![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 69 to 93 of 133. Go back in thread:
Posted by Squiggles on February 5, 2007, at 17:31:55
In reply to Re: Ashton Rocks! » Squiggles, posted by Phillipa on February 5, 2007, at 17:26:36
> Squiggles you can take up to 20mg of clonazepam as it is also used for seizure patients. And the t med you were trying to remember has one less oxygen ion and is trileptal taken from tegretol. Love Phillipa
Thanks. About 20mg clonazepam-- I would be
worried about respiratory depression. I think
that if you suffer from epilepsy, you don't take
such an amount everyday right?Squiggles
p.s. has anyone noticed that everytime the
benzo topic appears the thread runs into
eternity? Why is that, and where is Dr. Bob
to put it into the dark hole where all matter
eventually disappears.
Posted by Phillipa on February 5, 2007, at 17:32:15
In reply to Re: Ashton Rocks!, posted by Squiggles on February 5, 2007, at 14:57:48
Squiggles that happened to me too but my TSH all of sudden elevated when synthroid got it back to normal I deceased the xanax didn' need the higher dose anymore. The thyroid if hasimotos destroys itself. Love Phillipa ps it's an autoimmune disease.
Posted by Quintal on February 5, 2007, at 17:55:40
In reply to Re: Ashton Rocks!, posted by valene on February 5, 2007, at 17:02:41
>Since then I have come to realize that benzos are not "evil" and they can be very beneficial for certain people.
Do you really expect me to believe your own basic intelligence didn't tell you this in the first place? (!)
>Quintal I don't like your condescending attitude toward me.
Likewise. Maybe it has something to do with the tone of your introductory post to this thread? I am none too taken myself by, what seems to me, your ebullient aggression toward myself and the work of Heather Ashton.
> So forgive me if I don't recall the exact name of the forum, but it was the previous iteration of Benzo Island. They clean the boards periodically to get rid of anyone who might suggest that they take any other drug, such as an aspirin or I have seen people chastised for taking magnesium.
Benzo Island still exists today. The activity of these groups has nothing to do with myself nor the work of Heather Ashton, other than they may try to misquote her for their own purposes. I don't see why you bring it up here.
>To me this is not any "religious" statement whatsoever.
Earlier you posted this:
>"When you join the forum, you must agree and I quote "benzodiazepines were created in the depths of hell by the very devil himself, and distributed freely here on earth by his demons". Hope that answers some questions about the origins of benzo.uk or whatever. I refuse to ever go back there, as it scared the daylights out of me with the extreme notions that *any* and all psych. meds are horrendous and people got thrown off the forum for taking a vitamin (not kidding)."
Which to me, sounds as though you are insinuating some sort of religious cult or fundamentalism, which also seems to be in line with the sentiments of other posters with their veiled accusations of scientology and cultism. You have not identified the author of those words with any certainty. If he (whoever he is, and if it is a 'he') really is being sarcastic it seems the quote was taken out of context - a real danger then that it may be misunderstood. Please try to give a fair representation of the facts when quoting other people. Also, in that post you claim that this explains the origins of benzo.org.
Q
Posted by Quintal on February 5, 2007, at 18:44:51
In reply to Re: Just a question » Quintal, posted by Meri-Tuuli on February 5, 2007, at 15:54:11
>I didn't know I was older than you!! I always imagined you to be older (alot?) than me.
Hmmm.......I'm pretty sure you wouldn't if you met me in real life :-)
>Its strange the misconceptions we get in our heads.
It is indeed!
>To be fair, and in my opinion, it seems abit harsh that a potentially useful drug is withheld from people who need it. I mean, I know Ashton says that you can get benzos for no more than 4 weeks, but in reality GPs won't really presribe them, if you see what I mean.
GP's do prescribe them - that's how I became addicted to benzos myself.
>Isn't it up to the indivdual to make these sort of choices about their lives?
Up to a point, but medicine is not yet a utilitarian service. Doctors and pdocs et al certainly need to learn to do their homework become healers if they are to avoid that.
>Lots of things are addictive -- and you get withdrawal syptoms etc like coffee, cigarettes etc, but that doesn't nesscarily mean that they're banned or whatever.
As I've said before, benzos aren't banned. Almost all powerfully addicting drugs are controlled though. The incongruences of alcohol and tobacco annoy me - especially since most people addicted to those drugs don't usually consider themselves to be addicts in the same way as those addicted to other drugs of abuse, despite the fact they have a damaging and potentially fatal habit. My own mother was one of them. I mean, she died of lung cancer, which to my mind was the direct result of her drug addiction - tobacco, yet we don't think of her death in the same way you might someone dying of a heroin overdose.
>How did that guys life get wrecked by benzos?
I'm not sure, but this has nothing to do with Heather Ashton's work. People like that often seem to exaggerate their problems, and I suspect benzo addicts tend to understate or deny the extent to which they're impaired as well - I know I did. Six and two threes! I might post my old rating of clonazepam from RemedyFind and let you see just how strongly pro-benzo I was at one point and how much I despised Heather Ashton.
>I'm sure alot of people could say the same thing about say, alcohol, an addiction to sex/gambling/chatlines/whatever.
Yes, they could. Look, I think there's some confusion about what exactly I am saying and Heather Ashton's motives. When she says that these drugs are not good for you - that you may be healthier without them - she's simply telling the truth. I've seen no judgement from her about people who do choose to take benzos long term, but as a scientist she must report facts, and that's all she's doing. In fact she has gone to considerable lengths to defend people who might have their benzos withdrawn against their will, as shown by the letter in my original post. Maybe it's because she's so terse and formal that to some 'ears' (especially American ears) she might sound militant and uncompromising. But she isn't. Really, just have a good look at a broad section of her work (not just on benzos) without prejudice and I think you'll see what I mean.
>And another thing, I'm just curious, how does a taper from a benzo differ in the suffering caused that from an AD for instance? For me, withdrawal from celexa and venlafaxine was no fun, it was miserable in fact. And was pretty much unsupervised by any GP. In fact, I don't think they offered any withdrawal advice whatsoever. I've never withdrawn from a benzo, so I have no comparison.
