![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 51 to 75 of 175. Go back in thread:
Posted by Alan on October 22, 2002, at 17:25:07
In reply to Re: My Klonopin (Clonazepam) isnt working ??, posted by hiba on October 22, 2002, at 5:25:54
The bottom line about the subject, an argument put forward by many a professional that know their business based on the most reliable and recent clinical and statistical information is two-fold:
1) If one is unwilling or unable to distinguish between addiction and medical dependence, one could talk until doomsday and it would be nothing other than an incredible waste of time.
2) One can not generalise their own situation and extrapolate out for the general population based on their experience. It is not a logically sound form of reasoning - especially in the science of medicine.
Needless to say, both still prevail in the anti-benzo movement and that doesn't even take into account the similarly commercially driven opinions of the APA, ASA, APDA, AA, AAPRA, AAA, AARP, BSA, 20 year old texts, or whomever you want to list (all, by the way, relying on the original prescribing information made by the companies and completely ignoring the plethora of more independent studies over the last 40+ years - reviewed by the World Health Organisation).
Yeah, I've dialougued with Ray and Rand and similar anti-benzo zealots and it's a waste of time. The only positive outcome of such invasions by them is to counter bad information with better information. Then it becomas painfully clear to the vulnerable anxiety sufferer that they're attempting to broadside that there's no great mystery and demon factor when it comes to these medications - more than any other. It's just their "thing" to do.
The profit motive in promting AD's for anxiety disorders from "face time" is laughingly obvious - and has even emboldened pharmecutical representatives to infiltrate bboards of vulnerable anxiety suffers to "advise" them as if giving out medical advice....second hand from a small group of doctors they've "consulted" with.
I mean, come on. How much more obvious can this elephant standing in the room become before someone says anything?
Alan
Posted by Squiggles on October 22, 2002, at 17:29:33
In reply to Re: My Klonopin (Clonazepam) isnt working ??, posted by Alan on October 22, 2002, at 17:25:07
I don't wish to discuss addiction versus
medical dependence. I will talk about it
with a linguist, or a philosopher but that's
it.If you don't mind saying Alan, i am interested
in knowing whether you are a doctor or a nurse.
I notice that you constantly refer to the World
Health Organization, and I wonder why you do
so.Squiggles
Posted by Alan on October 22, 2002, at 19:15:50
In reply to Re: My Klonopin (Clonazepam) isnt working ?? » Alan, posted by Squiggles on October 22, 2002, at 17:29:33
> I don't wish to discuss addiction versus
> medical dependence. I will talk about it
> with a linguist, or a philosopher but that's
> it.Then the refusal to make the distinction (what all physicians make all of their decisions based on - on a daily basis worldwide) is your own decision to put into the catagory of linguistics or philosophy. There's nothing to stop you from doing that. But for the reasons that I mention, the reasons that make that point relevant, are indeed also based in science and medicine.
>
> If you don't mind saying Alan, i am interested
> in knowing whether you are a doctor or a nurse.
> I notice that you constantly refer to the World
> Health Organization, and I wonder why you do
> so.
>
> SquigglesI am not in the medical profession but know a lot about medicine based on the struggle to understand this disorder myself..and talking with other knowledgeable people and other doctors that know their stuff.
If you want to read about the one remaining, least commercially, idealological influenced, broad minded organisation left to adjudicate through all of the crap put out by cults and zealots alike, then just read the 57 page report they put out on the subject at:
http://whqlibdoc.who.int/hq/1996/WHO_PSA_96.11.pdf
By the way, just because Healy and Breggin stand up for patient's rights and for full transparency and disclosure from big pharm. doesn't necessarily always make them fall under the influence of the anti med/bzd lobby. They are consumer advocates that want rightfully to hold the corporations to a higher standard.
Of course that doesn't keep the cults from using them and misrepresenting them out of contesxt for their own political and moralistic purposes....
Alan
============================================
Posted by Squiggles on October 22, 2002, at 20:29:17
In reply to Re: My Klonopin (Clonazepam) isnt working ?? » Squiggles, posted by Alan on October 22, 2002, at 19:15:50
Alan,
I would like to read this, but I have to
print it first. It may take some time as
I have to find someone to print it for me.Thank you--i'm really delighted to have
access to it. Just glancing at the References,
I must say that the familiar names: Bousto,
Ashton, and many others are interesting.I'll get back to you on this and make comments
if that means anything to anyone.Squiggles
Posted by hiba on October 22, 2002, at 23:49:05
In reply to Re: My Klonopin (Clonazepam) isnt working ?? » hiba, posted by Squiggles on October 22, 2002, at 8:04:58
Dear Squiggles,
ACE inhibitors are not in the class of beta blockers. They are very safe medicines if used properly. But what I was trying to prove is, pharmaceutical manuals always carry more than enough warnings to terrify patients. If you are following manuals, you can't use any antibiotics because almost all antibiotics carry a risk of renal toxicity. ACE inhibitors too have this side effect. But simply emphasizing on the risks and toxicity of life-saving medications doesn't make enough fun at all. This is the same with benzos.
