![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 26 to 50 of 65. Go back in thread:
Posted by paulk on June 15, 2001, at 20:02:09
In reply to Linky-link, posted by grapebubblegum on June 15, 2001, at 10:18:17
> > Back to my point, my pdoc did renew a klonopin Rx for me recently but with some reservations. Typically I think she is the smartest pdoc in the world, and maybe she is, but I didn't appreciate her mini-lecture that klonopin is ok only for a very short-term therapy because it does not address the root of the panic disorder (like SSRIs DO address it? I think not) and that klonopin is only a "feel-good" pill.Seriously, your pdoc doesn’t seem to be up on the seritinergic effects of klonopin. Klonopin is THE benzo of choice for long-term treatment.
> >The "root cause" argument is a common error that people make when trying to justify undermedicating anxiety disorders (and pain, for that matter). I get that rap all the time when I mention that I take buprenorphine for depression. The fact is, nobody knows what the "root cause" of panic disorder (or any other psych disorder, for that matter) is. There's no reason whatsoever to suppose that antidepressants "address the root cause" and that benzos don't.
>I sometimes think that the "root cause" fallacy is a red herring, that what people really mean when they say this kind of thing is that suffering is good for the soul and that if you have spontaneous panic attacks (or whatever), you must deserve them in some way. Ahh, modern Puritanism.
> > I was disappointed in her basically pooh-poohing the only med that has made me feel normal for a long time.
>I know just how you feel.
> > Keep in mind I only take .125 mg three times per day, which is ridiculously miniscule but actually helps me.
>Like, a quarter of the smallest strength tablet? Weird. I wonder if maybe you don't metabolise it normally or something. That's a very low dose even for someone who's taking it around the clock (although, as you note, taking it that way has the advantage of preventing panic attacks).
Not that weird. I only need just a little - .25/day. Many others are in the same boat. My doc tells me he has many that take .25 at bedtime and .125 for the day.
See my rant at http://www.dr-bob.org/babble/20010605/msgs/65469.html> In my experience, a tiny steady dose of benzo keeps me feeling normal and raises my threshhold for P.A.s; if not prevented, P.A.s once underway require so much benzo it would kill me to derail the attack.
DITTO – BULLS EYE – EXCELLENT POINT! I hope some docs read what you just said. ( I think this phenomena is called ‘kindling’ in the litature.)
The worst problem with Benzos is the memory side effect. I think a good way to figure if you are taking too much benzos is if it starts to kill memory. Seems like it would be easy to run some tests for this. Tell your doc to test you if she thinks you are on a detrimental dosage (you aren’t) to test your memory.
I have seen folks deteriorate over time on very large dosages Benzos.
If the benzo is long acting, it sure seems it is easier to keep it at a low dose for me. I Really don’t think it is good practice to use benzos per attack (unless its for someone who is bi-polar.) If it is a short acting benzo “as per needed” is a good way to get someone with PA in even bigger trouble.
Klonopin, for me, even at a VERY low dose makes all the difference in what I do when I lose my temper. It also prevents the panic attacks (although I didn’t have that many).
Getting off higher dosages of Benzos can be nightmarish. I watched a fellow patient go through the “cold wet sheet pack treatment” getting off Valium. I think switching to klonopin and tapering would have been a much better way.
- Paulk
Posted by Elizabeth on June 15, 2001, at 22:10:17
In reply to Re: more about Xanax and depression » Elizabeth, posted by paulk on June 15, 2001, at 18:53:43
> I hadn’t heard that there was a XR version anywhere. Who is making it?
Pharmacia & Upjohn, the same company that makes regular Xanax. Xanax SR isn't marketed in the USA, though.
> I talked to a University Psydoc about this very issue - he said because the patent was out, no one would pay for the studies - etc. etc. (and several other cures are gone wanting for the same reason)
That's true, although there is something called a "use patent" (which is why you still can't get generic Prozac in the US).
> I’m taking a very low dose (.25mg/day) of Clonazepam, which is also suspected of having some antidepressant effect (some study mentioned some seritonin activity), but in my mind Xanax (Alprazolam) was even better that way.
Most people find it to be, and there's evidence that Xanax is an antidepressant when used in high doses.
> Unfortunately, it was quite a bear to manage frequent dosing at a low level, so I stopped it many years ago. Xanax quits so fast and nasty that I can see why it would be addictive. Sure wish there was an XR version to try.
Addiction results from using large doses of a drug to get high. Anybody who's been taking Xanax for a long time will get withdrawal symptoms; that's not drug addiction, it's a normal reaction.
> I’m now also taking Nardil. Figured out why it is started the way it is – (starts off at 15mg – ramps quite rapidly and then back to 15 – 30mg/day) – the drug only has a 1-2 hour half-life – so it seems strange – until you figure that the enzyme it is deactivating has a much longer half-life of being replaced (no mention of this in the PDR BTW).
Nardil is an irreversible enzyme inhibitor; its elimination half-life isn't relevant. There's no reason to take it in divided doses, even, except perhaps to even out any side effects that you might get.
I know a guy who was able to decrease his need for Xanax dramatically when he started taking Nardil. Nardil is a great drug for anxiety.
> You need to have about 90% of MO enzyme deactivated before it can start to work – and then it might take a few weeks.
That's because antidepressant effects aren't due to the direct effects of the drugs, they're due to longer-term adaptations to the direct effects. (MAOIs seem to work faster than other ADs sometimes, though, and the anxiolytic effects of Nardil in particular may kick in sooner.)
> Do you know if the low BP side effect is a ‘primary’ effect of the drug or a result of the lowering of the MO enzyme level?
I'm not sure I understand the question. Orthostatic hypotension (slowed cardiovascular adaptation to changes in posture) is probably due to central activation of alpha-adrenergic receptors (which results from increased norepinephrine, which results from destruction of MAO).
> I understand why one shouldn’t take SSRIs and the like but I don’t understand why there would be a need to discontinue other MOAIs when switching between types? After all, the Nardil would wash out in a day or so? Are they acting on different enzymes?
That one is a mystery. It may only be a problem when switching between Nardil or Marplan (the hydrazide MAOIs) to Parnate (an amphetamine-like MAOI).
> I’m also wondering if I should get a med-alert bracelet - I understand that Demerol (meperidine) can be fatal – I would hate to be in a car accident and get Demerol in the ER that could kill me.
Demerol's pretty crappy anyway. They should use morphine. :-) Yeah, it probably is a good idea to have a medical emergency bracelet or necklace. (I prefer the latter; the bracelets seem to get in the way a lot.)
-elizabeth
Posted by Elizabeth on June 15, 2001, at 22:15:35
In reply to Re: Didn't appreciate my pdoc calling it a feel-good » Cam W., posted by paulk on June 15, 2001, at 19:02:35
> Actually, "mother's little helper" used to mean a mix of amphetamines that is now sold as Adderal – back when the song came out it had a different name and was used (unsuccessfully) as a diet pill.
There used to be diet pills that combined amphetamines with short- or intermediate-acting barbiturates, with names like Desbutal (methamphetamine + pentobarbitol) and Dexamyl (d-amphetamine + amobarbitol). I have trouble imagining what the purpose of such a combination pill would be, other than to get really trashed. (The reasoning for adding the barbiturate was that a lot of people get anxious on stimulants.)
-elizabeth
Posted by Elizabeth on June 15, 2001, at 22:32:07
In reply to Re: Linky-link » grapebubblegum, posted by paulk on June 15, 2001, at 20:02:09
> Seriously, your pdoc doesn’t seem to be up on the seritinergic effects of klonopin. Klonopin is THE benzo of choice for long-term treatment.
Not necessarily, although it is definitely a first-line treatment for panic disorder or generalised anxiety. Most benzos have the potental to cause or exacerbate depression, though, including Klonopin; Xanax is often preferable for people with anxiety and depression, despite the need for frequent dosing.
> >Like, a quarter of the smallest strength tablet? Weird. I wonder if maybe you don't metabolise it normally or something. That's a very low dose even for someone who's taking it around the clock (although, as you note, taking it that way has the advantage of preventing panic attacks).
>
> Not that weird. I only need just a little - .25/day. Many others are in the same boat.That's surprising. I took Klonopin for a few weeks at one point, and I needed 4 mg/day (1 mg in the morning and afternoon, 2 mg at bedtime). What do you take it for? (I was taking it for panic disorder and a REM sleep parasomnia.) And most people I know who take Klonopin for panic or anxiety disorders need at least 1 mg/day.
