![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 82 to 106 of 175. Go back in thread:
Posted by Rick on October 26, 2002, at 15:22:55
In reply to Re: Does Klonipin have dopamine effects, posted by BrittPark on October 26, 2002, at 12:21:03
> The problem with boards like this is that, for the most part, people report negative results.
This is a great point that bears regular repeating. Clearly, someone who is, or has, had severe withdrawal (or even addiction) difficulties is much more motivated to write, either looking for support/advice and/or to share their experiences as a good-intentioned warning to others. (And there's also the occasional benzophobe who is making the whole thing up for effect, though I don't get the impression that this happens much on this board). While those with significant difficulty may represent a pretty small proportion of responsible benzo users who taper off appropriately, there are so many benzo users in total that the absolute number of bad experiences is large.
Rick
>The weight of clinical evidence is that benzos are safe for both short and long term use and that withdrawal symptoms are mild to non-existent if discontinuation is handled slowly.
>
> I've taken very large doses of both clonazepam and alpralozam (up to 6mg/day) on several occasions and have never had any withdrawal symptoms when discontinuing.
>
> My 2 cents,
>
> Britt
>
Posted by Squiggles on October 26, 2002, at 15:23:18
In reply to Re: RATIONAL USE OF BENZODIAZAPINES (5.) » viridis, posted by Squiggles on October 26, 2002, at 13:59:53
I notice here a point that has been laboured
through this discussion--withdrawal syndrome
occurring at therapeutic dosage:"During the 1960s, withdrawal symptoms were
reported to occur upon discontinuation of long-term
use of benzodiazepines at doses several times
higher than the usual therapeutic dose. More
recently, a number of studies have shown that
withdrawal syndromes can occur even at therapeutic
doses." [p. 20]The syndromes are described and my point that
ideally they should be used symptomatically and
not for long-term is noted. I notice also the
point about respiratory distress. Do they know
why? It is remarked here that in general it is
a contraindication. When I was searching for the
reason why I had panic attacks and dyspnea at night,
I came across an article on respiratory suppression
by benzos, and also another article by an anesthsiologist
who described the benzos as having the effect of
respiratory suppression. Bingo, I said to myself.
Now, if you say that this happens with some people
and not others depending on their age, etc. I will
grant you that any drug, to have an effect required
both the taker and the drug; it is a two-way street,
just as all interactions between a and b are; but this
is also the case with aspirin or any other substance.
It is the case with coffee or milk for that matter.
And if you say that such effects depend on the subject
alone, you are eliminiating the chemical aspect of the
drug for which it is designed, i.e. a human or animal
organism, with a particular area of the brain as target.
Therefore, it should not be surprising that an
anti-depressant effects the brain, whereas a Beta-blocker
effects the vascular system, and predictably in similar
ways.6. STRATEGIES FOR PRESCRIBING BENZODIAZEPINES
a) Screening instruments
I imagine these are questionnaires?
b) The Clinical Interview
I am very happy to see the inclusion of examining
the patient for prior history of dependence on
drugs and comorbid psychiatric disorders. However,
just because we are doing psychology here, does
not mean that there should not be an examination
of PHYSICAL COMORBID DISORDERS. I don't see this
here. For example, hyperthyroidism, heart disease,
etc.c) General Medical Evaluation
This is a projection of the possible problems
of prescribing benzos.d) Physical Examination
This is a one sentence vague proposal for a general
examination. I think the variety of conditions
that induce anxiety and panic, should be outlined;
there are many.
May I suggest that the age of the person, and in
cases where ethnic background has an effect on the
metabolism of benzodiazepines be considered in the
initial examination.
6.2.5 DiscontinuationThe protracted withdrawal syndrome is omitted.
And the re-emergence of an initial anxiety state
is presumed.
These are grave errors.Not all benzos are the same in effect of
withdrawal. I have yet to see the papers which
must exist on what is different about an anxiolytic
and an anti-convulsant - chemically.6.2.6 Withdrawal management
Any kind of management would be humane and welcome.
These drugs have been taken very lightly, and I don't
think that doctors are aware of how serious the withdrawals
are. In a letter to the Health Minister, the
Hon. Alan Rock, and in a similar letter to Hoffman
LaRoche and Upjohn, i had suggested, as a consumer,
that the problem was serious enough to merit the
opening of clinics for withdrawal. I think the
doctors are well-meaning but too busy, considering
the enormous amount of prescriptions for this
3rd ranking class of drugs on the market. Ha!For programs and schedules, see Ray Nimmo's site
www.benzo.org.
6.3.1 and 6.3.2The consideration for children and elderly is
good and the fact that benzos can be more potent
in CNS disorders in these age groups. However,
the age of elderly and children is not defined.6.3.3 Pregnancy
Yes, this is well written; the embryopathy that
is discussed may be damaging to the brain what the
Benzo group call cited many cases of "floppy baby syndrome".
This is discussed here too. They should be used
with caution if at all.6.3.4 Alcohol
I don't know much about this; I have noticed
a compounded effect with a glass of wine or
beer and so if i drink, I drink 1/2 a glass
with dinner or not often. I have heard that benzos with
alcohol are an effective means of suicide,
assuming you do not throw up - not sure of
the dose.6.3.5
Same here, though I imagine they are used
to come down from stimulating drugs. That
would not be a bad thing.