I've withdrawn from both benzos and venlafaxine cold turkey. As you say, neither of them were fun. It's hard to compare them because there's a different quality of awfulness between them. They are in the same ballpark, except with benzos there's the seizure risk of course. Heather Ashton has also provided some good work on tapering off SSRIs and she gives some advice on them here: http://www.benzo.org.uk/ssri.htm. Please try to see it for what it is - a very terse and dense appraisal of the facts by an experienced psychopharmacologist, and not as though she has some hidden agenda.
Heather Ashton was a qualified doctor before Valium was even a twinkle in Leo Sternbach's eye, she saw these things coming into being and has most likely a more thorough, balanced and reasonable view of benzos than any of us posting here. Many people have no problem with slagging SSRIs for causing awful withdrawal syndrome (and bloody awful side effects too during treatment), yet it's almost as though benzos can do no wrong here. As you'll see, Heather takes the same approach to antidepressants as she does to benzos. If she seems to be obsessed with them that's because they were the most widely used (and therefore most widely problematic) psych drugs during her career, and she devoted a large part of her career to helping people who had problems with them. Would we really feel so strongly about her if she was quoted saying the same things about SSRIs as she does about benzos? Yes - most likely some would, but since you have experience with antidepressants yourself maybe you'll be better able to judge her position when you've read her article: 'SSRIs, Drug Withdrawal and Abuse: Problem or Treatment?'.
You might recall that I encouraged you to take the oxazepam when you posted here asking for advice?
http://www.dr-bob.org/babble/20061123/msgs/707905.htmlI am not anti-benzo though for most of this thread I seem to have spent a lot of time and energy probably seeming that way for defending Heather Ashton against malicious snipers (and I don't mean you, Phillipa or Squiggles).
Q
Posted by Quintal on February 5, 2007, at 18:55:22
In reply to Re: Just a question » Meri-Tuuli, posted by Quintal on February 5, 2007, at 18:44:51
I can't help noticing a certain befuddledness about most of the posts here written by benzo users. Almost as if they were slightly impaired in some way that made organising information difficult......
Q
Posted by Quintal on February 5, 2007, at 19:08:57
In reply to Re: Ashton Rocks!, posted by Squiggles on February 5, 2007, at 15:22:24
>20mg is what they give to epileptics -- that
is so high;The most my doctor prescribed was 8mg (in addition to some other benzo-like sleeping tablets). I was buying clonazepam from online pharmacies by the time I was taking 20mg - and for a short while only. It did indeed cause respiratory depression - I seemed to be choking at one point though I was taking it with tramadol for euphoria too which would have contributed of course.
>Coming off such a high amount though, must
take a long time to do and to recover.I was forced by circumstances (and my GP) to quit cold turkey - no taper for me, yet the Heroin addicts at the clinic they sent me to were given disability benefit and free methadone prescriptions for as long as they needed(!).
Again that's what Heather was saying about drug detox clinics not being suitable for benzo addicts. The counsellors there had no idea how to go about helping me with my underlying anxiety disorder, they were used to easing people back into a normal life not treating psychiatric problems.
Q
Posted by Phillipa on February 5, 2007, at 19:15:19
In reply to Re: Just a question » Meri-Tuuli, posted by Quintal on February 5, 2007, at 18:44:51
Quintal thanks and I think ad's are too often prescribed for the sadness we all have in life it things don't go exactly the way we would like. Love Phillipa
Posted by Phillipa on February 5, 2007, at 19:17:40
In reply to Re: Ashton Rocks! » Squiggles, posted by Quintal on February 5, 2007, at 19:08:57
Quintal do you know why they use clonazapam for seizure patients? I don't. Love Phillipa
Posted by bassman on February 5, 2007, at 19:28:17
In reply to Re: Just a question » Meri-Tuuli, posted by Quintal on February 5, 2007, at 18:44:51
Schweizer et al. (58) have conducted an 8-month, placebo-controlled study of continuation therapy for panic disorder with alprazolam and imipramine that found sustained efficacy for both compounds with no dose escalation, suggesting an absence of tolerance to the therapeutic effect
Preliminary evidence for the efficacy of continuation therapy of GAD comes from two studies (43, 47). In both studies the benzodiazepine therapy achieved sustained remission of anxious symptomatology with no tolerance and no dose escalation over a 6-month period.
http://www.acnp.org/G4/GN401000129/CH127.html
A total of 136 patients received clonazepam nightly for a mean 3.5 (+/- 2.4) years, with no significant difference in initial versus final mean dose: 0.77 mg (+/- 0.46) versus 1.10 mg (+/- 0.96). Similar results were obtained with chronic alprazolam treatment and with other benzodiazepine treatments. CONCLUSION: Long-term, nightly benzodiazepine treatment of injurious parasomnias and other disorders of disrupted nocturnal sleep resulted in sustained efficacy in most cases, with low risk of dosage tolerance, adverse effects, or abuse.
Fifty-nine panic disorder patients originally randomized to treatment in a controlled trial comparing alprazolam, clonazepam, and placebo were reevaluated in a follow-up study. At a mean follow-up of 1.5 years, 78% of patients remained on medication and the mean dosage of alprazolam and clonazepam did not increase.A 15 year study:
Maintenance medication was common. No benzodiazepine abuse was reported. CONCLUSION: PD has a favourable outcome in a substantial proportion of patients. However, the illness is chronic and needs treatment. The short-term treatment given in the drug trial had no influence on the long-term outcome.I think this is interesting because it basically says the physicians are quite prejudiced concerning benzo use, even when it comes to outcome. Who knows the benefits better, the physician or the patient? That’ s easy.