> DITTO – BULLS EYE – EXCELLENT POINT! I hope some docs read what you just said. ( I think this phenomena is called ‘kindling’ in the litature.)
Kindling refers to increased frequency of seizures in untreated epilepsy. (More generally it can refer to the same type of phenomenon in mood disorders or panic disorder.)
> I have seen folks deteriorate over time on very large dosages Benzos.
I haven't. But I have seen people take the same dose for years without problems and without needing to increase it.
> I Really don’t think it is good practice to use benzos per attack (unless its for someone who is bi-polar.)
Huh? Benzos are sometimes used to reduce psychomotor agitation in mania, but they're also used for various types of episodic anxiety. It's completely reasonable.
I think it makes more sense to take the benzo around the clock if you have frequent panic attacks. I take an antidepressant around the clock and Xanax as needed, because the antidepressant reduces the frequency of panic attacks.
> If it is a short acting benzo “as per needed” is a good way to get someone with PA in even bigger trouble.
That doesn't make sense to me. If you only take it as-needed, you don't need to be concerned about pharmacologic dependence if you ever want to go off it (or if you miss a dose). Anxiety patients, as a rule, don't abuse their medication (those who do are almost invariably abusing other drugs too).
Xanax has the additional advantage for as-needed dosing that it's fast-acting, so it can prevent an attack if you take it as soon as you feel the attack.
> Klonopin, for me, even at a VERY low dose makes all the difference in what I do when I lose my temper. It also prevents the panic attacks (although I didn’t have that many).
Benzos for anger? That's interesting. Some people with anger problems become disinhibited on benzos (like alcohol).
> Getting off higher dosages of Benzos can be nightmarish.
That's true if you take them around the clock. But then again, a lot of people really do need much higher doses. You're lucky -- maybe it's because you're taking it primarily for anger and never had frequent panic attacks.
> I watched a fellow patient go through the “cold wet sheet pack treatment” getting off Valium. I think switching to klonopin and tapering would have been a much better way.
That's the right way, yes: switch to a long-acting benzo, such as Klonopin or Tranxene, and then taper off *very* slowly. Any doctor who takes someone off benzos cold-turkey should have his license revoked, IMO.
-elizabeth
Posted by Cam W. on June 15, 2001, at 23:22:42
In reply to Re: Didn't appreciate my pdoc calling it a feel-good » Cam W., posted by paulk on June 15, 2001, at 19:02:35
> Actually, "mother's little helper" used to mean a mix of amphetamines that is now sold as Adderal – back when the song came out it had a different name and was used (unsuccessfully) as a diet pill.
Paul - I had wondered about that as I wrote my original post. It would make more sense. I had thought that it would be an amphetamine. Preludin™ came to mind, but I am not sure what was in them. I know my mom sure liked them. She did all her housework very quickly with them and was sure upset when the doc would not give her any more. - Cam
Posted by Daveman on June 16, 2001, at 0:06:29
In reply to Re: Linky-link » grapebubblegum, posted by paulk on June 15, 2001, at 20:02:09
One of the things I like about this site is the sane discussion of benzos. When reading these discussions I'm always reminded of my college philosophy courses in Hegelian logic. To simplify, Hegel believed that ideas go through three phases: Thesis (where the idea is presented absent criticism), Antithesis (where the idea comes under attack), and Synthesis (where the original idea, tempered by criticism, is modified to a more rational conclusion). In this case, benzos first were thought of as "wonder drugs" because they were so much safer than what came before as minor tranquilizers, such that they were wildly overprescribed, particularly Valium, thus the Thesis; then came the Antithesis, where the problems of benzo dependency became apparent and there was a tremendous backlash against their use. Hopefully we are starting to arrive at a Synthesis, where benzos are only prescribed were appropriate, the doses are kept at a reasonable level, and patients are properly monitored. I for one don't know what would have happened had Xanax not been available to break my panic spiral earlier this year that saw me go more than a week with almost no sleep.
Incidentally, the SSRI's are going through the same process. First the "wonder drug" Thesis, with SSRI's being given for everything from depression to anxiety to PMS to, it seems, the common cold. Now we are entering the Antithesis phase, where critics are pointing out the problems with the SSRI's, particularly the withdrawal problems that many patients were not warned about and thus suffered unnecesarily by quitting "cold turkey". Eventualy the SSRI's will reach a synthesis phase, particularly as they go generic and stop being such a cash cow for the pharmaceutical manufacturers (I say this as a happy but properly warned and monitored Celexa customer).
Dave
Posted by Cam W. on June 16, 2001, at 0:18:17
In reply to Hegelian logic and benzos, posted by Daveman on June 16, 2001, at 0:06:29
Dave - Nicely stated. Mind if I use your interpretation of meds using Hegelian logic (thesis - > antitheis - > synthesis) in some of my presentations? I think that it explains our beliefs and stances on meds very nicely. - Cam
Posted by grapebubblegum on June 16, 2001, at 11:32:15
In reply to Re: Hegelian logic and benzos » Daveman, posted by Cam W. on June 16, 2001, at 0:18:17
You all overwhelm me with your smartness.
Cam: I am a lousy housekeeper. It amazes me that women could get Rx's to do housekeeping faster way back when, and those of us who need fractions of the lowest dose of clonazepem to survive get rolled eyes from jaded health care professionals. Anyway, maybe I finally know why I can't clean house worth a darn. Did they actually have any reason given for the Rx's? Did docs diagnose needs for women to get Rx's very easily back them? I'm assuming they felt they had a good psychiatric reason to prescribe "mothers little helpers."
Elizabeth: I missed it if you stated this before, but are you a physician or some sort of professional other than a plain old layperson like myself? I'm just curious since you seem to know your shizzit.
Whoever mentioned this: (can't remember who - can't remember,it's that klonopin, right? arggghhhh!) (that was a joke)
My pdoc was probably unfairly selectively and even misquoted by me. She did say that clonazepam is excellent for the purposes for which I am using it and she did say that if I am taking it, it is preferable to take it round the clock rather than "as needed," although taking it as needed is most definitely preferable to not taking it at all should a crisis arise as she would prefer to see me go to sleep rather than go to E.R. if things get that bad on any particular night.
She did say also that she has seen a huge range of responses to clonazepam with some people needing very little and some needing a lot in terms of responsiveness and tolerance.
I was joking when I said, "the amount needed to derail a P.A. would kill me." What I mean was that I have taken I think... 1.5 mg over the course of a bad evening and STILL stumbled into the E.R., and while I could hardly stand, walk or talk, the P.A. was still raging within my brain. It was like a fight between my brain and my body. One particular occasion I remember included a nurse giving me a shot of Ativan in my posterior and I could feel the Ativan pulling me down and my brain pulling me back up, like a battle. It's like my P.A. kept coming back up for air, gasping to say alive, and as I lapsed into unconciousness, the final image in conscious brain was a vague vision of vicious dog with bared teeth, then I went out. I'm not afraid of dogs, per se...I'm sure it was just a general "anxiety" picture pulled at random from that card catalog at the back of my brain.
But my point was.... She was not overjoyed to hear that the E.R. docs gave me Ativan and sent me home with a bottlefull the next day... I took one dose as directed and walked around and literally could not remember what I did that day. I guess that's why she does not favor Ativan except maybe at the time the E.R. docs did what was best for that situation.
She does keep reminding me that clonazepam can worsen depression. I don't know what to make of that. I don't think I am a classically depressed person. At one time she had me on clorazepate (tranxene) and she felt it was not good enough and that is when she switched me to clonazepam which I believe is her favorite benzo (she admits it does a good job and that is why she prescribes it.)
As for valium, I was given that once during a medical procedure and it made me sleepy but did not do a good job of alleviating the panic attack that ensued from the pain of the procedure. It was bad: like being too knocked out to move or speak but panicking inside. She was also not pleased to hear that I was given IV valium for a procedure that is normally done under general anesthesia. Incidentally, I saw on the b.p. monitor that my b.p. was 80/40 or less.
Posted by paulk on June 16, 2001, at 15:07:23
In reply to Re: more about Xanax and depression » paulk, posted by Elizabeth on June 15, 2001, at 22:10:17
>That's true, although there is something called a "use patent" (which is why you still can't get generic Prozac in the US
Tell me more – how much longer can they stretch it out with this?
> > Do you know if the low BP side effect is a ‘primary’ effect of the drug or a result of the lowering of the MO enzyme level?
