Benzodiazepine Question

[psych_0]

Working on a grand rounds regarding benzodiazepines and wanted to touch on the addictive potential (amongst other things, obviously), but I'm having trouble finding good articles describing how common benzo abuse actually is. For example, lots of my outpatient colleagues LOVE to brag about how they never prescribe benzos. This got me thinking, have we ever had a study to back this up? If I were to prescribe 1000 different people a 30-day supply of Ativan for GAD, how many of them are going to be beating my door down for early refills or using them in ways other than I have prescribed on the bottle? How many of them will go on to be diagnosed with benzodiazepine use disorder, or be "dependent" to benzos long term? I wanted to put a number on this that was backed by evidence, because the hive mind of my outpatient colleagues gives off the impression that this number is >90% to the point where I feel like we are starting to throw benzos in the same category as Oxycodone.

Best I could find so far was this JAMA article from 1988 and this large cross national survey from 1981 which suggests that the overwhelming majority of patients who are prescribed benzos only take them for <3 months.

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[Stagg737]

Study from finland showing ~40% of those prescribed benzos become long-term users:

Incidence of and Characteristics Associated With Long-term Benzodiazepine Use in Finland

This cohort study uses national longitudinal data from the Social Insurance Institution of Finland to investigate the incidence of long-term use of benzodiazepines and related drugs among new users and factors associated with development of long-term use.

jamanetwork.com

Misuse accounts for 20% of benzodiazepine use:

Benzodiazepine Use and Misuse Among Adults in the United States - PubMed

Benzodiazepine use among U.S. adults was higher than previously reported, and misuse accounted for nearly 20% of use overall. Use by adults ages 50-64 now exceeds use by those ages ≥65. Patients also prescribed stimulants or opioids should be monitored for benzodiazepine misuse. Improved access...

pubmed.ncbi.nlm.nih.gov

Benzos and contraindications in PTSD, shows not only lack of efficacy but worsening of outcomes:

Benzodiazepines for PTSD: A Systematic Review and... : Journal of Psychiatric Practice®

treating PTSD. Methods: The review protocol was undertaken according to the principles recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and is registered with the PROSPERO international prospective register of systematic reviews...

journals.lww.com

Cochrane report on the difficulties of tapering long-term benzo use:

Psychosocial interventions to reduce sedative use, abuse and dependence

www.cochrane.org

 

[birchswing]

or using them in ways other than I have prescribed on the bottle?

<Not a doctor or medical student>

Using them as prescribed on the bottle is the worst possible outcome.

I wish I had stumbled across a recreational drug forum rather than listening to a CAP when I was prescribed benzos. They at least know about tolerance. These people dabble in everything and are afraid of benzos ruining their lives. They may take high doses recreationally, but they seem to know a bit more what they are doing. The Coleman Institute (which I know is controversial in its own right) says it's easy to get a patient who uses high doses benzos recreationally off of them but that they have less success in patients who have taken them long-term, as prescribed, and who have an anxiety disorder. Look at who they consider good candidates for their program: Rapid Benzo Detox and Benzo Withdrawal FAQs - The Coleman Institute (FAQ 7) You're a better candidate if you take the drug not as prescribed rather than long-term for an anxiety disorder, and this is according to an organization that some would say makes over the top claims and promises--they still say their unique protocol doesn't work as well for people with long-term, as prescribed use.

 

[annoyedpsychiatrist]

I think its underreported. When I worked in a community health setting, I would see people presenting for benzo misuse very frequently. Even in my new setting which are more moderate acuity, im in a state/area with a very bimodal population (most of my patients are either young patients in their 20s, or geri patients >65). Probably 1/3 of my intakes are geri patients who have been on routine benzos for most of their life, and as a result getting them off it is absurdly hard. But, they continue to get older. They continue to tolerate it less and have falls, start using opiods, develop OSA, etc. Then what do you do?

And that is what I tell patients. Ok you're 40 years old using benzos daily. What happens when you're 65 and higher and tolerate them less and less? Your disorder will likely still be there but now we cant use benzos, the only medication your body has really known/adapted to.

I prescribe stuff like klonopin occasionally but I typically never give out more than 14 tabs per 30 day period to limit risk of dependence and need for tapering off in the future.

 

[Merovinge]

Study from finland showing ~40% of those prescribed benzos become long-term users:

Incidence of and Characteristics Associated With Long-term Benzodiazepine Use in Finland

This cohort study uses national longitudinal data from the Social Insurance Institution of Finland to investigate the incidence of long-term use of benzodiazepines and related drugs among new users and factors associated with development of long-term use.

jamanetwork.com

Misuse accounts for 20% of benzodiazepine use:

Benzodiazepine Use and Misuse Among Adults in the United States - PubMed

Benzodiazepine use among U.S. adults was higher than previously reported, and misuse accounted for nearly 20% of use overall. Use by adults ages 50-64 now exceeds use by those ages ≥65. Patients also prescribed stimulants or opioids should be monitored for benzodiazepine misuse. Improved access...

pubmed.ncbi.nlm.nih.gov

Benzos and contraindications in PTSD, shows not only lack of efficacy but worsening of outcomes:

Benzodiazepines for PTSD: A Systematic Review and... : Journal of Psychiatric Practice®

treating PTSD. Methods: The review protocol was undertaken according to the principles recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and is registered with the PROSPERO international prospective register of systematic reviews...

journals.lww.com

Cochrane report on the difficulties of tapering long-term benzo use:

Psychosocial interventions to reduce sedative use, abuse and dependence

www.cochrane.org

This is the best response to a lead question I have read on SDN in sometime. Nothing else to say, but .

