Probably one of the same reasons I change my mind, lol. I worry at times my colleagues will think I don't know what I'm doing, or I worry I've somehow shared personally identifiable information, or on typing it all out I figure it out on my own.
Do not want
You've answered your own question. It's basically just my preference, and like you said it works out about the same.
Lucky u
Yeah, Xanax is devilishly addictive.
Yes, I feel really trapped and emotionally manipulated by this patient case. And the combination of xanax and certain personality traits makes the situation that much harder.
I wish I'd done that too now, but I suppose if you start the process you can't all that easily get out of it... or can you? Maybe a better way of framing the situation from now on is that high doses of xanax are not safe and the diazepam is not meant to replace per se, but ease the xanax taper process.
Try not to take it personally. Perhaps self protective but I consider this type of person to be fragile at the onset, brain not functioning optimally now and panicked which results in maladaptive behavior and manipulation in order to get their needs met.
There's such an irony that Xanax was advertised in psychiatric medical journals for the purpose of fostering improved therapy sessions, much in the same vein psychedelics were (among many other things it was advertised for). And this is not ancient history. I'll see if I can find the ad regarding therapy. I remember there was also one saying it was less addictive than other benzos specifically because of its short half life—I can't remember the exact reasoning. It was something convoluted about the person not being under the effect of it the next day after taking it at night, which seems to be exactly what this patient was suffering from (daytime withdrawal).
Yeah, benzos are actually counterproductive to therapy. They give you mild amnesia so you cannot internalize as much of what you learn, and they work so well that why bother with non pharm skills?
I might do that. As a follow up question, the logistics of that do bother me. Would you taper the diazepam, just quickly? Would that not increase risk of overuse of Xanax again?
When I did it the few times in the past I converted current dose of Klonopin or Valium back to Xanax which was a bit lower than the dose they originally came to me on. I educated them it is a safe dose, will not result in a medical emergency due to abrupt w/d symptoms and therefore no accommodations will be made for overuse. Its been a while but as I recall I didn't hear a peep until I met with them again and restarted chipping away at the Xanax.
How do you account for the long half life or clonopin or valium, though? is that where the relatively lower dose of xanax comes in?
You have to be mindful that the benzos came about during the heydey of psychodynamic psychiatry. The idea of prescribing medications for anxiety and depression and other neurotic disorders was anathema to most of these psychiatrists. Indeed, psychiatry residents of that era would have been pilloried by their supervisors for prescribing medications for patients with neurotic disorders. No psychiatrist would buy into a biomedical model of distress, so the marketing would never have been successful trying to convince psychiatrists to prescribe medications if that was the messaging. Instead, they had to align with the psychodynamic theories of the time. You notice that the idea of depression and anxiety were dynamically oriented in the ads, and also contextualized the problems in the patients' interpersonal relations. Even with this marketing, it was very hard to convince psychiatrists to prescribe this medication, so they had to claim it was adjunctive to the real work of psychotherapy. Otherwise it would have been seen as a threat to the very existence of psychiatry. Interestingly, the so-called "biological revolution" in psychiatry, and the launch of Prozac coincided with direct-to-consumer advertising, and it was with this change, that marketing to patients recoded problems in terms of crooked molecules and chemical imbalances.
I was assuming you had started a minimal reduction when you initially changed from Xanax and could either continue the planned taper or hold at the current dose when changing back to Xanax. Frequency would be based on the individual medication but the total daily dose is a relatively straight forward conversion from Klononpin or Valium to Xanax.
I was doing a crosstaper, so currently the patient is on part xanax and part valium. I think if we were to convert back to all xanax, we'd have to account for the longer half life of valium and actually have the daily xanax dose be a little lower than what is predicted by the conversion. Either way, it's going to be a reduced dose of xanax from where we originally started.
I see. I’ve never done it like that but hopefully it will get easier and generally speaking if you are able to get the original dose down a bit that is a win.
That's very interesting. But benzos caught on earlier. The Rolling Stones had a song in the 1960s, Mother's Little Helper. Maybe that was being done by GPs in parallel to the analysis being done by psychiatrists. So do you think the pharma industry wanted to expand medication into psychiatry more? I had always heard the driving force against analysis and therapy in general in psychiatry was the cost of the time taken up by it. But I suppose it could have been pharma pushing its way in, as well, getting psychiatrists to do what GPs had been doing?
This feels very atypical, but maybe I'm the one who's off. I thought the typical plan was just to switch to the longer-lasting benzo, without needing to cross-taper.
<I am not a doctor or medical student>
Of course they will try to emotionally manipulate you. It’s like a dealer telling a heroin user to consider a switch to methadone or suboxone because the literature says so. The addict will scream, cry, beg, and do all but listen to reason. It's the addiction speaking. If you aren't pissing off a % of (controlled) substance patients, then chances are you are the local candyman.
Yes, exactly. Much of the early prescription of antidepressants (TCAs) and benzos etc were done by primary care physicians who were already prescribing the forerunners to these drugs. Before benzos, there were barbiturates, and Miltown (meprobamate). Before TCAs, there was benzedrine. The early antidepressants were called "psychic energizers" as they weren't believed to reverse any physiological process but treating symptoms. With the invention of amitriptyline, Merck was quick to market this drug as an antidepressant medication treating the new illness of depression. Primary care doctors were so unfamiliar with this new diagnosis, that Merck bought 100 000 copies of Frank Ayd's Recognizing the Depressed Patient in order to "educate" them of this new diagnosis in order to sell this drug.
I actually referenced the website @birchswing linked, Heather Ashton’s protocol. The idea behind it is that you crosstaper and also gradually go down, and the Valium helps with the withdrawal effect. I guess you can either do the switch directly or crosstaper. I just thought the crosstaper would be gentler, if you will.