>I'm not sure I understand the question. Orthostatic hypotension (slowed cardiovascular adaptation to changes in posture) is probably due to central activation of alpha-adrenergic receptors (which results from increased norepinephrine, which results from destruction of MAO).
From what you said that would be a secondary effect – the primary effect of the drug would be the destruction of MAO. A secondary effect would be the increase in neuro transmitters. I saw some lowering of my BP quite as soon as I took the med – I’m thinking it might be a primary effect?
> > Unfortunately, it was quite a bear to manage frequent dosing at a low level, so I stopped it many years ago. Xanax quits so fast and nasty that I can see why it would be addictive. Sure wish there was an XR version to try.
>Addiction results from using large doses of a drug to get high. Anybody who's been taking Xanax for a long time will get withdrawal symptoms; that's not drug addiction, it's a normal reaction.
Not sure I’m tracking you here – my father gave some of his terminal patients enough painkiller for them to become ‘physically addicted’ – in my mind if there are physical side effects from withdrawal one is physically addicted. On the other hand, I would say there are lots of people who are psychologically addicted to coffee.
I think we agree on this – I might be using a different definition of addiction? I would even call the fever I got discontinuing Effexor a physical addiction. Perhaps I’m just not being PC enough< grin >. I see no problem in getting physically addicted to a drug if it is beneficial in the long term.
I think I remember hearing a ‘modern’ definition about addiction being where one loses the ability do deny oneself the drug (I guess I might be addicted to food - some of the amino acids can make me feel much better - (unfortunatley they tend to be found in association with high fat content)).
> > I understand why one shouldn’t take SSRIs and the like but I don’t understand why there would be a need to discontinue other MOAIs when switching between types? After all, the Nardil would wash out in a day or so? Are they acting on different enzymes?
>That one is a mystery. It may only be a problem when switching between Nardil or Marplan (the hydrazide MAOIs) to Parnate (an amphetamine-like MAOI).
My guess is that the different MAOIs must be knocking out different MAOs or they would all have the same effect other than their side effects.
> > I’m also wondering if I should get a med-alert bracelet - I understand that Demerol (meperidine) can be fatal – I would hate to be in a car accident and get Demerol in the ER that could kill me.
>Demerol's pretty crappy anyway. They should use morphine. :-)
Or heroin – it is supposed to be the best painkiller (there might be some new synthetics – I don’t know about). Back when heroin was used as a painkiller most folks had no problem becoming dependent on it. The name had something to do with the heroic effect it had combating pain. It probably got its bad reputation because so many coming back from the war had been treated with it at one time. Out of this large number enough had addiction problems that it earned its ‘bad drug’ status. If a different opiate had been popular for pain control at that time it would have earned the same ‘bad drug’ status. (I suppose one could make some points about the half-life of some opiates makes them more addicting.) Anyway – many people who were given large amounts of heroin for pain had no problems getting off the drug.
There are times when I have a bad influenza that I wish I could get some opiate for a day or two while I recover – it is near impossible to get codeine cough syrup and when I’m sick, I’m not likely to go to more than one drug store.I also, have had a run-in with opiates=bad when I had my second kidney stone. (I had no idea what was happening with the first one.) I came into the emergency room – told them I was having a kidney stone. The ER thought I was an addict and just put me on hold for 45 min – until I got mad and demanded they run an IVP on me so I could prove I really did have a stone and get the pain med I needed. I didn’t get pain med for over 2 ½ hours.
Posted by paulk on June 16, 2001, at 15:09:16
In reply to diet pills » paulk, posted by Elizabeth on June 15, 2001, at 22:15:35
> > Actually, "mother's little helper" used to mean a mix of amphetamines that is now sold as Adderal – back when the song came out it had a different name and was used (unsuccessfully) as a diet pill.
>
> There used to be diet pills that combined amphetamines with short- or intermediate-acting barbiturates, with names like Desbutal (methamphetamine + pentobarbitol) and Dexamyl (d-amphetamine + amobarbitol). I have trouble imagining what the purpose of such a combination pill would be, other than to get really trashed. (The reasoning for adding the barbiturate was that a lot of people get anxious on stimulants.)
>
> -elizabethI remember those also - but what is now Adderal was once known by a different name.
Posted by paulk on June 16, 2001, at 15:45:00
In reply to Re: Linky-link » paulk, posted by Elizabeth on June 15, 2001, at 22:32:07
> > Seriously, your pdoc doesn’t seem to be up on the seritinergic effects of klonopin. Klonopin is THE benzo of choice for long-term treatment.
>
> Not necessarily, although it is definitely a first-line treatment for panic disorder or generalised anxiety. Most benzos have the potental to cause or exacerbate depression, though, including Klonopin; Xanax is often preferable for people with anxiety and depression, despite the need for frequent dosing.
>
I sure think it would be better in a XR version.> > Not that weird. I only need just a little - .25/day. Many others are in the same boat.
>
> That's surprising. I took Klonopin for a few weeks at one point, and I needed 4 mg/day (1 mg in the morning and afternoon, 2 mg at bedtime). What do you take it for? (I was taking it for panic disorder and a REM sleep parasomnia.) And most people I know who take Klonopin for panic or anxiety disorders need at least 1 mg/day.Our neuro-chemistry is probably much more variable than the shapes of our faces – YMMV. Also the effects at high dosages may not at all the same as what I get out of the drug. A similar example – Effexor has very little NE effect at 75mg and acts mostly like a SSRI, but at 300mg it becomes a true SNRI.
> > DITTO – BULLS EYE – EXCELLENT POINT! I hope some docs read what you just said. ( I think this phenomena is called ‘kindling’ in the litature.)
>
> Kindling refers to increased frequency of seizures in untreated epilepsy. (More generally it can refer to the same type of phenomenon in mood disorders or panic disorder.)
>
Yes, I’m talking about kindling as it refers to mood.
> > I have seen folks deteriorate over time on very large dosages Benzos.
>
> I haven't. But I have seen people take the same dose for years without problems and without needing to increase it.It isn’t pretty. I went to a funeral of a friend who had lost his hygiene habits after too many bezo over 15 years. He died choking to death on a hotdog. (this is not a joke)
>
> > I Really don’t think it is good practice to use benzos per attack (unless its for someone who is bi-polar.)
>
> Huh? Benzos are sometimes used to reduce psychomotor agitation in mania, but they're also used for various types of episodic anxiety. It's completely reasonable.
>
I guess I’ve seen too many people who got in trouble with benzos when I was in hospital. That dosen’t mean everyone will, but some do.> > If it is a short acting benzo “as per needed” is a good way to get someone with PA in even bigger trouble.
>
> That doesn't make sense to me. If you only take it as-needed, you don't need to be concerned about pharmacologic dependence if you ever want to go off it (or if you miss a dose). Anxiety patients, as a rule, don't abuse their medication (those who do are almost invariably abusing other drugs too).
>
I would humbly disagree; the short half-life of Xanex causes withdrawal symptoms of ‘panic and anxiety’ in some patients with a single dose. When I took Xanex – I would get quite irritable as the drug wore off. This makes a drug spiral – take Xanex for anxiety – it works, but as it wears off anxiety is there, but worse – take more – and more. Now, this doesn’t happen to everyone – but it sure happens to some folks.> > Klonopin, for me, even at a VERY low dose makes all the difference in what I do when I lose my temper. It also prevents the panic attacks (although I didn’t have that many).
>
> Benzos for anger? That's interesting. Some people with anger problems become disinhibited on benzos (like alcohol).Not me – I still get mad – I just don’t kindle into a rage.
>
> > Getting off higher dosages of Benzos can be nightmarish.
>
> That's true if you take them around the clock. But then again, a lot of people really do need much higher doses. You're lucky -- maybe it's because you're taking it primarily for anger and never had frequent panic attacks.
>
Yes – more I’m more of GAD with Atypical depression – my entire life.> > I watched a fellow patient go through the “cold wet sheet pack treatment” getting off Valium. I think switching to klonopin and tapering would have been a much better way.