7. SOCIAL AND ECONOMIC ISSUES7.1 Attitudes
The discussion on the public's negative perspective
of people taking benzos must be something someone
did a thesis or research on. I think that all
psychiatric drugs are viewed with some suspicion.
I know someone who was denied insurance on the grounds
of taking an AD, for example.In general the discussion of moral and social
aspects is very extensively covered in David Oaks'
SCI advocacy groups. It's too huge to talk about
here.
9. SUMMARY AND RECOMMENDATIONSActually, I think this is a good report in general;
I would like to see the protracted syndrome mentioned.
And I have a question: have opiates been considered
instead of benzos for similar disorders?And finally, a personal question:
Is clonazepam prescribed for manic depression because
manic depression is considered a species of
epilepsy? Does anyone know why clonazepam is so
difficult to withdraw from (after many years?).I hope that the careful and well-researched
aspects of this report can actually be put
into practice. I believe that doctors in general
may be too busy to follow guidelines like this,
but let us hope; who knows, maybe the pharmaceutical
concerns will see some advantage in assisting
with prescription and withdrawal.I'd like to thank you for letting me know
about this document and for letting me take up
so much bandwidth to comment on it.Squiggles
Posted by Rick on October 26, 2002, at 15:38:18
In reply to Re: RATIONAL USE OF BENZODIAZAPINES (5.) » Squiggles, posted by viridis on October 26, 2002, at 13:13:09
For the most part, my pdoc's reaction was the same. He's been prescribing benzos for 20 years,and says that as long as I never exceed 3 mg Klonopin (I'm nowhere near that, BTW), it's not very likely a slow withdrawal will present significant difficulty.
He actually preferred that I be treated with an AD, but not becuase of dependence or addiction concerns. Instead, it's because he feels that some benzos, especially Klonopin, are "dumb drugs." (The extent to which that's true is another issue for debate.) But at this point, he feels, "whatever works" is the way to go. Although, every once in awhile he asks if I'd like to try Tranxene (clorazepate) again instead of Klonopin. (I'm starting to digress here...) Of course I always give a quick "no" to that suggestion. I don't think Social Anxiety is one of his areas of specialty, although I like the fact that he's cautiously open-minded about treatment alternatives. E.g., at my request, he recently agreed to let me try adding hydergine to my regimen. (That stuff sure isn't easy to find in U.S. pharmacies, at least in my area!)
> Hi Squiggles,
>
> I'm sorry to hear that you had such a bad experience with benzo withdrawal, and I know that some people do react in very negative ways. However, the weight of scientific evidence indicates that withdrawal for most can be managed very effectively by slow taper and careful supervision. You spoke in an earlier post about "variables" and "objectivity". When dealing with medications, the patients themselves are major variables in the sense that different people have different reactions to both the drugs and discontinuation of the drugs, whether you're talking about benzos, ADs, blood pressure meds, or most other classes of medications.
>
> I haven't attempted benzo withdrawal, and have no plans to do so in the near future, since Klonopin has been so beneficial for me in terms of anxiety, depression, and general quality of life. So, I can't offer any personal experience there. However, I can relate my pdoc's experiences and advice based on his use of benzos for numerous patients, both short and long-term. He screened me very carefully before prescribing benzos, explained that medical dependency was likely to develop, and said that he is very alert to signs of escalating dosage and misuse (although he was also very willing to increase the dose if appropriate). After well over a year at the same low dose of Klonopin (1 mg/day) plus occasional Xanax, he and I are very pleased with the results. When I asked him about what would happen if I decided to discontinue it, he said that he's rarely seen a problem as long as the withdrawal is gradual. He emphasized that these are not drugs that should be stopped suddenly, but said that supervised withdrawal is generally quite straightforward in his experience.
>
> For me, though, he predicts that discontinuation would return me to the same pattern of anxiety/ panic attacks/ severe depression that I've experienced since childhood. I'm not willing to live that way any more (and I expect it would shorten my life -- not that I'm suicidal, but chronic anxiety takes a toll on a person's mental and physical health). Approaches such as antidepressants, therapy, alternative treatments, and lifestyle changes were of no or limited use, or actually made things worse (SSRIs, Wellbutrin). So for me, long-term use of Klonopin seems like the most sensible option, and my pdoc agrees.
Posted by Alan on October 26, 2002, at 15:41:05
In reply to Re: RATIONAL USE OF BENZODIAZAPINES (5.) » viridis, posted by Squiggles on October 26, 2002, at 13:59:53
> Once again, the amount of dose, the length of time,
> the abruptness of cessation, and the increase or non-increase
> of dose over time, are variables that will influence
> the severity of withdrawal with these drugs.
================================================
And if I may interrupt, here is of where much of the misunderstanding lies within the tightly knit anti-benzo movement.Since an individual's respose to a drug is so highly idiosyncratic as to the above mentioned points, especially regarding psychotropics, not just bzds, it is virtually impossible to extrapolate that these variables apply to the population in general. They are mere basic medical guidelines that don't increase the risk TO THE INDIVIDUAL as implied by the anecdotal and highly indiviual adverse responses to these meds as reported by a small minority of the population at benzo.org and similar sites.
