely suggest trying alternatives and/or lower dose: "Oh God, no! Please don't take my pills away! Please, I'm begging you! They're the only thing that helps me. Oh God!"
Benzos have been around for multiple decades and haven't, to my knowledge, been as clearly problematic as alcohol...or perhaps are on the same level with it's risk potential,....but it's a "recreational drug"...and bezos aren't supposed to be.
So, I should perhaps prepare myself for a fierce defense of the use of alcohol as I close this blog piece,....from those who so fiercely oppose the medicinal use of benzos. I do not drink....but I do prescribe the short term use of bezos.
Hmmm.....am I confused! Perhaps I should be prescribing a shot or two of vodka q AM , and up to q 8 hours, for those anxious moments..., at least until the Celexa has kicked in!
To add to the "safety" profile: The LD50 in rats, translated to humans on the LOW end of the toxicity range. A 125 pound patient would have to swallow 18,800 tablets to kill him/her self 50% of the time. It could go as high as 123,313 tablets if we get nervous about making the comparison to rats.
From the link provided by Sermo Doc 33:
Application of the term troll is highly subjective. Some readers may characterize a post as trolling, while others may regard the same post as a legitimate contribution to the discussion, even if controversial. The term is often used as an ad hominem strategy to discredit an opposing position by attacking its proponent.
Often, calling someone a troll makes assumptions about a writer's motives. Regardless of the circumstances, controversial posts may attract a particularly strong response from those unfamiliar with the robust dialogue found in some online, rather than physical, communities
patients these days.
And I direct these comments at the psychiatrist too, who also tend to spend too little time with
any other class of medication that I know of. I have never seen death or even an allergic reaction to a benzodiazapine. I have seen deaths and many G-I bleeds secondary to NSAID's.
I will agree that Xanax (alprazolam) seems to generate more problems than any of the others in that class. I also like chlordiazdepoxide. It is relatively long acting, it works, and it is dirt cheap. Lexapro is a great drug, but it is very expensive. Generic celexa is a real $$ saver; but you just have to use twice as much.
I will also restate my objection to alcohol as recently mentioned by another writer.
Far too addictive and dangerous but most in the US including physicians continue
to drink. Why? Maybe a benzo would be safer; I've never seen cirrhosis from a benzo.
I realize that making alcohol illegal was a Disaster for the country. Don't vaccum up
and out-law a sometimes useful, effective medication with minimal side effects.
I volunteer at a local rehab.
Here is the street stuff. Meth addicts love xanax the Best to come down from a Meth run. One guy says his dealer sells the "High" the Meth and the "net" the xanax to catch you on the way down.
I also see loads of people on Oxy's most from local dope houses.
A) At least half of the patients we see daily are anxious and/or depressed, especially in more rural or poverty stricken areas.
B) Many people with chronic diseases, including diabetes and heart disease, are depressed and frequently anxious
C) Psychiatrists are very unavailable in many places, with wait times of one to three months.
D) Psychologists or other therapists are difficult to see on a timely basis, even if they "take the patient's insurance"
Please follow me around my office, just for a day. What would you like me to do? Meditate and pray with the patient? Give them an SSRI when "I'm really not educated enough to dispense SSRIs?"* Give them a benzo when "I can addict the patient then end up dumping them on the poor psychiatrist?" Give them a sticker and a lollipop?
*By the way, I do know that anxiety disorders require less of a dose of SSRI.. 'Think I learned that in residency from a psychiatrist.
I do a lot of "therapy" myself although i am "untrained" for CBT and psychoanalysis.
For example: I was seeing a patient for diabetes and foot pain. I asked him..."You seem to be upset or perhaps depressed."
The patient tells me about the horrible things happening: "Well doc, my son was arrested for drugs the other day, and I can't sleep and I cry all the time." The patient then cries and opens up. We talk. I mostly listen. i discuss things he can do to help themselves besides meds. I prescribe a med (usually no benzo) if indicated. He feels better. He is told to come back soon.
Another example: A chronic pain patient is very anxious. I ask about her childhood and her marriage (even though I have maybe 20 min at the most). She tells me about the time her stepfather raped her from age 8 to 14. We talk. I mostly listen. She finally tells me she rarely talks about this stuff. She is seeing a psychiatrist already. I reassure her it's ok to talk about her feelings. She cries and thanks me.
Enough for ya? Sheesh....
Yes, substance abusers will use benzodiazepines to treat the side effects of the
drugs that the prefer. I worked in a psychiatric hospital for 6 years doing the medical
part. We frequently used benzodiazapines to blunt serious CNS side effects of
alcohol withdrawal. They work for that; and they are darn safe!
I saw all kinds of abusers in that hospital. Patients whose primaryt problem was
substance abuse and mentally ill with co-morbid addiction/abuse. I saw patients that abused alcohol (most common), metamphetamine, cannabis, crack, crank, Ectasy,
PCP, steroids, oxycontin, all opioids, tobacco, LSD, other hallucinogens, glue, gasoline
and spray paint. I probable left out a few. These guys would take a benzo if they
couldn't get anything else. However; they are just not most of them want.
If you have a patient with cataplexy would you refuse to use amphetamines? They
do have a street value; but they also work for cataplexy.
Meth is a disaster.
Maybe Sermo Doc 18, you never get anxious. Maybe you have such excellent self-control, and self-confidence that you have never had a panic attack. Maybe it seems to those of you people who are so sure that benzos are Satan's medicine, that one can never touch a benzodiazepine type medication without an immediate addiction, similar to an injection of heroin. The invective on this post reminds me of what people used to say about masturbation: if you touch yourself "down there" it'll just shrivel up and fall off.
I work with a lot of people who have panic attacks. I see young people, hard working, stressed, trying hard to make it at IT, financial services, sales, even law who have crises and show up with somatic symptoms--tightness in the chest, shortness of breath, dizziness, tingling in extremities. Some have come to my practice from the ER, when they called 911 thinking they had an MI, only to have all cardiac pathology ruled out.
Guess what!!! They do really well on Klonopin 1mg PRN, and/or hs during this acute crisis, no more in my practice than 1 mg BID, for the first week, and then 1 mg hs which, with its long half life, can work to calm them during the day. Often these symptoms are precipitated by the loss of a significant other plus increasing demands at work. Starting an SSRI shortly AFTER the panic is calmed by the benzo is the way I prefer to do it, as I have seen a few patients react to an SSRI with an immediate increase in anxiety and agitation.
I treat these patients with a thorough psychiatric evaluation to determine the current stresses and losses, their current medical condition, substance use or lack therof, and history of family of origin. I see them at first twice a week if possible, during the time of crisis, then once a week. I perform psychotherapy, not even CBT, but psychotherapy to tease out the stressors, and to help the patient by mobilizing the patients relatives and friends to offer support, problem solving what issues at work may be amenable to change, reminding the patient of his/her current strengths and talents which are forgotten during a crisis. I find that looking into their interpersonal skills, finding who can support them now, plus knowing that the psychiatrist has the patients back during this crisis, plus the damnable BENZO often lead to recovery within 2 months. Starting an SSRI at the beginning, such as Lexapro, Celexa, Cymbalta, Zoloft while still using the benzos I find a very effective treatment. (I posted this on another thread, in slightly more detail)
I think if a family medicine doctor, or any doctor, has the time, he/she can be a caring person and does not need the training of a neurosurgeon to help people at a time of crisis.
