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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 38. This is the beginning of the thread.
Posted by Bob on March 12, 2010, at 11:43:58
Is anyone familiar with what the current concensus is on long term benzo treatment, e.g. for years. Is it often a useful part of people's treatment or are they something that should be used for the absolute shortest amount of time. More importantly, do prevailing theories suggest that people develop long term tolerance to the drugs and then get stuck on them?
My pdoc wants me to augment my treatment with ativan 'for awhile' in keeping with the hypothesis that the antidepressants are causing muscle tension and restlessness. I agree that something needs to be done, but I'm worried about benzos. I've been on clonazepam for extended periods in the past and it was always difficult to get off of in then end, and that drug has a real long half-life. I have no idea what an alternative treatment would be if we are to stick with his hypothesis.
I'm also concerned about the relatively short half-life and the probably need to dose it multiple times per day. Clonazepam addressed that issue, but was a quite depressogenic and sometimes sedating drug.
Posted by manic666 on March 12, 2010, at 12:42:19
In reply to Benzodiazipine maintenance treatment?, posted by Bob on March 12, 2010, at 11:43:58
bob i am the prince of ativan//the blue cobra is with me for life.//i would argue its the best an most additive benzo there is,// many a life saver an many a life taker//i am now on 4 mg a day ,the most ant english gp will priscibe long term.///but they are the ones that got me hooked all those years ago.//i am stable on 4mg but you have to special to achieve that//once addicted to 10 mg a day an dont forget thats about 80mg of valium////i was space man of the year, //i set a limit of 10 a day //i new i was intouble at that //the withdrawl of the 6mg was forced on me by a p doc an to say the withdrawl was bad ia a massive understatment.//im lucky to be alive.//death does seem a esayer option when witdrawing, 10 time harder than heroin to get off an a lot longer,but i carnt shift the last 4mg so the blue cobra is my life blood
Posted by ron1953 on March 12, 2010, at 13:11:55
In reply to Re: Benzodiazipine maintenance treatment?, posted by manic666 on March 12, 2010, at 12:42:19
I was prescribed Klonopin for 7 years at amounts up to 4mg daily (admittedly took more at times). It is extremely addictive. I wasn't told about the tolerance profile, nor did any so-called professionals recognize withdrawal symptoms when presented. I tried tapering off a couple of times with no success. I finally went cold turkey 4 years ago. The withdrawal was horrible, to say the least. No more prescription drugs for me. For some very good info, visit:
Posted by Phillipa on March 12, 2010, at 13:16:19
In reply to Re: Benzodiazipine maintenance treatment?, posted by ron1953 on March 12, 2010, at 13:11:55
40 years later and switched back and forth as new came out. During menopause highest dose now take less each day. Just don't want or need them. Phillipa I think it depends on the person whether they have an addictive personality.
Posted by ed_uk2010 on March 12, 2010, at 13:32:14
In reply to Benzodiazipine maintenance treatment?, posted by Bob on March 12, 2010, at 11:43:58
I think it's fair to say that withdrawal from benzos can be exceptionally difficult and unpleasant, especially if done too rapidly. Benzos are mainly appropriate for the short/medium term treatment of severe anxiety or panic. I do not think that reducing the side effects of antidepressants is a good reason to take a benzo on a long-term basis. Benzos can be useful when first starting an antidepressant but should be tapered after a week or two.
If your antidepressant is making you feel very tense and restless, it would be more sensible to consider a substantial dosage reduction or a different antidepressant. Adding drugs to treat the side effects of other drugs can be problematic to say the least.
Given that you found clonazepam withdrawal difficult, lorazepam withdrawal is certainly likely to be very difficult if you have taken it for a long period. By all means take lorazepam briefly, but long-term treatment should only be considered if there is no alternative. It is not a decision which should be taken lightly.
Best regards
Posted by manic666 on March 12, 2010, at 13:44:13
In reply to Re: Benzodiazipine maintenance treatment?, posted by Phillipa on March 12, 2010, at 13:16:19
no it depends on if your ill or not/// if your anxierty is off the radar ,you would take20mg of loz ie genetic ativan . //what your talking is valium that is so weak you use it as you come off ativan //ativan is 8 times the strenth of valium an very short lasting, compaired to ativan it a walk in the park to d tox
Posted by Bob on March 12, 2010, at 13:59:31
In reply to Re: Benzodiazipine maintenance treatment?, posted by manic666 on March 12, 2010, at 13:44:13
> no it depends on if your ill or not/// if your anxierty is off the radar ,you would take20mg of loz ie genetic ativan . //what your talking is valium that is so weak you use it as you come off ativan //ativan is 8 times the strenth of valium an very short lasting, compaired to ativan it a walk in the park to d tox
If Valium is such a breeze to get off of, then why is it that docs don't seem to prefer it? In other words, why isn' it
a first choice as an anxiolytic?