Statistics and pharmacokenetic curves in some texbook or pharmrep presentation do not apply to the individual - which becomes quite evident when one understands that these medications are so highly effective IF PRESCRIBED, DIAGNOSED, AND MANAGED properly....or to directly use the words of the report..."Used rationally".
The key complaint is that Benzo.org-like sites seize on risk appropriate to the individual and then mistakenly generalises for the population.
So what does the average consumer think when they read this? Where does it leave their naturally anxiety ridden, hyperaroused, med phobic minds? Oh! This must apply to me...extrapolating in the same style by example of that which the benzo.org folks have already (mistakenly) used as their model.
Terribly misleading as to proportionality of risk/benefit assesments applied to any medication much less bzds. What is particular unethical is the exploitation of the "A" word (addiction) when it is used as a pejorative.
Refusing to accept the distinction to "sustained medical dependence" is a conscious choice to continue exaggeration of risk to the individual consumer. The term "Addiction" is used as inflammitory rhetoric to push an agenda that would otherwise be a relative non-issue.
This is not to minimise those cases that have bad experiences coming off of bzds but to acknowledge that it happens to a small minority of the poulation henceforth the use of "RATIONAL USE" as the title of the report.
Alan
Posted by Alan on October 26, 2002, at 15:44:26
In reply to Re: RATIONAL USE OF BENZODIAZAPINES (5.) » viridis, posted by Rick on October 26, 2002, at 15:38:18
How do you use hydergine? and what has it done for you re: your dx. I take Klon maint. and ativan PRN for breakthrough with GAD and SAD.
Thanks!
Alan
Posted by Rick on October 26, 2002, at 16:31:03
In reply to Re: RATIONAL USE OF BENZODIAZAPINES (5.) » Rick, posted by Alan on October 26, 2002, at 15:44:26
Just started it about ten days ago. Take 3mg/day of generic ergoloid mesylates. That's the max recommended by the FDA; my pdoc says he's gone as high as 6 mg. I know in Europe it's typically given in higher doses, e.g. 9 mg/day.
It's too early to report any results. I've noticed some mild improvement in memory, and some added "calm alertness," but at such an early stage these could very well be coincidences/placebo effects -- although I certainly hope it's a sign that the med is starting to work for me. If indeed it works, the effects of hydergine are said to be quite gradual. I sure haven't experienced any side effects, other than some barely-noticeable nausea at first and less-variable blood pressure (a good thing).
At the moment the only other psychotropic med I'm on is my mainstay daily Klonopin (1 mg, all first thing in a.m.), for non-depressive social phobia.
I'll report back as the experiment continues.
Rick
> How do you use hydergine? and what has it done for you re: your dx. I take Klon maint. and ativan PRN for breakthrough with GAD and SAD.
>
> Thanks!
>
> Alan
Posted by Rick on October 26, 2002, at 16:59:01
In reply to Re: RATIONAL USE OF BENZODIAZAPINES (5.) » Squiggles, posted by Alan on October 26, 2002, at 15:41:05
Well said!
In additional to the irrational reasons you and others have cited, I believe that some of today's benzophobia was fueled by the early days of benzos -- especially Valium -- when many GP's would indiscriminately hand them out like candy. You had people coming in with what was clearly a depressive, rather than anxious, disorder, and the doc would throw benzos at the patient.
Long before I had ever heard of social phobia (even though I sure had it!), I asked a college counselor to prescribe something to help me get through job interviews without shriveling and quavering. She refused, but later left me a note which included a reluctant prescription for Valium. (I guess I've always been good at laying guilt trips.) I was completely naive to anything but over-the-counter drugs at that point, and found the Valium useless -- not even a placebo effect.
I'm so glad different benzos have different properties, because for my social phobia the difference between Valium (or my pdoc's "beloved" Tranxene) and Klonopin is night-and-day.
BTW, in all fairness to Tranxene (drugs have feelings, too, y'know), I understand it can very smooth and effective for GAD.
Rick
> > Once again, the amount of dose, the length of time,
> > the abruptness of cessation, and the increase or non-increase
> > of dose over time, are variables that will influence
> > the severity of withdrawal with these drugs.
> ================================================
> And if I may interrupt, here is of where much of the misunderstanding lies within the tightly knit anti-benzo movement.
>
> Since an individual's respose to a drug is so highly idiosyncratic as to the above mentioned points, especially regarding psychotropics, not just bzds, it is virtually impossible to extrapolate that these variables apply to the population in general. They are mere basic medical guidelines that don't increase the risk TO THE INDIVIDUAL as implied by the anecdotal and highly indiviual adverse responses to these meds as reported by a small minority of the population at benzo.org and similar sites.
>
> Statistics and pharmacokenetic curves in some texbook or pharmrep presentation do not apply to the individual - which becomes quite evident when one understands that these medications are so highly effective IF PRESCRIBED, DIAGNOSED, AND MANAGED properly....or to directly use the words of the report..."Used rationally".
>
> The key complaint is that Benzo.org-like sites seize on risk appropriate to the individual and then mistakenly generalises for the population.
>
> So what does the average consumer think when they read this? Where does it leave their naturally anxiety ridden, hyperaroused, med phobic minds? Oh! This must apply to me...extrapolating in the same style by example of that which the benzo.org folks have already (mistakenly) used as their model.
>
> Terribly misleading as to proportionality of risk/benefit assesments applied to any medication much less bzds. What is particular unethical is the exploitation of the "A" word (addiction) when it is used as a pejorative.