My patients are reassured to carry around the klonopin knowing that if the panic should strike, they have a quick remedy. They rarely abuse this.
Have I been duped by my patients? Yes, of course. But my effectiveness rate is fairly good.
Please do not say something I didn't say and then attack me for saying what I didn't say.
My success rate for treating panic is 100% for decades. But so what.
Xanax prn is a great way to get a person addicted. Xanax withdrawal feel like panic, so many people addicted think they have panics!
Klonopin prn is placebo. Have you any idea how slowly it rises in its active plasma metabolites?
Rebreathing is a great gimmick that physiologically works better than a bet a blocker.
But you'll never get detailed on rebreathing.
See, I actually care enough about my patients to sympaethize but with their anxiety but also don't want to get them addicted or harmed by irrational treatments that are laced with placebo.
Now think about the pharacokinetics of klonopin. For a typical individual, peak plasma can take up to 8 hours, though usually 1 - 2 hours. Typical panic is a few minutes and ends within a few minutes.
So how does Klonopin break a panic attack that is already under way? It doesn't. The panic remits because of placebo.
What you must remember is that the typical residency "psychopharmacologist" is not. There are a few programs with actual researchers who know a lot and teach a lot. A larger number of programs have researcher s on the take from pharma. These are outright frauds. The large majority of programs have self styled experts who have learned the pharma propaganda and mouth it to pose as experts. These are the ones who go one at length about cytochromes and use lots of abbreviations
It is funny to ask these poseurs about an MK constant (Michaelis-Menten) or to tell you the difference between pharmacodynamics and pharmacokinetics.
vo = v max S / Km + [S]
This is why most psychiatrists also have no idea what rational prescribing is.
Xanax addicts at the 10 10 range. Only placadyl would be worse.
By the way, nobody details anyone on klonopin or xanax these days either. I do not use xanax for anything except an immediate, one time problem such as an airplane phobia. I am fully aware that there is a rebound anxiety after a few hours of taking xanax, when it starts to wear off, if someone takes it more than once a day for a few days at a time. I never recommend xanax, except for a one time use, and I said as much previously.
but, as you yourself have said, klonopin has a longer half life, and using it hs can lead to a much more restful sleep and add to calmness during the day. It is also useful to carry around knowing that it can help with a panic attack. If a patient has a phobia of driving across a bridge, he can take the klonopin either 1/2 hr prior to the drive, or carry it knowing that it will start to work within 20-30 minutes. Maybe the peak level takes longer than twenty minutes, but a soothing effect starts within about 20-30 minutes, and that can be enough to take the edge off the anxiety.
As I posted above, I did have one patient with a severe panic attack, that he thought was a heart attack, who turned out to be in excellent physical health. I started him first on an SSRI, perhaps Celexa, and he became so agitated that he thought of suicide. He then was given Buspar, to which, to my great surprise, he responded well. Then he took another SSRI, with the caveat that he could add klonopin if his anxiety rose again. This worked well. Within two months he no longer needed any klonopin, later reduced the buspar, and now has stopped his SSRI. I do not know if you respect any anecdotal reports. I have a number of patients who use benzos PRN unusual work challenges.
I also think that exercise helps a lot, and I prescribe that. I am happy to use whatever modalities work so long as they are not harmful to the patients. I try not to be too judgmental of my colleagues who may use other modalities. I think tolerance is a sign of world experience and of having made enough mistakes in life that you think twice before throwing the first stone.
WAY TOO MUCH HYSTERIA on this thread!
Just use your medical judgment: anytime anyone says "always" or "never" you can be assured that hysteria is driving the bus, not judgment.
YES!! Some patients "need" and do very well on daily benzodiazepine dosing. For example, some people seem to have a "hyperactive cortex" that causes initial insomnia. Some try and fail relaxation. Non-BZD's can help, such as trazodone, Rozerem, Seroquel, etc. can help - - - - but there ARE those who do best on a benzodiazepine.
There are several studies demonstrating that people who need these meds do NOT abuse them. Of course, still monitor for overuse or non-compliance and deal with these.
I have noticed that more patients reduce or discontinue their benzodiazepines than accelerate their dose and begin abusing. But that may be because the latter are thumped from my practice and referred to an addictions specialist as soon as their behaviors are spotted.
I remember when I was an intern little old ladies with terminal cancer were taken off their self-controlled morphine pumps if they dosed themselves more than the chief resident thought appropriate. I suspected they were rapid metabolizers - they never showed signs of toxicity. Nonetheless they were cut off.
On the bell curve of life, there are always outliers.
Sermo Doc 21 - please don't be too harsh on the drug reps...I was one well before med school. they have very little pharmacological knowledge beyond what they are fed by the company - and of course, all they get is the propaganda. When I was selling, i was not ALLOWED to give the negative aspects of the drug - cost, side effects, etc.
anybody ever use propranolol for prophylaxis against "stage fright"?
Is there any rationale for Klonopin more than once a day? It doesn't make sense from a half life point of view. Half life is 18-50 hours.
How about Ativan once a day? half life 10-20 hours.
Is Ativan better than Xanax, less addictive?
I'd feel a bit better about these meds if they were given just once a day.
"Now think about the pharacokinetics of klonopin. For a typical individual, peak plasma can take up to 8 hours, though usually 1 - 2 hours. Typical panic is a few minutes and ends within a few minutes."
Sorry if I missed a post somewhere. What Sermo Doc 18 wrote holds true for Xanax too, no? I.e., the onset of action of Xanax (20 minutes) is longer than the length of the panic attack itself. Of all my panic patients, the longest reported attack was 18 minutes. Pt's describing "panic attacks" of 1-8 hours in duration are mislabeling their symptoms. So any effect from any benzo taken during an actual panic attack is simply placebo effect. I'm beginning to like the rebreathing solution more and more.
I am beginning to realize that most of the posters don't know what rebreathing is.
But my mantra recently is
You break it, you buy it.
If you don't know what you are getting into, and it gets out of hand...then maybe you shouldn't have been prescribing it in the first place?
I hope everyone goes back and reads that thread about benzos, it was very informational. Seeker was there, and Galaxy, Stu Gitlow,Maxwell Edison and many other very thoughtful and sincere doctors commented. Lawdoc was even in favor of Klonopin two years ago.
Here is the Classic Comic Book version of what I learned from one of the true great psychopharmacology researchers of the mid 20th century who always said that if you give someone a pill, you rob him of dignity and convince him he cannot do it without a pill. (Interesting insight from someone who's business was researching the use of pills!)
Do you remember that if you infuse lactic acid in someone with panic attacks that it triggers a panic attack? That people with panic attacks spend more time with anticipatory anxiety than they do in panic attacks?
Anxious people are seldom aware of their rate and breathing capacity?
Simple behavior modification to raise awareness of breathing, use paper bag, holding breath, cupped hands, to EMPOWER a person to modify his own acid base/ O2 CO2 balance.