Posted by ed_uk2010 on March 12, 2010, at 14:25:01
In reply to Re: Benzodiazipine maintenance treatment?, posted by Bob on March 12, 2010, at 13:59:31
> If Valium is such a breeze to get off of, then >why is it that docs don't seem to prefer it? In >other words, why isn' it
> a first choice as an anxiolytic?This is entirely dependent on where you live. Here in the UK, diazepam is prescribed far more frequently than any other anxiolytic benzo. Alprazolam (Xanax) is not prescribed. Clonazepam is used rarely and is not approved for the treatment of anxiety, only epilepsy.
After long-term treatment at high doses, diazepam is not a breeze to stop. Many people have difficulties. It is, nevertheless, much easier to taper than short-acting high-potency benzos such as alprazolam (Xanax) and lorazepam (Ativan).
Posted by Bob on March 12, 2010, at 20:58:51
In reply to Re: Benzodiazipine maintenance treatment?, posted by ed_uk2010 on March 12, 2010, at 13:32:14
> I think it's fair to say that withdrawal from benzos can be exceptionally difficult and unpleasant, especially if done too rapidly. Benzos are mainly appropriate for the short/medium term treatment of severe anxiety or panic. I do not think that reducing the side effects of antidepressants is a good reason to take a benzo on a long-term basis. Benzos can be useful when first starting an antidepressant but should be tapered after a week or two.
>
> If your antidepressant is making you feel very tense and restless, it would be more sensible to consider a substantial dosage reduction or a different antidepressant. Adding drugs to treat the side effects of other drugs can be problematic to say the least.
>
> Given that you found clonazepam withdrawal difficult, lorazepam withdrawal is certainly likely to be very difficult if you have taken it for a long period. By all means take lorazepam briefly, but long-term treatment should only be considered if there is no alternative. It is not a decision which should be taken lightly.
>
> Best regardsBelieve me, all my med decisions are made with much deliberation and often a heavy heart.
Posted by manic666 on March 13, 2010, at 3:36:19
In reply to Re: Benzodiazipine maintenance treatment?, posted by ed_uk2010 on March 12, 2010, at 14:25:01
bob thats what i was trying to say //in my ham fisted straight talk//valium in england is used as you an i say to detox much stronger benzo,s///if a person walks in the surgery the doc will access the patient, if you shaking of the chair, out comes the ativan//because he knows in half a hour you will carm down///if a peson is in minor distress out comes the valium //mabye 2mg 3 times a day //about 2 thirds of 1 ativan//if the patient dont come back maby she or he wasnt so ill an the the name valium cured them not the med///when i was convulsing at even had to sit in the carpark of the gp as to not look odd //detoxing then 10 ativan //they gave me valium in 40mg doses//but you have to wait to long for effect if any. //if you have been on a high dose of ativan //i asure you valium is a pussycat/// half american house wifes carry them in there hadbag like sweets.//i have a buddy who takes a drugs cocktale an 100mg of valium is part of it for it long life . if he took the same dose in ativan 12 mg a day he would be nuked.
Posted by ed_uk2010 on March 13, 2010, at 9:06:00
In reply to Re: Benzodiazipine maintenance treatment? » ed_uk2010, posted by Bob on March 12, 2010, at 20:58:51
> Believe me, all my med decisions are made with much deliberation and often a heavy heart.
Hi Bob,
I hope I didn't offend. Just wanted to make sure that you understood the potential risks, which you clearly do.
I hope you find a solution to your current situation.
Best regards
Posted by manic666 on March 13, 2010, at 12:44:39
In reply to Re: Benzodiazipine maintenance treatment? » Bob, posted by ed_uk2010 on March 13, 2010, at 9:06:00
me to bob, if at the time i had not found ativan//i may have even been dead //they were a life saver //ok im hooked on them 2mg in the mornig with my other meds an 2mg at night an they give me even after all these years a good nights sleep.// i find if this interest you if i take 2mg at 8pm then i whatch tv , computer, play giutar ,whatever.//11pm they kick in an i go to bed about 12pm straight to sleep///the addiction dont bother me as im stable at 4mg//if i was craveing more thats another story
Posted by Phillipa on March 13, 2010, at 19:18:04
In reply to Re: Benzodiazipine maintenance treatment?, posted by manic666 on March 13, 2010, at 12:44:39
Manic seriously I've taken ativan and they begin working in a much shorter time than three hours. How many years on them? As after the years I've been on benzos I don't require as high a dose? Phillipa
Posted by Abby Cunningham on March 14, 2010, at 14:57:58
In reply to Benzodiazipine maintenance treatment?, posted by Bob on March 12, 2010, at 11:43:58
Hi Bob,
I've been on xanax since about 1983 - was up to 3mg. (equivalent of 30 mg. valium, so Ashton says), and now down to 1.5 mg. Now I feel I am much less sedated and no longer tired. Others are right, withdrawal is not fun at all. :-(
My 89-year-old mother has been on valium (diazepam) for 50 years or however long it's been out. She takes 5 mg. per day and has never raised the dosage. She is very healthy, by the way.