The participants were 93 patients over 60 years of age using a benzodiazepine for insomnia and 25 physicians comprising sleep specialists, family physicians, and family medicine residents. The main outcome measure was perception of benefit and risk scores calculated from the mean of responses (on a Likert scale of 1 to 5) to various items on the survey. RESULTS: The mean perception of benefit score was significantly higher in patients than physicians (3.85 vs. 2.84, p < 0.001, 95% CI 0.69, 1.32). The mean perception of risk score was significantly lower in patients than physicians (2.21 vs. 3.63, p < 0.001, 95% CI 1.07, 1.77). CONCLUSIONS: There is a significant discordance between older patients and their physicians regarding the perceptions of benefits and risks of using benzodiazepines for insomnia on a long term basis. The challenge is to openly discuss these perceptions in the context of the available evidence to make collaborative and informed decisions.
The Task Force Report, although over 10 years old, is still a standard reference for benzodiazepine use. Its points—that there is undue reluctance to use minor tranquillizers, and that many people are under treated—still hold, and are borne out by the Roy-Byrne study. Other relevant literature includes a review of 2719 adult out-patient charts2 (medical and psychiatric) for evidence of benzodiazepine abuse that found no patients meeting the criteria. Another study, of long-term alprazolam users, found no dose escalation with long-term use.3 Tyrer’s 19884 paper on minor tranquillizers notes an absence of evidence that benzodiazepine dependence leads to dangerous long-term sequellae, and blames "excessive media attention" for distortion of scientific attitudes.
http://fampra.oxfordjournals.org/cgi/content/full/20/3/347
Benzodiazepines are relatively safe drugs that are probably under- rather than overprescribed. Periodic reassessment of chronic users is appropriate, although generalized anxiety disorder and panic disorder are chronic conditions for which long-term treatment may be necessary. In the more recent era of safer antidepressants, these agents may be able to supplant minor tranquillizers for the control of chronic anxiety in many patients. Long-term benzodiazepine use is appropriate for some patients.
http://fampra.oxfordjournals.org/cgi/content/full/20/3/347
Tolerance is the need to increase the dose of a drug to maintain the desired effects. Tolerance to the anxiety-relieving effects of benzodiazepines is uncommon and most individuals do not increase their benzodiazepine dose
http://www.daap.ca/factsonbenzodiazepines.html
http://www.psychservices.psychiatryonline.org/cgi/content/full/54/7/1006
Posted by Squiggles on February 5, 2007, at 19:38:16
In reply to Re: Just a question, posted by bassman on February 5, 2007, at 19:28:17
I haven't done it, but I am pretty certain
that if you go to PubMed to look at articles
presenting exactly the contrary of these
conclusions, you will find them.The point I find interesting in your post
is the one about tolerance. I will grant
you that tolerance need not develop until
maybe 5 or more years into a benzo dose, but
once it does, there is the danger both for
the patient and the doctor, that new symptoms
crop up. These symptoms may not even be
recognized as tolerance-related. BTW, I think
it takes about 3 months to get addicted to Xanax,
and then gradually the effect fades and more is
needed.All narcotic and GABA drugs are like that-- any
doctor worth his/her salt should know that. It's
old school stuff.Clonazepam remains a mystery to me - i am speculating the least likely-- that I am actually
withdrawing by taking the same dose for 15 yrs,
but the brain has changed in the meantime and God help me if i try to quit again.Squiggles
Posted by bassman on February 5, 2007, at 19:58:15
In reply to Re: Just a question, posted by Squiggles on February 5, 2007, at 19:38:16
Please go find those research articles that say that tolerance and addiction are common with benzos; I'm sure we'd all like to see them.:>} But really, I agree with you mostly. I personally think it is prudent to be careful with any drug that is taken chronically, including benzos. It just that most panic disorder people, for whatever reason, have to be brought yelling and screaming to take meds. So telling them that benzos/other meds are the Devil's Brew is less than a service to mankind. And they very seldom, as the articles articulate, become tolerant and increase their dosages. Certainly some people do get themselves in trouble with benzos, and that is very unfortunate, and I'm sure we all have empathy for them. Sometimes it feels like at the time that it is worth anything to get out of the pain of mental illness: be it suicide or imprudent use of medication.
There is just a big range of opinion on just about any drug-look at the withdrawal board here and effexor! Same for pain killers, anti-hypertensive agents, statins for cholesterol, SSRI's, MAOI's, aspirin therapy, herbals, etc.
My point is that there are two sides to the discussion; nothing more.
Posted by Squiggles on February 5, 2007, at 20:27:59
In reply to Re: Just a question, posted by bassman on February 5, 2007, at 19:58:15
> Please go find those research articles that say that tolerance and addiction are common with benzos; I'm sure we'd all like to see them.:>}
Sigh....
1: Can J Psychiatry. 2006 Jun;51(7):445-52. Links
Predictors of long-term benzodiazepine abstinence in participants of a randomized controlled benzodiazepine withdrawal program.* Voshaar RC,
* Gorgels WJ,
* Mol AJ,
* van Balkom AJ,
* Mulder J,
* van de Lisdonk EH,
* Breteler MH,
* Zitman FG.Department of Psychiatry, Radboud University Nijmegen Medical Centre, The Netherlands. r.oudevoshaar@psy.umcn.nl
OBJECTIVE: To identify predictors of resumed benzodiazepine use after participation in a benzodiazepine discontinuation trial. METHOD: We performed multiple Cox regression analyses to predict the long-term outcome of a 3-condition, randomized, controlled benzodiazepine discontinuation trial in general practice. RESULTS: Of 180 patients, we completed follow-up for 170 (94%). Of these, 50 (29%) achieved long-term success, defined as no use of benzodiazepines during follow-up. Independent predictors of success were as follows: offering a taper-off program with group therapy (hazard ratio [HR] 2.4; 95% confidence interval [CI], 1.5 to 3.9) or without group therapy (HR 2.9; 95% CI, 1.8 to 4.8); a lower daily benzodiazepine dosage at the start of tapering off (HR 1.5; 95% CI, 1.2 to 1.9); a substantial dosage reduction by patients themselves just before the start of tapering off (HR 2.1; 95% CI, 1.4 to 3.3); less severe benzodiazepine dependence, as measured by the Benzodiazepine Dependence Self-Report Questionnaire Lack of Compliance subscale (HR 2.4; 95%CI, 1.1 to 5.2); and no use of alcohol (HR 1.7; 95% CI, 1.2 to 2.5). Patients who used over 10 mg of diazepam equivalent, who had a score of 3 or more on the Lack of Compliance subscale, or who drank more than 2 units of alcohol daily failed to achieve long-term abstinence. CONCLUSIONS: Benzodiazepine dependence severity affects long-term taper outcome independent of treatment modality, benzodiazepine dosage, psychopathology, and personality characteristics. An identifiable subgroup needs referral to specialized care.