>
> Refusing to accept the distinction to "sustained medical dependence" is a conscious choice to continue exaggeration of risk to the individual consumer. The term "Addiction" is used as inflammitory rhetoric to push an agenda that would otherwise be a relative non-issue.
>
> This is not to minimise those cases that have bad experiences coming off of bzds but to acknowledge that it happens to a small minority of the poulation henceforth the use of "RATIONAL USE" as the title of the report.
>
>
> Alan
>
>
Posted by Squiggles on October 26, 2002, at 18:02:18
In reply to Re: RATIONAL USE OF BENZODIAZAPINES (5.) » Squiggles, posted by Alan on October 26, 2002, at 15:41:05
The pejorative and loaded use of the word
"addiction" occurs only amongst the most
radical reactionaries and bible thumpers.
Not all are of this group on Benzo.As for the extrapolation to all people;
if you grant me that this group is a group
which has experienced withdrawal and addiction
with benzos, then i will grant you that you
have knowledge of a counter-group which has
not.Comparing notes may be interesting, given
the same variables.Squiggles
Posted by Alan on October 26, 2002, at 23:17:11
In reply to Re: RATIONAL USE OF BENZODIAZAPINES (5.) » Alan, posted by Squiggles on October 26, 2002, at 18:02:18
> The pejorative and loaded use of the word
> "addiction" occurs only amongst the most
> radical reactionaries and bible thumpers.
> Not all are of this group on Benzo.Anyone that does not, but indeed outright refuses to make the medical distinction between "addiction" (which appears too many times to count on the websites of this nature) and "pharmcological dependence" is using it out of ignorance or as a pejorative. It is not wordsmithing as you have suggested earlier because not only the word is changed but the fundamental concept behind the word is entirely different.
The deliberate blurring of the lines of these distinctions by these groups is actually the glue that holds their speculative ramblings together. Without them, poof! Their rationale disappears. There is no foundation in which to support their house of cards.
>
> As for the extrapolation to all people;
> if you grant me that this group is a group
> which has experienced withdrawal and addiction
> with benzos, then i will grant you that you
> have knowledge of a counter-group which has
> not.
>
> Comparing notes may be interesting, given
> the same variables.
>
> SquigglesEverybody experiences withdrawal in degrees of severity. It is the hallmark of drugs that build tolerance. Ad's are no different.
Well the problems are many-fold. Two that come immediately to mind are:
1) Addiction is not the proper word to use in the "rational" use of bzds, only when in circumstances that they were misprescribed, used to get from high to high, and most importantly sought out by the individual reflecting the attitude towards the drug of seeking a high -predisposed or not.
2) If they are "addicted" and indeed in the same way like those withdrawing from illicit drugs such as heroin and cocaine ("information" that these groups like to strut around infront of the public like a badge of honour), then these folks don't even equate with the panic population that use the drug properly for legitimately diagnosed anxiety disorders that have very little of the dire risk of severe withdrawal symptoms that this group extrapolates for!
So from where I stand, the middle ground stands right where I've laid it out. One doesn't compromise what is known to be true in a barter for what is known not to be.
Thanks but I'll pass.
Alan
Posted by viridis on October 27, 2002, at 0:14:29
In reply to Re: RATIONAL USE OF BENZODIAZAPINES (5.) » viridis, posted by Rick on October 26, 2002, at 15:38:18
It's interesting how differently people react, even to different drugs within the same class. Klonopin hasn't dulled me out at all (except a bit in first 1-2 weeks that I took it). In contrast, my thinking became much sharper and more focused -- maybe because I wasn't constantly agonizing over trivial details, sleeping 2-3 hours a night, and so on. It's not just my imagination either, since friends, family, and co-workers commented on how I'd suddenly become so "on target" and enthusiastic.
On the other hand, Valium really is a "dumb drug" for me -- when I take even a small amount, it puts me in a haze (and not pleasant, just a general stupid/drugged feeling).
Posted by hiba on October 27, 2002, at 0:49:33
In reply to Re: RATIONAL USE OF BENZODIAZAPINES (5.) » hiba, posted by Squiggles on October 26, 2002, at 10:32:44
Hello Squiggles,
I got a "Please be civil" warning from Dr.Bob and I am sorry if I made any personal offence.
((Once again, what kind of evidence would you like?
Statistical evidence can only be gathered by
testimonials of people who have taken these drugs
for a long time. Would you rather rely on the
behaviour of rats over a period of 3 months, under
the supervision of Hoffman LaRoche or Eli Lilly's
white-coats?))I was asking for a scientific evidence for "Protracted withdrawal syndrome" which you attributed to benzos in your thread. After carefully reading your reply, still I couldn't find any. "Protracted withdrawal" is quite strange to medical professionals. And my common sense doesn't allow me to take biased views of anti-benzo groups and their testimonials without a grain of salt. Meanwhile I had named some references in my message. And "Pharmacological basis of therapeutics" was one of them. Can you show me a single instance of "Protracted withdrawal syndrome" in that book which describes therapeutic pros and cons of medications?
I don't advocate for any drug. I believe all drugs have their pros and cons. But I could sense your attempt to project benzos as the most dangerous drugs in psychiatric practice. Labelling them as addictive will make matters much easier, as the term "addictive" is terrorizing to an already overanxious patient.
