Last night I came across a medical student web site that included a link to a post of mine from a couple years ago, that described my feelings about Xanax, Valium, Klonopin, and other benzodiazepines.   The people commenting at that site appreciated my comments, and my comments were ‘seconded’ by other physicians.  Here’s the post again, for those who missed it the first time:

Twelve Things I Hate About Benzodiazepines

Author: J Junig MD PhD

Because of several highly publicized deaths from combining Suboxone with benzodiazepines or “benzos”—a class of sedative medications that includes Xanax and Valium—I am frequently asked about the safety of combining Suboxone with those medications. The risk of life-threatening respiratory depression can be mitigated fairly easily, but that does not mean that benzos are safe or appropriate medications for people with or without addictions. They are commonly prescribed medications, and there are a number of misconceptions among laypeople about their proper use, so they deserve a thorough discussion. Most doctors with a bit of experience have learned to cringe every time a patient says the word “anxiety,” knowing that in all likelihood they are about to be placed in a difficult position. They will either do the right thing and disappoint their patient, or do the wrong thing and struggle with the consequences of their actions for months or years.

The problem is that the non-medical community sees SSRI’s as “antidepressants,” and believes that the proper treatments for anxiety disorders are sedatives like Valium or Xanax. Whereas the sedatives are appropriate for acute or short-term anxiety, chronic anxiety disorders are more appropriately treated using SSRI’s or SNRI’s.

Today, I saw a new patient who asked for treatment of her addiction to pain medications. When I asked about other psychiatric symptoms, she said that she takes alprazolam and clonazepam for anxiety and panic attacks. I explained that those medications are very dangerous for addicts and are intended for short-term use, and the primary treatments for anxiety disorders are SSRIs or SNRIs. I asked her dose and wasn’t surprised to hear that her tolerance was quite high. A milligram of alprazolam doesn’t do anything, she said—intending to mean that the meds are not potent enough to worry about. I of course took it the opposite way—she has taken benzos to the point that a very large dose has no effect due to her high tolerance. She then said she also has ADD and takes Adderall (ie, amphetamine). I explained that it makes no sense to take both amphetamines and benzos, particularly a long-acting benzo like clonazepam, which has a half-life of around 30 hours. Benzos CAUSE deficient attention; that is how they work! Worry consists of too much attention to a problem or a fear, and benzos prevent the brain from attending, attaching and remembering. In fact, anesthesiologists and dentists use the short-acting benzodiazepine midazolam during uncomfortable procedures to block the patient’s memory. Most adults have had the experience of watching the medication injected into the IV tubing, and next waking up to people saying “you’re OK—it’s all done.” Don’t take a benzodiazepine if you are nervous about an exam the next day! Beyond the amnesia, it is simply a bad idea to take two polar-opposite medications as this patient is doing. Stimulants cause wakefulness, attention, tight muscles, and anxiety. Benzos cause drowsiness, amnesia, relaxation, and the inability to remember what you were supposed to worry about. Instead of taking both, take neither.

A related question came to me by e-mail yesterday:

Hello, I found your website and see that you do phone consultations. I have been having anxiety problems and attacks for over a year. It has gotten worse and worse. I’ve been to the doctors in my area but no one wants to treat me for it…they just want to keep giving me Paxil, Zoloft, Prozac, Cymbalta and all these things I’ve tried and nothing seems to be helping me. I have anxiety attacks all the time where my heart beats out of my chest and I can’t breathe and go almost into this blackout stage. I have a lot of things that trigger it; one is my anxiousness all the time. I can’t focus, and any little dilemma sets me off. Everything is a crisis to me. And on top of that, I have the responsibility to take care of a 3 year old all by myself. I’m so scattered and anxious and upset all the time it is affecting me being a good mother. I cannot take it anymore and I am at the end of my rope. I don’t know what to do; no one will treat me with anything to calm me down along with the Paxil because of all the other people in this county that have abused it.. I DO NOT know what else to do. I have no one to talk to or turn to. It’s affecting my job, my personal life and my life in general. If you can’t help me maybe you know someone who will.

The person doesn’t come right out and say it, but her comments about needing to be calmed down and about abuse of the meds by others suggest that she is asking for a benzodiazepine.