I've sort of resigned myself that my gaba receptors are messed up - it is not addictive personality. I did manage to reduce the dosage in half and would like to get down to 1mg. per day. Good luck.
Abby
Posted by Bob on March 15, 2010, at 15:20:20
In reply to Re: Benzodiazipine maintenance treatment? » Bob, posted by ed_uk2010 on March 13, 2010, at 9:06:00
> > Believe me, all my med decisions are made with much deliberation and often a heavy heart.
>
> Hi Bob,
>
> I hope I didn't offend. Just wanted to make sure that you understood the potential risks, which you clearly do.
>
> I hope you find a solution to your current situation.
>
> Best regards
>Don't worry, I didn't take offense.
Posted by floatingbridge on March 16, 2010, at 0:02:58
In reply to Re: Benzodiazipine maintenance treatment?, posted by Abby Cunningham on March 14, 2010, at 14:57:58
Ummm. I have a question. Is Valium not preferred treatment in the US?
I've been given klonopin (depressive), librium (restless legs), Xanax CR (currently on maintenance dose of 1-1.5). Works well and said to have muscle relaxant effects which I seem to need.
Why has my doc not suggested Valium? Is there no xr version? Just curious--not looking to change. I associate Valium
with 'Valley of the Dolls'. (Now I'm NOT saying there is any validity to that association.) It's not any more tolerance producing, is it?And 3mgs of Xanax equals 30mg of
Valium? Oh well....Bob, best to you in your decision-making process.
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.
Best wishes,
Sukarno
Posted by floatingbridge on March 16, 2010, at 10:19:43
In reply to Xanax on private prescription in UK, posted by sukarno on March 16, 2010, at 7:26:26
Your post was very informative--answers why I was never prescribed Valium. Thanks!
Why is it exactly that Xanax is so difficult to discontinue? I would think ativan with it's shorter half life would be worse....
Posted by manic666 on March 16, 2010, at 13:44:17
In reply to Re: Xanax on private prescription in UK » sukarno, posted by floatingbridge on March 16, 2010, at 10:19:43
valium has a lot of cred with the heroin addicts,// ativan with the rave set an clubers as you can drink an drink an drink without realy feeling pissed an you seem to stay alert//you would think it did the opposit , but years ago now i would take 2mg go out with the boys an out drink the lot///2 big downfalls/you talk at a hundred mile a hour. an you have 2 hangovers in the morning.
Posted by floatingbridge on March 16, 2010, at 13:53:46
In reply to Xanax on private prescription in UK, posted by sukarno on March 16, 2010, at 7:26:26
Is Xanax more difficult to taper/withdraw?
If so, why?
Posted by manic666 on March 16, 2010, at 14:39:05
In reply to Xanax on private prescription in UK, posted by sukarno on March 16, 2010, at 7:26:26
you will be ok with setraline, its an easy one to start no major upsets // perhaps sleepy to start wih but thats good as its chilling you out// it takes a long time to really kick in//i had side effects so i swapped to citalopram //there obout the same really mabye citalopram seems a little weaker.//i changed because of weight gain ,but i think it wasnt so much the med as my eating habits //as im still the same on this med . but for depression there cool
Posted by Phillipa on March 16, 2010, at 23:07:34
In reply to Re: Xanax, posted by floatingbridge on March 16, 2010, at 13:53:46
Floatingbridge been gone all day for a 4.5 hour doc appoint infection guy but to answer your questions on benzos in most areas of US for some reason klonopin is first choice, valium is the very mildest and used for tapering from others even in hospitals that offer rehab as the half-life is so long. In the past I've simply switched or cut down no problem on valium. The UK valium is about the only benzo used. Xanax is the shortest acting a google search will show that. The long acting version your're on for some works well and othes need to add regular xanax as doesn't always release equally. I myself use the regular version as the long acting simply brand and generic didn't work for me. Ativan is longer lasting and now not as popular. But for while it was highly prescribed and if you take luvox as I do it's the only benzo that doesn't build up in your system to act as higher doses. Luvox has a lot of meds that are tolerant with it. Might want to google it. Valium is also an antiseizure med for withdrawal or even IV for real seizures not always. But I took valium for years am almost off it as I don't want the all day med in my system. Prefer the fast acting xanax regular as it if placed under the tongue will stop a panic attack within a few minutes. I thing valium has at time an hour to work. Check babble and see. Love Jan ps never got high on any of them but depressed on klonopin
Posted by floatingbridge on March 16, 2010, at 23:28:17
In reply to Re: Xanax » floatingbridge, posted by Phillipa on March 16, 2010, at 23:07:34
Thanks Phillipa,
So Ativan isn't like big guns benzo? Had an injection once of ativan, the only time I've had it. Who knows the dose, but knocked me cold which was just what I needed. I thought ativan was the fastest acting.