 

[psych_0]

Study from finland showing ~40% of those prescribed benzos become long-term users:

Incidence of and Characteristics Associated With Long-term Benzodiazepine Use in Finland

This cohort study uses national longitudinal data from the Social Insurance Institution of Finland to investigate the incidence of long-term use of benzodiazepines and related drugs among new users and factors associated with development of long-term use.

jamanetwork.com

Interesting. I wonder why other large studies like this one find such different results (1 in 20 people in this study of 206,933 Canadians)?

 

[psych_0]

Misuse accounts for 20% of benzodiazepine use:

Benzodiazepine Use and Misuse Among Adults in the United States - PubMed

Benzodiazepine use among U.S. adults was higher than previously reported, and misuse accounted for nearly 20% of use overall. Use by adults ages 50-64 now exceeds use by those ages ≥65. Patients also prescribed stimulants or opioids should be monitored for benzodiazepine misuse. Improved access...

pubmed.ncbi.nlm.nih.gov

I think the "Main Reason for Misuse" table is interesting. Relax /relieve tension (47.1%), sleep (26.6%), help with feelings/emotions (10.1%) combine to be 83.8% of "misuse." Could argue that the medication was improperly prescribed. If a PCP & psychiatrist gives a patient Klonopin 1mg qday for GAD alongside a new SSRI - (a dosing regimen which is not uncommonly seen) - they're set up to fail from the start. Would that same patient "misuse" Klonopin 0.25mg TID or QID? I would argue they'd be much less likely to abuse it if prescribed more appropriately, which that study doesn't control for, unless I am misinterpreting the methods section.

 

[psych_0]

Benzos and contraindications in PTSD, shows not only lack of efficacy but worsening of outcomes:

Benzodiazepines for PTSD: A Systematic Review and... : Journal of Psychiatric Practice®

treating PTSD. Methods: The review protocol was undertaken according to the principles recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and is registered with the PROSPERO international prospective register of systematic reviews...

journals.lww.com

I feel like this is common knowledge and not what I was asking. Feels kinda extra. Like, should we also post the "benzos don't help borderlines" articles too?

 

[psych_0]

Cochrane report on the difficulties of tapering long-term benzo use:

Psychosocial interventions to reduce sedative use, abuse and dependence

www.cochrane.org

I feel like this is also sorta common knowledge. My point was to ask: starting brand new with no previous exposure to benzos, how likely are they do become benzo "addicts" or "dependent." Everyone acts like it's settled science, but judging by the various articles posted in this thread by you and I, I'm not convinced it is such settled science that we should be avoiding these like the plague across all patients with some sort of blanket "I am not a benzo prescriber" policy. I'm not arguing every patient who mentions the word anxiety should get a benzo, I'm just saying if it helps in the short term while patients wait in 3-6 month lines to get into therapy...if they can even afford therapy, or get the time off to attend therapy (and yes don't prescribe it during therapy because therapy doesn't work as well on benzos, I get it)... or if it helps while patients wait until they finally win the SSRI guessing game, why not? Yes, avoid it in the elderly and substance abusers and BPDs of the world, but what about the regular folks?

 

[ObsequiousAplomb]

I feel like this is also sorta common knowledge. My point was to ask: starting brand new with no previous exposure to benzos, how likely are they do become benzo "addicts" or "dependent." Everyone acts like it's settled science, but judging by the various articles posted in this thread by you and I, I'm not convinced it is such settled science that we should be avoiding these like the plague across all patients with some sort of blanket "I am not a benzo prescriber" policy. I'm not arguing every patient who mentions the word anxiety should get a benzo, I'm just saying if it helps in the short term while patients wait in 3-6 month lines to get into therapy...if they can even afford therapy, or get the time off to attend therapy (and yes don't prescribe it during therapy because therapy doesn't work as well on benzos, I get it)... or if it helps while patients wait until they finally win the SSRI guessing game, why not? Yes, avoid it in the elderly and substance abusers and BPDs of the world, but what about the regular folks?

The answer is that it's probably safer than many people tend to act. Many people are so upset by the patients who do have problems that they make a blanket policy to avoid it in patients where it isn't as contraindicated.

I would say that the odds of someone banging down an office door for the second month prescription two weeks early are incredibly low for any drug, even opioids. They're generally very pleasant when they ask for the second bottle. For many patients, the decision to prescribe a second bottle is probably much more influential than the first. After years of high dose daily use, then yeah some people do behave very annoyingly.