Benzodiazepines include long-acting medications like clonazepam (Klonopin) and diazepam (Valium), intermediate-acting medications like lorazepam (Ativan) and alprazolam (Xanax), and the short-acting sleeping pills from my training years like triazolam (Halcion) and temazepam (Restoril). As an anesthesiologist, I gave patients midazolam (Versed) more than any other medication. All of these medications are appropriate in certain settings. Most have a street value. Some have active metabolites that accumulate in the body over time. All are sedating, all cause tolerance, and all have the potential to cause significant withdrawal symptoms. The longer-acting medications will self-taper to some extent, but the intermediate-acting agents in particular have the potential to cause withdrawal syndromes that are severe, and even fatal. The first patient I mentioned has been taking an anticonvulsant since presenting to the ER with a grand mal seizure while stopping Xanax “cold turkey.”

All of these medications have appropriate uses, almost always for short-term conditions. When given long-term, they cause problems. In fact, from the top of my head, I can think of 12 reasons to avoid prescribing benzos for “anxiety.”

1. Many anxious patients aren’t truly anxious. When a patient complains of anxiety, he or she is often complaining of something else. If I ask a patient to describe the symptoms without using the word anxiety, I often find that the patient is bored, restless, angry, depressed, overwhelmed, or appropriately frightened. Take a look at the second patient—the one who is “scattered,” “at the end of her rope,” and “caring for a 3-year-old boy all by herself.” Do you really think she will be a better mom if she is taking alprazolam or clonazepam? She is feeling overwhelmed, angry, tired, afraid, hopeless, depressed—feelings that when added together become anxiety. Do we really want to give a person in this condition a medication that will make her sleepier, more forgetful, more scattered, and more disinhibited?

2. Even if we get it right, her relief will be short-lived due to tolerance. Patients often escalate their dose at some point—no matter how many times they promise that they won’t. Dose escalation is not the patient’s fault—it is simply what these meds do. Once a pattern of dose escalation begins, it is difficult to control; patients will call after two weeks, reporting that they are out of alprazolam, and the doctor feels pressured to issue a refill to prevent withdrawal.

3. Benzos turn manageable anxiety into an anxiety disorder. Patients get a calming effect from the medication, but as the medication wears off, the anxiety returns, including extra anxiety from a rebound effect—a miniature form of withdrawal. Patients do not usually attribute that anxiety to rebound, but instead believe they have a horrible anxiety condition that appears as soon as the medication wears off. When I worked in a maximum security prison for women in Wisconsin, many inmates were taking benzos upon arrival; several months after the benzos were discontinued, the most amazing thing happened: the anxiety disorders went away!

4. A problem specific to addicts is that they don’t take sedative medications to achieve the absence of anxiety, but rather until they feel relaxed. They are not seeking normalcy; they are seeking relaxation. There is a difference between the two states: one is feeling normal without feeling excessive worry or panic; the other is feeling relaxed, something other than feeling normal. This doesn’t make addicts bad people; it is simply a consequence of the conditioning process during addiction. Addicts are not aware that they are seeking a fuzziness that non-addicts often find to be uncomfortable.

5. Again specific to addicts, benzos (like other medications that have an immediate psychotropic effect) direct the person’s attention inward. An addict becomes obsessed with how they feel; a goal in treatment is to get the addict out of his or her own head to experience life on life’s terms. Benzodiazepines encourage the opposite effect, encouraging the addict to focus on internal feelings and sensations.

6. Addicts with one favored class of drugs, for example opiates, will often move to a different substance when the first drug of choice is removed, for example using Suboxone. This phenomenon is called “cross addiction.”

7. A final concern for addicts is that benzos help preserve the mistaken thought that the person cannot function without taking something.

8. Benzos impair driving and have the potential to impair a person working with dangerous machinery. After all, patients get anxious at work too. They also make a person appear intoxicated by causing slurred speech, forgetfulness, and sometimes loopy behavior, risking the person’s job and having other unforeseen consequences. Some people have completely different personalities when disinhibited by benzos.

9. Benzos have been linked to fetal anomalies and early miscarriage.

10. They destroy sleep in the long run through tolerance and through rebound effects. If the patient takes the benzo during the day, he or she will be trying to sleep just as the sedation is wearing off. The alternative is to take the medication at bedtime, defeating the goal of finding relief for daytime anxiety. If the person takes benzos both day and night, tolerance increases even more quickly.

11. I have already mentioned the need to taper off benzodiazepines and the risk of seizures and worse during withdrawal.

12. Benzodiazepines may calm a truly anxious patient, but they do not generally increase the patient’s function. A person who can’t get out of bed becomes less likely to get out of bed. Bills that are unpaid become even less likely to be paid. Relationships do not generally improve when one partner is nodding off as the other talks about feelings.