PMID: 16838826 [PubMed - indexed for MEDLINE]
1: Drugs. 1983 May;25(5):514-28. Links
Rational use of anxiolytic/sedative drugs.* Lader M,
* Petursson H.The benzodiazepines are the most effective, safest, and most widely used antianxiety drugs. As a class of drugs, there are few major differences between the various benzodiazepine derivatives. The main distinguishing features are different plasma half-lives and the presence or absence of pharmacologically active metabolites. Plasma half-lives vary considerably, from 2 to 3 hours to more than 100 hours. All benzodiazepines are equally effective in the short term management of anxiety and insomnia, and their classification into 'anxiolytics' and 'hypnotics' is not justified. There are numerous other indications for benzodiazepine use, such as muscle spasm in osteoarthritic conditions, and acute alcohol withdrawal, but the benzodiazepines have no antidepressive or analgesic effects. While there is no good evidence for their long term efficacy in the treatment of anxiety and insomnia, the benzodiazepines are more effective and safer than their main predecessors, the barbiturates. Some of the benzodiazepines, particularly those with long plasma half-lives which are commonly used as hypnotics, have a prolonged duration of action and cause marked 'hang-over' effects. Alcohol enhances the effects of these drugs, and thus can also increase their side effects. Adversely effects such as oversedation, tremor, ataxia and confusion are much more common in elderly patients. Ever since the benzodiazepines were first marketed 20 years ago their use has increased rapidly, and it is now estimated that between 12 and 16% of the adult population in developed countries use tranquillisers at some time each year. However, their overall use has probably diminished somewhat in the last few years. Although their indications are very common, it is possible that some of this extensive usage may be the result of dependence. Until recently, published reports of such dependence were comparatively few. However, withdrawal symptoms have now been demonstrated in a substantial proportion of patients on long term, normal dose benzodiazepine treatment. The abstinence syndrome usually lasts for 8 to 10 days, and is characterised by insomnia, anxiety, loss of appetite and bodyweight, tremor, perspiration, and a host of perceptual disturbances. More serious developments such as epileptic fits and psychosis are probably infrequent during withdrawal from therapeutic doses. The overall incidence of benzodiazepine dependence remains unknown.
PMID: 6134609 [PubMed - indexed for MEDLINE]
1: Curr Opin Pharmacol. 2005 Feb;5(1):47-52.Click here to read Links
GABAA receptor subtypes: any clues to the mechanism of benzodiazepine dependence?* Wafford KA.
Department of Molecular and Cellular Neuroscience, Merck Sharp & Dohme Research Laboratories, The Neuroscience Research Centre, Harlow, Essex CM20 2QR, UK. keith_wafford@merck.com
Chronic use of benzodiazepines for the treatment of anxiety has revealed that these drugs can lead to dependence as indicated by withdrawal symptoms following cessation and tolerance to the drugs effects. Together with their reinforcing properties, this has led to them being labelled as scheduled drugs. Our new knowledge regarding the molecular structure of the benzodiazepine binding site and the growing ability to differentiate GABA(A) receptor subtypes, either by genetic manipulation or subtype selective compounds, have begun to facilitate our understanding of what underlies the mechanism of benzodiazepine dependence. In addition, the involvement of GABA(A) receptors in this phenomenon is leading to a greater understanding of other drugs such as alcohol and opiates.
PMID: 15661625 [PubMed - indexed for MEDLINE]
1: Gen Hosp Psychiatry. 2006 Sep-Oct;28(5):374-8.Click here to read Links
Outcome of new benzodiazepine prescriptions to older adults in primary care.* Simon GE,
* Ludman EJ.Group Health Cooperative, Center for Health Studies, Seattle, WA 98101, USA. simon.g@ghc.org <simon.g@ghc.org>
OBJECTIVE: The objective of this study was to examine the indications for benzodiazepine use, and the baseline characteristics, duration of use and clinical outcomes of older primary care patients prescribed benzodiazepines. METHODS: Computerized records were used to identify outpatients (n=129) aged >or=60 years who received new benzodiazepine prescriptions from primary care physicians of a group model managed care organization. A baseline telephone survey assessed indications for prescription, sleep quality (Pittsburgh Sleep Quality Index), depression (Symptom Checklist depression scale and Structured Clinical Interview for DSM-IV), alcohol use (CAGE) and functional status (SF-36). A 2-month follow-up survey assessed benzodiazepine use, sleep quality and depression. RESULTS: The most common indications for prescription were insomnia (42%) and anxiety (36%). At baseline, participants reported moderate sleep disturbance (mean Pittsburgh Sleep Quality Index=9.3, S.D.=4.0), only 15% met criteria for current depressive episode and only 3% reported at-risk alcohol use. After 2 months, 30% of participants used benzodiazepines at least daily. Both those continuing daily use and those not continuing daily use reported significant improvements in sleep quality and depression, with no difference between groups in rates of improvement. CONCLUSIONS: Initial benzodiazepine prescriptions to older adults are typically intended for the treatment of anxiety or insomnia, with little evidence for occult depression or alcohol abuse. A significant minority develops a pattern of long-term use, raising concerns about tolerance and dependence.