Benzos carry a risk of dependence. Yet this risk can vary from person to person. But it is very unfortunate to see a well informed one like you is always emphasizing on the dependence potential of benzos and conveniently ignoring their potential in treating the agony of excessive anxiety and obsessive worries. The dependence potential of benzos is only a very small price a patient has to pay, because if you go through the side effect profile of any benzo, and compare it with other medicines used in psychiatric, or general practice, I am sure you can feel the difference. Almost all antidepressants carry a risk of seizure especially in susceptible individuals. But can you show me a single benzo that will cause a seizure? Rather some benzos are very useful in treating seizure disorders. Older tricyclics carry a risk of agranulocytosis. A potentially life threatening disorder which requires very immediate medical intervension. Newer ADs like mianserin and mirtazepine both have this risk with a higher incidence.There are reports of tardive dyskinesia attributed to prozac use. It is an irreversible movement disorder. But benzos are absolutely free from toxic adverse reactions. The only toxicity that can be attributed to benzos is they cause seizures if stopped abruptly after long-term use . Still a gradual tapering never cause this problem and there is no fatality at all. I have seen some patients with significantly impaired renal function because of the long-term exposure to anti-inflammatory analgesics. And fatal nephrotoxicity is not uncommon in constant antibiotic exposure. Beta-blockers if stopped abruptly after long term use can cause myocardial infarction. This warning can be seen in the safety profile of Visken(pindolol). Still I am not trying to prove all these medicines are toxic and cannot be touched. If used properly under medical supervision, they can be life saving miracles. But if you try to project their risks, there will be no medicine a patient can use.
Now I like to make a comparison.The only risk factor of benzos is their potential for dependence. But what will you chose when you are given a choice between irreversible physiological damage and a slight medical dependence ?About the hollow-feeling: This is what accompanies when you come off prozac and similar SSRIs. It is neither depression nor anxiety. But it is a nothing like feeling. It is very difficult to describe in words. You will not understand what is wrong with you, but there will be only a nothingness inside your head. Terrible! I am still on prozac only to escape from this hellish feeling. Recently I tried to quit prozac and gave wellbutrin a try. But only to boost my depressive symptomatology. So the reinstatement of prozac was inevitable.
Good luck Squiggles, take care!
HIBA
Posted by viridis on October 23, 2002, at 0:29:01
In reply to Re: My Klonopin (Clonazepam) isnt working ??, posted by hiba on October 22, 2002, at 23:49:05
Medical dependency is a small price to pay for peace of mind and the ability to think and function normally. For some, like me, benzos provide this option, without side effects or substantial medical risks. Arguments over benzo dependency, "addiction", etc. are just plain silly. This class of meds may not be appropriate for everyone, but they're a great deal safer and more tolerable than much of what's out there.
Posted by Squiggles on October 23, 2002, at 7:34:59
In reply to Re: My Klonopin (Clonazepam) isnt working ??, posted by hiba on October 22, 2002, at 23:49:05
HIBA,
I hope you find something to wean you off PROZAC--
it is ironic that these SSRIs present with as many
and possibly as serious discontinuation problems
as benzos.I think you make excellent points about the relative
side effect profile of all drugs. It is true that they
all carry their risk and that the risk is described
in the brochure that comes along with the drug (a tome
in itself for the busy doctor with 100 patients to
tend to).I also agree that some benzos are necessary for
convulsion conditions such as epilepsy. Infact,
I think that the correct administration of benzos
may not be that problematic. But there's the rub:
"the correct administration"--it is only with the
loud group advocacy of such groups as the benzo
group, that it has been brought to the attention
of physicians and pharmacists that benzos can be
addictive in the same way as heroin. And by that I
mean that after some time the drug will not only
NOT work, but created withdrawal which is horrible
and can be mistaken for another disorder.One more thing that is different about benzos
from other drugs, is the number of people who
are taking them are have been in the past 30 yrs.
or so. I do not have the statistics at hand but
I know that Xanax and Valium for example were way
understimated in their adverse effects and given
out as the aspirin of anxiety.The result is--a generation addicted to benzos.
And once again, I do not have anything against
addiction--infact, I wish they would consider
giving opioids for anxiety on a small dosage level--
but the unexpected and savage withdrawals as well
as the protracted withdrawal syndrome.I believe that Dr. Heather Ashton and Dr. Busto and
others have described these symptoms very well.I will read that WHO report today or tomorrow I hope
and look forward to gleaning through these aspects.Thank you for the thoughful and informative post.
Squiggles
Posted by Squiggles on October 23, 2002, at 7:47:37
In reply to Re: My Klonopin (Clonazepam) isnt working ??, posted by viridis on October 23, 2002, at 0:29:01
I confess that this "appropriate for everyone"
line does get on my nerves. Nothing personal,
but the variables are kept constant when discussing
a pharmacological problem like this. Otherwise,
it is just unscientific and illogical thinking.In any event, I know that these drugs have
almost magical anxiolytic properties and I know
that they are necessary under certain condtions.Once again, let us hope that your doctor knows
when the time is right to raise the dose, and
not to let you get off without supervision.If you want to know the effects of not having
that kind of vigilance, you can read 'em and weep
at the benzo group through the testimonials of
hundreds of people who have had access to the net
and describe them.Squiggles
Posted by musil on October 23, 2002, at 8:38:02
In reply to Re: My Klonopin (Clonazepam) isnt working ??, posted by viridis on October 23, 2002, at 0:29:01
I wonder if the use of atypical antipsychotics for managing anxiety carries far more risk than long term bzd? I intend to approach my pdoc tonight on this subject, as I'd like to get off Seroquel having gained 15lbs. I did well on bzd but got so afraid of them I wouldn't take them when needed -- and now I know to be worried more about Seroquel than bzd. This thread has been very meaningful to me, BTW, thank you all for your contributions.
> Medical dependency is a small price to pay for peace of mind and the ability to think and function normally. For some, like me, benzos provide this option, without side effects or substantial medical risks. Arguments over benzo dependency, "addiction", etc. are just plain silly. This class of meds may not be appropriate for everyone, but they're a great deal safer and more tolerable than much of what's out there.
Posted by Alan on October 23, 2002, at 10:01:25
In reply to Re: My Klonopin (Clonazepam) isnt working ??, posted by viridis on October 23, 2002, at 0:29:01
> Medical dependency is a small price to pay for peace of mind and the ability to think and function normally. For some, like me, benzos provide this option, without side effects or substantial medical risks. Arguments over benzo dependency, "addiction", etc. are just plain silly. This class of meds may not be appropriate for everyone, but they're a great deal safer and more tolerable than much of what's out there.