I do prescribe benzodiazepines, usually for the short-term or while recommending they be taken no more than every other day. Some patients do fine with them, but for others, benzos are a Pandora’s Box that should never be opened. As a psychiatrist, I often resent the treatment that led to the mess that I try my best to clean up—such as the case with the first patient I mentioned. I think most doctors who read this will understand what I am saying, and many will have similar thoughts about benzodiazepines. Perhaps others will find the use of benzodiazepine much more beneficial than harmful. Comments anyone?

I received the following e-mail a couple days ago:

Hi

I had been on Suboxone for 9 years. I was put on it the week it was approved by FDA. I found your posts in a blog. I was looking for a class action suit against this terrible drug. That man who said he was enjoying a Suboxone was right. I was on it almost 9 years and did get high and stay high all day, just like methadone. It causes depression and brain damage. I have been off it for 2 months now and am very sick with depression, panic attacks, and have not been able to even take care of myself. Please, if people want to get off drugs help them and send to treatment and AA NA.

thanks

nancy

Those of you who have read this blog for a while may remember the posts ‘back in the old days’—a few years ago—when I would get these kinds of messages often. Thankfully, I rarely get them nowadays, although every now and then someone stops by SuboxForum.com intent on harassing people taking buprenorphine.

I get your complaint Nancy, I really do—but I don’t agree with your thought process, or your conclusions. First of all, buprenorphine has been around for over 30 years, and has never been associated with ‘brain damage.’ The high doses of buprenorphine used for opioid dependence have been in around for 15-20 years overall, 8 years in the US. Several million prescriptions for high-dose buprenorphine have been written—without evidence for any significant harmful effects from buprenorphine.

Your description of how you felt while taking the medication are not at all consistent with the descriptions I’ve heard from the several hundred people I’ve treated over the past 5 years; people almost always report feeling nothing from the medication after being on it for a week or two. Every now and then a person will say that he/she notices opioid effects after each dose, but the sensations are always subtle, and people have to focus to tell if they are really feeling them. Frankly, given that the feelings usually come well before the 45-minute absorption time of the medication, I think that they are often imagined, or created by the mind, as a ‘placebo effect.’

Preliminary studies suggest a role for buprenorphine for treating refractory depression. I would not recommend that use for the medication in people who are not already addicted to opioids- but the findings of mood elevation in some people runs counter to your suggestion that the drug causes depression.

Buprenorphine is different from methadone in a number of ways, the most critical being the mu receptor profile, where buprenorphine acts as a partial agonist, and methadone acts as an agonist. This difference is responsible for the unique actions of buprenorphine, compared to methadone and other agonists.

But my primary disagreement with you is because you completely disregard the conditions that you had before starting buprenorphine. I assume that you were dependent on opioids, as that is why the vast majority of people take buprenorphine. And opioid dependence is not a benign condition. In fact, opioid dependence is often fatal, particularly over a span of ten years. When you blame your depression and anxiety on buprenorphine and Suboxone, where do you get the image that you use as a comparison for your current condition?

For example, if you didn’t take buprenorphine, what are you assuming would have happened? The success rates for ‘treatment’ without buprenorphine are very low—well below 10%. And many young people who have taken opioids for more than a year or so can list several former confidants who have died from opioids. In other words– you seem to be assuming that you would have been fine without Suboxone, when the odds are more in favor of you having significant problems from your addiction—and maybe death.

You may have scraped up $5K – $50K to enter treatment and been in the lucky few percent who ‘got’ recovery; in that case, the odds would have been high that you would relapse in the next few years. As for depression and panic, those are common symptoms in anyone with longstanding opioid dependence—are you just assuming that you would have been fine?

You may have gotten arrested for doctor shopping, shoplifting, or theft from your best friend’s medicine cabinet. You may have gotten disgusted with yourself and committed suicide. You may have lost everyone close to you, and ended up living on the street. We don’t know what might have happened—but I remember the days before buprenorphine was available, and remember the revolving door of treatment centers and NA meetings. Heck, those revolving doors are still in use by the people who will buy into your comments!

This is where my anger used to really well up… every person who you convince with your story — fueled by your lack of recognition of the condition you were in and your lack of appreciation for the substance that saved your life—every one of those persons will have a higher risk of mortality, thanks to you.

And—sorry for my French—that still pisses me off!

