Posted by sukarno on March 16, 2010, at 7:26:26
In reply to Re: Benzodiazipine maintenance treatment?, posted by ed_uk2010 on March 12, 2010, at 14:25:01
Hi Ed. I think you can get alprazolam in the UK if you avoid the NHS and get it by private prescription. Is that right?
I have been on benzodiazepines for 20 years and found diazepam to be the easiest to taper, however, the withdrawal, while being milder, is longer lasting. I tapered using Xanax and found the withdrawal was worse, but it was over sooner.
That said, Valium tends to build up in the system (fat cells, if I remember correctly) due to its long half-life. Valium is also very rapid-acting. According to the British National Formulary (BNF), diazepam is the benzodiazepine with most rapid onset. I truly believe that too. I could feel its effects hit me almost all at once in 7 minutes (I could time it on my wristwatch).
In fact, I feel that diazepam is much more likely to cause psychological dependence due to its rapid onset of action and barbiturate-like effects. Its myorelaxant effects are very pronounced, as is ataxia and basically feeling "liquored up".
On Xanax I have failed to feel "high" or "liquored up", even on a high dose or when taking an extra dose. Taking an extra dose does not produce anything in the way of psychological effects, but it has caused me some incoordination which caused me to trip and fall once. Taking an extra dose of diazepam will result in feeling "drunk" or oversedated (with lowered inhibitions and slurred speech) by comparison.
I'm on 1mg QID and feel far less sedation than I did on 5mg diazepam TID. I never developed a complete tolerance to the myorelaxant and soporific effects of diazepam. Alprazolam does make me sleepy, but much less so and controls my anxiety much more effectively.
It is interesting that a less sedating BZD such as alprazolam (since the short half-life precludes it from accumulating in the tissues, etc) is more effective for my panic attacks (I have none on alprazolam or at most only 1 every 2 months) and agoraphobia than the heavily sedating diazepam.
I would feel snockered on diazepam and still have a panic attack in the mall. On alprazolam, I feel relatively alert and have no anxiety, or very little, when in the shopping mall.
Alprazolam is excellent medication, but one should really only take it long term if there is no other option (for severe panic disorder which is refractory to other treatments). One must be made aware by the prescribing physician that alprazolam is going to be your lifelong partner and that tapering is very difficult for most folks.
Diazepam can be substituted, but since I have sleep apnea, I must avoid it. Alprazolam is safer for sleep apnea, although, ideally I would like to transition to clobazam (Frisium) as doctors here recommend that, especially if you have obstructive sleep apnea. Do you have Frisium in the UK?
Frisium is said to be less sedating than any other BZD and has almost no abuse liability. I am unsure of its efficacy in the treatment of panic disorder. It just seems to be the "in vogue" BZD where I live.
I must say though, I feel no psychological dependence on alprazolam (no cravings) and wish I could take clobazam instead. Diazepam gives me a "rush" and its pro-apnea effects prohibit me from using it. Diazepam also has a lot of street value when known by its trade name "Valium". That is not to say Xanax does not, but most people recognise the term "Valium" and will usually hustle you to get some.
At the same time, alprazolam has (probably) the worst withdrawal syndrome of any BZD besides triazolam (Halcion), so it must be tapered very slowly. My psychiatrist told me in 1997 that I should prepare 6 to 18 months if I want to taper off BZDs as it should be done very slowly to minimise any withdrawal symptoms.
I once tapered off diazepam in 1993 and had little or no trouble. No physical symptoms, but some psychological symptoms such as excessive worry, nervousness, mild insomnia, etc. The day after stopping I was fine and actually slept better than I had in years. After ten days my classic panic attacks (3 to 5 a day as it was prior to BZDs) returned, but not in a rebound fashion.
Several psychiatrists I have seen have agreed that because I cannot tolerate TCAs and have adverse reactions (e.g. GI bleeding on fluoxetine along with rashes) to fluoxetine, that SSRIs despite the differences in chemical structure wouldn't be right for me. They feel uncomfortable prescribing those to me. For now I take Stablon but after five years of treatment it seems to have lost most of its efficacy (unless I keep raising the dose, and it is very expensive!). It is better as an anxiolytic than antidepressant, IMHO.
I might consider taking the plunge into the world of SSRIs because I like the idea of apathy/emotional blunting. I need something to buffer me against depression. Light box therapy is all I use right now besides Stablon but that is very inconvenient.
I had read some abstracts which seem to indicate that GI bleeds might be prevented by taking an H2RA (famotidine, ranitidine) or PPI. I'm allergic to PPIs so I might have try famotidine again. I do have a sample of sertraline here, but I know that if I start taking that it will be about as difficult to quit as tapering a BZD. :-( Also, there is the loss of libido which accompanies SSRI use.
I've also thought about pramipexole as an antidepressant, but am told it is full of side effects and gave some people full blown panic attacks. Yet, another abstract says it was beneficial for panic disorder with agoraphobia.
I'm not sure what I can take for depression. I don't have problems with panic attacks anymore on Xanax, but my depression is a big problem if I don't use my light box for 2 hours each day. If I skip a day it will come back in full force. :-(
I don't wish depression on anyone. I might be willing to risk loss of libido with SSRIs and GI bleeding (if acid blockers can prevent it).. I am not sure. I have a sample of sertraline here on my desk. It's been there for several months. I am quite afraid to take it.
I also have pramipexole 0.25mg here too and have been too afraid to take it also.
I guess I'm just "chicken" when it comes to medications for depression.
Take care everyone. Sorry for the long and rambling post. If you have made it this far, I congratulate you on your patience. hehheh.