The lower risk than many people may worry about would especially be true if you wrote for 14 tablets per month instead of 30, 60, or 90 tablets. Of all the outpatients I have given an initial benzodiazepine prescription (never more than 14 tablets) to,
Everyone else I write outpatient prescriptions for was a chronic benzodiazepine patient long before they saw me.

Nobody that I've given 24 mg / day of Ativan for catatonia x 2-4 weeks as a challenge or longer if they have a robust response has ever displayed addiction behaviors with the Ativan, just a return of catatonic symptoms when stopped.

 

[Stagg737]

I feel like this is common knowledge and not what I was asking. Feels kinda extra. Like, should we also post the "benzos don't help borderlines" articles too?

Yet I'm sure we have all lost count of the number of new PTSD patients in clinic who come in on benzos that haven't been able to get off of them or don't want to. It may be common knowledge here, but worth noting that there's some solid evidence behind the concept when we see the opposite so frequently. I guess it is kind of extra, but anecdotally I also think PTSD and those with panic attacks are the most likely to end up struggling with benzo dependence (physiologic or psychologic).

I feel like this is also sorta common knowledge. My point was to ask: starting brand new with no previous exposure to benzos, how likely are they do become benzo "addicts" or "dependent." Everyone acts like it's settled science, but judging by the various articles posted in this thread by you and I, I'm not convinced it is such settled science that we should be avoiding these like the plague across all patients with some sort of blanket "I am not a benzo prescriber" policy. I'm not arguing every patient who mentions the word anxiety should get a benzo, I'm just saying if it helps in the short term while patients wait in 3-6 month lines to get into therapy...if they can even afford therapy, or get the time off to attend therapy (and yes don't prescribe it during therapy because therapy doesn't work as well on benzos, I get it)... or if it helps while patients wait until they finally win the SSRI guessing game, why not? Yes, avoid it in the elderly and substance abusers and BPDs of the world, but what about the regular folks?

Sure, this one is more common knowledge. I agree that I wouldn't subscribe to the manta of all benzos are evil and should never be used. Imo benzos have their place, it's just a much more narrow space than how they've been advertised and utilized for the past 60 years.

To the bolded, I'd argue this is where prescribing purely based on DSM criteria and diagnoses as opposed to a more psychoanalytic approach probably fails. We can diagnose 2 people with GAD and find out that the actual psychological processes behind the anxiety are completely different. One patient may be motivated to do therapy, while the other becomes completely satisfied with the benzo becoming chronic because "the pill works, why should I stop?" or a dozen other justifications. I think this lines up with your observation from the misuse article that the whole situation, including initial diagnoses and prescribing, is much more nuanced than what any research article is going to capture.

 

[Stagg737]

Interesting. I wonder why other large studies like this one find such different results (1 in 20 people in this study of 206,933 Canadians)?

I find it interesting that in that study they found that long-term benzo use was about twice as likely when being prescribed by a psychiatrist than another prescriber (odds ratio 2.11). My guess is that a fair amount of discrepancies in studies like this have to do with how those countries' health systems are run and possible federal regulations with controlled substances. I'd be interested to see a large scale study like that come out of the US.

 

[Candidate2017]

I'm not arguing every patient who mentions the word anxiety should get a benzo, I'm just saying if it helps in the short term while patients wait in 3-6 month lines to get into therapy...if they can even afford therapy, or get the time off to attend therapy (and yes don't prescribe it during therapy because therapy doesn't work as well on benzos, I get it)... or if it helps while patients wait until they finally win the SSRI guessing game, why not? Yes, avoid it in the elderly and substance abusers and BPDs of the world, but what about the regular folks?

At the end of the day, anxiety disorders require clinically significant distress and impairment. I'd say the majority of people coded for anxiety disorders don't actually qualify under the DSM, much less the people on benzos. Depression and schizophrenia cause significant distress and impairment. Being anxious does not, for the vast marjority of people complaining about "anxiety". They are merely complaining about not being able to tolerate an emotion.

Anecdotally, I inherited a panel with 40% on benzos and have reduced it to under 5% on benzos. Everyone is ok. After the initial protests, whining, and stomping of feet, everyone is still working or smoking weed or carrying on about their daily lives as usual without benzos. The patients still on benzos, tiny doses, are actually significantly impaired by anxiety. Literally. These patients are so anxious, that after learning about the risks of benzos, they do everything to avoid benzos, when they really do need benzos. I literally have to push benzos on them. This reminds me of schizophrenics who need antipsychotics but will do everything to avoid them and the giant needles wielded by nurses.

 

[annoyedpsychiatrist]

I mean they're meant to be prescribed PRN rather than daily. This is just my personal opinion, but if you give someone enough to take them daily, and say "dont use them every day" when they have a bad case of GAD, its like putting beer in front of an alcoholic and saying "only use this modestly". Avoidance of anxiety never improves anxiety which is what benzos offer. I explain that the purpose of the benzo isnt to help with your day to day anxiety, its for emergency situations during a panic attack or other serious discomforting event.