I use Xanax regular as an emergency med. I agree--within minutes I'm fine.
I'm curious what luvox is--will Google.
4 hours at the doc? Hope it was beneficial.
Thanks again.
Posted by Phillipa on March 16, 2010, at 23:56:46
In reply to Re: Xanax » Phillipa, posted by floatingbridge on March 16, 2010, at 23:28:17
Fb you didn't mention delivery system as ativan IM is extremly fast acting and was the only thing that worked for me for severe vertigo and also when thyroid messed up and needed ativan 2mg IM and then felt normal. Luvox shouldn't be taken with xanax or valium but in my case my dose is so low of luvox that the pdoc likes it. As I said lots of new stuff. I hope it's good. I do know will be expensive and could involve surgery. Got to get the Mri and results of labs back first. Love Jan
Posted by sukarno on March 17, 2010, at 0:27:14
In reply to Re: Xanax » floatingbridge, posted by Phillipa on March 16, 2010, at 23:56:46
Yeah, lorazepam (Ativan) is short-acting, but intermediate in its onset. Everyone is different though, but when I took Ativan for sleep I remember nothing happening until almost an hour later so I took another one. I slept like a baby when it finally kicked in and when I woke up I could almost hear music playing in my head (very foggy headed).
The advantage of lorazepam, as Phillipa pointed out, is there are no drug interactions. Lorazepam does not interact with the P450 liver enzyme system. It can be given to those with liver problems without fear of accumulation.
Alprazolam (Xanax) is metabolised by CYP3A4 and interacts with many medications (those that are also metabolised by CYP3A4), such as fluvoxamine (Luvox) and even grapefruit juice. Kava-kava should never be taken whilst on Xanax. There were a few reports of folks passed out who took Xanax along with Kava-kava or who added Kava-kava to their existing Xanax regimen.
Alprazolam binds very tightly to the GABA receptor complex relative to other BZDs. It is thought, although perhaps controversial, that it might target a subset of GABA receptors that diazepam does not. Thus, diazepam seems not to have full cross tolerance with alprazolam. This is controversial though. Some say that diazepam will suppress all withdrawal symptoms and will switch their patients directly to diazepam from alprazolam. Other physicians will perform a cross taper.
I'm not sure whether lorazepam has the same or worse withdrawal than Xanax. They are both very potent BZDs, although Xanax is approximately twice as potent (roughly 1mg alprazolam = 2mg lorazepam, although this can vary from patient to patient).
Halcion (triazolam) supposedly has the worst withdrawal syndrome if abused and taken regularly. Some patients would take it throughout the day instead of using it as a sleep aid. One patient abused it to the tune of 14mg/day and discontinued it abruptly. The patient was given IV chlordiazepoxide (Librium), but still experienced a seizure despite coverage from Librium. I can't remember whether this patient died or not.
Death from discontinuation of BZDs, even Xanax, is rare in the medical literature, despite the seizure risk. However, there was a female patient who had taken [xxx]mg Xanax for one week and went through acute withdrawal in the ER, presenting with all the symptoms of withdrawal and high fever.
This patient was not adequately treated by the hospital and unfortunately died due to a series of epileptic fits.
[xxx]mg is an extreme amount (almost [xxx]mg/day!).
In the literature, there are a few reports of deaths due to status epilepticus from abrupt withdrawal (and one report of seizure during tapering).
With diazepam I believe this is unheard of. Seizures can happen with diazepam withdrawal, but much less so than with alprazolam.
I was forgetful one night and skipped one of my Xanax doses. I couldn't understand why I was hyperventilating and feeling like I was going to "lose my mind" until I looked at the clock and realised it had been 2 or 3 hours since I was supposed to take my medication.
I would rather take Xanax XR instead as a friend of mine told me it is less sedating and has far less peaks and valleys, but the price is exorbitant. I think it is almost USD$2 per tablet. I would have to take two 2mg XR tablets, which would cost me $4/day. :-(
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Dr. Bob is Robert Hsiung, MD,
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