================================================
Of course, you're correct. To corner and demomise one class of medication as Hiba also so astutely points out is discriminatory - especially when using inflammitory language such as "addiction" when not appropriate to the situation or comparing illicit medications that drug addicts are "hooked" on. What would drive a med-phobic anxiety sufferer faster from consideration of a medication that is the most effective for the general population for anxiety disorder than any other?
Is someone "addicted" to the medications in exactly the same way that one is addicted to AD's for instance?
All "addiction" is not created equal and when those that insist on focusing so tightly upon one drug use that to inflame those fears that are already med-phobic as a result of their anxiety disorder, then all distinctions are lost
(actually what we're seeing now is ssri-avoidant behaivor in these instances because of these drug's anxiety provoking properties).
Perhaps this message from our own elizabeth will give just one small glimpse into why it's important to make the distinction between "addiction" and a "sustained medical dependence". Perhaps her posting will enuciate more clearly than I a bit of the substantial importance of making such distinctions:http://www.dr-bob.org/babble/20010618/msgs/67768.html
Alan
Posted by Alan on October 23, 2002, at 10:38:28
In reply to Re: My Klonopin (Clonazepam) isnt working ?? » hiba, posted by Squiggles on October 23, 2002, at 7:34:59
> HIBA,
>
> I hope you find something to wean you off PROZAC--
> it is ironic that these SSRIs present with as many
> and possibly as serious discontinuation problems
> as benzos.Actually more serious since the manufacturers have tried to dumb down the public with euphemisms such as "discontinuation syndrome" for withdrawal and "poop-out" for tolerance. They even have covered up their own test results which showed such manifestations during drug trials. That is what the paxil suit is all about. BZD tapering has been the norm from the very beginning as suggested by their own manufacturers.
>
> I think you make excellent points about the relative
> side effect profile of all drugs. It is true that they
> all carry their risk and that the risk is described
> in the brochure that comes along with the drug (a tome
> in itself for the busy doctor with 100 patients to
> tend to).
>
> I also agree that some benzos are necessary for
> convulsion conditions such as epilepsy.But not long term for chronic anxiety disorders?
Infact,
> I think that the correct administration of benzos
> may not be that problematic. But there's the rub:
> "the correct administration"And this has been my point all along. The proper diagnosis, teatment, and management (follow-through) is what will eliminate a majority of the misunderstandings about what some peole are misunderstanding as the "dangers" of these medications.
--it is only with the
> loud group advocacy of such groups as the benzo
> group, that it has been brought to the attention
> of physicians and pharmacists that benzos can be
> addictive in the same way as heroin. And by that I
> mean that after some time the drug will not only
> NOT work, but created withdrawal which is horrible
> and can be mistaken for another disorder.Actually, the stridency of these "advocacy" groups (a euphemism unto itself) is finally deterring doctors and patients alike - especially those that follow the appropriate diagnosis, treatment, and mangement - from being persuaded of the commonality and epidemic terms in which their arguments are framed.
The "facts" have been so demagoguged by these groups that these sites don't even pass the laugh test when it comes to physicians that know their stuff about these medications.
The attempt at polarising the situation can not work in an atmosphere of anecdotal evidence and extrapolation based on an individual's experience.
>
> One more thing that is different about benzos
> from other drugs, is the number of people who
> are taking them are have been in the past 30 yrs.
> or so. I do not have the statistics at hand but
> I know that Xanax and Valium for example were way
> understimated in their adverse effects and given
> out as the aspirin of anxiety.
>
> The result is--a generation addicted to benzos.It is precisely for this reason (inappropriate prescriptions) that many physicians and patients have had trouble with these medications. That's just part of the life-cycle of a drug. The backlash being felt only now after overprescription when the drug first came out. Same is happening now with SSRI'S.
> And once again, I do not have anything against
> addiction--infact, I wish they would consider
> giving opioids for anxiety on a small dosage level--
> but the unexpected and savage withdrawals as well
> as the protracted withdrawal syndrome.
>
> I believe that Dr. Heather Ashton and Dr. Busto and
> others have described these symptoms very well.Unexpected? After all of the rationale that you've presented? Savage for those that are drug addicts or who were mismanaged or misdiagnosed or misprescribed, or had a predisposition to addictive behaivor in the first place - maybe. Adjust statistically for all of those variables and you've basically got a red herring as far as the importance of bzd "dangers" are concerned.
Of course that doesn't mean that there aren't bad reactions to medications....but proportionally, bzds have proven to be at least 75% effective in the vast majority of the population for good reason.
By the way, "protracted withdrawal syndrome" is not even on the radar screen when it comes to medical diagnosis is concerned. And the more those that push for such a diagnosis will continue to hurt a cause which may be legitimate.
There are long term consequences for many on many different drugs that deserve being looked at since these drugs are highly idiosyncratic in some respects. For instance, "protracted" meaning what exactly? For those that prescribe Zoloft and don't expect a withdrawl and see one after 4 weeks...is that protracted - simply because the doctor wasn't expecting it?
And the claim that manifestations of various symptoms are a "syndrome". What is to distinguish these syndromes from other maladys or return of or worsening of original symptoms when heightened symptoms could easily appear while the patient was on the medication? What is to be done about these possibilities - especially if the point of getting the medical comunity to look at something seriously is to persuade rather than hype? It goes against human nature to be persuasive and yell hyperbole at the same time.
I'm not saying that these possibilities are to be dismissed, but to exclusively pinpoint anecdotal reports as fact hurts the cause if indeed these problems do exist.
But one can only cry wolf for so long.
>
> I will read that WHO report today or tomorrow I hope
> and look forward to gleaning through these aspects.I'm sure that your observations will prove to be quite interesting.