>
> That's the right way, yes: switch to a long-acting benzo, such as Klonopin or Tranxene, and then taper off *very* slowly. Any doctor who takes someone off benzos cold-turkey should have his license revoked, IMO.They tapered – the anxiety returned – only treatment was CWSP. This was a hospital that was down on drug therapy and thought they could talk away everyone’s problems (sadly some who had thyroid disease)
Posted by Daveman on June 16, 2001, at 18:22:51
In reply to Re: Hegelian logic and benzos » Daveman, posted by Cam W. on June 16, 2001, at 0:18:17
> Dave - Nicely stated. Mind if I use your interpretation of meds using Hegelian logic (thesis - > antitheis - > synthesis) in some of my presentations? I think that it explains our beliefs and stances on meds very nicely. - Cam
Feel free. It's not original to me after all:)
Dave
Posted by Elizabeth on June 25, 2001, at 23:58:25
In reply to Re: more about Xanax and depression » Elizabeth, posted by paulk on June 16, 2001, at 15:07:23
> >That's true, although there is something called a "use patent" (which is why you still can't get generic Prozac in the US
>
> Tell me more – how much longer can they stretch it out with this?It's not clear. However long the FDA will continue accepting bribes, I guess. < g >
> >I'm not sure I understand the question. Orthostatic hypotension (slowed cardiovascular adaptation to changes in posture) is probably due to central activation of alpha-adrenergic receptors (which results from increased norepinephrine, which results from destruction of MAO).
>
> From what you said that would be a secondary effect – the primary effect of the drug would be the destruction of MAO. A secondary effect would be the increase in neuro transmitters....because one of their major metabolic pathways is cut off, right. (There are other enzymes, such as catechol-O-methyltransferase (COMT), that catalyse the metabolism of these neurotransmitters, but those are relatively minor. I did once speak to someone who'd tried using a COMT inhibitor for depression and ADD, but he wasn't impressed by it in comparison to the MAOIs.)
> I saw some lowering of my BP quite as soon as I took the med – I’m thinking it might be a primary effect?
It's (probably) a consequence of the increased neurotransmitter concentrations (norepinephrine in particular). It's not a "direct" effect in the sense you seem to mean, but it is observable after a single dose, as opposed to the AD effects which usually require chronic dosing (for at least a couple weeks, although my impression has been that many people find that MAOIs work faster than other ADs).
> >Addiction results from using large doses of a drug to get high. Anybody who's been taking Xanax for a long time will get withdrawal symptoms; that's not drug addiction, it's a normal reaction.
>
> Not sure I’m tracking you here – my father gave some of his terminal patients enough painkiller for them to become ‘physically addicted’ – in my mind if there are physical side effects from withdrawal one is physically addicted.I discussed this in another post:
http://www.dr-bob.org/babble/20010618/msgs/67768.html
"Addiction" is a really loaded word and can cause confusion since different people have different ideas of what it means.
> On the other hand, I would say there are lots of people who are psychologically addicted to coffee.
Caffeine causes a mild withdrawal syndrome -- fatigue, headaches, etc. I once heard somewhere that something like 80% of adult Americans are pharmacologically dependent on caffeine, though (in other words, they need their morning coffee).
> I would even call the fever I got discontinuing Effexor a physical addiction.
The presence of withdrawal symptoms is evidence of what you call "physical addiction," yes. (I personally don't like that term because "addiction" is such a loaded word, and because it implies that mental processes are somehow "nonphysical.)
Besides its moral/political overtones, "addiction" also implies a pathological condition, whereas withdrawal symptoms are normal consequences of discontinuing certain drugs after you've been using them regularly for a while. Almost anyone who takes morphine for a few weeks will experience some uncomfortable withdrawal signs and symptoms if they attempt to stop taking it, especially if they stop "cold turkey." Most people who take morphine for pain have no trouble staying off it after stopping it, once the initial withdrawal period has abated (assuming that the source of their pain was treated so that they no longer require an analgesic).
> I think I remember hearing a ‘modern’ definition about addiction being where one loses the ability do deny oneself the drug (I guess I might be addicted to food - some of the amino acids can make me feel much better - (unfortunatley they tend to be found in association with high fat content)).
That's the defining characteristic of "addiction," yes. If an "addict" goes too long without their drug of choice, he starts obsessing about it and experiencing intense cravings -- even if he doesn't experience withdrawal symptoms.
> My guess is that the different MAOIs must be knocking out different MAOs or they would all have the same effect other than their side effects.
Nope. Nardil and Parnate are both nonselective inhibitors of MAO. They do have other effects in addition to MAO inhibition, though: Nardil is also an inhibitor of GABA metabolism, while Parnate is *thought* to have some sort of dopaminergic effect (perhaps induction of dopamine release: Parnate is chemically extremely similar to amphetamine).
> >Demerol's pretty crappy anyway. They should use morphine. :-)
>
> Or heroin – it is supposed to be the best painkiller (there might be some new synthetics – I don’t know about).No, fentanyl (which isn't all that new) is probably a better analgesic. Heroin (diacetylmorphine) is really just a semisynthetic version of morphine. The acetyl groups cause it to be taken up into the CNS very rapidly if it's taken intravenously (heroin, if taken through other routes, is transformed into morphine before it makes it to the CNS).
> Back when heroin was used as a painkiller most folks had no problem becoming dependent on it.
Well, they often became dependent on it (often in the form of unlabeled patent remedies with names like "Mrs. Brown's Soothing Syrup"). But because they had unlimited access to it, they didn't have trouble functioning as a result of their dependence.
> It probably got its bad reputation because so many coming back from the war had been treated with it at one time.
I'm kind of embarrassed to say that I don't know which war you're referring to. < G > But anyway, like almost every illegal drug, heroin's bad reputation originated in racism -- it was the recreational drug of choice of many of those wild, creepy, dangerous (i.e., black) jazz musicians.
> If a different opiate had been popular for pain control at that time it would have earned the same ‘bad drug’ status.
A number of different opiates, including morphine and laudanum, were used widely as analgesics in the late 19th and early 20th centuries. They were used in a wide variety of "nervous disorders" (anxiety and depression -- laudanum could be said to be the original "mother's little helper") as well.
> (I suppose one could make some points about the half-life of some opiates makes them more addicting.)
Not the half-life: the rapid onset of action. Heroin "hits" extremely fast when injected into a vein. Oral heroin, on the other hand, is effectively the same as morphine (which isn't very orally active itself: oxycodone has much better bioavailability when taken by this route).
> Anyway – many people who were given large amounts of heroin for pain had no problems getting off the drug.
Of course they didn't. Neither do most people who take the strongest opioid analgesics -- fentanyl, hydromorphone (Dilaudid), oxymorphone (NuMorphan), etc. -- today. Try explaining this to a politician, though!
> I also, have had a run-in with opiates=bad when I had my second kidney stone.
Oh jeez. I never had those, but I know how painful they are. There seem to be a lot of doctors out there -- especially ER docs -- who hate getting duped so much that they'd rather leave people in agony than risk giving "narcotics" to an addict (because if these doctors felt they'd been had, their precious egos would suffer irreparable bruising).
-elizabeth
Posted by Elizabeth on June 26, 2001, at 1:54:50
In reply to Re: diet pills » Elizabeth, posted by paulk on June 16, 2001, at 15:09:16
> I remember those also - but what is now Adderal was once known by a different name.
Obetrol.
-e
Posted by Elizabeth on June 26, 2001, at 2:56:27
In reply to Re: Linky-link » Elizabeth, posted by paulk on June 16, 2001, at 15:45:00
> Our neuro-chemistry is probably much more variable than the shapes of our faces – YMMV.
That's for sure. The human brain is one of the most complicated objects in nature.
> Also the effects at high dosages may not at all the same as what I get out of the drug.
Maybe, but I wonder if in this case there might be a difference of metabolism involved. 4 mg/day of Klonopin is a pretty typical dose for panic disorder (and the upper end of the recommended dose range for epilepsy is 20 mg/day).
> > I haven't. But I have seen people take the same dose for years without problems and without needing to increase it.
>
> It isn’t pretty. I went to a funeral of a friend who had lost his hygiene habits after too many bezo over 15 years. He died choking to death on a hotdog. (this is not a joke)That's terrible, but I do hope your example doesn't scare people unnecessarily! I really would be interested to know the details, if you're comfortable discussing them -- like the individual's age, why he was taking the benzos (and which ones and how much), whether he had other medical conditions that could have contributed, etc.
Some people abuse benzos, and they can develop truly massive tolerance. The worst case of this I've heard of involved a guy who was using more than 100 mg of Xanax a *day*. Some people have general sedative abuse problems, and they often combine benzos with other CNS depressants, such as alcohol, barbiturates, meprobamate, industrial solvents (inhalants), etc. As I mentioned, most people who abuse benzos also abuse other drugs.