But I dont look at benzos as evil. I look at scheduled benzos as kicking the can down the road, waiting for the inevitable problem of what do you do when they have been on them for so long and start developing issues/getting older?

 

[clausewitz2]

its for emergency situations during a panic attack or other serious discomforting event.

But that's the thing, panic attacks aren't actually dangerous or an emergency. It sucks to have one and no one wants to have them and they're incredibly unpleasant, but there is no threat. We reinforce the threat if we treat it as a crisis.

 

[PsyDr]

1) Comparing the duration of a panic attack to the time for a pill fo be digested… well that kinda ruins the idea of a BZ as a rescue med for a panic attack.

2) isn’t there some literature that indicates consistent BZ use increases anxiety? Last I saw, that guy might be associated with Breggin, so maybe not.

 

[annoyedpsychiatrist]

But that's the thing, panic attacks aren't actually dangerous or an emergency. It sucks to have one and no one wants to have them and they're incredibly unpleasant, but there is no threat. We reinforce the threat if we treat it as a crisis.

No I agree with you on that, in the benzo reliant patients I stray away from reinforcing that concept but in the ones using it responsibily and occasionally I do like to validate their use so they dont feel guilty using it if they're using it 1-2x a month. I absolutely do not like benzos but I think sometimes the people who misuse them contribute to a stigma for people who use them appropriately.

 

[WisNeuro]

But that's the thing, panic attacks aren't actually dangerous or an emergency. It sucks to have one and no one wants to have them and they're incredibly unpleasant, but there is no threat. We reinforce the threat if we treat it as a crisis.

Over-treating anxiety/panic is how you turn panic disorder into panic disorder with agoraphobia.

 

[ObsequiousAplomb]

1) Comparing the duration of a panic attack to the time for a pill fo be digested… well that kinda ruins the idea of a BZ as a rescue med for a panic attack.

2) isn’t there some literature that indicates consistent BZ use increases anxiety? Last I saw, that guy might be associated with Breggin, so maybe not.

The rescue med isn't to abort the panic attack. It's to decrease the overall anxiety and discomfort that persists after the attack.

 

[WisNeuro]

The rescue med isn't to abort the panic attack. It's to decrease the overall anxiety and discomfort that persists after the attack.

And also to reinforce the panic attack and to now add a safety cue, which makes the panic attacks worse in the future.

 

[ObsequiousAplomb]

And also to reinforce the panic attack and to now add a safety cue, which makes the panic attacks worse in the future.

Yeah, that's why the informed consent process involves telling people that. Maybe if you were a psychiatrist you would know that.

 

[WisNeuro]

Yeah, that's why the informed consent process involves telling people that. Maybe if you were a psychiatrist you would know that.

Nope, just someone who has specific expertise in the neurobiology of anxiety, is trained in PCT, and sees a lot of people harmed by benzos. But, maybe if you actually treated anxiety rather than made it worse, you would know that.

 

[annoyedpsychiatrist]

remember guys were all on the same side here, lol.

 

[Stagg737]

And also to reinforce the panic attack and to now add a safety cue, which makes the panic attacks worse in the future.

I mean, it depends on the specific patient. If we're talking about patients having occasional to rare panic attacks (a couple of times per month), who are also on SSRIs and in therapy, they can be very beneficial. I'd agree that patients with multiple panic attacks per week who utilize them nearly daily or more are being primed for worsening anxiety. I'd compare it to the idea of suppression vs repression as a coping mechanism, one is healthy and meant to be used intermittently while the other becomes a chronic dependency that only worsens the problem and can later lead to more severe and sometimes explosive problems.

 

[clausewitz2]

I mean, it depends on the specific patient. If we're talking about patients having occasional to rare panic attacks (a couple of times per month), who are also on SSRIs and in therapy, they can be very beneficial. I'd agree that patients with multiple panic attacks per week who utilize them nearly daily or more are being primed for worsening anxiety. I'd compare it to the idea of suppression vs repression as a coping mechanism, one is healthy and meant to be used intermittently while the other becomes a chronic dependency that only worsens the problem and can later lead to more severe and sometimes explosive problems.

It is a safety behavior regardless of how common the panic attacks are but I agree that engaging in that safety behavior more probably is worse than doing it less. At the same time being able to carry around the Magic Pill That Makes Everything Better can get in the way even if you never open the bottle. It still involves buying into the idea that panic attacks are a crisis or an emergency, which is simply not the case.

 

[clausewitz2]

Yeah, that's why the informed consent process involves telling people that. Maybe if you were a psychiatrist you would know that.

not sure informed consent is a good justification for suggesting an intervention likely to exacerbate the problem you are trying to address.

 

[WisNeuro]

I mean, it depends on the specific patient. If we're talking about patients having occasional to rare panic attacks (a couple of times per month), who are also on SSRIs and in therapy, they can be very beneficial. I'd agree that patients with multiple panic attacks per week who utilize them nearly daily or more are being primed for worsening anxiety. I'd compare it to the idea of suppression vs repression as a coping mechanism, one is healthy and meant to be used intermittently while the other becomes a chronic dependency that only worsens the problem and can later lead to more severe and sometimes explosive problems.