I was not mentioning rats or any other reptiles. I know what makes patients complain benzos are addictive. In most cases it is "patient awkwardness". Using a powerful drug for years and stopping it abruptly will cause more than enough discomforts to an individual. And most testimonials of withdrawal symptoms are the fruits of this kind of awkwardness. I have mentioned this matter many times in my threads. Why benzos alone?? If you are using beta-blockers for a long period of time and stopping it abruptly, there is a chance of fatal myocardial infarction.
((I have quoted the Merck before here and
The American Family Physician, and Goodman and Gillman's
Pharmaceutical Therapeutics on the addictive nature and need
for caution in benzo withdrawal, which also mention the
risk of seizure upon sudden discontinuation.))Where in the "Goodman and Gilman's Pharmacological basis of therapeutics" mention benzos are ADDICTIVE ? CAN YOU PLEASE SHOW ME THAT TERM "ADDICTIVE" IN IT ?? I have the latest edition (10th edition) in my hand. Just refer that page in your response. Note: If you have the same edition with you I recommend to read the page 628 carefully. It talks about dependence. (PHARMACOLOGICAL DEPENDENCE)but not addiction.
Unfortunately, I don't have access to "AMERICAN FAMILY PHYSICIAN". But I think PDR is the most authentic therapeutic guide used worldwide. MARTINDALE comes next to it. Nowhere in those guides I see the term "addictive". And if I see it in American Family Physician or Merck manual, I will definitely consider it as an "EXCEPTION". Why? Because I have more authentic source in my hand to refer.Dr. Ashton may be running the clinic for years. But I like to know what kind of patients and she used to treat. Those who stopped their benzo intake abruptly will surely have a majority there. And those multiple drug users who uses benzos for recreational purpose do not represent the ideal benzo users. I am talking about those patients who use benzos under medical supervision, where abuse and withdrawal complications never occur. But if you want to abuse a drug, no matter what kind of drug that may be, you can abuse antihistamines and can have withdrawal symptoms. Periactin is being abused by underweight patients who like to utilize its appetite stimulating properties. Phenergan is also being abused because of its sedative properties. Phenergan, if combined with alcohol can be fatal sometimes.
So my initial question still remains. Can you show me an instance of "Protracted withdrawal syndrome"in any reputed therapeutic guides ? Can you show me the term "addictive" attributed to benzos in PDR, or MRTINDALE, or GOODMAN AND GILMAN'S...THERAPEUTICS ?
Good luck Squiggles, take care
HIBA
Posted by viridis on October 27, 2002, at 1:00:20
In reply to Re: Evidence Please!! Squiggles,,, posted by hiba on October 27, 2002, at 0:49:33
Hi Hiba, Squiggles and co.,
I had an interesting experience a few months ago. I decided to go off Klonopin for a day after having taken it for several months. As the day progressed, I got more and more anxious -- not unbearably so, but it was very unpleasant. Finally, I took some Klonopin and felt normal again.
I was still in the "don't want to get hooked" phase, and reported this to my psychiatrist the next time I saw him. He asked me a simple question -- was the anxiety worse than what you experienced before taking Klonopin? I said no, it was about like what I'd often felt before, but it was very disturbing. His response was that of course it was disturbing, but he asked me again, was it worse or different than what you've experienced before? Again I said no, quite honestly. And I realized (without him having to tell me this, although he did) that I'm an anxious person who doesn't like being anxious. Did I experience withdrawal? I'm not sure, but it brought home the point that I'm much better with Klonopin than without -- I'd just forgotten how awful anxiety can be.
I wonder how many people in "withdrawal" are just returning to their pre-benzo state and find it very upsetting.
That being said, my pdoc definitely believes that these drugs can cause medical dependency, and advocates a slow, supervised taper if one chooses to discontinue their use. But it did make me question just how common or severe "withdrawal" from benzos is, and how to distinguish it from a return to an intolerable condition. I have no doubt that for some people, withdrawal from benzos (and ADs etc.) is very serious and creates effects that are worse than the initial condition. But what proportion of people on the anti-benzo sites are just going back to an intolerable "ground state"?
By the way (Squiggles) -- your posts to me have been very reasonable, helpful, and understanding, so I don't mean this as an attack on you. It sounds like you're someone who really did have a bad reaction, and you have much longer-term experience with benzos than I do. I just wonder about the points I've raised above.
Posted by Alan on October 27, 2002, at 1:06:49
In reply to Re: Evidence Please!! Squiggles,,, posted by hiba on October 27, 2002, at 0:49:33
You are quite right Hiba. Our own elizabeth has posted about this very issue some time back and refers to exactly that text in her last paragraph. Although redundant, it might be of some benefit for those that are following this thread to review the entire content of her post:
http://www.dr-bob.org/babble/20010618/msgs/67768.html
There are serious consequences as the result of not making the distinction between the two which she points out in a rather eloquent fashion.