I have written about the sleazy actions of health insurer Humana.  Today I filed a formal complaint with the Wisconsin Commisioner of Insurance regarding their practices.  I’ll copy my letter below, rather than take the time to write everything over again.  If there is an attorney willing to work the case on contingency, please contact me.  Likewise, if other patients or physicians are having similar problems with Humana, send me an e-mail through my website at www.fdlpsych.com.

The complaint:

My patient, XXXXXX, has been treated for opioid dependence for two years, using maintenance treatment with Suboxone.  He has maintained sobriety from opioids.  He also suffers from panic attacks and takes Effexor daily.  He uses lorazepam, a sedative, several times per month, and takes a sleeping medication, Ambien, most nights.

The standard of care for treating opioid dependence with Suboxone includes long-term use of Suboxone, particularly in young people (Mr. XXXXXX is in his early 20′s).  Mr. XXXXXX was fully compliant with treatment, including attending weekly psychotherapy and avoiding illicit substances.

In December of 2010, Humana stopped covering Suboxone for XXXXXX.  When I wrote to the company and asked for an explanation, I was told that he was denied because he did not meet the criteria of the company’s ‘buprenorphine coverage policy’.  This new policy was introduced without warning, and stated that people would not be covered if they were prescribed ‘benzodiazepines’ like lorazepam.

I appealed the decision by Humana, stating that the lorazepam was important for treating Mr. XXXXXX’s panic disorder.  But I wrote that his life depended on buprenorphine (Suboxone)– so we would stop the lorazepam immediately so that he would fit their ‘buprenorphine coverage policy’. 

The company continued to deny coverage.  I wrote again, asking for an explanation, and they wrote that Mr. XXXXXX was not eligible because ‘he was taking the benzodiazepine Ambien.’  I noted that Ambien is NOT a benzodiazepine, and does not therefore violate their policy.  But again, I wrote that I would not debate whether Ambien was or was not a benzodiazepine, but instead we would stop the Ambien, given the importance of Suboxone to the patient’s life and health.

The company again denied coverage through the appeal process, writing that ‘maintenance treatment for addiction was not indicated.’  Humana did not explain WHY his addiction treatment was not indicated.  I note that many patients receive buprenorphine for years, and the death rate from untreated opioid dependence is significant and well established.  I appealed the decision, asking for the name of their medical director.  Humana refused to provide the name, even after I called their offices repeatedly.  They continue to deny coverage, and today Mr. XXXXXX received notice that his final appeal was denied.

In summary, Humana was covering maintenance treatment for Mr. XXXXXX’s opioid dependence using Suboxone.  They then abruptly stopped coverage.  Mr. XXXXXX was forced to go through withdrawal without any warning–to him or to his physician–placing him at great risk of relapse and death.  When I attempted to re-establish his coverage, Humana wrote that they had instituted a ‘buprenorphine coverage policy’ without any prior warning. The policy is arbitrary and discriminatory, essentially stating that patients who are treated for opioid dependence are not eligible for treatment of other mental disorders, including panic disorder.

Finally, Mr. XXXXXX was willing to give up treatment of panic disorder in order to receive Suboxone—a medication that is vital to his continued sobriety.  I have repeated notified Humana that Mr. XXXXXX now complies with their arbitrary coverage policy– yet they continue to deny his claim.

This is a very dangerous situation.  Patients who are taking buprenorphine can do very well when compliant with treatment using Suboxone.  Humana pulled the rug out from under Mr. XXXXXX without warning, suddenly denying the medication, and then refusing coverage even when the patient clearly met all criteria according to Humana’s own unfair, arbitrary coverage policy. 

At minimum, Mr. XXXXXX should have his coverage for buprenorphine resumed.  Humana should be punished to prevent this dangerous, discriminatory behavior from hurting other patients.

Another chapter from my untitled book, ‘Clean Enough,’ begins with comments from a reader of my blog.  The picture has nothing to do with anything, except that the Packer win was pretty awesome.  The view is from my seat at Lambeau during a game this season.

Lambeau

I have been using various opiates for the past 2 years.  I’m sure it has affected my life in numerous destructive ways, but at the same time I feel that it has given me hope.  As a lifelong sufferer of anxiety and depression I have always looked for solace, and found it in books, art, music etc. But as I got older I got into drugs, in my case a path leading straight to opiates. As soon as   found them they were solution to all of my problems; I felt secure, safe, confident, sociable, and adventurous.  I found myself taking the risks socially, academically, and spiritually that I always wanted to. The doubt, insecurity, contempt for myself and others were rendered inconsequential. I felt I had attained a balance in my mind that allowed me to be who I really was.