However, most anxiety patients who take therapeutic doses (which can mean up to around 6 mg/day of Xanax or Klonopin) do not have problems with them. They certianly don't become demented or unable to care for themselves; on the contrary, benzos can eliminate crippling anxiety. It is true that some people suffer cognitive impairment (slowed thinking, memory problems) from benzos; these people usually end up taking alternative anxiolytics (such as antidepressants) instead (although most people I know who take ADs for panic disorder still occasionally need to take benzos).
> I guess I’ve seen too many people who got in trouble with benzos when I was in hospital. That dosen’t mean everyone will, but some do.
That's rather surprising. Anxiety patients tend to use medication as directed or, if anything, to use *less* than the prescribed amount, not more.
> I would humbly disagree; the short half-life of Xanex causes withdrawal symptoms of ‘panic and anxiety’ in some patients with a single dose.
Some people might experience rebound anxiety (just as people who use short-acting benzos such as Halcion for insomnia may be subject to waking up in the middle of the night when the med wears off), but if they are truly taking the drug only on an occasional basis, rebound effects (if any) are unlikely to be serious. Also, people who have continuous anxiety (rather than, or in addition to, short-lived anxiety or panic attacks) will become anxious again after a benzo wears off: that's not a rebound reaction. Single, isolated doses of benzos do not cause dependence, by any definition you use.
> When I took Xanex – I would get quite irritable as the drug wore off. This makes a drug spiral – take Xanex for anxiety – it works, but as it wears off anxiety is there, but worse – take more – and more. Now, this doesn’t happen to everyone – but it sure happens to some folks.
Ahh. Irritability isn't an indication for benzos, and they have been known (and documented) to cause bad reactions in some people who had preexisting mood-regulation disorders (which often tend to manifest as irritability or atypical/mood-reactive depression). I don't know all the details, just that the disinhibiting effects of benzos can cause serious problems for some people. It would be interesting to read these reports in more detail; it might turn out that the patients described were suffering from a sort of rebound effect. Xanax has a particularly bad reputation for this compared to other benzos, incidentally. (I haven't ever read, or even heard, of such a rebound effect in people who take benzos on an ad-lib basis for anxiety or panic attacks.)
People do vary widely in their tendency to adapt to drug effects. Some people rapidly develop tolerance and dependence to a particular class of drugs, or to drugs in general. I wouldn't rule out the possibility that certain identified patient populations are unusually liable to become tolerant to drugs. (Tolerance and dependence are both due to adaptations: some people may adapt very rapidly to drugs.)
> They tapered – the anxiety returned – only treatment was CWSP.
"CWSP?" (Is there something I'm supposed to know about here?)
> This was a hospital that was down on drug therapy and thought they could talk away everyone’s problems (sadly some who had thyroid disease)
< groan >
-elizabeth
Posted by paulk on June 26, 2001, at 16:22:10
In reply to benzos » paulk, posted by Elizabeth on June 26, 2001, at 2:56:27
>“They do have other effects in addition to MAO inhibition, though: Nardil is also an inhibitor of GABA metabolism, while Parnate is *thought* to have some sort of dopaminergic effect (perhaps induction of dopamine release: Parnate is chemically extremely similar to amphetamine).
!@# Lawyers – I sure wish that information had been in the PDR. –The Nardil has just kicked in in the last week or so – I still question that the low BP is caused by other than the increase in the monoamines – from what I understood until 90% of the MAO is knocked out There isn’t enough rise in neuro transmitters to do anything.
I seem to be doing OK except I am starting to have trouble with word selection – and sometimes the wrong word will come out. I wonder if it is a side effect of the GABA? Perhaps I should take the med at night? I am still at the high dose 60/mg day – perhaps it will get better when they lower the does back down. Was the inhibition of the GABA metabolism a direct effect of the drug or secondary?
>
> > It isn’t pretty. I went to a funeral of a friend who had lost his hygiene habits after too many bezo over 15 years. He died choking to death on a hotdog. (this is not a joke)>That's terrible, but I do hope your example doesn't scare people unnecessarily! I really would be interested to know the details, if you're comfortable discussing them -- like the individual's age, why he was taking the benzos (and which ones and how much), whether he had other medical conditions that could have contributed, etc.
>Some people abuse benzos, and they can develop truly massive tolerance. The worst case of this I've heard of involved a guy who was using more than 100 mg of Xanax a *day*. Some people have general sedative abuse problems, and they often combine benzos with other CNS depressants, such as alcohol, barbiturates, meprobamate, industrial solvents (inhalants), etc. As I mentioned, most people who abuse benzos also abuse other drugs.
>However, most anxiety patients who take therapeutic doses (which can mean up to around 6 mg/day of Xanax or Klonopin) do not have problems with them. They certianly don't become demented or unable to care for themselves; on the contrary, benzos can eliminate crippling anxiety. It is true that some people suffer cognitive impairment (slowed thinking, memory problems) from benzos; these people usually end up taking alternative anxiolytics (such as antidepressants) instead (although most people I know who take ADs for panic disorder still occasionally need to take benzos).
He was taking – I think it was Restaril – (sp??) . He was very bi-polar yet a dear friend – very smart – didn’t usually go psychotic in his mania. He really needed to be in a halfway house to have someone monitor is medications. The lack of supervision is what I blame for his death. I think the benzos may have surpressed his gag reflex or dis-coordinated his swallowing enough to cause the problem. I don’t think this would be a common problem with people who can manage there own meds.
> > > I guess I’ve seen too many people who got in trouble with benzos when I was in hospital. That dosen’t mean everyone will, but some do.
> >That's rather surprising. Anxiety patients tend to use medication as directed or, if anything, to use *less* than the prescribed amount, not more.
Most of these people were in the hospital because they had benzo problems – sort of self-selected. Remember everyone reacts differently.> > I would humbly disagree; the short half-life of Xanex causes withdrawal symptoms of ‘panic and anxiety’ in some patients with a single dose.
It sure does it to me. – That’s why I’m interested in the slow release version. I would take it for anxiety and it worked – wonderfully – but then as it wore off I would feel even worse than before.>Some people might experience rebound anxiety (just as people who use short-acting benzos such as Halcion for insomnia may be subject to waking up in the middle of the night when the med wears off), but if they are truly taking the drug only on an occasional basis, rebound effects (if any) are unlikely to be serious. Also, people who have continuous anxiety (rather than, or in addition to, short-lived anxiety or panic attacks) will become anxious again after a benzo wears off: that's not a rebound reaction. Single, isolated doses of benzos do not cause dependence, by any definition you use.
I didn’t use Xanex after the prescription ran out because of that problem – I didn’t get addicted – but I sure wanted to keep taking more and more, but realized I shouldn’t. I really liked and hated the drug. Sure wish I could try the XR version.
> > When I took Xanex – I would get quite irritable as the drug wore off. This makes a drug spiral – take Xanex for anxiety – it works, but as it wears off anxiety is there, but worse – take more – and more. Now, this doesn’t happen to everyone – but it sure happens to some folks.
>Ahh. Irritability isn't an indication for benzos, and they have been known (and documented) to cause bad reactions in some people who had preexisting mood-regulation disorders (which often tend to manifest as irritability or atypical/mood-reactive depression).
I would say that irritability is a symptom of anxiety?? The irritability wasn't there until the drug was wearing off. You might be forgetting the wide variation of how these drugs effect people. (YMMV grin). I know the nasty discontinuation effects of Effexor – yet for many folks they can stop cold with out any problem.
> > They tapered – the anxiety returned – only treatment was CWSP.
>"CWSP?" (Is there something I'm supposed to know about here?)
CWSP = Cold Wet Sheet Packs – THE non-drug treatment for anxiety. (I wouldn’t want it done to me – its not fun to watch – but it seems to work a bit.
I’m thinking that there needs to be a new specialty in medicine – an endroconologist/pycopharmacologist. It sure would be nice if there were better and objective tests that could show what drugs to try first. – perhaps spinal fluid tests or long term urine collection for cortisal tests?
Reminds me – I ran into yet another old friend who tried Effexor – told me he went sort of manic (couldn’t sleep – roofed a house all night long in the dark) – his doc now thinks he may be a bit bipolar. – Perhaps putting someone on a SSRI for a couple of days and re running psyc evaluation would help spot hidden bipolar tendencies? I think that side effect may happen more than one would believe by reading the PDR.