Alan
Posted by Squiggles on October 23, 2002, at 10:57:52
In reply to Re: My Klonopin (Clonazepam) isnt working ?? » Squiggles, posted by Alan on October 23, 2002, at 10:38:28
Alan,I will read the WHO report and in my net
search on pharmaceutical corporations and
their government relations, i see that i
am a novice in this area. Nevertheless,
it is interesting and if i have the time i
will continue to read the stuff.I confess though, that this idea has crossed
my mind: as i don't know who you are, the
possibility crossed my mind that you are
setting me up to do the devil's advocate work.But what the hell--i always wanted to
be a lawyer :-)Squiggles
Posted by Alan on October 23, 2002, at 12:11:30
In reply to Re: My Klonopin (Clonazepam) isnt working ?? » Alan, posted by Squiggles on October 23, 2002, at 10:57:52
>
> Alan,
>
> I will read the WHO report and in my net
> search on pharmaceutical corporations and
> their government relations, i see that i
> am a novice in this area. Nevertheless,
> it is interesting and if i have the time i
> will continue to read the stuff.
>
> I confess though, that this idea has crossed
> my mind: as i don't know who you are, the
> possibility crossed my mind that you are
> setting me up to do the devil's advocate work.
>
> But what the hell--i always wanted to
> be a lawyer :-)
>
> Squiggles
>======================================
No such intent from my end.I'm just an educated consumer that at one time got burned by the medical system (like yourself) but in my case it was the witholding of BZDS as an equal option to all other psychotropics for chronic anxiety disorder (because of the effective scare tactic "they were "addictive" misinformation") that led to my wanting to join others to set the record straight..at least straighter than it has been. Proportionality in risk assessment is all that I am trying to iform people about - without all of the hype.
I am afraid that as technical (and comprehensive, which is my point) as the report is, there is only one way to dispute it. Either disredit the organisation or take out of context those bits that are what gives it the comprehensive strength that it enjoys.
I really do not view this as a competition of stats knowing the highly idiosyncratic nature of individual responses throughout the psychiatic field concerning psychotropics.
Sincerely,
Alan.
Posted by Squiggles on October 23, 2002, at 20:34:11
In reply to Re: My Klonopin (Clonazepam) isnt working ?? » Squiggles, posted by Alan on October 23, 2002, at 12:11:30
Hi Alan and musil, viridis, hiba, whoever
else is interested in the WHO "Rational Use
of Benzos" document:My husband kindly printed it for me. I started
reading it tonight. It's rich. It is also
from 1996; nevertheless, i am amazed at how
many similarities i see (just skimming it) with
the knowledge acquired at the Benzo Group.1. General Introduction
I am glad that the target audience is both
psychiatrists and GPs as both use them.2. Epedimiology
2.1 Introduction
These drugs are prescribed in 3rd place, after
heart and circulatory drugs. Why is this? Is
it because anxiety is rampant, or backaches,
or insomnia; or is there some other reason, such
as dependence necessitating the continued prescription
of these drugs;2.2. Indications
The recent restriction of benzos to fewer
disorders is a goo move. The marked discrepancy
for which they are prescribed and the knowledge
or perception that the patient has, is a very good
point. In my case, i have no idea why I was prescribed
the anti-convulsant Clonazepam. I was certainly not
having convulsions. I have heard rumours that
bipolars are epileptics and have seizure-type electrical
activity in the brain, but i think this was at least
theoretical in my time (20 yrs. ago).The recommendation for short term prescription
is also something that the Benzo group was aware
of as the wisest course of action. I was taking
Xanax and Clonazepam for about 12 years, every day.2.4 Prescription Data
The statistics show a high propensity for
physicians to prescribe for non-psychiatric
reasons.2.5 Consumption of benzos
Some interesting hints of contradictory data
here:- "Difficulty in disontinuing the medication was
linked to age (over 45) and duration of use,
but not to the kind of benzodiazepine nor to the
sex of the use (Dunbar et al., 1989). Comparing
data with Balter, these researchers concluded that overall
prevalence use might have declined, but long-term
regular use of benzodiazepines had increased
substantially."- how do we interpret the above; may i suggest
that discontinuation was just unsuccessful and
continued use was the result? Also, i don't know
about the studies here (probably none) but for
some reason clonazepam is more difficult to withdraw
from than others. That was my experience and it
was also reported at the Benzo group.2.6 Conclusion
Benzo prescription and use is increasing.
3. PHARMACOLOGY
3.1 Introduction
A sentence that caught my attention points to
the significant pharmacological differences
between benzos (though of course there are mostly
similarities). Wonder what they are, besides
time and absorption.3.2 Benzo receptors
I notice that the mean duration of benzo treatment
for patients is 50 months. He he he.--- much which is techinical in these sections--
3.4 Clinical importance of pharmacokinetics3.4.1 Anxiolytic use of benzos
This is the main use of benzos. Withdrawal
problems are well described and well known here;
why don't the doctors read this stuff?3.4.3 Anticonvulsive use
They are used for epilepsy; i see no mention
of manic-depression;3.4 Clinical importance of pharmocokinetics
Mania:
This is an excellent and rational use of
benzos! The point is made here that benzos
are used in the initial phases of benzos and
in when in other psychiatric disorders for the
very good reason that they do not counteract
with the anti-psychotics such as lithium. Lithium
with neuroleptics instead of benzos, would
easily result in the truly undesired tardive
dyskinesia and neuroleptic malignant syndrome.But indefinitely? I guess.
-------------I am going to stop now and resume
tomorrow; as i said I am quite amazed at how
consistent the facts here are with the documents
collected at the Benzo group.--------
Squiggles
Posted by Alan on October 23, 2002, at 22:12:32
In reply to Re: My Klonopin isnt working ?? (WHO Benzos) » Alan, posted by Squiggles on October 23, 2002, at 20:34:11
Yes but considering that the Devil is in the details, it's how that "information" is interpreted and ultimately used and disseminated that distinguishes benzo.org and other anti-benzo movements as to whether their claims could possibly withstand the test of time within the structure of science generally and in medicine particularly.