Alan
Posted by hiba on October 27, 2002, at 2:08:59
In reply to Re: RATIONAL USE OF BENZODIAZAPINES (5.) » hiba, posted by Squiggles on October 26, 2002, at 10:32:44
Hello Everyone,
I searched online for American Family Physician and Merck Manual with success. I have found something interesting."Benzodiazepines are effective in treating panic disorder; they are also used to treat generalized anxiety disorder and social phobia, two common comorbidities of panic disorder. In contrast to antidepressants, benzodiazepines relieve anxiety within hours,7 can prevent panic attacks within a few days to a few weeks,5 and are free of troublesome activating effects.7 Nevertheless, benzodiazepine use in treating panic disorder can be complicated by abuse, physiologic and psychologic dependence, and sedative and neurocognitive side effects.7,8
(AMERICAN FAMILY PHYSICIAN)
The term "ADDICTION" is nowhere here.Secondly I post a link where viewers can have access to Merck Manual. Please check this link
http://www.merck.com/pubs/mmanual_home/sec7/92.htm
Contrary to my anticipation, Merck scientists are emphasizing on benzodiazepine's safety and effectiveness over Alcohol, barbiturates and chloral hydrate. The term "Addictive" is still lacking, although in a title I can see it. But it is not directly attributed to benzos. Rather it can be seen directly attributed to narcotics.What do these mean? Aren't these reputed scientists aware of the difference between Addiction and dependence??
Oh! it is only a linguistic squabble !!
HIBA
Posted by Squiggles on October 27, 2002, at 8:11:10
In reply to Re: Evidence Please!! Squiggles,,, posted by hiba on October 27, 2002, at 0:49:33
hiba,
It's OK - i am not really offended at all,
though I see that Dr. Bob is very cautious
about things escalating to a higher level
of conflict (LOL):Here are some articles on Protracted Withdrawal Syndrome:
http://search.freefind.com/find.html?id=3519954&pid=r&mode=ALL&n=0&query=Protracted
___________________
The Edition of Goodman and Gilman, which I have
is the 6th edition.Ch. 17 HYPNOTICS AND SEDATIVES
- Stewart C. Harvey
BENZODIAZEPINES:
Adverse Psychological Effects:
"Benzodiazepines may cause paradoxical effects....
Anticonvulsant benzodiazepines sometimes induce
motor stimulation and precipitate grand mal
seizures. Antianxiety benzodiazepines have been
reported to release bizarre uninhibited behavior in
some users with low levels of anxiety. Paranoia,
depression, and suicidal ideation occasionally
accompany the use of antianxiety benzodiazepines.
..........
Although benzodiazepines have a reputation for
causing only a low rate of *abuse* and *dependence*
the possibility of this complication of chronic
use must not be overlooked."p. 439
Tolerance and Physical Dependence
"High doses of benzodiazepines must be given
for long periods of time and then abruptly withdrawan
before marked withdrawal symptoms, including
seizures, appear (see Allquander, 78). Habituation
can occur however, because of the long half-lives
and conversion to active metabolites; withdrawal
symptoms after chronic use may not appear for a week
after abrupt continuation of the drug."__________________________
THE MERCK (16th Edition)p. 1633
"Benzodiazepine Abuse and Dependence
....
There is considerable debate about benzodiazepine
dependence. ... Abrupt discontinuation after significant
exposure may lead to withdrawal syndrome remarkably
similar to that associated with alcohol withdrawal,
including anxiety, irritability, tremor, nausea
hypertension, tachycardia, hyperacusis, muscle
twitching, hyperreflexia, depersonalization, hallucinations,
and major motor seirzures.....
Discontinuing the medicine will lead to a
complicated differential of drug withdrawal vs.
symptom reemergence. [in other words they don't
know if the withdrawal is continuing or if they
can attribute it to an "underlying disorder" popping
up again]."[Query:
Could it be that it is not the withdrawal syndrome
itself which causes these long-yeared waves of
protracted symptoms, but the abruptness with which\
the patient has been pulled off the drug?]
I include this part as it points to importance
of physical pre-examination (something not emphasized
in the WHO document, though mentioned):"Treatment with Benzodiazepines
Very few patients need continuous treatment.
..... The causes of anxiety are many, but
ordinary environmental causes should be searched
first; e.g. occupational or marital problems, [etc.]
MANY MEDICAL DISORDERS CAN BE SIGNIFICANT: E.G.
HYPERTHYROIDISM, ARRHYTHMIAS, CHRONIC PULMONARY
DISEASE, HEART FAILURE, ABUSE OF CAFFEIN OR OTHER
STIMULANTS, ALCOHOL WITHDRAWAL, AKATHISIA ASSOCIATED
WITH ANTIPSYCHOTICS, COMPLEX PARTIAL SEIZURES, AND
PEHOCHROMOCYTOMA [my emphasis]....."