Paulk
Posted by gilbert on June 26, 2001, at 20:26:17
In reply to Re: benzos » Elizabeth, posted by paulk on June 26, 2001, at 16:22:10
Well I just ever can't resist to jump into the whole benzo debate issues. The evil benzos, the addicitive benzos, people dying on benzos....what a load of crap. I'll tak my chances on benzos before you will get me on and MAO....How many people have died from bad reactions and hypertensive crisis from MAO"s....Study after study shows that panic patients don't abuse benzos. They always use the least dose possible and usually throw away half their damn pills. Also I am an ex junkie and drunk and I have felt way more stoned and I mean way more stoned on most antidepressants than xanax. I have been totally out of it like completely detached from reality...numb...no ability to cry even. I take two xanax per day and never have rebound, never have withdrawal and it is by far the most effective anti panic med I have ever had....and without side effects. Seems everyone is always trying to push an antidepressant or mood stabilzer down our throats. The side effect profile long term for xanax is mild compared to these other drugs. I am not sure I want my testosterone levels to drop below sea level from long term use of ssri's. I also don't want to have to ask the waiter if there is aged cheese in the lasagna so I don't have an MOA crisis. I sure as hell haven,t had any good experiences on other newer antidepressants, and the rap on benzos is simply political....no more patents. I know I have trouble with gaba shortages this is my chemical defiency...all the seratonin in the world didn't do me any good. So when the patent's run out on all of the ssri's we will be hearing about the wicked ssri's. The number of bad incidents from benzo use are microscopic compared to other drugs. Am I to believe all the bad press on ssri's....I mean there is loads of this stuff on the internet. Even lists of all the suicides of people on an ssri. I don't buy it. If your friend died from choking on a hot dog it sounds like he died from choking on a hot dog....he didn't choke on giant xanax pill did he? It is so easy to blame the drug....Or maybe he should have taken smaller bites when he ate. My pdoc even said xanax was long tested and one of the safest drugs for me to be on. Should everyone quit Effexor and Wellbutrin because of the lady in Texas killing her kids....She was on Effexor and Wellbutrin and I believe an antipyschotic as well. I don't think so.
Gil.
Posted by paulk on June 26, 2001, at 21:08:06
In reply to Re: benzos, posted by gilbert on June 26, 2001, at 20:26:17
>Well I just ever can't resist to jump into the whole benzo debate issues. The evil benzos, the addicitive benzos, people dying on benzos....what a load of crap. I'll tak my chances on benzos before you will get me on and MAO....
I think you should see some of the other stuff I have written – I like Benzos – and take one – I just was pointing out they can have bad effects on some – especially if they aren’t well monitored.
See what I wrote at
http://www.dr-bob.org/babble/20010605/msgs/65469.html
http://www.dr-bob.org/babble/20010605/msgs/65469.html>How many people have died from bad reactions and hypertensive crisis from MAO"s....
Less than you would think.
>Study after study shows that panic patients don't abuse benzos
I agree – but I have also see the few who get into trouble. I think doctors are way to restrictive about Benzos.
>Also I am an ex junkie and drunk and I have felt way more stoned and I mean way more stoned on most antidepressants than xanax.
I agree again – The biggest problem with Benzos is that they can interfere with learning and memory – I remember a pre med student who took 1mg/day of valium for a semester – had poor final scores and tells me he can’t remember much of that semester.
>I take two xanax per day and never have rebound, never have withdrawal and it is by far the most effective anti panic med I have ever had....and without side effects.
Wish it worked that way for me YMMV.
>Seems everyone is always trying to push an antidepressant or mood stabilzer down our throats.
>I am not sure I want my testosterone levels to drop below sea level from long term use of ssri's.
Hadn’t heard of this side effect??? The SSRI do interfere with sex – but I didn’t know they lowered Testosterone?? Where did you read this? Benzos can kill sex for some people. Again YMMV.
>I also don't want to have to ask the waiter if there is aged cheese in the lasagna so I don't have an MOA crisis.
I don’t think MOAIs are for most folks – but they have been reported to work very well for people with atypical depression – and the diet restrictions vs my depression is an easy trade – I really hate my depression. My take so far is I have less side effects than with Effexor – (Effexor would kill my sex life)
>I sure as hell haven,t had any good experiences on other newer antidepressants
Again, I say that our neuro chemistry is probably much more variable that the way we look – and the effects of the drugs vary greatly form one person to another thus YMMV. I found that on Effexor I knew what it was like to be normal for the first time in my life – made me sad to realize all I had missed. For others SSRIs don’t do a thing.
> and the rap on benzos is simply political....no more patents.I agree to a point – Benzos had a bad rap even when the patent was in place.
> The number of bad incidents from benzo use are microscopic compared to other drugs.
I would have to disagree. Some depressed folks are pushed farther into depression with Benzos – so for them it can be bad – there have been many suicides with benzos plus alcohol. I would like to see suicide statistics of SSRIs vs Benzos. I bet SSRI would have fewer.
>Even lists of all the suicides of people on an ssri. I don't buy it. If your friend died from choking on a hot dog it sounds like he died from choking on a hot dog....he didn't choke on giant xanax pill did he?
I don’t think he was a typical benzo user – he didn’ t have it together enough to manage his own meds – really should have been in a halfway house and given benzos when he was in mania – he took a LOT of benzos – more than anyone else I have known.
>It is so easy to blame the drug....Or maybe he should have taken smaller bites when he ate. My pdoc even said xanax was long tested and one of the safest drugs for me to be on. Should everyone quit Effexor and Wellbutrin because of the lady in Texas killing her kids....She was on Effexor and Wellbutrin and I believe an antipyschotic as well. I don't think so.
Some one taking an antipyschotic is in a whole differnt world that folks with anxiety and depression - they have breaks with reality - don't know what is real or in their head. Effexor is not listed for use for Schizophrenia or Mania.
I would be much more worried about the memory and learning effects of benzos than the choking risk. My point remains, that there are SOME people who have big time trouble with benzos. Most people use them very well, and IMHO benzos are under prescribed.
paulk
Posted by grapebubblegum on June 26, 2001, at 21:10:53
In reply to Re: benzos, posted by gilbert on June 26, 2001, at 20:26:17
And Gilbert knows that I just have to jump in when he posts. You said: "They always use the least dose possible and usually throw away half their damn pills."
True, how true... I just cleaned out my cabinets and found a forgotten old dusty bottle of klonopin, and there were about 25 of the 30 originally prescribed pills still in there, prescribed and filled sometime in '99.
Posted by grapebubblegum on June 26, 2001, at 21:24:10
In reply to Re: diet pills » paulk, posted by Elizabeth on June 26, 2001, at 1:54:50
Elizabeth, I think you missed my question or I missed your answer so I'll reprint it: "Elizabeth: I missed it if you stated this before, but are you a physician or some sort of professional other than a plain old layperson like myself? I'm just curious since you seem to know your shizzit."
Also to whoever mentioned this: What is the cold wet sheetpack treatment and how does it work, if it does? Could someone explain how it supposedly works, scientifically?
Posted by gilbert on June 27, 2001, at 10:27:00
In reply to Re: benzos » gilbert, posted by paulk on June 26, 2001, at 21:08:06
I would agree people that have a diagnosis of depression would not probably do well on benzo monotherapy....however for all of us panic and anxiety patients and for me personally I feel my depression is a direct result of the inability to do things because of fear...I >E > agoraphobia. In this case if I am able to function on xanax my depressive episodes lift because I can now be functional. I aslo think that benzos are not without some drawbacks as are all drugs. I would rather over sleep a little or be midly depressed once in a while than have no sex life or be unable to sleep at all. Like I said in my last post I have felt my mood was more altered by antidepressants than xanax. I felt completey stoned on luvox. I was quick to temper and detached on the other ssris's. I did have sexual dysfunction on all of them including effexor which took my blood pressure up. So I feel I am using the least of all evils so to speak. I am sorry I am so defensive but it just always seems that the benzos get no credit and it get kicked around a little more than other drug classes. I have to defend what has given me my life back.
P >S > benzo suicides are almost always in combination with other drugs be it alcohol or whatever. I have a feeling that if those same people had a bottle of inderol they would have swallowed it down with some vodka. Also being alcoholic myself I know very rarely do people kill themselves without a chemical primer. The prevalence of benzo scripts versus beta blockers or some other downer would indicate it was simply the tool available to end their life not necessarily the tool that caused them to end their lives.
Gil
Posted by Elizabeth on June 27, 2001, at 10:31:20
In reply to Re: benzos, posted by paulk on June 26, 2001, at 16:18:19
> >“They do have other effects in addition to MAO inhibition, though: Nardil is also an inhibitor of GABA metabolism, while Parnate is *thought* to have some sort of dopaminergic effect (perhaps induction of dopamine release: Parnate is chemically extremely similar to amphetamine).