Alan
Posted by Squiggles on October 24, 2002, at 8:41:31
In reply to Re: RATIONAL USE OF BENZODIAZAPINES » Squiggles, posted by Alan on October 23, 2002, at 22:12:32
Alan,
Once statistics are out, and the further
understanding of the effect of benzos on
the GABA system is accomplished, the
"interpretation" of those devilish details
should not exceed the capacity of an
intelligent physician.I continue from 3.4, where I made a remark
that if benzos must be used for agitated
depression or anxiety or mania along with
an anti-psychotic, then THIS is a good thing.
And it is a pleasure to see the vigilence
against tardive dyskinesia and neuroleptic malignant
syndrome if the antipsychotics are mixed with
antidepressants.Something I missed on 3.3.6 about the lipophilic
tendency of the benzos. I am quite surprised to
see this here because in the Benzo group, some
people claimed that benzos tended to stay in the
fat cells and therefore could delay the withdrawal
process or introduce erratic w/d symptoms. Others,
said this was just pseudo-science. It is no longer
1996 so perhaps some current research has settled
this question.
4. INDICATIONSThis means for what these drugs are given (mainly
anxiety and insomnia). Anxiety is defined pretty
extensively. However, the causes and duration of
anxiety is not mentioned, which I think would certainly
influence the understanding of why benzos must commonly
be administered for longer than a year.It is interesting that there are different headings
for Phobias and Panic Attacks; though different
in name, if a doctor were to look at the physical
manifestations (such tachycardia, sweating, dry mouth,
trembling, infact all the autonomic overactivity
symptoms) they would see that there is little
difference. This might reduce the number of
prescriptions that have escalated since 1996, making
the benzos among the top 5 drugs prescribed.Again--differential diagnosis. Autonomic overactivity
may also be caused by thyroid toxicity and other
physical disorders; and as the medical psychiatry
model knows so very well--the body influences the
mind.Mania is very briefly discussed. I think it
is inadequate. "In manic episodes benzodiazepines
may be used adjunctively with mood stabilizers."
Does this mean that we wait for the manic episode?
Do we give the benzo to those described as manic depressives.
And, this is a point which disturbs me greatly--
is mania a possible side effect of unrecognized
benzo withdrawal, for which more benzos are prescribed?Again--differential diagnosis-- ask the patient
if he or she has been taking benzos, and if she or
he has stopped suddenly or forgotten to take them
for some weeks or decided on his own he no longer
needs them.4.1.4 Benzo and alcohol withdrawal
I did not know that chlormethiazole could be used
for withdrawal; i thought phenobarbitol was.
Anyway, the statement that benzos are of great
value in the management of the withdrwal state
ensuing abstinence from alcohol or benzos or hypnotics,
begs the question in the case of benzos. Why,
would one want to get off benzos if they are
prescribed for these disorders so effectively?
Does the patient say, I no longer have a phobia,
or insomnia, or mania? And if that is the case,
how will the doctor distinguish between the
"underlying disease" having been cured by benzos,
and the assumption that time alone has cured it.
What medical criteria are there for these
diagnostic problems?4.1.5 Personality Disorders
I think this is a good assessment, and
takes into account very important aspect
of the patient's health such as physical
problems, drugs taken, and personal toleration
of these drugs. The voluntary aspect may
be something to consider too, and again where
panic is mentioned, a physical examination
should be stressed.4.1.2 Psychoses
I'm going to break here before continuing with
Psychoses.Squiggles
Posted by Rick on October 24, 2002, at 22:46:25
In reply to Re: My Klonopin (Clonazepam) isnt working at all!!!!! » Jefff, posted by Alan on October 19, 2002, at 23:02:14
Seriously, I've taken it for three years and haven't noticed any increase in iritability frequency or intensity except while taking it with other meds including Serzone and Provigil (both of which I like, BTW). Of course, YMMV. Maybe it's more likely to have this effect at higher doses or in combos.
Rick
P.S. I haven't read the whole thread, so my apologies if anything I've posted is redundant. No wait..why should I apologize? Why should I be expected to waste my time reading EVERYTHING??? Who do you people think you are, anyway?!?! <fume, fume>
Posted by utopizen on October 25, 2002, at 6:03:52
In reply to Re: RATIONAL USE OF BENZODIAZAPINES » Alan, posted by Squiggles on October 24, 2002, at 8:41:31
What I never got was why there's so many people on this board, including me, who have been working with a doctor for a while trying a lot of different drugs, and then don't get benzos, which are seen as a last resort by our docs.
Then we get to turn our heads and see benzo sales top so high other prescriptions. I mean, I can't even get Klonopin prescribed, and would never even bother asking my doc for something like Valium or Xanax. Yet sitcoms mention it like it's sold next to the hard candies, and somehow enough people get prescribed it to top sales listings. So why are people who resorting to boards like this everyday for help still not getting them, then people who probably couldn't spell them get them given without asking (as I assume, since so many are sold, and only a certain percentage are of those who bother to research these things).
Still, they do sedate, which I don't like...
Posted by Squiggles on October 25, 2002, at 8:13:14
In reply to Re: RATIONAL USE OF BENZODIAZAPINES, posted by utopizen on October 25, 2002, at 6:03:52
These observations may be personal. I think
that you are generalizing. Maybe there are
doctors who ARE prescribing them, but you are
not there at the scene to see it.Maybe there has been some influence from the
noisy Brits and Canadians about using caution
in prescribing them for every little thing.