In so doing, person learns that can control panic if has one, relaxes, has fewer.
The physiology is spot on.
If you do enough behavioral mumbo jumbo around teaching and practicing the technique, with empowerment language mixed with a little education on physiology, you should get 100% success without use of medication at all in simple panic disorder.
Panicky people are fearful of losing control, right?
So tellem "you don't want to become more helpless by being dependent of pills? My God! You could lose the pills. Then WHAT!"
"So I'll teach you how to take charge of yourself ..."
It is fun because there is so much showmanship.
If you are dealing with a character disorder, then you need to do more therapy around the technique.
A lecturer once demonstrated a "technique" to eliminate the gag reflex - on a med student in front of the rest of the class - it worked perfectly. Just involved tapping around the side of the head while delivering the patter and then using the tongue blade again with remarkable results.
Do you remember the reflex demonstration scene in Young Frankenstein?
On the other hand, how many out there go home after a really crappy day, or on a weekend sitting back watching a ball game and have a beer? A lot of people in this country utilize GABA receptor substances to make life a little less stressful and don't over do it. Telling us to forget about using benzos would be like bringing prohibition back. That worked well! NOT. Come on folks use common sense when prescribing these drugs, understand what you are doing, make sure the patient understands and do your darndest not to get them hooked on the stuff. Will it happen you bet. Have we all seen nightmare cases, you bet. Universal proclamations on the other hand are worthless. That's why it's called the art of medicine.
When insurance and the government start paying for people to see counselors and therapists is when we will see a decrease in the use of addictive substances, until then get off your High Horse and let's start talking about Reality instead of Utopia.
Now I think I need a beer after that tyrade. Breathe in, hold, breathe out, breathe in, hold, breath out, etc. Hey yea that works.
My opinion is that anxiety IS the problem, and treating it is not "putting a band-aid on an amputated limb" or whatever flippant irrelevant comparison someone previously used. Anxiety and mood problems cause issues, not the other way around. Mood is genetic, and no amount of fear or guilt mongering lecturing by a physician is going to change that; it likely will make it worse. As a patient once said to me, "I've had a LOT of therapy, and I know why I drink too much." When I put her on alprazolam she said, "Now I not only know why I drink, but I actually stopped." Oh, right, she really didn't, nor did any of the rest of the patients that have told me that, they (and their family and friends) have all lied to me and I'm too naïve to know that.
Here's a possibility - genetic mood disorders are the problem, and issue centered counseling is what is nothing more than band-aid therapy, offering little more than a temporary solution that addresses the predominant issue du jour in their life, the manifestation of that mood disorder, rather than addressing the real underlying problem. And, meanwhile, specialists of various sorts go on blithely evaluating and diagnosing one somatic symptom after another, shoving scopes and scans at anxious people over and over as they circle the drain, anxiety leading to more physical, interpersonal, and economic problems, leading to still more anxiety, while we tell them, "You just need to learn to relax." How about people just learn to lower their BP and cholesterol, too?
We need to get past the idea that a patient feeling better is evidentiary of a drug being abused rather than used effectively.
Sermo Doc 123: "Come on folks use common sense when prescribing these drugs, understand what you are doing, make sure the patient understands and do your darndest not to get them hooked on the stuff."
Come on, Sermo Doc 123, use some common sense and don't prescribe it just because someone else did!
So you mean that my now ex-wife spending MY money on her boyfriend's trailer renovation, Lortab addiction, cheating on me with half the town INCLUDING our sons' high school friends, etc was NOT the cause of my acute anxiety and depression? Dammit, now I'm pissed.....even though we got divorced ten years ago and I got better, I suppose now I'm still anxious and depressed???
You are correct about oxazepam. It is very effective for etoh detox.
If you don't feel comfortable using benzos then don't, but if you do use them when indicated. That having been said, I don't rx Xanax
Not sure what Sermo Doc 18 has against serax. It actually has almost no street value, is very slowly absorbed and poorly crosses blood/brain barrier. It, and librium, are the two least-valued benzos on the street, which is why they are my most prescribed when needed.
I'll make 2 points before I go back into seclusion:
(1) No, I'm saying YOU weren't the cause of HER problems.
(2) And "dammit" you seem easily "pissed" by nature. I'm saying THAT'S genetic/endogenous.
Now I remember why I stopped visiting here and posting. Perhaps I should tell you what I'd read all too often here, what we should tell patients who are "problems" to us - "AMF YOYO". Not fighting with you has given me more time to try to help those patients.
>I'll make 2 points before I go back into seclusion:
(1) No, I'm saying YOU weren't the cause of HER problems.
(2) And "dammit" you seem easily "pissed" by nature. I'm saying THAT'S genetic/endogenous.
Now I remember why I stopped visiting here and posting. Perhaps I should tell you what I'd read all too often here, what we should tell patients who are "problems" to us - "AMF YOYO". Not fighting with you has given me more time to try to help those patients. <
Bravo!!
Don't leave. You've more wisdom in your little finger than some have in their whole brain.
It would be so much better on Sermo if we could discuss anecdotal uses of meds, some that have worked well for us individually, some off label, without fear of being insulted contemptuously by those who disagree.
If you are worried about suicide potential when sending a patient out of the ER a small Rx of benzo would be the safest thing to use.
Nothing beats rebreathing for breaking an acute panic attack or hyperventilation.
It is too hard for too many people simply to acknowledge a lack of true knowledge and admit that maybe one has made a mistake.
Psychiatric residencies do a terrible job in teaching psychopharmacology, but other fields do even worse. Sermo Doc 28's comments gell with mine, because I would never think of treating HTN in a patient on anything but an emergency basis and there was no alternative whatsoever. I see it as a duty to seek out and respect my limits.
That is not to disown my medical background, and I have made some pretty good diagnostic pickups in my time, but then I refer.
For some reason, we do not teach doctors to respect one's own limits.
PCPs have vast knowledge, but they cannot function as specialists; their knowledge is not deep.. Specialists have vast knowledge, but it is narrow. We have to know when and how to work together.
Thus spake Rodney King!
Using your rationale, I'm not supposed to do anything at all. It's reminiscent of my alma mater's dismissal of FP as unnecessary and insufficient in expertise, since every problem it presumed to treat was already "owned" by a specialty that was more "qualified" to treat it. Obs delivered babies (and presumably even did Paps) better, nephrologists claimed to know more about treating hypertension, ophthalmologists could more thoroughly evaluate corneal abrasions, and so on down the line. Heck, some problems like hypertension even had 2 different specialties fighting with each other over who should be treating it. As I resident I witnessed a medical staff war over who shouldn't have the "privileges" to do colonoscopy - GI said they had it first, GS said they invented it, GI told them to go do a GI residency if they wanted to do it, and GS ultimately found out the GI who was doing the most had learned to do it from the rep who sold him the scope. And who couldn't enjoy the manage (pun there) a trois between ophth, ENT, and plastics over a blow out (pun there, too) fracture of the orbit. In the end we're probably left fighting for the right to do rectal exams without someone to give us a hand.....