>
> !@# Lawyers – I sure wish that information had been in the PDR. –Lawyers? Quoi?
> The Nardil has just kicked in in the last week or so – I still question that the low BP is caused by other than the increase in the monoamines – from what I understood until 90% of the MAO is knocked out There isn’t enough rise in neuro transmitters to do anything.
No, the increase in neurotransmitter concentrations takes place immediately. That's not directly responsible for the antidepressant effect of the drug, but a lot of the side effects, direct or indirect, happen sooner, orthostatic hypotension being one of these. MAOIs (and tricyclics) decrease the compensatory cardiovascular response to changes in posture.
> I seem to be doing OK except I am starting to have trouble with word selection – and sometimes the wrong word will come out.
That's a common effect of antidepressants, especially tricyclics and MAOIs. Anticholinergic drugs are the worst that way, but norepinephrine has some effects that oppose those of acetylcholine. MAOIs upset the reciprocal interaction between NE and ACh; as a result, they virtually abolish REM sleep. In light of this, their effects on implicit or associative memory are surprisingly subtle.
> I wonder if it is a side effect of the GABA?
In the case of Nardil, that might have something to do with it too. (I had the word-finding problems on Parnate as well, although it wasn't a big deal with any of the MAOIs.)
> Perhaps I should take the med at night?
I tried taking Nardil on every imaginable dosing schedule. Didn't make any difference in any of the side effects.
> I am still at the high dose 60/mg day – perhaps it will get better when they lower the does back down.
I don't think that's such a good idea. First of all, 60 mg is *not* a "high" dose; it's a normal dose. Also, although it was once thought that the right way to give people antidepressants was to start with a high "loading" dose and then decrease it down to a very low "maintenance" dose, this has proven not to work very well. (My own experience with MAOIs bears this out: at one point I tried decreasing the Nardil to 30 mg, and my depression and panic started coming back. I've also tried dropping the Parnate down to 30, 20, and even 10 mg, and it just doesn't work very well when I do that.)
> Was the inhibition of the GABA metabolism a direct effect of the drug or secondary?
I'm still not sure what you mean by that (although I know what *I* would mean < g >). I'm also not sure the mechanism is known. But I believe it's an early effect, not one that takes a week or more to happen.
On to the benzos....
> He was taking – I think it was Restaril – (sp??) . He was very bi-polar yet a dear friend – very smart – didn’t usually go psychotic in his mania. He really needed to be in a halfway house to have someone monitor is medications. The lack of supervision is what I blame for his death. I think the benzos may have surpressed his gag reflex or dis-coordinated his swallowing enough to cause the problem.
It's really horrible to think about this, but the fact is, people with serious mental illness who don't have family to take care of them are at high risk of death for a whole lot of reasons. For example, a person with bipolar disorder, especially one who has trouble functioning to the point where he needs to live in a halfway house, is pretty much guaranteed to be on a lot of medications, possibly including neuroleptics (and perhaps anticholinergics to offset the side effects), lithium, and/or anticonvulsants. All of these have known risks, some of which can be quite serious. Bipolar disorder is associated with a high risk of suicide attempts and substance abuse as well.
Restoril (temazepam) is generally prescribed only for insomnia, not for daytime anxiety. It is unlikely that your friend was prescribed this medication in very large doses.
> I don’t think this would be a common problem with people who can manage there own meds.
Well, it isn't. It also isn't a common problem with benzodiazepines in general. The other medications used to treat bipolar disorder are much more dangerous. A lot of times I hear of people dying from polydrug overdoses, but some particular drug (usually a controlled substance) is singled out as the cause. When someone dies from an overdose of benzos and alcohol, it's not because benzos are dangerous or toxic. If either drug by itself is to blame in such a case, it's the alcohol -- an incredibly toxic drug (several characteristics of ethanol make me want to label it a solvent rather than a drug, and it certainly has no place for systemic use in modern medicine).
> Most of these people were in the hospital because they had benzo problems – sort of self-selected. Remember everyone reacts differently.
Fair enough. But I bet that most of those people abused other drugs, not just benzos. I've known a few people who abused benzos, but without exception they were addicted to alcohol or heroin and abused other drugs (cocaine, amphetamines). Addicts sometimes use benzos to substitute for their DOCs when supply is short, and they can easily become dependent because they tend to self-medicate (i.e., take the benzos in an unsupervised fashion) with very large doses (some people apparently can get high on benzos, but I've never known anybody who could get high on the usual prescribed doses!).
[re withdrawal symptoms:]
> It sure does it to me. – That’s why I’m interested in the slow release version.Well, remember, slow release doesn't mean slow elimination. A lot of people have a hard time getting off of Effexor XR, for example. Xanax SR would be great for people who need to take it every day, though.
> I would take it for anxiety and it worked – wonderfully – but then as it wore off I would feel even worse than before.
I guess I'm confused. What sort of anxiety were you taking it for? (Any diagnosis?)
> I didn’t use Xanex after the prescription ran out because of that problem – I didn’t get addicted – but I sure wanted to keep taking more and more, but realized I shouldn’t.
"Wanting" to take increasing doses of a drug is always a good sign that you're headed for addiction, yes.
> I really liked and hated the drug. Sure wish I could try the XR version.
If you're going to take it for a while and then stop, it's still going to cause withdrawal symptoms. I don't know about this rebound anxiety that you speak of, because I don't think I've ever heard of that before even with regular Xanax.
> I would say that irritability is a symptom of anxiety??
I guess it depends on your definition. I usually think of anxiety as involving inhibition, and irritability as involving disinhibition.
However you want to slice it, the people who have these weird reactions to Xanax (I looked into it, and some of them seemed to involve self-injury in people with a history of cutting, etc.) are people who have problems with emotion regulation. Sometimes that looks a lot like anxiety (presumably that's how they got prescribed Xanax in the first place).
> The irritability wasn't there until the drug was wearing off. You might be forgetting the wide variation of how these drugs effect people. (YMMV grin).
I'm not forgetting. I've known dozens of people who took benzos, mostly Xanax and Klonopin. None of them ever had this problem. Some people experience irritability or peevishness during benzo withdrawal, but that's after discontinuing chronic use.
Did this "rebound anxiety" happen the very first time you took Xanax? And how often were you taking it? (Frequent use, even if it's not around-the-clock, can lead to some degree of dependence.)
> I know the nasty discontinuation effects of Effexor – yet for many folks they can stop cold with out any problem.
Yeah, I didn't have a problem stopping it, but I'd only been on it for a month or so. (Plus, I had to stop because of a rather nasty reaction, so even if I had withdrawal symptoms I might not have noticed them!)
> CWSP = Cold Wet Sheet Packs – THE non-drug treatment for anxiety. (I wouldn’t want it done to me – its not fun to watch – but it seems to work a bit.
Remind me never to submit to "inpatient detox." < g >
> I’m thinking that there needs to be a new specialty in medicine – an endroconologist/pycopharmacologist. It sure would be nice if there were better and objective tests that could show what drugs to try first. – perhaps spinal fluid tests or long term urine collection for cortisal tests?
Oh, that would be great, but reliable tests of the type you're talking about (even those involving lumbar puncture, which, BTW, is not a practical test to do routinely) just don't exist, with few exceptions (the dexamethasone suppression test can be used to determine which depressed patients are potential candidates for steroid-suppression therapy; urinary levels of the norepinephrine metabolite MHPG are pretty consistently elevated in depressed patients who respond to alprazolam).
> Reminds me – I ran into yet another old friend who tried Effexor – told me he went sort of manic (couldn’t sleep – roofed a house all night long in the dark) – his doc now thinks he may be a bit bipolar.
Not conclusively by any means. Unipolar depressives -- no family history of bipolar disorder, no personal history of mania or hypomania, and no subsequent spontaneous manias or hypomanias -- can sometimes have this kind of reaction to antidepressants. It's idiosyncratic, but not unheard of. Some people are sensitive to a particular AD or class of ADs, and some ADs have a greater tendency than others to trigger mania. (Tricyclics have a particularly bad reputation for this, and my pdoc says he thinks Effexor is a bit worse than the other new-generation ADs.)
-elizabeth
Posted by Elizabeth on June 27, 2001, at 10:44:30
In reply to Re: benzos, posted by gilbert on June 26, 2001, at 20:26:17
> Study after study shows that panic patients don't abuse benzos. They always use the least dose possible and usually throw away half their damn pills.