On one hand the opiates must correct something that is defective in my physiology—they are the solution to my problems. This is not to say that I attain some sort of elevated state of consciousness by ingesting them, but that the opiate boost to my system allows me to function in a way that is actually healthier than my “natural” state.  But on the other hand I am afraid that my addiction is about to come to a head. I can no longer go more than a day without a dose, and all I do is think about pills. To cover up my use I drive great distances and spend thousands of dollars. The lying is increasing, and so are my withdrawal symptoms. I have tried to stop my use, but I am absolutely dejected without them.  I want to do something before I have ruined my life. But unfortunately it seems that the system is not receptive to people who are on the brink of ruining their lives–just those that already have. I have seen shrinks for the past decade, been on every anti-depressant/anxiety medication known to man all with little to no success. Is there any other, less dramatic way to detox or begin some kind of maintenance therapy without checking into an in-patient rehab center? Would buprenorphine make sense for this situation?

This letter that captures the thoughts many addicts have as they get close to seeking treatment, and I will use the letter as a backdrop for a couple broad points. My intent, as always, is not to ridicule the writer, but rather to challenge some of the writer’s perspectives.

Remember that addiction is a disease of insight, and realize that a person cannot ‘analyze himself.’  A person may see some patterns in his thought processes and make educated guesses about his unconscious motives, but he cannot ‘know’ his own unconscious—by definition, for one thing.  And if a person’s unconscious contains a conflict that affects behavior, the same unconscious mind will easily keep the conflict from conscious awareness.  So I consider it to be a waste of time for an addict seeking early recovery to try too hard to figure himself out.  A much better use of time would be to work on accepting his limitations in this regard.  In fact, one of my favorite sayings is ‘a good man knows his limitations;’ recovering addicts should have version of that idea at the ready at all times, in order to quickly end those dangerous moments when we think that we ‘understand ourselves.’

The same point is made at a meeting when someone reminds a particularly-intellectual addict the ‘KISS’ principle:  for ‘Keep It Simple, Stupid.’   I am making the point when I interrupt a patient in my office from explaining all of the reasons he relapsed, to tell him ‘it doesn’t matter.’   That’s right– IT DOES NOT MATTER.   When I write about unconscious factors that contributed so someone becoming an addict, I am writing for the sake of thinking about how the mind works—not to suggest a path to a cure.  Reflective, self-analytic thinking will not generally keep a person clean.

The writer also makes a common claim that opioids serve a purpose by medicating some troublesome psychological symptom.  Maybe someday science will support the idea that some people have ‘endogenous opioid deficiency syndrome,’ but for now the idea is not taken seriously by the addiction-treating community.   Even if the writer does have some type of deficiency, opioids are not likely the solution.  See my next paragraph for more on this issue.

All opioid addicts have the fantasy that they will find a way to keep using.  Early on, that fantasy fuels a great deal of frustration and broken promises.  “I know… I will only use on Thursdays!” we say to ourselves.  But there is NO way to make it work. End of story, period. I am a smart guy, and I tried every way possible to make it work.  And thousands of people smarter than me have tried and failed as well.  The only people who can take opioids without being destroyed are… people who don’t like taking opioids.  How is THAT for a messed up situation?  For example, my wife had kidney stones in 1993 and was given a bottle of Percocet tablets.  She took one, hated how it made her feel, and put the rest in the back of the cupboard for me to find a year later.  I decided, upon finding them, that I would take one each day to self-medicate my depression and my social anxiety.  Unlike my wife, I LIKED them.  And they were all gone two days later.  I know where the writer comes from when he says there MUST be a way to take those wonderful pills that provide safety, comfort, security, and adventure.  But smarter people than he or I have proven, many times over, that there is no way to have those good things without having the other stuff as well–   the lying, depression, and self-loathing.

My final point refers to the writer’s complaint that care isn’t present at the time, or in the form, that he needs it.  Such complaints used to be more common, and I would have answered the question ‘is there a less dramatic way to enter treatment?’ with a resounding ‘no!’  But buprenorphine has increased the options for addicts seeking treatment.  Successful treatment used to require the near-total destruction of the addict, which in turn caused sufficient desperation to fuel adequate motivation.  Buprenorphine allows treatment before the addict loses everything, provided the addict is truly sick and tired of using.  The availability of buprenorphine for treatment is an amazing step forward, but it is not a miracle.  The addict must truly want to be clean in order for buprenorphine to be effective.  But it is a far cry from the situation ten years ago, when an addict had to be at death’s door in order to ‘get’ recovery.