If I took the advice of NYU, and many specialists, and "respected my own limits" the way they think I should, I'd have left FP decades ago and retrained for a real specialty. But the way I see it, you should instead be asking me why, some years ago now, 24/25 FPs at a focus group meeting thought that promoting a drug as "the #1 antidepressant used by psychiatrists in the US today" was such a profoundly negative statement that they would have left it off the advertising piece. Today that would likely be 25/25, since, after further experience in practice, I'd like to change my vote.
Psychiatry has a lot more limits than it realizes, and it's close-mindedness that's the biggest one. The biggest problems in medicine is not narcissism, it's arrogance.
I suggest you read what I actually said.
Those who think this is about turf instead of knowledge see:
md.sermo.com
Let's try again, in case I wasn't clear/direct enough - I exceed my limits every time I see a patient in the mind of someone in another specialty. Sometimes I exceed my limits 3, 4, or even more times in a single visit.
"I am all for limiting who practices in my specialty also"
Let's try again, in case you weren't clear/direct enough - but first you're for limiting who practices in your specialty from outside your specialty, no? It's never a "turf" war when it's your specialty, when it's always about ensuring "quality of care".
Perhaps it can be best summed by realizing that wisdom comes from the capacity to say "I didn't know that" more than it tends to get said.
There is a tendency for some, upon hearing a criticism to reply with an attempt to change the subject and say "well you do so and so..."
It really doesn't matter if more psychiatrists are inept at psychiatry than FPs at FP.
There are proper ways to do some things, and some people will be in a better position to know that, whether they follow through or not.
There is no valid reason for an FP to begin a person on xanax, there are rare, select cases for psychiatrists to do so.
Almost ALL xanax prescriptions shouldn't be.
The defensive responses from those who prescribe it anyway speaks volumes for itself.
The ONLY benzo that can break a panic pharmacologically is halcion because it works so fast.
Most benzo treat the inter panic anticipatory anxiety, not the panic.
Either you learned your lesson from the detail rep, or the poseur who taught you psychopharmacology in residency learned that form the detail reps.
Alpazolam doesn't reach significant plasma levels in time to have even a marginal impact on an acute panic.
So, you do not recognize a PLACEBO when you see it.
I reiterate the word m NEVER because if a large number of specialists can't get it right, why should a generalist?
While an infinite improbability may remain a finite possibility, somethings are impossible,
Don't take my word, ask Kurt Godel.
vo = v max S / Km + [S]
explain to me how alrazolam can break a panic attack that lasts only a few minutes.
Please, not because some poseur taught you in residency, or because in an earlier era the detail rep told you so.
Just so you understand that if it were up to me, a huge number of psychiatrists wouldn't be allowed to prescribe either.
www.ncbi.nlm.nih.gov
treat/ manage panic disorder,...outside of the placebo affect, and why acute exacerbations did not result in symptom relief until 42-108 mins after dosing..
(add the placebo effect and the patients saw 10-30 min onset of symptom relief)
This reminds me of how back in the days cocaine was an okay thing to use.
BTW I am a practicing doctor and a practicing lawyer as I have posted numerous times before.
I think 3 minutes onset is a little optimistic...clinical effect would probably be present by 30 minutes. Useful in an ACUTE panic attack? Doubtful.
.
.
Do as I say, not do as I do?
So why don't you just give us the citations that show xanax working in 3 minutes?
Xanax can be bitten and held under the tongue, and absorbed sublingually, resulting in somewhat quicker effect. There is a new formulation of klonopin that is dissolvable under the tongue, klonopin IR probably. I wonder if anyone would agree that that is useful? Could someone provide the proper mathematical constants for that?
I do like the image of holding a paper bag over ones mouth, while hyperventilating into it, driving one-handed, possibly even talking on a cell phone? while assuming that your panic will immediately subside because of the "rebreathing" treatment while driving across the Golden Gate Bridge. It sounds perfectly conceptualized and therapeutic to me. I don't know why we don't all use this technique. I do think that the size and capacity of the paper bag would need to be taken into account, however.
And if I choose to "defend" Sermo Doc 18 or anyone else, I will feel free to do so - I don't require your permission to speak freely here. What are you - some kind of moderator or something?
citation,please.
ditto
If you can make up stuff (which you do often) why can't someone else?
I'm not saying that AK has made up anything BTW, but it is amusing to see you, of all people, take offense.
I am still waiting for the cites that demonstrate onset of action of xanax in 3 minutes.
And besides - as Sermo Doc 26 has suggested - he can speak for himself.
When you mentioned the three minute onset - you didn't say anything about other modalities.
There is not cite. I am soooo bitterly disappointed!
You are dead wrong about the indications and appropriate use of Provigil.
I don't disagree with you about the use of Xanax being rare but in the case of Provigil you should follow your own advice and leave it to the doctors who are experienced at using it.
>Ebola - just because you're sore that I proved you wrong on the other post - you don't have to stalk me over here and jump into this little discussion. <
You didn't (prove me wrong).
I didn't (stalk you).
You really need to read people's responses.
Its approval was another abomination of fda.
But I am open to reading actual cites that give me information I don't have.
Please cite.
And, as a doctor experienced in using it, please tell us what follow criteria you use to make sure that the positive results you see are not placebo? Not due to diversion?
Please, please, tell us.
There is practically no street value for provigil. I have never had anyone seeking it.
I will cite the info. This is a great med with low or no abuse potential.
I am leaving work now so I will have to give you the info tomorrow.
It would actually have to have some pharmacologic impact before it had street value. It is high priced caffeine, should not be on the market, and never prescribed.
This is one place I agree with the insurance companies that no one should pay for this junk.
I'm sorry, I misunderstood your comment about "diversion" of Provigil to mean you thought it had street value.
BTW amoxicillin has pharmacological effect yet has no street value. ;-)
I will get some cites for you though if you don't believe them, which you just stated, I doubt It will convince you of anything.
Remember that the cites are only the starting point. I have yet to see a single well designed study that has shown to provigil as anything more than caffeine. So I am always happy to see if there are others that say otherwise.
Sad.
That said, my point is that provigil is nothing but expensive caffiene, and the insurance companies are correct in making you do a lot of work to justify prescribing a medicne that has no reason ever to have even been approved.
Then, when in front of the licensing board are shocked when all the rationalizations don't work and they lose their licenses.
Study showing that modafinil works in excessive drowsiness in shift work published NEJM.
content.nejm.org
www.sciencedirect.com
Study in JAMA on effects of Dopamine suggesting potential for abuse.
jama.ama-assn.org
Study in Journal of Pediatrics showing effect in ADHD children.
www.jpeds.com
Study Published in Annals of Clinical Psychiatry showing effectiveness of modifinil in augmentation of SSRIs in the treatment of MDD.
www.informaworld.com
There are many articles out there attesting to the effectiveness of modifinil in the approved indications as well as off label use. Yes, some of these are sponsored by Cephalon.
I have some other things to do today but I'll get back to tell you how I use it.
And to paraphrase Vincent Laguardia Gambini: "Are you sure about that 3 minutes?"
These cites, such as they are, do demonstrate how many people who prescribe drugs have no idea what hey are doing, but if the detail reps give you a mug, whell you are bought.