I notice that the words "protracted withdrawal
syndrome" do not occur. I would not take that
as evidence that this syndrome does not exist
therefore. It is quite possible that follow-up
studies of abruptly discontinued patients were
not undertaken at that time.One more observation about protracted withdrawal
syndrome: although reinstatement of a dose or
even higher (as is recommended in the cases of
seizure withdrawal) may stop the very severe
aspects, there are waves which continue regardless'
of the reinstated benzo dose. This suggests to
me that some sort of damage or immediately
irreversible chemical state has taken place which
requires a long time to return to ground 0.Squiggles
Posted by Squiggles on October 27, 2002, at 8:29:09
In reply to True extent of benzo withdrawal? » hiba, posted by viridis on October 27, 2002, at 1:00:20
Yes, thank for being so understanding. I
got off Klonopin or did not take it many
times in the early years of taking and did
not have serious problems at all. It was
after MANY years of taking it that it became
so incredibly difficult.I appreciate your note very much; i confess
that this conversation with people who seem
to be studying perhaps, but have little experience,
reminds me of that classic painting of the
examination of the wounds, by poking at the guy
to see if it *really* hurts.Squiggles
Posted by Squiggles on October 27, 2002, at 8:37:36
In reply to Re: Evidence Please!! » hiba, posted by Alan on October 27, 2002, at 1:06:49
Very nice--I agree with Gilman and Goodman;
As a physician or scientist,
i would be embarrassed to confuse addiction
(or in pragmatic terms what happens when
a drug is withdrawn) with cultural and
pulp fiction associations of dens of inequity,
and heavily made up harlots, shooting up
addictive drugs so they can get high.Squiggles
Posted by Dr. Bob on October 27, 2002, at 9:31:08
In reply to Re: RATIONAL USE OF BENZODIAZAPINES (5.) » Squiggles, posted by Alan on October 26, 2002, at 23:17:11
> Anyone that does not, but indeed outright refuses to make the medical distinction between "addiction" (which appears too many times to count on the websites of this nature) and "pharmcological dependence" is using it out of ignorance or as a pejorative.
Please be sensitive to the feelings of others, respect their views even if you think they're wrong, and neither jump to conclusions about them nor post anything that could lead them to feel accused or put down. I've asked you before to be civil, so now I'm going to block you from posting for a week.
Bob
PS: Follow-ups regarding posting policies, and complaints about posts, should be redirected to Psycho-Babble Administration; otherwise, they may be deleted.
Posted by Squiggles on October 27, 2002, at 9:38:02
In reply to Re: please be civil » Alan, posted by Dr. Bob on October 27, 2002, at 9:27:52
How could I forget Dr. David Healy?
Here is something on the squabble on the
term "addiction" (i hope this will be my
last word on it), from his book:"The Creation of Psychopharmacology"
Harvard U. Press, 2002, pp. 169-170:"Using the ease with which an animal can be
induced to crave a drug as a yardstick, researchers
found the abuse liability of the benzodiazepines
was low to ninexistent. [122]. Consequently,
in the 1980s it made perfect sense for an addiction
specialist to state that physical dependence on
the benzodiazepines was possible but that they
caused neither addiction nor drug dependence.
This was a semantic step too far not just for
the public but for most of the medical profession.
In the laboratory the benzodiazepines might not
be seen to be drugs of addiction, but saying that
they were not drugs of addiction did not solve
what had become a pressing public problem."I have not read the whole chapter, so i hope i am
not misinterpreting Dr. Healy's words; he does
seem to emphasize the comparable addiction to
SSRIs. I think that one feature that is common
to both AD withdrawal problems as well as
benzos is the lack of CRAVING which we associate
with the opiates. but though there is lack of
craving for the drugs, there is certainly relief
upon reinstating them.Squiggles
Posted by Rick on October 27, 2002, at 10:52:55
In reply to Klonopin as a dumb drug, posted by viridis on October 27, 2002, at 0:14:29
For me it's not so much a cognitive dulling problem on Klonopin as memory problems, especially short-term (including VERY short term). But I think AD's, and even a purported memory-booster like Provigil, have exacerbated this annoyance. In terms of many other aspects of mental agility, I find as you do that I'm actually sharper than pre-Klonopin.
Word-finding is one interesting aspect, however. At times my brain can't summons up even the simplest words to save my life , but at other times the words just flow, much better than pre-Klonopin. It seems as if the problems are more in extemporaneous speaking than in writing. One theory I have is that, despite my greatly reduced "fear of people", I can still feel inhibitory pressure to come up with the right things to say when someone's staring at me and waiting for me to speak (or worse yet if I feel I need to organize and express my thoughts quickly to keep their attention). OTOH, I can certainly have the word-finding difficulties when I'm just thinking to myself, too. I could go on here with other thoughts related to this topic, but I think you get the general idea.
Getting back to your original topic and summarizing, other than amnesic effects I don't consider Klonopin a dumb drug either. Since you didn't mention memory issues, I assume you don't experience them.
Rick
P.S. One reason as-needed Xanax bombed out for my SP is that it *did* cause cognitive dulling, maybe related in part to the physical dulling sensations I felt. Klonopin never made me feel so physically slow, not even the first dose. I was amazed to feel so much more calm with nothing more than a smidge of fatigue, an effect which soon went away -- especially after I determined that "less" worked *better* for my SP than "more."
> It's interesting how differently people react, even to different drugs within the same class. Klonopin hasn't dulled me out at all (except a bit in first 1-2 weeks that I took it). In contrast, my thinking became much sharper and more focused -- maybe because I wasn't constantly agonizing over trivial details, sleeping 2-3 hours a night, and so on. It's not just my imagination either, since friends, family, and co-workers commented on how I'd suddenly become so "on target" and enthusiastic.
>
> On the other hand, Valium really is a "dumb drug" for me -- when I take even a small amount, it puts me in a haze (and not pleasant, just a general stupid/drugged feeling).