I'd argue that it's actually worse to give it for these less frequent panic attacks. This is the exact situation that reinforces that safety cue and strengtens the belief that the panic attacks are "dangerous" and that the pill is what can help reduce the panic. Telling a patient all about this, and them understanding intellectually is very different than the behavioral and somatic reinforcement process that is actually happening.

 

[forchinet121]

I'd argue that it's actually worse to give it for these less frequent panic attacks. This is the exact situation that reinforces that safety cue and strengtens the belief that the panic attacks are "dangerous" and that the pill is what can help reduce the panic. Telling a patient all about this, and them understanding intellectually is very different than the behavioral and somatic reinforcement process that is actually happening.

What do you recommend to patients that have a history of panic attacks and are prescribed 5 Xanax pills a month that they don’t really take but just like to have it and decreases their panic attacks, do you take it away from them?

 

[clausewitz2]

What do you recommend to patients that have a history of panic attacks and are prescribed 5 Xanax pills a month that they don’t really take but just like to have it and decreases their panic attacks, do you take it away from them?

It's not the hill I am going to die on if more debilitating or urgent things are going on with them but slowly, over time, being careful to get buy-in from them at every step along the way? Yes, absolutely. Help them try and get to a willing/acceptance place first to make it more of an exposure than a trigger. "What do you think it would be like to have only 4 this month?"

 

[WisNeuro]

What do you recommend to patients that have a history of panic attacks and are prescribed 5 Xanax pills a month that they don’t really take but just like to have it and decreases their panic attacks, do you take it away from them?

MI. First, I'm skeptical that it really does much on overall frequency and severity of panic attacks. And, if so, just reinforcing the notion that that safety cue outs a cap on how much they can actually manage their panic/anxiety. If they are fine with that, so be it, they've made their choice. But you, as a provider just need to know what your choice is when some of those patients start increasing their usage and want more.

 

[psychmd03]

Study from finland showing ~40% of those prescribed benzos become long-term users:

Incidence of and Characteristics Associated With Long-term Benzodiazepine Use in Finland

This cohort study uses national longitudinal data from the Social Insurance Institution of Finland to investigate the incidence of long-term use of benzodiazepines and related drugs among new users and factors associated with development of long-term use.

jamanetwork.com

Misuse accounts for 20% of benzodiazepine use:

Benzodiazepine Use and Misuse Among Adults in the United States - PubMed

Benzodiazepine use among U.S. adults was higher than previously reported, and misuse accounted for nearly 20% of use overall. Use by adults ages 50-64 now exceeds use by those ages ≥65. Patients also prescribed stimulants or opioids should be monitored for benzodiazepine misuse. Improved access...

pubmed.ncbi.nlm.nih.gov

Benzos and contraindications in PTSD, shows not only lack of efficacy but worsening of outcomes:

Benzodiazepines for PTSD: A Systematic Review and... : Journal of Psychiatric Practice®

treating PTSD. Methods: The review protocol was undertaken according to the principles recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and is registered with the PROSPERO international prospective register of systematic reviews...

journals.lww.com

Cochrane report on the difficulties of tapering long-term benzo use:

Psychosocial interventions to reduce sedative use, abuse and dependence

www.cochrane.org

Literally the only response this thread needs

 

[Stagg737]

It is a safety behavior regardless of how common the panic attacks are but I agree that engaging in that safety behavior more probably is worse than doing it less. At the same time being able to carry around the Magic Pill That Makes Everything Better can get in the way even if you never open the bottle. It still involves buying into the idea that panic attacks are a crisis or an emergency, which is simply not the case.

I mean, if we're going to argue that it's problematic just because it's a safety behavior then a lot of the coping skills we often encourage are also problematic: removing oneself from the situation, grounding, really anything done acutely in response to a panic attack. It absolutely does not involve buying into panic attacks being an emergency or crisis, it simply involves the idea that panic attacks are uncomfortable and that we need to do something more than just ride it out. It's why psychoeducation regarding panic attacks and their management is as important as the actual management, to understand that the action in response to a panic attack is about minimizing the discomfort and not treating it like a true emergency. Frankly, if carrying around a single pill that they never use makes them feel more comfortable, then I have little problem with that unless there's an addiction component involved. I've had patients who ask for 5 tabs a year "just in case" that they ended up throwing out because the meds expired before they used them.

I'd argue that it's actually worse to give it for these less frequent panic attacks. This is the exact situation that reinforces that safety cue and strengtens the belief that the panic attacks are "dangerous" and that the pill is what can help reduce the panic. Telling a patient all about this, and them understanding intellectually is very different than the behavioral and somatic reinforcement process that is actually happening.