PMID: 16950371 [PubMed - indexed for MEDLINE]
1: Pharmacol Ther. 2003 May;98(2):171-95.Click here to read Links
Neuroadaptive processes in GABAergic and glutamatergic systems in benzodiazepine dependence.* Allison C,
* Pratt JA.Department of Physiology and Pharmacology, Strathclyde Institute for Biomedical Sciences, University of Strathclyde, Taylor Street, G4 ONR, Glasgow, UK.
Knowledge of the neural mechanisms underlying the development of benzodiazepine (BZ) dependence remains incomplete. The gamma-aminobutyric acid (GABA(A)) receptor, being the main locus of BZ action, has been the main focus to date in studies performed to elucidate the neuroadaptive processes underlying BZ tolerance and withdrawal in preclinical studies. Despite this intensive effort, however, no clear consensus has been reached on the exact contribution of neuroadaptive processes at the level of the GABA(A) receptor to the development of BZ tolerance and withdrawal. It is likely that changes at the level of this receptor are inadequate in themselves as an explanation of these neuroadaptive processes and that neuroadaptations in other receptor systems are important in the development of BZ dependence. In particular, it has been hypothesised that as part of compensatory mechanisms to diazepam-induced chronic enhancement of GABAergic inhibition, excitatory mechanisms (including the glutamatergic system) become more sensitive [Behav. Pharmacol. 6 (1995) 425], conceivably contributing to BZ tolerance development and/or expression of withdrawal symptoms on cessation of treatment, including increased anxiety and seizure activity. Glutamate is a key candidate for changes in excitatory transmission mechanisms and BZ dependence, (1) since there are defined neuroanatomical relationships between glutamatergic and GABAergic neurons in the CNS and (2) because of the pivotal role of glutamatergic neurotransmission in mediating many forms of synaptic plasticity in the CNS, such as long-term potentiation and kindling events. Thus, it is highly possible that glutamatergic processes are also involved in the neuroadaptive processes in drug dependence, which can conceivably be considered as a form of synaptic plasticity. This review provides an overview of studies investigating changes in the GABAergic and glutamatergic systems in the brain associated with BZ dependence, with particular attention to the possible differential involvement of N-methyl-D-aspartate and alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid receptors in these processes.
PMID: 12725868 [PubMed - indexed for MEDLINE]
1: J Subst Abuse Treat. 1991;8(1-2):19-28. Links
Protracted withdrawal syndromes from benzodiazepines.* Ashton H.
Department of Pharmacological Sciences, The University, Newcastle upon Tyne, England.
The benzodiazepine withdrawal syndrome is a complex phenomenon which presents serious difficulties in definition and measurement. It is particularly difficult to set out precise limits on its duration. Many withdrawal symptoms are a result of pharmacodynamic tolerance to benzodiazepines, some mechanisms for which are discussed. Such tolerance develops unevenly in different brain systems and may be slow to reverse. Withdrawal symptoms occurring in the first week after cessation of drug use tend to merge with more persistent symptoms that may last for many months. These prolonged symptoms do not necessarily constitute "true" pharmacological withdrawal symptoms, but are nevertheless related to long-term benzodiazepine use. Such symptoms can include anxiety, which may partly result from a learning deficit imposed by the drugs, and a variety of sensory and motor neurological symptoms. The protracted nature of some of these symptoms raises the possibility that benzodiazepines can give rise not only to slowly reversible functional changes in the central nervous system, but may also occasionally cause structural neuronal damage.
PMID: 1675688 [PubMed - indexed for MEDLINE]
1: J Clin Psychiatry. 1987 Dec;48 Suppl:12-6. Links
Long-term anxiolytic therapy: the issue of drug withdrawal.* Lader M.
Department of Clinical Psychopharmacology, University of London, England.
Although widespread use has confirmed their efficacy as anxiolytic agents, the benzodiazepine drugs are indicated only for short-term or intermittent therapy at as low a therapeutic dose as possible because of their liability for causing dependence or abuse. When first introduced, benzodiazepine drugs appeared to be therapeutically equal or superior to barbiturate agents, while causing fewer side effects, being safer in overdose, and producing fewer dependence and abuse problems. Although benzodiazepine drugs have become the most commonly prescribed anxiolytic agents, evidence has emerged that their use in long-term therapy can cause severe withdrawal problems, even when relatively low doses are used or when the drug is discontinued gradually. Based on results from both animal models and clinical investigations, buspirone appears to be as effective in treating anxiety as the benzodiazepine drugs while causing fewer withdrawal problems. Data suggest no appreciable propensity to cause physical dependence or abuse associated with buspirone therapy. The drug demonstrates no cross-tolerance with either the barbiturate agents or the benzodiazepine drugs and seems to be a dysphoriant at high doses rather than a euphoriant. Although buspirone seems to be an appropriate drug for patients requiring longer-term anxiolytic therapy, careful monitoring for withdrawal problems and other adverse side effects is essential as buspirone is introduced to successive markets.
