Wednesday, March 29, 2017

Those Big Bad Benzodiazepines

Rare events in the midst of really large numbers of people are still quite common

I often get into debates with Pharma-brainwashed doctors and addiction specialists about the relative dangers and abuse potential of benzodiazepines like Klonopin, Valium, and Ativan. Even the DEA recognizes that they have low abuse potential by classifying them as Schedule IV, which literally means "low abuse potential." Adderall and opiates, in contrast, are Schedule II, which means high abuse potential.
Well, low abuse potential still means that some people will abuse them, but with any drug, risks must be weighed against benefits.
As to the risks, unless you are mixing them with other central nervous system depressants like opiates or alcohol,  the worst thing about being addicted to a benzo is that you are addicted to a benzo. For the vast majority of people, they don't cause any inebriation, and they have almost no side effects. For the few who do get troublesome side effects, the doctor can in those cases discontinue prescribing them. Just like with any other drug!
Benzodiazepines are worth their weight in gold in the treatment of panic disorder with agorophobia. Antidepressants can also help, but often not as much. And they have many more side effects, including destroying a patient's sex life.
At the VA, where benzo's are discouraged, I literally saw veterans who were housebound since Vietnam because of comorbid PTSD and panic disorder (the two conditions are co-morbid in 50-70% of veterans with PTSD according to the only two studies). If antidepressants did not stop their panic attacks, doctors would not prescribe benzo's! If you had choose between having no life and being addicted to a benzo, which would YOU choose? I know what I would do.
For patients with borderline personality disorder who self mutilate - the "cutters" and "burners" for example - benzodiazepines can be combined with SSRI (or MAOI) antidepressants. This combination often results in either complete elimination of or a significant decrease in the frequency of this behavior. Much better and far more quickly than dialectical behavior therapy does, by the way.
There are no clinical trials that support that last statement because the pharmaceutical companies will not do them. Benzo's and antidepressants are generic and cheap, and they'd rather that docs prescribe drugs like antipsychotics that have far more risks. But I've been treating this population for forty years in two states, and in a variety of different clinical settings (private practice, academia, public mental health centers and inpatient units, and the VA), with tremendous results. And other doctors who do this get the same results that I do. So tell me it's anecdotal. So is the belief that parachutes reduce the number of deaths and injuries after falls from airplanes.
A common retort to my position has to do with emergency room admissions caused by misuse of benzodiazepines, as well as the fact that methadone and suboxone clinic patient love to mix those drugs with benzos. On the latter point the solution is simple: be careful prescribing the drugs in that population. And the former?
According to JAMA Psychiatry, there are an estimated 271,000 visits to emergency rooms annually for non-medical uses of benzodiazepines (and how many of these involve simultaneous use of other substances of abuse such as alcohol or opiates is not quantified, but it is probably very highly significant).

That sounds like (and is) quite a few - until you also learn that about 5% of adults between 18 and 80 are taking the medications, which is roughly 12.25 million people. So only about two percent of users end up with severe medical issues per year. Not zero, but a relatively small percentage, and btw, there were also an average of about 78,000 annual ER trips for problems during the same period related to...Tylenol. Maybe we should we ban it.

1 comment:

  1. I think you hit the nail on the head when you pointed out that benzos are generic and therefore cheap, at that point pharma *has to* change people's focus to something under patent and one way of doing that is by saying that they "underestimated" the negative effects of older drugs (while hiding reports on negative effects of newer ones of course).