Yeah. People with panic disorder tend to be really afraid of meds and really sensitive to side effects. They're *not* prone to overusing them.
But don't go jumping on MAOIs. They're good broad-spectrum antidepressants, and they're very safe if you use them properly (rather like benzos, no?). (Plus, it's a great opportunity to learn about different types of cheese!)
> It is so easy to blame the drug....
It's especially easy to blame controlled drugs, even though they're controlled because of "abuse potential," not because of toxicity. (I mean,
antineoplastics -- the most toxic drugs used in modern medicine -- are not controlled substances, because nobody would ever take them unless they had to.)> Should everyone quit Effexor and Wellbutrin because of the lady in Texas killing her kids....She was on Effexor and Wellbutrin and I believe an antipyschotic as well. I don't think so.
Yeah, lately it's become fashionable to blame SSRIs and other modern ADs for all kinds of crazy incidents. Occasionally, ADs do cause mania or agitation. People need to know about the possibility so they can get treatment if there's any sign of such a reaction. It's not like these things happen all of a sudden with no warning whatsoeer. I had an undeniable case of serotonin syndrome, complete with delirium and vomiting, while I was taking Effexor, but it wasn't like I just woke up in the morning completely psychotic. As soon as I started feeling sick, I recognised the symptoms and got myself to a hospital, and by the next day I was feeling a little bit spacey but otherwise fine. (Plus, I certainly wasn't with-it enough to hurt anybody seriously, even if I'd been inclined to.)
-elizabeth
Posted by Elizabeth on June 27, 2001, at 11:31:23
In reply to Re: benzos » gilbert, posted by paulk on June 26, 2001, at 21:08:06
> >Study after study shows that panic patients don't abuse benzos
>
> I agree – but I have also see the few who get into trouble.The question I'd ask is, were these patients diagnosed with panic disorder?
> I agree again – The biggest problem with Benzos is that they can interfere with learning and memory – I remember a pre med student who took 1mg/day of valium for a semester – had poor final scores and tells me he can’t remember much of that semester.
People who have that sort of problem tend to notice it pretty quickly. (Although I have to say, I've encountered a lot of pre-meds who weren't on any Valium and whose grades probably would have been better if they had been. < g >)
> Benzos can kill sex for some people. Again YMMV.
CNS depressants seem to have opposing effects on men's and women's sexuality (at least, alcohol and barbiturates do).
A common side effect of benzos, which most people don't seem to know about, is that they can make you really hungry. On several occasions, I've found myself getting really hungry after coming down from a panic attack with the aid of Xanax or Ativan. And once, when I was really depressed and wouldn't eat or drink anything, a concerned friend convinced me to take a Xanax. Within 30 minutes I was not only up and about, but fixing myself some pasta. *That* was impressive.
> I don’t think MOAIs are for most folks – but they have been reported to work very well for people with atypical depressionThey work for a wide variety of types of depression, not just atypical (although they haven't been tested adequately in melancholic depression, the existing data are positive). I definitely don't have atypical depression, but of all the standard antidepressants that I've tried, the MAOIs have come the closest to fixing whatever's wrong with me. Most people with melancholia take tricyclics, Effexor, or Remeron, etc. I couldn't tolerate tricyclics or Effexor, and Remeron didn't seem to work.
> I agree to a point – Benzos had a bad rap even when the patent was in place.
Like SSRIs and Ritalin, they were vastly overused. That probably accounts for a lot of it.
> I would have to disagree. Some depressed folks are pushed farther into depression with Benzos
Yes. Xanax seems to be superior in this regard (it even acts as an antidepressant for some).
> there have been many suicides with benzos plus alcohol.
Yeah, but blaming the benzos for that is kind of silly. There've been many suicides with any-drug-you-name-it plus alcohol. There've also been plenty of accidental deaths from alcohol poisoning, no other drugs required. Alcohol is just plain toxic.
> I would like to see suicide statistics of SSRIs vs Benzos. I bet SSRI would have fewer.
Let's leave out polydrug overdoses; those can get really complicated. The number of suicides committed with SSRIs alone is incredibly low. But so is the number with benzos alone. In order to get enough benzos to commit suicide, you would have to acquire a huge amount, by hoarding them, getting them on the black market, going to multiple doctors, etc. -- even an entire month's supply for someone taking them regularly would be very unlikely to kill a normal healthy adult.
Also, let's not forget that benzos have been around for more close to 50 years, while SSRIs have been around for about 15 years. (I'm not sure exactly when fluvoxamine, the first marketed SSRI, first became available, but it was only after Eli Lilly's impressive marketing of Prozac in the USA that the use of SSRIs became widespread.)
> I don’t think he was a typical benzo user – he didn’ t have it together enough to manage his own meds – really should have been in a halfway house and given benzos when he was in mania – he took a LOT of benzos – more than anyone else I have known.
How many? You said he was on Restoril -- that's a sleeping pill. Was a cause of death ever determined? Was there a quantitative toxicology screen? If not, it's hardly reasonable to attribute his death to any one thing. Like I said, people in that situation -- severely mentally ill, nobody to support them, probably don't have access to the best medical care, etc. -- are endangered in all sorts of ways.
> Some one taking an antipyschotic is in a whole differnt world that folks with anxiety and depression - they have breaks with reality - don't know what is real or in their head. Effexor is not listed for use for Schizophrenia or Mania.
Lots of people with bipolar disorder can't get by on mood stabilisers alone; they need to take an antidepressant too. There's also something called schizoaffective disorder -- schizophrenia plus major depression or bipolar disorder. Psychotic depression needs to be treated either with a combination of antidepressants and antipsychotics or with ECT. Many people with schizophrenia suffer from major depressive episodes following psychotic episodes ("crashes," you could say; the research diagnostic criteria set is labelled "postpsychotic depressive disorder of schizophrenia"), and they need to be treated with antidepressants. Some people with OCD and certain types of severe nonpsychotic depression need antipsychotics in addition to antidepressants. People with borderline personality disorder or complex posttraumatic stress disorder often need a combination of several different types of drugs (which may include antipsyhotics) in addition to intensive psychotherapy.
Mental illness is not an either-or thing, not by any means.
> I would be much more worried about the memory and learning effects of benzos than the choking risk.
I think that the high-potency benzos cause less cognitive impairment than the low-potency ones --although Halcion, the most potent benzo of all the marketed ones, is known to cause memory lapses -- which is why it's only used as a sleeping pill; while Librium, a very low-potency benzo, doesn't seem to cause much impairment at all.
Also, a lot of people *don't* suffer these side effects at all, especially those who are able to get by on low doses. Even when I was taking Klonopin (4 mg) every day, I didn't have a problem with memory or learning (and as a science student, I'd certainly notice any such impairment). I think I mentioned that I know someone who used to abuse Xanax and was at one point taking over 100 mg/day. Guess what? He's a scientist too (we went to school together), and he was actually functioning surprisingly well on that amount of Xanax. (Today he's stable on I think somewhere around 10 mg/day -- for depression as well as panic disorder -- and is completely functional, much more so than he was without medication. He's also stopped self-medicating altogether.)
> My point remains, that there are SOME people who have big time trouble with benzos. Most people use them very well, and IMHO benzos are under prescribed.
Most people use them properly *and* don't have significant side effects. Most people who have panic disorder would choose benzos over antidepressants any day. In fact, I bet that a lot of people with depression would prefer to take high doses of Xanax or Deracyn than have to deal with all the side effects of antidepressants.
-elizabeth
Posted by Elizabeth on June 27, 2001, at 11:36:41
In reply to pssst: Elizabeth! and sheetpacks, posted by grapebubblegum on June 26, 2001, at 21:24:10
> Elizabeth, I think you missed my question or I missed your answer so I'll reprint it: "Elizabeth: I missed it if you stated this before, but are you a physician or some sort of professional other than a plain old layperson like myself? I'm just curious since you seem to know your shizzit."
I didn't miss the question, but I did avoid it. I'm a student; I'd rather not go into any more detail than that. (Bad past experiences with internet harrassment and namecalling, you know.)
But thank you for the kind words. It's nice to be appreciated.
> Also to whoever mentioned this: What is the cold wet sheetpack treatment and how does it work, if it does? Could someone explain how it supposedly works, scientifically?
I think it's a form of torture inflicted on all those evil drug addicts by their "treaters." :-)
(I've known a fair number of drug addicts in my time, and although there were a few bad apples among them, by and large they were decent, caring, sensitive people -- perhaps too sensitive for this world.)
-elizabeth
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