(I have noticed some papers for example on
the elderly and how their driving may be
impaired in taking these drugs on the Internet
Mental Health network and McGill Research Dept.Is it possible that it is just your doctor
that does not think it advisable for you to
take them?Squiggles
Posted by Squiggles on October 25, 2002, at 9:18:38
In reply to Re: RATIONAL USE OF BENZODIAZAPINES » Alan, posted by Squiggles on October 24, 2002, at 8:41:31
OK - back again and continuing remarks on the
WHO document at 4.1.2:4.1.2 Psychoses
Organic Psychoses
a) Acute organic brain syndrome
BTW, i like the title of that, it's very general
indeed---what does it mean and how many conditions
does it cover? Also, is there inorganic brain
syndrome?I remember the 60s, when it is mentioned here
that benzos are used for LSD or hallucinogenic-
induced psychosis or "freaking out". Yup, my
friends had mentioned something - Valium i think
and i recall thinking--yikes! they want to take
another drug too!As for neuroleptics, i have read so many awful
things about them and their ability to induce
neuroleptic malignant syndrome, that i hope a
new edition of this document would get rid of
them altogether.
b) Chronic organic brain syndromeFirst they define this as dementia, then they
say that benzos are not good for it; since the
definition is so general, what if includes
something like Parkinson's or Alzheimer's
or any of the myriad other CNS disorders?Too general. Benzos may infact be good for
Parkinson's if THAT particular brain syndrome
presents with anxiety.Schizophrenia and related disorders:
Well, i should hope that by now there may be
new drugs for schizophrenia. I find the use
of benzos for catatonia rather pardoxical but
i'm no doctor.Other psychoses
4.1.3 Mood Disorders
Depression
I think they've got this one right; antidepressant
for depression with the adjunct benzo for the
effects of the antidepressant. Once stabilized
thought, one wonder why these drugs are given
prophylactically.. is this really necesssary?Mania
They've got this right too-throw out the
neuroleptics.
Once stabilized
thought, one wonder why these drugs are given
prophylactically.. is this really necesssary?
4.1.4 Drug and alcohol withdrawal syndromesYes, yes, yes. I don't know about alcohol, but
I can tell you pesonally, that in the case of
benzos, withdrawal should be tapered not only
with time (which is what I tried to do with the
Chunk-0-Meter) but with another benzo--e.g. Valium
or anything longer-life than the one you are
addicted to. With Xanax time was enough and I have
been told the withdrawal is relatively easy
because i was covered by the Rivotril. But with
Rivotril, time did not work; i should have tapered
off with Valium as Dr. Heather Ashton recommends.BTW, we have taken off the Chunk-0-Meter from
the Benzo group, because of the stroke or aneurysm
or whatever I got after 1 and a half yrs w/drawing
from 1.0mg Rivtoril. I think that time is not
enough. Again I did not know chlormethiazole was
used.
4.1.5 Personality disorderIf there is one thing that curls my hair, it's
"dependent personality disorder" and "emotionally
unstable personality disorder", and "Dahli fan
personality disorder", thouth this last one may
be an organic brain disorder indeed. Sigh...
well, at least they do not recommend drugs
for character.4.1.6 Suicidal patients
I don't know about this; maybe cocaine first or
something like it along with a benzo... a
sucidal person may be very depressed as well
as agitated - problem is how to turn that around
fast.
4.2 Other medical disorders4.2.1 Seizures
What are dissociative convulsions?
Status epilepticus - obviously you need
an anti-convulsant; but is manic depression
a species of epilepsy? Or was it the fashion
to just give it for accompanying anxiety or
GAD as it is affectionately called;4.2.2 Tardive dykinesia and akathisia
--
4.2.3 Somatic presentations
What are these? Is this what one of the people
at Benzo has - complaining of the entire body
being in pain from withdrawal of benzos?4.2.4 Muscle spasm
I think it was the vogue in the 70's to give
benzos for muscle pain; infact i think a relative
of mine was given these and got addicted. This
may explain the effects of addcition which looked
like an inexplicable state of anxiety and
rage. Benzos unless taken properly and on a
rigid program, can present with truly psychotic
episodes and behaviour. And nobody would suspect
it unless they knew the effects of intermittent
withdrawal, underdose, overdose, discontinuation,
etc. Muscle spasm, unless something medically
serious, should be considered as a minor ailment
for which benzos should be prescribed short-term
and some physiological therapy following it.
4.2.5Other indications
---
4.3 Symptomatic use4.3.1 Sleep disorders
Insomnia
I think this is the worst reason for giving benzos;
first of all the REM is changed, and your sleep
is crappy, but most importantly, the reason for
insomnia is not examined. The person, i bet you
more often woman gets hooked; it inevitably escalates
into addiction and having the responsibilities of
work and family the person has no choice.
But I think they realize this here.Disorders of arousal
--
4.4. Other situationsYup, this is excellent. Benzos should be used
as psychological ban-aids until the wound is
treated and healed.The next section is 5. (ADVERSE EFFECTS) hee hee!
(sorry to have to break now--i hope you can
follow it); BTW I wonder if this is the latest
version of WHO or a next one is coming up;
Squiggles
Posted by linkadge on October 25, 2002, at 19:07:38
In reply to Re: RATIONAL USE OF BENZODIAZAPINES » Alan, posted by Squiggles on October 24, 2002, at 8:41:31
For some reason I am under the impression
that Klonopin has dopamine raising effects,Kurt Cobain used this drug (probably abused it)
in his attempt to withdrawl from Heroin. In him it caused psychosis.Does anyone have information as to wheather this drug raises dopamine levels.
Linkadge
Posted by Ritch on October 25, 2002, at 20:11:44
In reply to Does Klonipin have dopamine effects, posted by linkadge on October 25, 2002, at 19:07:38
> For some reason I am under the impression
> that Klonopin has dopamine raising effects,
>
> Kurt Cobain used this drug (probably abused it)
> in his attempt to withdrawl from Heroin. In him it caused psychosis.