PMID: 2891684 [PubMed - indexed for MEDLINE]
1: Fundam Clin Pharmacol. 2006 Jun;20(3):235-8.Click here to read Links
Benzodiazepines prescription in Dakar: a study about prescribing habits and knowledge in general practitioners, neurologists and psychiatrists.* Dieye AM,
* Sylla M,
* Ndiaye A,
* Ndiaye M,
* Sy GY,
* Faye B.Laboratoire de Pharmacologie et de Physiologie, Faculte de Medecine, de Pharmacie et d'Odonto-stomatologie, Universite Cheikh Anta DIOP, BP5005, Dakar, Senegal. ctdieye@yahoo.fr
Benzodiazepines are relatively well-tolerated medicines but can induce serious problems of addiction and that is why their use is regulated. However, in developing countries like Senegal, these products are used without clear indications on their prescription, their dispensation or their use. This work focuses on the prescription of these medicines with a view to make recommendations for their rational use. Benzodiazepine prescription was studied with psychiatrists or neurologists and generalists in 2003. Specialist doctors work in two Dakar university hospitals and generalists in the 11 health centres in Dakar. We did a survey by direct interview with 29 of 35 specialists and 23 of 25 generalists. All doctors were interviewed in their office. The questionnaire focused on benzodiazepine indications, their pharmacological properties, benzodiazepines prescribed in first intention against a given disease and the level of training in benzodiazepines by doctors. Comparisons between specialists and generalists were made by chi-square test. Benzodiazepines were essentially used for anxiety, insomnia and epilepsy. With these diseases, the most benzodiazepines prescribed are prazepam against anxiety and insomnia and diazepam against epilepsy. About 10% of doctors do not know that there is a limitation for the period of benzodiazepine use. The principal reasons of drugs choice are knowledge of the drugs, habit and low side effects of drugs. All generalists (100%) said that their training on benzodiazepines is poor vs. 62.1% of specialists, and doctors suggest seminars, journals adhesions and conferences to complete their training in this field. There are not many differences between specialists and generalists except the fact that specialists prefer prazepam in first intention in the insomnia treatment where generalists choose bromazepam. In addition, our survey showed that specialists' training in benzodiazepines is better than that of generalists. Overall, benzodiazepine prescription poses problems particularly in training, and national authorities must take urgent measures for rational use of these drugs.
PMID: 16671957 [PubMed - indexed for MEDLINE]
------------
OK - don't make me go there again - each one of these articles has a link to similar ones when you look at the right hand column in the PubMed window;
Squiggles
Posted by Quintal on February 5, 2007, at 20:35:47
In reply to Re: Just a question, posted by bassman on February 5, 2007, at 19:58:15
There are plenty of reports of benzo tolerance and addiction in the medical literature, but as it's 2:30AM in the morning here in the UK I'm going to bed after I finish this post :-)
The same is also true of opiates given for pain in a medical context - most people can take them at the same dose for years, as in treatment of chronic arthritis pain with low dose codeine and propoxyphene. It's probably true to say that in a substantial number of these cases the perceived continued beneficial effect is mostly placebo, with the drug producing some low-level grogginess that the patient interprets as analgesia/anxiolysis.
I have no problem with the idea that people can take the same dose of a benzodiazepine for years and even lower the dose at times - I've heard of too many people doing that to doubt it; and indeed I managed to do that myself for a while. Again, I'm not sure what exactly are you getting at bassman? Neither I nor Heather Ashton have ever advocated people being encouraged or forced to stop taking benzos against their will, or that they may be beneficial to some people. As Heather herself said in a quote I posted further up the thread:
__________________________________________________The advantages of discontinuing benzodiazepines do not necessarily mean that every long-term user should withdraw. Nobody should be forced or persuaded to withdraw against his or her will. In fact, people who are unwillingly pushed into withdrawal often do badly. On the other hand, the chances of success are very high for those sufficiently motivated. As mentioned before, almost anyone who really wants to come off can come off benzodiazepines. The option is up to you.
http://www.benzo.org.uk/manual/bzcha02.htm
__________________________________________________The major clinical advantages of benzodiazepines are high efficacy, rapid onset of action and low toxicity. Adverse effects include psychomotor impairment, especially in the elderly, and occasionally paradoxical excitement. With long term use, tolerance, dependence and withdrawal effects ***can*** become major disadvantages. Unwanted effects can largely be prevented by keeping dosages minimal and courses short (ideally 4 weeks maximum, and by careful patient selection. ***Long term prescription is occasionally required for certain patients.***
http://www.benzo.org.uk/asgr.htm
__________________________________________________>My point is that there are two sides to the discussion; nothing more.
It seems we're in agreement. Ironically the whole point of me posting that original letter was to show Heather was fair and sympathetic to the needs of long-term benzo users in the way she cut Rosie Winterton and our Chief Medical Officer down to size over their handling of his shoddy letter advising GPs to reduce their benzo prescribing.
Q
Posted by Phillipa on February 5, 2007, at 21:01:02
In reply to Re: Just a question, posted by bassman on February 5, 2007, at 19:58:15
Bassman you are so right as I've never taken all the benzos my pdocs want me to. Maybe if I had I'd be better today. And I just cut down 1/4 of my valium. Love Phillipa
Posted by gardenergirl on February 5, 2007, at 22:38:20
In reply to Re: Ashton Rocks! » notfred, posted by Quintal on February 5, 2007, at 14:44:03
> However, your continued sniping is starting to seem to me like a wilful and malicious attempt to disrupt this thread.
Please don't post anything that could lead others to feel accused or put down. You've been asked before to be civil, so now I am blocking you from posting for a week.
If you or others have questions about this or about posting policies in general, or are interested in alternative ways of expressing yourself, please see the FAQ:
http://www.dr-bob.org/babble/faq.html#civil
http://www.dr-bob.org/babble/faq.html#enforceFollow-ups regarding these issues should be directed to the Administration board and should of course be civil. Dr. Bob has oversight over deputy decisions. Thus, you can always appeal this decision to him, and he may choose a different action.
namaste
deputy gg
Posted by gardenergirl on February 5, 2007, at 22:44:51
In reply to Re: Ashton Rocks!, posted by valene on February 5, 2007, at 17:02:41
> *******Quintal I don't like your condescending attitude toward me.Please don't post anything that could lead others to feel accused or put down, even if you yourself feel put down or accused. As Dr. Bob has said, "Two wrongs don't make a right."
If you or others have questions about this or about posting policies in general, or are interested in alternative ways of expressing yourself, please first see the FAQ:
http://www.dr-bob.org/babble/faq.html#civil
http://www.dr-bob.org/babble/faq.html#enforceFollow-ups regarding these issues should be directed to Psycho-Babble Administration and should of course be civil. Dr. Bob has oversight over deputy decisions, and he may choose a different action. If you wish, you can appeal this decision to him.
namaste
deputy gg
Posted by Meri-Tuuli on February 6, 2007, at 1:48:29
In reply to Re: Just a question » Meri-Tuuli, posted by Quintal on February 5, 2007, at 18:44:51
Hey sorry to see the block. I hope it wasn't anything to do with me!