Prescribing provigil causes no harm other than unneccessary cost.
Prescribing xanax is harmful as it is addictive, poses harm of dangerous withdrawal, and there are better alternatives. I guess it is is useful to the bottom line to keep your waiting room full of junkies?
Okla, is it possible for any doctor not to know about acid base balance and 02 CO2 balance? Is it actually possible? Don't you have to know about that in internal medicine residencies and for the boards?
1.Give us a citation or ANY proof that xanax is effective BY ITSELF in as little as 3 minutes - as you repeatedly claim.
2. Please tell me that your comment "...rebreathing actually just increases oxygen by using the central effect of hypercapnea..." was simply WRONG.
And THEN "let's go".
Let me clarify - panic attacks often are accompanied by HYPERVENTILATION. Hyperventilation causes an DECREASE in the pCO2 and a concomitant INCREASE in the pO2, RAISING the pH , thus being classified as a respiratory alkalosis. Rebreathing corrects this alkalosis.
True or False?
You will have to excuse me as I am at work today and don't have the time to fully support my position. I just want you to know that I'm not avoiding the question and can support the its appropriate use and will.
I haven't seen any studies comparing it to caffeine, however most with the serious indications have already tried coffee to no avail.
It certainly has less side effects than caffeine.
Please don't point to my hastily acquired cites as evidence of my ignorance of the med. I would put my knowledge of the correct prescribing and the pharmacology of Provigil against yours any day.
I don't say that about the meds you speak of in your specialty. I just feel you should stick to your own specialty when advising docs what meds do and do not work. You are way off base on this one.
Do you have OSA or Narcolepsy. If so do you just drink extra coffee as a treatment?
1.Give us a citation or ANY proof that xanax is effective BY ITSELF in as little as 3 minutes - as you repeatedly claim.
2. Please tell me that your comment "...rebreathing actually just increases oxygen by using the central effect of hypercapnea..." was simply WRONG.
Quit trying to avoid the 2 simple questions by throwing up irrelevant information. YOU have demonstrated a clear misunderstanding of the physiology of hyperventilation. Something a first year medical student should know.
"Strictly speaking,rebreathing treats 'hyperventillation' and its effects" - this is the only thing that you and I agree on.
As to Sermo Doc 18's "hidden motives" and "secondary gain" - I have no idea. Are you suggesting that he has stock in some competetive drug or something????
But I digress - please address the two questions or points that I have made - so far you haven't......
"ANYONE can memorize text and regurgitate..." with the possible exception of YOU when it comes to acid-base chemistry - since you are wrong in your understanding of rebreathing.
Sermo Doc 26 Internal Medicine
Posted Jan 21, 2010 at 8:57 AM
Lawdoc has his agenda on this board;he has secondary gains for the positions he takes on some issues but you can't even see that,can you???
1.Give us a citation or ANY proof that xanax is effective BY ITSELF in as little as 3 minutes - as you repeatedly claim.
2. Please tell me that your comment "...rebreathing actually just increases oxygen by using the central effect of hypercapnea..." was simply WRONG.
1.Give us a citation or ANY proof that xanax is effective BY ITSELF in as little as 3 minutes - as you repeatedly claim.
2. Please tell me that your comment "...rebreathing actually just increases oxygen by using the central effect of hypercapnea..." was simply WRONG.
You've stepped over the line, pal.
You guys need to back away. No one gains anything from insults. I think AK's problems with your sort of logic (no logic) Okla doesn't stem from this post but from chronic interaction with you and your inability to be civil and eagerness to be caustic and to get down and personal. It may not be right but you bring this kind of personal attack on yourself by attacking others personally and badgering them until they reply, sometimes having lost their patience with you (imagine that).
You can consult Sermo Doc 18 about legal recourse but I doubt you have a case. It is my understanding that AK's statements about you would only be actionable if they weren't true.
Furthermore - if I was a graduate of ANY school of medicine and didn't understand the BASICS of hyperventilation and acid-base chemistry, I wouldn't be so quick to cast stones.
And speaking of losing patience - as I recall - AK was the FIRST to question Sermo Doc 18's knowledge yet he is too obstinate to simply ADMIT that he was just making up the 3 minute comment AND too afraid to ADMIT that he doesn't understand hyperventilation.
And this really isn't your fight, is it Ebola?
I'm sure you don't mind if I quote you, do you AK?
AK - do you have boards in anything? What?
Did you do a residency?
Nevertheless, screwing up my courage I am adding some references to the usage of rebreathing for hyperventilation. I do hesitate to add anything here, so feel free to ignore me and just keep punching guys. But I did look up rebreathing, and these articles may be in support of AK4700. (gasp) Also, if this is long enough and boring enough, maybe the above elevated adrenaline and testosterone will subside for a bit?
From en.wikipedia.org
Paper bag rebreathing
Many panic attack sufferers as well as doctors recommend breathing into a paper bag as an effective short-term treatment of an acute panic attack.[13] However, this treatment has been criticised by others as ineffective and possibly hazardous to the patient, even potentially worsening the panic attack.[14] They say it can fatally lower oxygen levels in the blood stream,[15] and increase carbon dioxide levels, which in turn has been found to be a major cause of panic attacks.[16]
It is therefore important to discover whether hyperventilation is truly involved in each case. If it is, then rebalancing the oxygen/CO2 levels in the blood and/or re-establishing an even, measured breathing pattern is an appropriate treatment which may be also achieved by extending the outbreath either by counting or even humming.[17]
But, breathing into a paper bag restricts the fresh air you are able to get. Without fresh air, too little oxygen is in the air you're inhaling. So, breathing into a paper bag dangerously lowers the amount of oxygen in your bloodstream. There have been several documented cases of heart attack patients incorrectly thinking they had hyperventilation syndrome and fatally worsening their heart attacks by breathing into a paper bag.
......
To make matters worse, several studies now show a link between high concentrations of CO2 and panic attacks, which means that artificially increasing CO2 in inhaled air is likely to trigger more feelings of panic in patients who suffer from anxiety.
The best treatment of hyperventilation syndrome is to stay calm and practice breathing slowly and not too deeply. Calmness and breathing exercises have just as much success as paper bag breathing, and no one is going to die from staying calm.
Sources:
Callaham, M. "Hypoxic hazards of traditional paper bag rebreathing in hyperventilating patients." Annals of Emergency Medicine. Jun 1989 PMID: 2499228
van den Hout, M.A., et al."Rebreathing to cope with hyperventilation: experimental tests of the paper bag method." Journal of Behavioral Medicine. Jun 1988 PMID: 3139884
Ohi, M., et al."Oxygen desaturation following voluntary hyperventilation in normal subjects." American Journal of Respiratory and Critical Care Medicine. Mar 1994 PMID: 8118644
Griez, Eric J., et al. "Carbon Dioxide Inhalation Induces Dose-Dependent and Age-Related Negative Affectivity." PLoS ONE. 3 Oct 2007 PMID: 17912364
That is WIKIPEADEIA article so obviously written by a paranoid nut job that it begns with this disclaimer:
"This article is in need of attention from an expert on the subject. WikiProject Psychology or the Psychology Portal may be able to help recruit one. (January 2009)"
Why are you Xanax prescribers so afraid to challenge the junkies in your waiting rooms? Are you afraid you will lose too much income if you practice rational medicine?