>
> Does anyone have information as to wheather this drug raises dopamine levels.
>
> LinkadgeI do not believe it does. I have heard it has a mild serotonergic effect. It is an anticonvulsant (albeit a benzodiazepine), and they can cause psychotic or "paradoxical" symptoms in a tiny subset of people. Behavioral side effects rank somewhat higher with clonazepam than the usual BZD sfx, from what I remember. Interestingly, the two benzos that have the strongest antimanic efficacy are clonazepam and lorazepam.
Posted by Squiggles on October 25, 2002, at 20:22:07
In reply to Re: RATIONAL USE OF BENZODIAZAPINES (4.1.2) » Squiggles, posted by Squiggles on October 25, 2002, at 9:18:38
Hi,
back again: 5: ADVERSE EFFECTS
The benzos are favourably compared to ADs and
neuroleptics and considered safe and without
severe side effects. A brief look at the benzo
group will certainly contest this statement.
I have observed people getting off tricyclics
and SSRIs and as hard as that is, there is no
comparison with benzos. Benzos really should
be compared to heroin withdrawal. I've not yet
come to such variables as KIND of benzo, TIME taken,
and DOSE. These are decisive in the withdrwal
severity.In unmonitored, erratic dosing of benzos,
symptoms of psychosis may be indistinguishable
from the real thing (i.e. endogenous or non-benzo
related).
5.1 General adverse effectsAgain, I direct you to Ray Nimmo's site for
a collected array of side effects. I'm glad to
see the *falling* symptom here; when my Rivotril
dose was raised I got up from the chair and fell,
breaking my foot. I told my dr. i thought it
was the Rivotril that made me lose my balance but
it was hard to believe. Oh, and I am not elderly,
though I may look it by now :-).The inability to distinguish between adverse
effects and symptoms of underlying chronic diseases
is a good observation. However, this is a two-edged
sword, as the underlying chronic disease may take
precedence in the diagnosis to the the effects of
the benzos. This is particularly the case, in
withdrawal, sub-withdrawal, or erratic dosing, or
sudden stopping.
5.2 Withdrawal syndrome and dependence5.2.1 Withdrawal syndrome
Yes, they've got this right: only a therapeutic
dose is enough to cause withdrawal, given enough
time of taking the drug.The "nocebo" effect is nonsense. The rest is
very good. What is missing the "protracted withdrawal"
syndrome. This is even stranger than the paradoxical
and rebound phenomena.... my guess is that changes
take place in either the structure or the chemistry
of the brain, after the drug is used for a long time.
Stopping the drug, leaves the brain in a state that has
lost its initial equilibrium and either takes a very long
time (may GABBA receptors or dendrites have to regrow
or something) or equilibrium is never ever reached again.
Dr. Heather Ashton speaks of some long-term users suffering
motor effects for up to 15 years, for example.If you would like a personal example, I have had
diarrhea, and peripheral neuropathy as well as
tinnitus, and botched body temperature control since
the withdrawal... most of these after 2 years about,
have disappeared gradually fading.
5.2.2 DependenceThe definition should not concern a doctor so
much as a linguist. For purposes of medical
observation, cessation of the drug is followed
by very unpleasant and painful syndromes, which
can be reversed to some extent by reinstating
the drug. Call it "dependence" or "addiction"
or whatever; the main point is the practical
aspect of being on the drug, stopping the drug,
and reinstating the drug. It is true, there is
no craving, just extreme syndromes caused by
discontinuation.5.3 Overdose
I have heard, contrary to this "suicide-safe"
aspect of benzos, that with alcohol, they are
lethal. I recall a benzo member telling me how
much it would take, but I forget.
6. STRATEGIES FOR PRESCRIBING BENZODIAZEPINES6.1 Introduction
This is good advice, if followed.
6.2 General approach
I cannot find anything lacking or to disagree
with in this section. It's very wise. I would
only stress the necessity of monitoring and
carefully tapering the patient off, once the
treatment has been completed. Regarding the
chronic problems, such as panic disorder--i have
my reservations. I do believe that panic
and anxiety are symptoms and not a disorder itself.
Long-term treatment is very attractive for its
simplicity, but may be quite mistaken, by mistaking
the symptom for the sign.6.2.5 Discontinuation
Much can be learned from the Benzo group here.
I am glad to see that some physicians use
long-life benzos to get people off. The reduction
is smooth for some benzos but not others. The difference
between different benzos is not discussed here.
Again the "addictive" personality problem requiring
longer tapering, is at least insulting and at most
medically irresponsible.
6.2.6 Withdrawal managementThe time give 4-8-16 weeks worked for me for
Xanax at the therapeutic dose of 1.0 taken over
12 years or so. I still do not understand why
the clonazepam was so hard not just for me but
for many people reporting difficulty on the
Benzo group. Is its chemical structure different?
As an anti-convulsant, is this why i got a seizure
and myoclonic seizure as diagnosed by an emergency
doctor the year before (not my dr.).In general, i think this is quite good; part
of the problem is that physicians do not believe
that benzodiazepines can have such withdrawal effects,
and stick it to the "addictive personality" or
a hypochondriacal or hysterical patient. And, the
patient being in the majority women, this may
present a problem.
----got to go again--nest is 6.3 Special situations
Squiggles
Posted by Rick on October 25, 2002, at 22:24:26
In reply to Does Klonipin have dopamine effects, posted by linkadge on October 25, 2002, at 19:07:38
> For some reason I am under the impression
> that Klonopin has dopamine raising effects,Why is that? While many drugs can simultaneously have both pro and anti-dopaminergic effects, most studies have put Klonopin primarily in the latter category. Which in one way is odd, since both Klonopin and Dopamine Agonists are meds of choice in Restless Legs Syndrome.