Again, why psychoeducation is so important. You're right that knowing and doing are two different things, but part of our job is to help patients with therapies and strategies to make the doing portion happen. I disagree that it strengthens the belief that attacks are dangerous, I do think it reinforces the idea that pills equal comfort and can discourage the use of more effective and less harmful coping skills. MI is great, and I feel like it should be considered a core therapeutic modality taught in residency programs.

 

[WisNeuro]

I mean, if we're going to argue that it's problematic just because it's a safety behavior then a lot of the coping skills we often encourage are also problematic: removing oneself from the situation, grounding, really anything done acutely in response to a panic attack. It absolutely does not involve buying into panic attacks being an emergency or crisis, it simply involves the idea that panic attacks are uncomfortable and that we need to do something more than just ride it out. It's why psychoeducation regarding panic attacks and their management is as important as the actual management, to understand that the action in response to a panic attack is about minimizing the discomfort and not treating it like a true emergency. Frankly, if carrying around a single pill that they never use makes them feel more comfortable, then I have little problem with that unless there's an addiction component involved. I've had patients who ask for 5 tabs a year "just in case" that they ended up throwing out because the meds expired before they used them.



Again, why psychoeducation is so important. You're right that knowing and doing are two different things, but part of our job is to help patients with therapies and strategies to make the doing portion happen. I disagree that it strengthens the belief that attacks are dangerous, I do think it reinforces the idea that pills equal comfort and can discourage the use of more effective and less harmful coping skills. MI is great, and I feel like it should be considered a core therapeutic modality taught in residency programs.

This is essentially the core basis of anxiety as it relates to safety cues and behaviors.

 

[WisNeuro]

Regarding all of this, the following book would be highly recommended for those who routinely treat anxiety

Anxiety and Its Disorders: Second Edition: The Nature and Treatment of Anxiety and Panic

This landmark work is indispensable for anyone studying anxiety or seeking to deliver effective psychological and pharmacological treatments. David H. Barlow comprehensively examines the phenomena of anxiety and panic, their origins, and the roles that each plays in normal and pathological...

www.guilford.com

 

[Stagg737]

This is essentially the core basis of anxiety as it relates to safety cues and behaviors.

I don't think it can be simplified that easily, and I also don't think it's the best way to summarize it. The feeling doesn't necessarily need to be interpreted as "dangerous", just unwanted and perceived as unacceptable to the individual experiencing it. The idea that the feeling is dangerous certainly applies to a form of anxiety and I don't disagree that panic, at least initially, is typically interpreted that way. I don't disagree that the concept of anxiety as "danger" is a significant factor when discussing safety behaviors. As I said before though, if this were truly an axiom of anxiety as a whole and effective treatment, then many of our therapeutic techniques, including many CBT skills, would be considered detrimental or unacceptable in the way benzos are being portrayed above.

Imo, this is why it's so important to explore a patient's 'anxiety' more in-depth and why they're actually experiencing the anxiety as opposed to just checking off DSM criteria when deciding on what form of treatment one will implement.

 

[smalltownpsych]

Recognition that an effective medication in the short term can make the symptoms worse in the long run is not just found in benzo use. First time I ran into that dynamic personally was with over the counter sinus sprays when I was a kid. I still will use this every now and then to alleviate discomfort, I just know that if I use it for a couple of days, then it will actually make it worse so I don’t. I also will take opiates when the dentist does something really painful. If I had sensitivity to anxiety and had some severe symptoms at times, I would hope that a doctor would work with me on alleviating the worst of it while I try my best to implement the more optimal measures to treat the underlying condition.
Just because some people are addicts or don’t understand or care about tolerance or rebound effects doesn’t mean that we can’t use them for anybody.

 

[WisNeuro]

I don't think it can be simplified that easily, and I also don't think it's the best way to summarize it. The feeling doesn't necessarily need to be interpreted as "dangerous", just unwanted and perceived as unacceptable to the individual experiencing it. The idea that the feeling is dangerous certainly applies to a form of anxiety and I don't disagree that panic, at least initially, is typically interpreted that way. I don't disagree that the concept of anxiety as "danger" is a significant factor when discussing safety behaviors. As I said before though, if this were truly an axiom of anxiety as a whole and effective treatment, then many of our therapeutic techniques, including many CBT skills, would be considered detrimental or unacceptable in the way benzos are being portrayed above.

Imo, this is why it's so important to explore a patient's 'anxiety' more in-depth and why they're actually experiencing the anxiety as opposed to just checking off DSM criteria when deciding on what form of treatment one will implement.

Can you elaborate here?

 

[tr]

Literally the only response this thread needs

No bzd fan here but the definition of "long term use" in this study was "the prescriber continued the prescription for st least six months". That... doesn't seem particularly excessive to me? Like if I were to prescribe these for rare panic attacks, or temporarily for a life crisis or as 'bridge' to SSRI (I don't normally do this but I know a lot of people do), I wouldn't consider it a particular red flag if the patient wasn't completely off by six months later. A couple of years later maybe you have a problem. But even these people who take three Ativan a year for plane flights would count as "long term users" by this definition.