Even in the paranoid wiki article it says:
The best treatment of hyperventilation syndrome is to stay calm and practice breathing slowly and not too deeply. Calmness and breathing exercises have just as much success as paper bag breathing, and no one is going to die from staying calm.
And that demonstrates the point in the first place about training a person to maintain self control, which is undermined by the use of xanax.
I will stipulate that there MAY be disagreement as to the efficacy of rebreathing and its role in panic attacks - but that is all beside the point.
Here we have a (presumably) MD person who is berating me because I am a supposedly inferior DO - yet he makes a major blunder in discussing blood gases - and then refuses to just step up and admit he was wrong.
And also refuses to - again - just simply admit that he made up the 3 minute claim regarding xanax onset of action.
And finally - AK - please show me where I THREATENED you. If you are refering to my coment about seeking legal redress - I don't really believe that is considered a threat, more like discussing a perfectly reasonable legal option available to someone who is being slandered.
"They" are quite correct when "they" say that rebreathing increases the CO2 - that's the WHOLE POINT! As for it fatally lowering oxygen levls - one would have to imagine that long before someone became FATALLY hypoxic, they would drop the paper bag away from their face.
Nice citation, though, from WIKIPEDIA. At least it's more than AK can offer regarding the 3 minute claim.
You all have valid points.
DOs are the same as MDs, we know that. I refer to a surgeon who is a DO all the time because he is one of the best. One of the FPs in my office is a DO and he was named the best primary doctor in No. County (and he didn't have to pay for that). My relative in CA is an interventional radiologist and a DO.
Paper bag breathing probably would work for some, but not all, panic victims.
I don't initiate xanax, but have some pts who were already initiated by someone else, and it's sometimes hard to get them off.
Maybe he'll do the right thing and apologize. Then again, maybe he won't.
I think they still have training in manipulation and some in this area do a lot of it. I have referred patients for manipulation before.
I talked with a pain specialist a while back and he had a 7 day regimen for tapering pts off Xanax!
I'll try to ask him again. It might have something to do with the fact that they are starting the patient on other addicting substances?
I'm going to hold any discussion of Provigil for now in view of the present situational morass. Perhaps I'll do another post on it myself.
Okla, I wasn't trying to stick my nose into your fight, just calm things down but I didn't expect much from you and you lived up to my expectations. So just continue your useless, childish, shadow boxing.
A normal person rebreathing and getting a fatal hypoxia would be rare, I agree, but someone with a heart or lung problem could be another story.
I'm ready to "kiss and make up" as long as a sincere apology is offered.
Thanks - that helps so much.
"misspoke" is an understatement.
Ain't it the truth.
I've seen you wrong on many things yet I haven't seen you issue any apologies to those you maligned!
If I were you I wouldn't expect others to act more graciously toward you than you do toward them. Just a thought worth considering.
I think that calls for an apology.
OK, I'm sorry.
Now let it go.
Ebola, did you learn about blood acid base balance in your residency?
Now, notice that you never answer questions but just make attacks.
Do YOU have boards in anything?
California lets lots of fake professionals practice due to phony license tracks. I realize for the first time that California might have a fake license track for medicine too?
AK you make mistakes that a mediocre 2nd year med student shouldn't make. Do you actually have boards in anything?
>That is due to the lack of any real indication for this otherwise high priced caffeine for life-style choices masquerading as a disorder.<
Do you honestly believe that Obstructive Sleep Apnea and Narcolepsy are life style choices?? Perhaps you misspoke? I certainly hope so.
What are your boards?
Your question clearly indicates that you do not have boards, perhaps no residency, perhaps have snuck onto Sermo with a degree from an unaccredited institution and a California license.
Do you have boards in anything?
Can you give a cite that xanax has a 3 minute onset?
Can you explain hyperventilation at all? A second year med student should be able to.
Is it time to ask Sermo to re-check your license?
Now, answer what boards you have.
You cannot really be an internist
Okay - there you have it - AGAIN.....rebreathing INCREASES pCO2 and DECREASES pO2.......despite all of the fuss - you STILL don't know what you're talking about!! Incredible.
And no one evr said that panic attacks were acid-base disorders - talk about misquoting!
Saying that Xanax can be effective in 3-30 minutes means that it can be effective in AS LITTLE AS 3 minutes. You were NOT misquoted - that was your EXACT statement. And you know it.
I'm still waiting for an apology to us DOs.
You might want to try GOOGLING that - you might learn something Mr. Internist.
As for your false accusations of plagiarism - the quotes I used on another post were used with explicit permission....you might want to GOOGLE the defintion of plagiarism.
DIDDLING myself? What are you - an elementary school student??
Incidently - David Carradine supposedly died from autoerotic asphyxiation.....what's that got to do with hyperventilation?
Oh - so NOW (oral) xanax may be effective in LESS THAN A MINUTE??
You're out of control, pal......
Just admit you don't understand hyperventilation.......you made up the 3 minute claim on xanax and you apologize to the DOs - and it'll be over - or aren't you man enough to just "fess up?
Incidently - David Carradine supposedly died from autoerotic asphyxiation.....what's that got to do with hyperventilation?
Oh - so NOW (oral) xanax may be effective in LESS THAN A MINUTE??
Just admit you don't understand hyperventilation.......you made up the 3 minute claim on xanax and you apologize to the DOs - and it'll be over - or aren't you man enough to just "fess up?
Sermo Doc 12 Emergency Medicine Edited Jan 06, 2010 at 4:16 PM
My posts here - while i would like to take full credit aren't my own - they are from Godisimaginary and whywontgodhealamputees (which, BTW, the author gives free permission to share with others in an attempt to bring reason to humankind).
This is from the whywontgodhealamputees AND godisimaginary websites:
Would you like to help?
Here are four simple things that you can do today:
Add links to this web site in forums, blogs and newsgroups. Anywhere you see people discussing religion, add a link to this web site and quote specific sections that you think are relevant.
Link to this site in your own profiles, personal pages and blogs.
Email a link to this web site to your friends.
Encourage discussion and help others to start thinking rationally about religion.
pla⋅gia⋅rism
-noun 1. the unauthorized use or close imitation of the language and thoughts of another author and the representation of them as one's own original work.
2. something used and represented in this manner.
--------------------------------------------------------------------------------
So - smart guy - care to persist in accusing me of plagiarism? Also not copied but MANY posts before I actually used any quotes - I referenced these websites.
You can apologize for THIS now, also.
whywontgodhealamputees: "add a link to this web site and quote specific sections that you think are relevant."
case closed, pal.
Posted Dec 30, 2009 at 5:59 PM
I would encourage folks to browse through www.whywontgodhealamputees.com
for some thought provoking stuff.
OklaERdoc Emergency Medicine
Posted Dec 30, 2009 at 10:46 PM
will YOU check out whywontgodhealamputees with an open mind as well? It's an easy read (no flowery mumbo-jumbo) and a REAL eye opener.