Posted by Rick on October 27, 2002, at 11:02:18
In reply to Re: True extent of benzo withdrawal? » viridis, posted by Squiggles on October 27, 2002, at 8:29:09
>It was
> after MANY years of taking it that it became
> so incredibly difficult.Squiggles -
My aplogies if you've already said this somewhere else in this mammoth thread, but how much Klonopin were you taking, and at what time(s) of day?
Thanks,
Rick
Posted by viridis on October 27, 2002, at 12:42:21
In reply to Re: True extent of benzo withdrawal? » viridis, posted by Squiggles on October 27, 2002, at 8:29:09
Hi Squiggles,
I can certainly believe that the longer you take a drug like Klonopin, the harder it will be to get off. After all, these drugs do induce changes in brain pathways and neurotransmitter release/response, so it makes sense that this would become more pronounced over time. But this isn't necessarily bad, if the changes make your brain function like that of a normal person.
And yes, I am relatively naive, having only taken K for 1 1/4 years or so. I still wonder, though, when I read reports from people who say they've had severe withdrawal and/or permanent damage from benzos (especially after relatively short-term use), whether they've returned to their "ground state" and didn't realize just how bad it was. This is just speculation on my part, but it seems logical to me in at least some cases.
A friend of mine who's a dentist told me about one of his patients, a woman in her 70s who had been on the same dose of Valium for around 30 years with no measurable negative effects. Then she saw a new doctor, who refused to prescribe it because she was "addicted". She had a severe reaction that required hospitalization, and the end result was a new doctor who reinstated the Valium. Apparently, she's doing fine, will probably continue to take Valium for the rest of her life, and (I expect) will have a higher quality of life because of it. So, why did the doctor discontinue it (abruptly), and what's the harm in her using it if it helps her live a normal life?
I'm curious (you've probably addressed this here already, but it's hard to keep track in this thread) -- why did you want to get off Klonopin after taking it for so long? Was it no longer working, causing problems, did your doctor want you off it, or were you just tired of being dependent on a medication? I ask because for now at least, K is helping so much that I'd just as soon stay on it, yet I'd like to know what to expect in the long term.
Thanks again,
Viridis
Posted by Squiggles on October 27, 2002, at 13:16:43
In reply to Re: True extent of benzo withdrawal? » Squiggles, posted by Rick on October 27, 2002, at 11:02:18
For about 7 years 0.50mg K, then i started
getting severe dyspnea, especially when
taking the K close to lithium--i had to
crouch on all fours on the bed to be able
to draw in a breath; at this point my dr.
raised it to 1.0mg and if my memory is not
too awful that was for 5 years on.I can't remember when i took it - i experimented
with times of day.Presently i take 1.5 mg because after the
seizure, i seemed to need more.Squiggles
Posted by Squiggles on October 27, 2002, at 13:54:59
In reply to Re: True extent of benzo withdrawal? » Squiggles, posted by viridis on October 27, 2002, at 12:42:21
Viridis,
You raise some good points; given the severe
withdrawals from benzos (and here we are speaking
of long-life benzos - Valium and and medium-life
Klonopin) it seems to me unwise to withdraw,
unless the side effects are undesirable, or
the dose has not been raised enough to avoid
withdrawal.Regarding the 70-yr old woman who had severe
withdrawal, upon discontinuation from her dr.,
i would say the dr. did not know how to get
her off, whatever the reason she was gotten off
(perhaps respiratory problems), and she was
darn lucky to be hospitalized for withdrawals.As for my case, i would not have tried to get
off Klonopin had i known what it would entail.
My problem is that I sincerely do not know WHY
I was put on it. Also, the fact that i finally
was able to live without 2-5 panic attacks a
day from the Xanax dose for so many years (which
was really destructive), encouraged me towards
better health. I did not know it would be so hard.One more thing: I am still not sure if my diagnosis
of bipolar was ever correct. And the reason for that
is that when i was dx'd as bipolar i was prescribed
Valium, but since it was such a popular drug then,
(20 yrs ago), it was neither monitored nor withdrawn
with any program. So, as far as i remember, i just
took the stuff whenever, and very haphazardly. It was
a time of great stress at school, and socially, and
personally (marriage, moving, thesis, harrassment at
university, overload of academic work) and i had
a kind of nervous breakdown.The symptoms (like severe anxiety, panic, temper
outbursts, blood pressure changes, progressing
to severe depression, depersonalization, and 5-day
insomnia) were very abrupt symptoms. And though
lithium got rid of the depression in 5 days, i still
do not know if the lithium treated Valium-withdrawal
or bipolar depression.And so, I tried to get off these drugs. But it
seems to me that whether there was an incorrect
diagnosis or not, it is now too late - too late
because these drugs have actually changed my
brain; nor do i know of any doctor who would undertake
this challenge to see if indeed there was no endogenous
mental disorder in the first place.Squiggles
Posted by Squiggles on October 27, 2002, at 18:23:26
In reply to Re: True extent of benzo withdrawal? » viridis, posted by Squiggles on October 27, 2002, at 13:54:59
P.S. Just wanted to add that I may be
wrong after all about the Valium withdrawal;
I do recall reading my pre-Valium and lithium
diary, and it is full of descriptions of
dark days of depression. Since taking lithium
I have not been depressed. I think it is
safe to conclude that whether I am bipolar
or not, lithium has prevented depression on
a daily, chronic basis.Just want to present both sides.
Squiggles
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