Anyway thanks for your long reply. I appreciate it. And you've opened my mind to see that Heather Aston might just be a decent scientist. But I do have to say that just because someone has alot of work published in respectable journals doesn't always mean that its correct or represents a balanced viewpoint or that its the correct way of moving forward - I'm talking in general here, and not about Prof Ashton. There are scientists out there who publish work in nature/science and who are actually considered rather um like 'quacks' by the rest of the scientific community and who are professors at respectable universities - I know of one who's at Harvard. Anyway. Thats to do with my field. But I just wanted to make the point that you should always question stuff for yourself -which you seem to do - and not be blinded by the fact that someone is, say, a Prof at a snazzy uni and has published loads of work. They might not always be correct either. But I stress again, I'm not talking about Ashton I'm just saying you should be aware of this fact.
Anyway, I think you perhaps misunderstood my last post, I was just wondering why benzo-phobia exists to the degree that it does. I wasn't saying that you were in the anti-benzo league or anything like that, I just wanted to know what the dangers and misconceptions about benzos.
But yes I agree with you, if you're addicted to smoking or alcohol it doesn't seem to be in the same league as other addictions. Perhaps it has something to do with tax. But I am under the impression (from people here in babble) that benzos are somewhat safer than alcohol....
And its good to know that the benzo.org.uk website isn't actually run by Ashton, I was under the impression that it was.
I like your opinions on this benzo topic, you seem to be very balanced and have actually read the stuff for yourself and made your own opinions -- which is good. I just want to find out more about the whole thing. I'm completely neural to be honest and rather bemused as to the whole thing really.
Kind regards
Meri
Posted by Meri-Tuuli on February 6, 2007, at 2:18:15
In reply to Re: Just a question » Meri-Tuuli, posted by Quintal on February 5, 2007, at 18:44:51
I'll sort of put my questions here...
>>Lots of things are addictive -- and you get withdrawal syptoms etc like coffee, cigarettes etc, but that doesn't nesscarily mean that they're banned or whatever.
> > As I've said before, benzos aren't banned. Almost all powerfully addicting drugs are controlled though.Yes but you can't buy benzos over the counter at a newsagents can you? I am under the impression (which could be either correct or not) that it is quite hard to get a prescription for a benzo from a UK GP. So my point is, if we can readily buy alcohol and cigarettes, and we make the choice in our lives about whether to take them - can't we be allowed to do the same thing with benzos? Do you see what I'm saying? I mean, are benzos really really bad for you? Are they in the same league as heroin, or something like that? I am under the impression that alcohol is more harmful than benzos. Which I have no idea is true or not.
>When she says that these drugs are not good for you - that you may be healthier without them - she's simply telling the truth.
Yes I agree with the rest of this point. But then, why is there such a dichotomy between benzos and SSRIs (or other drugs for that matter). I think most drugs aren't good for your health longterm. My mother-in-law is currently suffering from Zyprexa - she's become obese, has lots of other secondary complications - yet she was prescribed it to replace the valium her GP was adamant she come off. So, then which is worse, valium or zyprexa? I guess this is the sort of thing Ashton is against. But then, how did this GP became adamant that Zyprexa is less harmful than valium?
> Many people have no problem with slagging SSRIs for causing awful withdrawal syndrome (and bloody awful side effects too during treatment), yet it's almost as though benzos can do no wrong here.
Yes this is true.
> I am not anti-benzo though for most of this thread
Well I think I've come across as being slightly pro-benzo, which I'm not. I would like to say that I'm completely neutral I'm just trying to find out what all the fuss is about.
Kind regards
Meri
Posted by dbc on February 6, 2007, at 4:11:05
In reply to Re: Just a question » Quintal, posted by Meri-Tuuli on February 6, 2007, at 2:18:15
As far as im concerned Quintal has outed himself with this thread as being completely anti-med despite what he claims and i will treat his posts accordingly from now on.
As trolling.
Posted by bassman on February 6, 2007, at 8:39:38
In reply to Re: Just a question, posted by Squiggles on February 5, 2007, at 20:27:59
Thanks, Squig! Did I miss something? It seems like most of these articles say, "benzos cause dependence". Of course, we all know that. The point of the articles that I posted was that sure, you become dependent on benzos, but very few people become "addicted", in the sense that they have drug-seeking behavior and just take more and more. So anyway, I'm genuinely confused. Maybe I just misunderstood; but I do appreciate the articles.
Different topic:
I couldn't find it, but somewhere on this board Quintal tells his/her experience with benzos, which include apparent addiction, and if I read it right, the idea that Quintal might have done some stuff under the influence of benzos that he/she would not have done-like stealing. All this followed by a less-than-kind abrupt withdrawal. If you can find the post, read it. It is a terrible story and I can see how Ashton being an advocate for tapering would sound really good to Quintal.
By comparison, benzos have helped me from being so agoraphobic that I would cry if I were 20 miles from my house or my car was being worked on...finally, it would take 30 minutes at work to be up the nerve to walk across the office floor to the mailroom. When I found an SSRI helped more than the benzos (because I was depressed, too), I dropped the benzo dosage abruptly. I stil take benzos daily, at a low dose, with AD's. The combination has worked wonderfully in terms of me being functional-and when I've reduced the benzos to zero 9which I can do without any withdrawal, and have done so several times throughout the years), back comes the agoraphobia. So the doc says, "you'll probably have to take a benzo at low doses with your AD for the rest of your life"-and I don't like it, because I don't want to take ANY meds, but I also don't want to spend the next 30 years hiding under my sofa with my cat.
Here's my point: reading Quintal's and my story, you can see why we might view both benzo use and Dr. Ashton differently. If a person thinks that benzos are a dangerous med, by all means, avoid them-but please, for those of us who's lives have been enhanced by them, please don't fuel our already guilty feelings about taking them.