OklaERdoc Emergency Medicine
Posted Dec 31, 2009 at 2:02 PM
I really, really hope that OPEN MINDED people that are following this post thoroughly peruse the whywontgodhealamputees website....please do yourself a favor. I will say no more as I have said enough.
jmh4kids Pediatrics
Edited Jan 07, 2010 at 2:27 PM
OklaERdoc, I have visited your referenced websites, as have others I'm sure. They offer interesting arguments, but no proof and certainly no indisputable facts. I just didn't want you to think that no one was following-up.
chilicat Pathology
Posted Jan 07, 2010 at 4:03 PM
When I said Bravo to OklaERdoc, I was well aware that he was using arguments from various sources. I was commending him for putting those arguments together in the fashion he did.
Sermo Doc 95 Internal Medicine
Posted Jan 07, 2010 at 5:45 PM
I had looked at the sites by Okla and understood that he had used them in his explanations. I was not confused,
AK - don't you feel like a real jerk now?
You have NO CASE, pal.
BUT - of course, all of this is simply a smokescreen to misdirect everybody from the original issue which revolves around YOUR evasion of these questions:
1.Why do you continually REFUSE to simply admit that you are confused about the physiology of hyperventilation (LOW pCO2 and HIGH pO2)?
2. Why won't you simply admit that you completely MADE UP the 3 minute onset of action claim about xanax (now amended to a ONE MINUTE claim)?
3. Why won't you apologize for your disparaging and unprofessional remarks about the legitimacy of DOs?
Answer the questions.........
-noun 1. the unauthorized use
Amazing, since some have also commented that I am an older, black woman.
2. Why won't you simply admit that you completely MADE UP the 3 minute onset of action claim about xanax (now amended to a ONE MINUTE claim)?
3. Why won't you apologize for your disparaging and unprofessional remarks about the legitimacy of DOs?
so now you're professing to be a SURGEON?
Are you all OK? Although I haven't seen much cursing, you all have been SO mean to each other. I don't think I've ever seen it this heated. There are so many posts I can't remember who said what against anybody.
Please take a deep breath, all of you and calm down. I run the risk of being insulted but this should be a debate based on facts and not opinionated insults.
DOs, MDs, psychiatrics, internists, ED docs, family med docs - I like all of you. Please show just the facts and quit the infighting. You all are frequent posters and all have good things to contribute.
as to deep breathes, no, you want to hold the breath so the level of CO2 rises. Since you are real internist, you understand this.
Some here just suffer too much es troll gen, don't sweat it, but thanks for the concern.
When you consider that this is the way physicians (yes, even DOs!) with over 23 years of education behave, do you understand why I don't think very many of my patients with half as much schooling and often even less brainpower and capacity for insight are going to benefit form counseling? When you look at the amount of anger and irritability, which I believe to be innate, do you understand why I like drugs that are potent enough actually to work?
As I've said before, alprazolam is hard to stop for one simple reason - it really works. Anti-depressants are easy to stop because - they don't (or people aren't depressed). If alprazolam doesn't actually do anything, then why do people, in your opinion, like to abuse it? What some people see as abuse, I see as effectiveness.
And, now, back to our show......
As I've said before, alprazolam is hard to stop for one simple reason - it really works. "
No, you see, it has withdrawal that mimics panic. After 10 days, most people are physiologically addicted. You try to wean them, and they cannot be weaned.
Here is the challeng: if klonpin works just as well, and it is hard to become addicted to klonopin, and klonopin is cheaper, and withdrawal from xanax can kill, but withdrawal from klonpin doesn't, why would you use xanax?
Many doctors, eyes wide shut, prescribe xanax, opioids, adderral, and thus keep their waiting rooms filled.
There is nothing harder to do than to say this and elicit the response: Reall? I hadn't thought about that. I will consider doing something different.
Link to this site in your own profiles, personal pages and blogs.
Email a link to this web site to your friends.
Encourage discussion and help others to start thinking rationally about religion. <
This is an excellent example of an atheist proselytizing!
BTW, I healed an amputee today!
Exactly what does that mean? Are you telling me I'm essentially just selling drugs to keep busy and for profit?
There is no substantive difference between alprazolam and clonazepam. To say that alprazolam has all manner of problems associated with it and clonazepam is totally different is just hair-splitting nonsense. The same nonsense has been said about diazepam and lorazepam for the past 30 years - diazepam was bad, but lorazepam was okay. The only significant difference is the time of onset and duration of action, which makes clonazepam useless as a prn; I'm just stunned by the frequency with which patients have been given prn clonazepam for panic attacks. If anyone can claim alprazolam doesn't work fast enough, then clonazepam for damn sure doesn't. And the objection to alprazolam seems to be that it DOES work quickly, which is why is can be diverted and misused while clonazepam much less so. How can it work quickly when misused, but not when properly used? Everything else is rhetoric, although I generally find alprazolam to be more effective. Some people do better with one, some with another.
I think we simply disagree, I'm sorry you have to frame that as a matter of competence and credentials. I think people are anxious, and I think benzodiazepines work far, far better than SSRIs, and you don't. I think people are better, you think they're just high. We just disagree. But, again, thanks for the personal attack on my professional character.
Green Lantern - you are correct - learned physicians have many of the same traits as "normal human beings" - we get angry, we fight, we antagonize, we're obstinate and some of us are very much on the edge......
"...this is the way physicians (yes, even DOs!) ..." - see? even YOU can't resist being a little "human" from time to time, can you?
I don't believe that you have ever made a mistake which you have acknowledged, though others can see it, have you?
So, do you include yourself as "human" also?
Uh, that was meant to be humorous. I just finished precepting a DO student over the last 2 weeks of December, a student at PCOM-Atlanta who was home over the holidays and needed a quick low-impact elective to make up some time. We chatted a lot about where medicine was before her and where it is today from both my and her perspective, particularly the changes in the way MDs and DOs see each other and the way both concepts have changed.
Not to go off topic, but it's interesting that apparently osteopathy is now aiming to "take over" or "take back" primary care, re-affirming their commitment having physicians provide primary care while the allopathic world has all but ceded it to NP/PAs as though it were beneath them. That's the message she's been getting; and, if she wants to go into surgery, they're recommending general surgery rather than the other sub-specialties. Osteopathy wants to "own" primary care medicine and (primary care) surgery. But that's another discussion.
"This is probably cause both sides don't see the same patients, well not in the same emotional state at least. "
Unquestionably true. I take care of a psychiatrist and his family; he does primarily drug rehab/substance abuse. At the outset it was clear to he didn't like alprazolam, but he's come to realize that he's not seeing the patients whom I treat who do well, but rather an entirely different group who have often never done well with anything, including antidepressants, and, if alprazolam isn't their answer, it certainly isn't their problem. Finally one day I asked, "Have you EVER seen a patient abusing alprazolam or another benzodiazepine who wasn't also previously, repeatedly, and currently abusing all sorts of other drugs?" and he said, "Well, now that you mention, it, no." Conversely, I would hope that in those patients who would otherwise wind up under his care I've stopped alprazolam and moved on to other treatments or referred them, vs. just dumping them (aka AMF YOYO), continuing to try to find them some sort of answer (presuming they want one). BTW, I also love Symbyax for treatment resistant anxiety, although that, also, is another discussion.