 

[psych_0]

No bzd fan here but the definition of "long term use" in this study was "the prescriber continued the prescription for st least six months". That... doesn't seem particularly excessive to me? Like if I were to prescribe these for rare panic attacks, or temporarily for a life crisis or as 'bridge' to SSRI (I don't normally do this but I know a lot of people do), I wouldn't consider it a particular red flag if the patient wasn't completely off by six months later. A couple of years later maybe you have a problem. But even these people who take three Ativan a year for plane flights would count as "long term users" by this definition.

Please stop with your common sense. It's uncalled for. He told you this was the only response this thread needs! Can you read?

/s

 

[annoyedpsychiatrist]

I think we need to consider evidence based medicine at the forefront but the reality is a lot of the people who we see are not engineers/phlisophers/neurosurgeons. Some people are barely holding it together as it is, and quality of life is always important and balancing that between evidence based medicine. Some people will never go through CBT, and many don't have access. A lot of therapists here are getting smart, doing cash only clinics because the cities around me are where wealthier people live, so access is steadily declining.

Another thing is, my area just underwent a natural disaster not too long ago where some people lost everything- their car, home, pets, all their belongings, etc. A lot of these people were barely holding it together before this happened. Am I saying we should give them xanax TID indefinitely? No. But do i care if they use a klonopin once or twice a week and they have no obvious medical contraindications? No, they're are bigger battles to fight.

 

[romanticscience]

if this were truly an axiom of anxiety as a whole and effective treatment, then many of our therapeutic techniques, including many CBT skills, would be considered detrimental or unacceptable in the way benzos are being portrayed above.

I'm reading the Tolin (2016) book someone recommended (it's awesome, by the way!), and I found this:

How to do situation selection and stimulus control like a champ
Prescribe judicious avoidance for clients with limited capacity for self-control. Sending a person with poor self-management ability back into a difficult situation can set him or her up for failure. Some degree of avoidance may be useful, at least on a temporary basis, until the client has had the chance to build and strengthen his or her capacity for self-control in CBT.

Maybe there's a differing opinion about the nature of Safety Behaviors or Signals. Like, to me, as a physician, I'm OK with them in the spirit of harm avoidance or the lesser of two evils.

For my anxious reassurance-seeking patients, should I be less warm, genuine, or soothing (they need exposure through neutrality)? Am I reinforcing their compulsion? Is my empathic understanding of delusion or obsession hurting the client by not confronting the cognitive distortion?

Just some thoughts. I'm enjoying the discussion!

 

[aim-agm]

In anxiety patients, I find PRN benzos most useful in patients who "have anxiety about anxiety" - they've experienced disabling severe anxiety in the past, and have poor tolerance for mild anxiety as they fear it will become severe (which is a self-fulfilling fear). Replacing the worst case-scenario of "my anxiety gets so bad it will disable me" with "my anxiety gets so bad I take a benzo" allows them to tolerate the mild anxiety and apply what we work on in therapy while actually taking/needing the benzo rarely if ever.

 

[Stagg737]

Can you elaborate here?

You said that anxiety, as it has to do with safety cues/behaviors, is the belief that anxiety or panic attacks are dangerous and that the use of benzodiazepines specifically as a safety behavior only reinforces that concept. By that logic, any form of treatment, whether it be a medication or a coping skill, enacted immediately as a response to acute anxiety (aka the safety cue) will only reinforce the concept that severe anxiety is dangerous. So why should we differentiate between benzodiazepines and other treatments geared at rapidly reducing anxiety such as removing oneself from the anxiety-inducing situation, breathing techniques, grounding, or any other number of skills we teach patients as therapists?

This is why understanding the actual form of anxiety and providing education on treatment and the cognitive aspects of treatment (which includes medications used) is so important. I'd agree that not all safety behaviors or cues are healthy, but I'd also argue that benzodiazepines being a safety behavior does not automatically make this malignant, nor does it have to mean that it will reinforce the anxiety as "dangerous". I would agree that benzodiazepines used in this manner are a form of avoidance as a coping skill. However, I'd also be sure to keep in mind that there are appropriate and healthy forms of using avoidance as well as forms of avoidance that are malignant. We shouldn't conflate the increasing use of benzos in a patient similar to those who develop dependence/reliance as the primary or sole form of coping with intermittent and ideally decreasing use (until completely tapered) of benzos to help bring anxiety to more manageable levels where healthier long-term skills can be utilized. Again, this involves significant education to the patient regarding the appropriate use of benzos and the development of treatment goals early so patients understand why and how they will be used.

 

[WisNeuro]

You said that anxiety, as it has to do with safety cues/behaviors, is the belief that anxiety or panic attacks are dangerous and that the use of benzodiazepines specifically as a safety behavior only reinforces that concept. By that logic, any form of treatment, whether it be a medication or a coping skill, enacted immediately as a response to acute anxiety (aka the safety cue) will only reinforce the concept that severe anxiety is dangerous. So why should we differentiate between benzodiazepines and other treatments geared at rapidly reducing anxiety such as removing oneself from the anxiety-inducing situation, breathing techniques, grounding, or any other number of skills we teach patients as therapists?

