Posted by Rick on July 6, 2001, at 1:15:21
In reply to Re: One more try - Klonopin and Wellbutrin » Rick, posted by Joe Schmoe on July 5, 2001, at 14:25:40
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> > I am a little curious, though, about the relationship -- if any -- between your earlier addiction to Xanax and your concern over *tolerance* potential with Klonopin.
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> Sure there is a relationship. I was told the reason that xanax was a temporary measure until the imipramine kicked in was because in the long run xanax was not practical due to the way tolerance developed; you upped and upped the dose till you hit the ceiling, and then what? When you are coming off a dose of xanax and hitting that rebound anxiety, you reach for the next dose and nothing is more scary than the idea that it might not be enough. It brings to mind images of heroin addiction.What kind of doctor told you that? Don't answer, I know -- a benzophobic one. If they told you that tolerance is a *possibility* for some people, that's fine. But suggesting it's the typical course of events is irresponsible, and just plain wrong in cases where the drug is being used responsibly by someone who is experiencing theraputic benefit for a chronic anxiety disorder. Conversely, dependence (real or perceived need to continue the drug to avoid distress, NOT the addictive desire to take more and more) is a much more common possibility. But potential dependence is certainly no reason to avoid the med that helps most. Just ask any insulin-dependent diabetic. If the med is subsequently discontinued, there could quite possibly be withdrawal distress -- the same kind lots of folks experience when trying to get off of Paxil or Effexor. But a gradual taper usually minimizes the severity of that distress.
There are certainly a minority of people who fall outside the typical pattern. It's generally been felt -- even by non-benzophobic docs -- that benzos should be "used cautiously if at all" for individuals with a history of substance abuse or addiction. But some very recent studies are demonstrating that even this caution has been overstated in many cases.
> What about when you are between doses? If you are out on the town or something and your last dose wears off, do you start getting the shakes? That was the problem with xanax. I have never had that problem since because I don't allow myself to take xanax very often. Handled it on an as-needed basis for over ten years now with no problem, although honestly there are many times I would have been more relaxed if I had been using it. I guess I have become somewhat puritanical about using it in order to avoid dependence. I probably suffer more than I should. I am wondering if Klonopin will allow me to feel okay all the time, or if I will have to use it sparingly to avoid dependence - and if so, how sparingly.Can't you make sure you have at least a little Klonopin on you at all times, say in a little pillbox? (CVS has a great unobtrusive little round one. I taped some cotton to the bottom of the lid to keep the pills from rattling around as I walk.) Even if you took Klonopin regularly, missing a day probably wouldn't be too awful because of the long half-life. If you had problems because you had no access to Klonopin, they'd probably creep up fairly slowly. I don't know where you travel, but in towns of any significant size, you should normally be able to get an emergency supply before all the med in your system wears out. You know -- call doctor (their emergency # if nec) and have a prescription faxed to a local drugstore, etc. If it does start wearing off before you can get some, go to the emergency room. They certainly know that problems can occur if a patient goes cold turkey on a benzo. But the need for these kinds of measures should occur very rarely, if at all. Hey, there's always a possibility that I'll get hit and killed by a drunken driver when I'm on the road (a lot worse than even horrible withdrawal symptoms, no?), but I won't give up the benefits of driving because of it. Did you run out of Xanax a lot? How distressful were the shakes? How much were you using at the time, and on what schedule?
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> The problem with as-needed regimens is that they make it impossible to have a job where you have to manage people and/or have confrontations or other unpleasant situations frequently and without warning. This is impeding my career. I need 9-to-5 protection and I am afraid to try to use xanax to get it. Thus my willingness to try Klonopin.Perhaps it's because I'm already in a long-lasting, strong relationship, but my biggest ongoing benefit from Klonopin has been been for my career. It's made a world of difference. I still don't like getting a sudden performance request thrown my way (and not just for reasons related to anxiety), but it's so refreshing not to suddenly panic. (On the other hand, I sometimes perversely enjoy watching myself calmly but firmly speak my mind during the confrontations that would freak me out in the past. Certainly not all at work!) It would seem that popping even a fast-acting pill after a swirl of anticipatory anxiety begins would be less beneficial than passively holding that anxiety at bay from the start.
BTW, how are things going so far with the new meds? I know it may be a little early to talk about theraputic benefits, but is everything going OK side-effect-wise?
Since I referred to "studies" several times,I feel compelled to include one small study abstract. This relates to both the mental and physical (withdrawal) effects of Klonopin discontinuation after 6-11 months of regular use.
YMMV, YMMV, YMMV!Rick
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J Clin Psychopharmacol 1998 Oct;18(5):373-8 Related Articles, Books, LinkOut
Discontinuation of clonazepam in the treatment of social phobia.Connor KM, Davidson JR, Potts NL, Tupler LA, Miner CM, Malik ML, Book SW, Colket JT, Ferrell F.
Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina 27710, USA.
Patients with social phobia who responded well to 6 months of open-label treatment with clonazepam were assigned to receive either continuation treatment (CT) with clonazepam for another 5 months, or to undergo discontinuation treatment (DT) using a clonazepam taper at the rate of 0.25 mg every 2 weeks, with double-blind placebo substitution. Clinical efficacy was compared between the CT and DT groups using three different social phobia scales. Benzodiazepine withdrawal symptoms were also measured. Relapse rates were 0 and 21.1% in the CT and DT groups, respectively. Subjects in the CT group generally showed a more favorable clinical response at midpoint and/or endpoint, although even in the DT group clinical response remained good. With respect to withdrawal symptoms, the rates were low in both groups (12.5% for CT and 27.7% for DT) with no real evidence suggesting significant withdrawal difficulties. At the end of 11 months of treatment with clonazepam, however, a more rapid withdrawal rate was associated with greater distress. This study offers preliminary evidence to suggest that continuation therapy with clonazepam in the treatment of social phobia is safe and effective, producing a somewhat greater clinical benefit than a slow-taper discontinuation regime. However, even in the DT group, withdrawal symptoms were not found to be a major problem. The study can be taken as supportive of benefit for longterm clonazepam treatment in social phobia, as well as being compatible with a reasonably good outcome after short-term treatment and slow taper.
poster:Rick
thread:68599
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