> Kurt Cobain used this drug (probably abused it)
> in his attempt to withdrawl from Heroin. In him it caused psychosis.Like many psychotropics, Klonopin can have paradoxical effects in certain people, especially when the dose is high and it's combined with other agents. Even though Klonopin is sometimes used as an adjunct mood stabilizer, the following is an example of where it apparently induced mania:
DICP 1991 Sep;25(9):938-9
Mania associated with clonazepam.
Dorevitch A.
Faculty of Medicine, Hadassah Hebrew University, Jerusalem, Israel.
Clonazepam is a potent, long-acting benzodiazepine approved for use in myoclonic and petit mal seizures. Initial reports have demonstrated encouraging results with clonazepam in the treatment of acute mania as well as a favorable side-effect profile. A trial of adjunctive clonazepam was initiated in a 41-year-old patient with chronic schizophrenia. Two weeks later, while on an 8-mg dosage, he became manic, developing pressured speech, euphoria, inflated esteem, agitation, and insomnia. Initiation of electroconvulsive therapy with gradual tapering and discontinuation of the clonazepam resulted in amelioration of the manic episode and a return to his previous clinical status. Clinicians should be alerted to the potential of clonazepam to cause manic-like behavior in susceptible patients.
Rick
Posted by hiba on October 26, 2002, at 1:15:00
In reply to Re: RATIONAL USE OF BENZODIAZAPINES (5.) » Squiggles, posted by Squiggles on October 25, 2002, at 20:22:07
Oh Dear Squiggles,
You are going far and far.
"In unmonitored, erratic dosing of benzos,
symptoms of psychosis may be indistinguishable
from the real thing (i.e. endogenous or non-benzo
related)"This is a wonderful finding. Do you have any scientific evidence to back this ? Benzos, if used for a long time in very high doses and stopped abruptly can cause a syndrome that resembles to psychosis.(But unlike stimulant psychosis which is irreversible, this can be reveresed and treated successfully). Is this what
you mean ? Some benzos in fact used to treat psycosis. Chlordiazepoxide, lorazepam and clonazepam for instance.
And if you have an access to ABPI DATA COMPENDIUM, please see the data sheets of antidepressants (especially tricyclics). You can see the warning: Tricyclics may cause activation of psychosis. Can you show me any such warning in benzodiazepine data sheets ?You are determined to rate benzo withdrawal as heroin withdrawal. I have witnessed many heroin and benzo withdrawals. And in the light of my experience, I can only laugh at your attempt. You are obsessed with the anti-benzo group.
About side effects: If you have experienced more side effects on benzos, you have a right to claim. But generally benzos are much much safer than hard antidepressants and all other medications used in psychiatric practice.. Pharmaceutical manuals (which you always refer in
your messages) will definitely clarify this.ABOUT WITHDRAWAL SYMPTOMS: Since you are not a Doc or clinical professional, I think it is better to give the reference along with your statements. I am not a Doc or professional . So I don't speak on my own. Let me quote American Psychiatric Association's Task force report on benzos:
"All psychiatric drugs, if taken for more than a brief period, may produce discontinuance signs and symptoms when abruptly stopped, and these symptoms may be an intensified recurrence of the original signs and symptoms, or may be the mirror image (for example, the opposite of the normal therapeutic effect of the drug). Sudden discontinuance of antidepressant drugs, for example, may produce a severe depression, rebound cholinergic symptoms, or agitation, or it may precipitate a manic state. Withdrawal dyskinesia is commonly seen after neuroleptics are abruptly stopped, and a recrudescence of manic symptoms has been reported after abrupt lithium termination." (Page 15)Then why should you blame benzos solely for dependence???
"What is missing the "protracted withdrawal"
syndrome."Oh! what is this? protracted withdrawal syndrome? Any scientific evidence to clarify this PROTRACTED? Plese don't quote those benzophobics or Dr. Ashton. There are enough pharmaceutical manuals which you would like to refer. Any hint from them? I can name some, if you need.
1. MARTINDALE:THE COMPLETE DRUG REFERENCE.2. PHYSICIAN'S DESK REFERENCE.
3. PHARMACOLOGICAL BASIS OF THERAPEUTICS.
4. ABPI DATA COMPENDIUM.
".... my guess is that changes
take place in either the structure or the chemistry
of the brain, after the drug is used for a long time.
Stopping the drug, leaves the brain in a state that has
lost its initial equilibrium and either takes a very long
time (may GABBA receptors or dendrites have to regrow
or something) or equilibrium is never ever reached again."You have your right to guess. But please don't impose them on patients in this board. Besides "GUESS" shouldn't always necessarily be right. The term GABBA for instance. It is not GABBA but GABA.(GAMMA-AMINOBUTYRIC ACID)Please check in your message.
I have personal experience of using benzodiazepines. I have used klonopin upto two years and gradually tapered WITHOUT ANY PROBLEMS AT ALL. Now I am afraid of those "PROTRACTED WITHDRAWAL SYMPTOMS"!!! I hope there will be a benzophobic to predict when I should begin to experience "PROTRACTED WITHDRAWAL SYMPTOMS".
If a benzo has made you sick, it is not fair to make all benzo users sick. There are millions who use benzos very effectively and benefit from them. Tell us your experience. It is welcome. But insisting on all patients should experience what you experienced is not fun at all.
About Ashton protocols: Her protocol is not working for everyone. The substitution of valium for xanax is not that effective. I have a friend who followed Ashton protocol to withdraw xanax and in his case it was an utter failure. Still I don't generalize this failure. But theoretically xanax is better substituted with klonopin. This is true in practice also.
Dr. Ashton is a single soul. I don't usually rely on such sole findings. Rather I will go for the combined work of scientists where there is only a very small possibility of error.. The references I named above are not the works a single scientist. They are compiled by some groups of reputed scientists.
Good luck Squiggles, Take care
HIBA
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