Interesting bit of DO history......in 1962...the State of Claifornia took over the DO schools that were in existencwe then and offered the DOs trained there an opportunity to CONVERT their DO degrees into MD degrees for a fee of $65....about one-half took them up on their offer and , to the DO community, they became traitors and referred to as "md's" (small case letters intentional).
The last state to accept DOs as unrestricted practitioners of medicine and surgery was Louisiana in 1971 - interstingly, the "birthplace" of Chiropractic.
In 1968 - well into the VietNam War - MDs had been drafted and forced to serve. DOs had not been recognized at that time and were ignored by the military and left to conduct their respective practices. The story goes that MDs who had been drafted - and previously sneered at the inclusion of DOs into the "brotherhood" all of a sudden decided that we really WERE equal to them and then, in 1968, the military accepted DOs. Henceforth - in the Armed Services - we were ALL known as "MC" Medical Corps...there is no special military distinction between DOs and MDs.
As you all may well know - some states have separate DO and MD Boards while others have combined Boards. The distinction these days is less and less obvious.
I will admit that, in the early days, DO training WAS inferior. These days - not so. I did my residency in the Air Force alongside MDs - and I did quite well comparatively speaking. We can all cite instances of MD colleagues and DO colleagues who have no business practicing medicine and we can probably all cite individual physicians - both MD and DO - who we would trust with our own lives.
I take great offense at the suggestion that we DOs are somehow "pretenders" or "poseurs" and would suggest that those who believe that nshould re-examine the facts and offer apologies where appropriate.
My shit stinks just like everybody else's, I fart and I belch and I'm not above a dirty joke. This has always served me well, because I think I can talk to ANYONE on their own terms. I can relate to people from all walks of life. I have even received FOOD STAMPS after college and before my job in pharmaceutical sales. I even used to be that scared stiff parent of a feverish kid long BEFORE becoming a doctor.
I've made plenty of mistakes - a very few of which ever caused anyone harm - thank God......I also should've made it MORE CLEAR that I was quoting whywontgodhealamputees and godisimaginary on the other post that Sermo Doc 26 has made such a fuss about - but I still adamantly deny that I committed any crime in doing so at the invitation of the author.
I wonder if others in this discussion can be so honest?
How about you?
Honest about what?
Before I became a doctor, I worked in the East Texas Oilfield Summers and Holidays while going to school, laying pipes, cleaning tanks, swamping for heavy equipment. During college I worked in the work-study program. During medical school I worked nights and weekends cross matching emergency blood at Charity Hospital NOLA.
This doesn't make me particularly special but I try to acknowledge when I have made a mistake and apologize if appropriate.
You, OTOH, are always demanding or waiting for an apology from someone yet never apologizing for your frequent mistakes, even refusing to support your own position while DEMANDING that others meticulously document their comments. You hold others to a much higher standard than yourself.
.
.
.
I will let others interpret your own words......but I certainly do not take these words as directed at only ME but at ALL DOs.....an apology is in order.
2. your statement: "...you need to attend a real medical school.You are actually an impostor practicing medicine by force of legislation..." is an insult to ANY DO - whenever they trained and wherever they trained. You have accused me and "my kind" of being "impostors" (sic). This calls for an apology.
3. The fact that you REFUSE to offer a proper apology for your unprofessional attacks SPEAKS VOLUMES - to use an overused cliche.
4. The fact is that I PRACTICE Emergency Medicine and have done so for nearly twenty years. Nowhere have I EVER claimed to ANYONE at ANYTIME that I am residency trained in EM. In fact, I missed the opportunity to "grandfather" in the Osteopathic realm by one year. Otherwise, I could claim to be Boarded without a residency at all! My Board was taken in FP. Many FPs gravitated to EM and have practiced as such for many years.
ACEP has a term for us - we are called "legacy physicians" by them and, in fact, are eligible to become members. So, I suggest if you have a problem with this - you could complain to the ACEP. But I suspect that they really could not care less about what YOU think.
Finally - as per YOUR statement: "...If you disagree with me that your particular medical school at the period you were enrolled was not less than exemplary..."
I actually agree 100% - my school was NOT LESS THAN EXEMPLARY...in fact, it WAS exemplary!! Thank you for the nice compliment!! Although it would seem to fly in the face of your other unprofessional comments.
Practice Resources > ACEP Policy Statements
The Role of the Legacy Emergency Physician in the 21st Century
Approved by the ACEP Board of Directors June 2006
ACEP believes that physicians who begin the practice of emergency medicine in the 21st century must have completed an accredited emergency medicine residency training program and be eligible for certification by the American Board of Emergency Medicine (ABEM) or American Osteopathic Board of Emergency Medicine (AOBEM).
ACEP acknowledges that emergency medicine's rapid growth resulted in a workforce that includes physicians who are not eligible for ABEM or AOBEM specialty certification. These legacy emergency physicians, many of whom are residency trained and/or board certified in other specialties, began the practice of emergency medicine prior to the 21st century.
Many legacy emergency physicians have demonstrated their commitment to the specialty through membership in ACEP. ACEP supports its members who are legacy emergency physicians.
ACEP acknowledges that legacy emergency physicians, by virtue of their primary training and emergency medicine practice experience, play an important role in the current emergency medicine workforce and patient care safety net.
ACEP supports the efforts of legacy emergency physicians who seek additional training and continuing medical education to enhance their ability to provide high quality patient care.
ACEP believes that the quality of care delivered by legacy emergency physicians should be a primary determinant of their hospital privileges and credentialing. Legacy emergency physicians should be subject to the same quality standards as ABEM/AOBEM certified emergency physicians. Legacy emergency physicians should not be forced out of the workforce solely on the basis of their board certification status.
At the rate things are going, I might be looking to convert my MD degree into a DO. Wouldn't that be a kick in the pants for NYU, my malma mater which still doesn't recognize the existence of FP - trading up their degree for a DO. FYI, I discussed this with my student last month and she told me it's $1000 now. I suppose California needs the cash, since in Orange County "the average pay and benefits package for firefighters was $175,000 per year" according to Steven Greenhut ( liberty.pacificresearch.org ) of the Pacific Research Institute (again, another discussion, but read the link for fun).
Where you practice, the setting, and your patient population must be taken into consideration. It's not possible to withhold benzos for anxiety if you practice in a dying industrial city, and you have a lot of unhealthy, undereducated Appalachian-types with 'bad nerves' (a result of centuries of inbreeding?) most out of work now on medicaid-like health plans (with timely referrals to specialists a luxury they do not have), choking your local clinic or urgent care to the breaking point...leaving you with no time to practice good medicine?... and then the corporate types give them a 'comment card' rating the Doctor's 'concern and proper treatment' for their illness after each visit, with your job/pay on the line if you don't do what they demand. With no support from management, since they drank the Kool Aid long ago and their entire raison d'etre is just to have a lot of happy 'customers' to make them bigger bonuses.
If i didn't prescribe the benzos, I would have to be on them myself.