This is why understanding the actual form of anxiety and providing education on treatment and the cognitive aspects of treatment (which includes medications used) is so important. I'd agree that not all safety behaviors or cues are healthy, but I'd also argue that benzodiazepines being a safety behavior does not automatically make this malignant, nor does it have to mean that it will reinforce the anxiety as "dangerous". I would agree that benzodiazepines used in this manner are a form of avoidance as a coping skill. However, I'd also be sure to keep in mind that there are appropriate and healthy forms of using avoidance as well as forms of avoidance that are malignant. We shouldn't conflate the increasing use of benzos in a patient similar to those who develop dependence/reliance as the primary or sole form of coping with intermittent and ideally decreasing use (until completely tapered) of benzos to help bring anxiety to more manageable levels where healthier long-term skills can be utilized. Again, this involves significant education to the patient regarding the appropriate use of benzos and the development of treatment goals early so patients understand why and how they will be used.

Because this is not the basis of the most efficacious treatment. Exposure treatment is geared specifically at sitting with the anxiety until it lessens to train the mind and body to NOT see it as dangerous. Anything that interferes with that habituation, or a safety cue that is associated with "removing the danger" acts against that notion. There is a reason that these sessions are 90 minutes long.

Edit: Psychoeducation is great. When it is part of an active, efficacious, psychotherpautic process. In dismantling studies, it is of little benefit.

 

[tr]

By that logic, any form of treatment, whether it be a medication or a coping skill, enacted immediately as a response to acute anxiety (aka the safety cue) will only reinforce the concept that severe anxiety is dangerous. So why should we differentiate between benzodiazepines and other treatments geared at rapidly reducing anxiety such as removing oneself from the anxiety-inducing situation, breathing techniques, grounding, or any other number of skills we teach patients as therapists?

I do tell my patients to please practice their breathing exercises daily at a time when they are not particularly anxious, partly for the purpose of making the exercise second nature, but also to avoid having them develop a counterproductive association of the sensation of anxiety with the breathing exercise itself.

Removing oneself from the situation is not a 'skill.' It is a quick fix that is counterproductive in the long run because it reinforces the conviction that the anxiety is dangerous and flight is an appropriate solution. What is ultimately therapeutic is *staying* in the situation (graded for tolerability of course) and learning for oneself that it is not harmful.

 

[annoyedpsychiatrist]

So i have a large number of geri patients on long term benzos being referred to me, and getting them off is very unfun. Have you guys noticed that once someone is on a benzo for several years continuously, prescribing stuff like SSRIs is the equivalent of giving them sugar water? I havent found anything really that typically helps that well with anxiety once they were on moderate dose benzos for multiple years.

 

[WisNeuro]

So i have a large number of geri patients on long term benzos being referred to me, and getting them off is very unfun. Have you guys noticed that once someone is on a benzo for several years continuously, prescribing stuff like SSRIs is the equivalent of giving them sugar water? I havent found anything really that typically helps that well with anxiety once they were on moderate dose benzos for multiple years.

My wife has had a good deal of success. I think a good deal is her rapport and demeanor with her patients, but she also does a very slow taper.

 

[clausewitz2]

So i have a large number of geri patients on long term benzos being referred to me, and getting them off is very unfun. Have you guys noticed that once someone is on a benzo for several years continuously, prescribing stuff like SSRIs is the equivalent of giving them sugar water? I havent found anything really that typically helps that well with anxiety once they were on moderate dose benzos for multiple years.

Here's where I think it is really important to clarify what people mean when they say anxiety. SSRIs can be very helpful for repetitive worried ruminations. They are never going to fool anyone into thinking it is a substitute for their klonopin. Agree with @WisNeuro that getting buy in and incredibly slow tapering is important, slow meaning potentially over the course of a year or more with very frequent follow-up.

 

[annoyedpsychiatrist]

Agreed that rapport is very important, often though we get seen as the enemy when removing their benzos because "it has worked for them". Do you guys switch to a long acting if theyre on something like xanax tid? I used to do that but ive had more success tapering down their short acting.

 

[aim-agm]

Here's where I think it is really important to clarify what people mean when they say anxiety. SSRIs can be very helpful for repetitive worried ruminations. They are never going to fool anyone into thinking it is a substitute for their klonopin. Agree with @WisNeuro that getting buy in and incredibly slow tapering is important, slow meaning potentially over the course of a year or more with very frequent follow-up.

I teach students that one of the most important questions to ask about complaints of anxiety is "Can you tell me what you are feeling without using the word 'anxiety'?" Frequently they are not actually experiencing what we call anxiety. They might mean restless/unsettled/etc., and then when you treat their undiagnosed ADHD their "anxiety" disappears. People can have somatic experiences of anxiety, and then confuse those symptoms with anxiety (e.g. a patient that thought he was anxious in the morning because he had abdominal discomfort...the "anxiety" got better when we trialled a morning antacid).