Posted by Squiggles on February 6, 2007, at 9:22:27
In reply to Re: Just a question, posted by bassman on February 6, 2007, at 8:39:38
bassman,
I have seen many debates on the meaning
of addiction versus dependence, and I have
participated in far too many of them. In the
heads and hands of medics who have not been
educated in linguistics or philosophy, the
debate is a lost cause. I will leave it at
that.Later today, I will be happy to search your
story and Quintal's about your benzo experiences.I agree with you, that benzos are particularly
helpful in agitating ADs, for example PROZAC and
others where a side effect is a motor or neural
excitability, like akathisia, or insomnia.One thing i did not mention which is probably very important for benzo tolerance is how *often* the drug is prescribed-- i.e. on a daily basis or on occasions of panic or crisis. I think you are more likely to become dependent on a daily prescription. But as one my friends said, there are worse things than becoming dependent on a drug which is better than not being on that drug.
Yes, there are worse things-- coming off abruptly or without the aid of another drug. :-)So, here are the things that should be watched out for from person to person:
TYPE OF DRUG (length of half-life, anxiolytic and/or anti-convulsant strength)
INTERACTION WITH OTHER DRUGS or ALCOHOL or other
BENZOS (benzos and some ADs can make you very lethargic, and each can potentiate the other)DOSE (can calm you or put you to sleep or be lethal or create cognitive problems)
DURATION (how long you have been taking it influences its efficacy and withdrawal potential)
WITHDRAWAL (requires knowledge of the drug and monitoring of the patient, and assessment of whether it is necessary to get off the drug; if the withdrawal leaves you with protracted symptoms it may be better to stay on indefinitely; also the process of withdrawal may be aided by another long-life drug to prevent things like seizures or other permanent disabilities.)
AGE (older people metabolize all drugs at a different rate and the same dose may be stronger for them)
INTER-DOSE WITHDRAWAL ( that is not in the books); it's an experience i gave a name to, when my need for a Xanax accelerated with time. From the minimal "as needed" dose, i started to get severe anxiety and panic unless I took more and more.
The relief became shorter and shorter within each dose, so the amount escalated -- you get the picture.There are many articles on other issues, e.g.
fractures in the elderly, etc., many physical side-effects during and after stopping-- but I am just posting what I think is really important.I think that we have to keep in mind people who live in dreadful circumstances, of domestic abuse, war-torn environments, deaths or crises in families, loss of home or job, terminal illnesses, etc. where any sedative is common sense. But at the same time, it is good to be educated about the effects of benzos, and not pretend that they are not addicting. Heck, I'm pro-heroin for depression and anxiety, if only it were legal.
Squiggles
Posted by Meri-Tuuli on February 6, 2007, at 9:47:02
In reply to Re: Quintal, posted by dbc on February 6, 2007, at 4:11:05
Hello
>As far as im concerned Quintal has outed himself with this thread as being completely anti-med despite what he claims and i will treat his posts accordingly from now on.
>
> As trolling.No, I don't think thats fair -- poor Q can't defend himself because he's blocked! I don't think he is particulary anti-med - no more so that me, for instance. He postively encouraged me to try my oxazepam but which I was petrified of doing (I'm petrified of poisoning myself, for some reason). I think that if Q were anti-med he wouldn't have done this. And he's clearly read up on the subject matter and has a balanced viewpoint, IMHO. I think he's a very clever and wise individual -- I honestly thought he was alot older than his 24 years.
But we are all only human, and obviously our past experiences colour our viewpoints to some degree, which is perhaps what happened with Q. This isn't a bad thing - we can try and pass on our experiences to our fellow human beings, which is the purpose of this board isn't it? I wish I'd discovered this board prior to my taking any sort of AD - I'd be in a much better place to make a balanced decision. And I think thats what Q is trying to do here, create balance. We are all entitled to our viewpoints.
Kind regards
Meri
Posted by valene on February 6, 2007, at 10:01:59
In reply to Re: Quintal » dbc, posted by Meri-Tuuli on February 6, 2007, at 9:47:02
I would like to clear the record and this is my last post on the subject.
I never said I did not like Heather Ashton . Ever. If you go back, Squiggles as you said you were in post to Bassman, maybe you can see that just 2 months ago, in December, 2006, I posted to someone who had been yanked off 60mg. of valium in 5 days.
I suggested to that person to read Heather Ashton's material on benzodiazpine withdrawal. I think she has done some *great* work in helping people and education, etc.
I think that I was misunderstood, in that someone thought I did not like Dr. Ashton. In my post the UK website was the topic of discussion. Heather herself has nothing to do with that web site. The one part of the web site that I do like is that they copy her material, and post her manual, of which I have a copy and have used.
Thanks, and peace,
Val
Posted by bassman on February 6, 2007, at 10:22:27
In reply to Re: Just a question, posted by Squiggles on February 6, 2007, at 9:22:27
The thing you call "INTER-DOSE WITHDRAWAL" is well-known-so much so that there is a joke that if you want to know what time it is, ask someone who is taking Xanax.
I complete agree with you about benzos causing dependence in many individuals and people should be cautioned about stopping abruptly...as is the case with many drugs. But if all drugs that should be tapered off of were taken off the market, we'd be treated for a lot of ills with M&M's.
I'm not sure a degree in philosophy is needed to understand the difference between dependence and addiction-and I also think it is important to understand the difference; which is huge.
Posted by gardenergirl on February 6, 2007, at 11:58:11
In reply to Re: Quintal, posted by dbc on February 6, 2007, at 4:11:05
> and i will treat his posts accordingly from now on.
>
> As trolling.Please don't post anything that could lead others to feel accused or put down. If you or others have questions about this or about posting policies in general, or are interested in alternative ways of expressing yourself, please first see the FAQ:
http://www.dr-bob.org/babble/faq.html#civil
http://www.dr-bob.org/babble/faq.html#enforceFollow-ups regarding these issues should be directed to Psycho-Babble Administration and should of course be civil. Dr. Bob has oversight over deputy decisions, and he may choose a different action. If you wish, you can appeal this decision to him.
namasté
deputy gg
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