Tuesday, March 27, 2012

Benzos for Recovering People?

Recently, a colleague asked my opinion on the use of anti-anxiety medications called benzodiazepines in people either struggling with or recovering from an addiction (to something else of course.) Benzodiazepines (benzos for short) include common medications such as alprazolam (Xanax,) lorazepam (Ativan) and clonazepam (Klonapin.) Here is my reply:

First, I personally think that the idea that no-one who is in recovery from an addiction should ever ever be prescribed another potential intoxicant is a remnant of the all or none thinking in 12 step groups and programs. It's not based in fact. Yes, there may be a relative increase in risk, but the risk of true addiction to benzos (as opposed to development of tolerance and physical dependence) in an anxious pt is near zero in most people so the absolute risk is pretty low in someone with alcohol or opioid addiction, for example. The same holds true for pain medication in alcohol dependent people. I try to balance risks and benefits as I do with any patient or treatment. The science tells us for most people that an addiction is specific to a drug, not to "addiction" or intoxication of any type. There is no such thing as an "addictive personality." The other thing I'm impressed with is how poor any current pharmacotherapy is for chronic anxiety. The best treatment is good CBT, but it's hard to find and many pts aren't good candidates (although they might be for skillful psychodynamic therapy.) So I don't know about you, but I often find myself and the pt between a rock and a hard place.

An example patient is someone who had childhood onset of moderate to severe anxiety, often starting with separation anxiety and school refusal. Some patients report the onset of panic attack before the age of 10. Most of these people are extremely anxious all of their lives. I see them because they have became alcohol dependent. I generally prescribe an antidepressant, an SSRI or SNRI, but these seem to have poor efficacy in these primary anxiety patients, as opposed to people with depression and anxiety together. In one recent patient I  stopped benzos and the patient got to the point where I thought she would relapse to drinking w/o relief so I prescribed lorazepam and she almost immediately got much better, more stable, and with markedly reduced desire to drink. To my knowledge she hasn't used benzos in an addictive fashion, although the other problems of tolerance and lack of long-term efficacy haven't gone away. I usually try everything else I can: beta blockers, anticonvulsants, antidepressants, rarely antipsychotics if nothing else works. I always prescribe relaxation training and breathing exercises, give patients info about mindfulness approaches and also always recommend a CBT workbook for anxiety. I may recommend seeing a therapist. But sometimes it's only benzos that seem to help.

Some years ago a colleague of mine studied vets with severe chronic PTSD who were on benzos, expecting their outcomes to be worse than others. Theirs were better than others. Now that may simply be due to this group being more stable/adherent so therefore benzos were continued. But still, where is the evidence in the published lit that shows that long-term benzo use is often damaging? I worry that we prescribe truly toxic drugs like antipsychotics and depakote or lamotrigine to avoid benzos. And where is the evidence that many of these drugs actually help anxiety or are safe to treat it?

I think also there is a bias here: with very weak evidence of risk, we withhold benzos and with no evidence of efficacy or safety we prescribe toxic risky drugs instead. Make sense?

Also, underlying the bias is the pervasive idea, spread by 12 step treatment programs that 12 step treatment or groups are 100% effective if the person just does as they're told. You and I both know that's absurd and untrue. Medicine frequently involves compromise between ideal and pragmatic goals, and balancing various risks and benefits.

Finally, there is fairly strong evidence that untreated insomnia, pain and anxiety contribute substantially to increased relapse risk. It's easy to say "they should just tough it out or go to more meetings" but that seems pretty unreasonable and unsupportable to me.

In the end, I view it as all coming down to outcomes. Is the pt better off? Are their sxs less? Are they more functional? Does a rx for benzos help them recover more fully?

Be good to discuss some time....

Mark

5 comments:

  1. There has been evidence showing that benzodiazepines don't add anything in terms of the usual polypharmacy environment that is used to treat mood and psychotic disorders. There is also the neurobiological argument that the dynamics of the reward system are nondiscriminatory in terms of pharmacological inputs. It is fairly common in clinical practice to observe that brief prescriptions of intoxicants triggering relapse even people who have been sober for many years. There is also the group of folks who clearly have tolerance to the therapeutic effect and at high doses are as symptomatic as when they were started on the original drug. The problem seems to be that we cannot predict which people have these responses at baseline any more than we can predict who will have euphoria and hypomania from initial doses of opioids. It would be easier to use the appropriate medication if we knew the person taking it was at low risk for tolerance to the therapeutic effect and addiction.

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  2. Regarding Dr. Dawson's comment that "it is fairly common in clinical practice to observe that brief prescriptions of intoxicants trigger relapse even [in] people who have been sober for many years", I wonder how much of this is because of the "abstinence violation effect" and a self-fulling prophecy? That is, people relapse because of the widespread practice of being told they will relapse if they use any substance that holds the potential for dependence – rather than being educated about how to use the medication in an appropriate way and to be monitored for abuse.

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  3. I just wanted to add a comment here to mention thanks for you very nice ideas. Blogs are troublesome to run and time consuming thus I appreciate when I see well written material. Your time isn’t going to waste with your posts. Thanks so much and stick with it No doubt you will definitely reach your goals! have a great day!

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  4. What about non drug treatments, like EEG Biodfeedback, for anxiety?

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  5. On a side note, has there been any investigation of Baclofen as an anti-craving/anti-reinforcing drug for the benzodiazepine dependent? I have heard anecdotal reports of individuals having been prescribed large doses of Baclofen, then being switched over to a benzo, and finding that the usual reinforcing effects (high) of the benzos are completely gone. Any thoughts?

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