I’ve been posting more lately, but I’m hoping to slow down by the end of the holidays to let everyone catch up.   I’ve also mentioned ‘my book’ several times in the past year, promising to myself and to others deadline that comes and go.  I wish I could take a month and work on it full-time, but I don’t see much chance of that happening… so I’ll have to just keep chipping away at it.  I can be a perfectionist and everything can be worded just a little better…  I’m the same way some mornings with my electric razor, until  my wife gets sick of watching me ‘make it perfect’ and takes the razor from me.  I came across an article the other day that described a form of OCD that involves exactly that behavior– so at least I know the nature of my problem! 

I want to thank those of you who responded to the ‘here to help’ post, and please, if anyone else has had positive or negative experiences with the Here to Help program run by Reckitt-Benckiser,  let me know.  You don’t have to report anything ‘profound’– just a general comment or two whether it was helpful, whether you stuck with it, etc.

I have written about benzos a number of times and I still have more to say.  I would hope that everyone is familiar with the danger of respiratory depression when combining benzos and opiates.  Most of the deaths involving buprenorphine that I have reviewed or read about had two things in common.  First, the person took buprenorphine along with a second respiratory depressant– often a benzodiazepine, but alcohol acts at the same receptor sites as benzos and so alcohol has similar dangers.  The other commonality is that the person who died was not ‘tolerant’ to high doses of opiates, benzos, or both.    I do not want to say anything that puts addicts at risk, and I am NOT condoning benzo use, particularly the use of medications that are not prescribed by your addiction doc.  Doing so will eventually destroy you– but for the opiate/benzo combination to kill someone quickly generally requires that the person is not tolerant to one or the other chemical.  THIS IS NOT SOMETHING TO RELY ON TO AVOID DEATH!  Did I make myself clear?   Understand that the danger of combining opiates and benzos is not greater than the risk of combining benzos with opiate agonists.  There is nothing ‘more dangerous’ about buprenorphine EXCEPT the false sense of safety that users may have about buprenorphine.  But other than that false sense of safety, combining a pure opiate agonist with a benzo is MORE dangerous than combining similar potencies of buprenorphine with the same benzo.

I wanted to get that issue out of the way so that I could get to the main danger for addicts on buprenorphine when taking benzos, i.e the long-term effects on sobriety.  Opiate addicts will become actively addicted to other drugs when opiate addiction is prevented if no efforts are made to change.    I have written about my opinion that ‘standard AODA counseling’ is not the best fit for many people.  But that does NOT mean that change is not required.   At the very least the addict must find a way to fill the time spent using, and find a way to tolerate the harsh glare of reality when the mind is not constantly occupied with using, coming down, craving, or regretting the use of opiates.   I have had many patiens go through an initial ‘happy honemoon’ stage, and several months later struggle with all of the feelings that were being held at bay by preoccupation with opiates.   That preoccupation burns off a great deal of emotional energy, and suddenly our minds have plenty of time to worry about OTHER things!   There is also the fact that many of us used to dull our feelings and our reactions to life’s challenges.  So opiate addicts often compain of ‘anxiety’ early in buprenorphine maintenance, as they experience unpleasant feelings that should really be considered plain old cravings rather than an anxiety disorder.  I’ve written about what people say when I ask them to describe their ‘anxiety– they feel edgy, there is nothing to do, they are pacing, restless– they sound more bored than ‘anxious!’   But right now, for the sake of  the argument I will accept that some addicts are having real ‘anxiety.’  This is a big thing to accept, since anxiety is fear, and the people with anxiety are generally not the ones taking on new challenges, but rather tend to be the people who are doing nothing but playing video games all day… so I’m not sure where the ‘fear’ is coming from.  But even so– if that person was in residential treatment (before the days of buprenorphine) and complained of anxiety, every counselor would say ‘poor baby…. how HORRIBLE that you feel so ANXIOUS!  And so UNIQUE–  why, nobody has EVER felt like THAT before!!’

Do you get my point?  Sorry to be such an ass about it, but we are dealing with a fatal illness here.  Before buprenorphine, addicts would avoid narcotics after surgery in efforts to avoid risking relapse– now with buprenorphine, some people want to take the easiest way that they can find.  I will tell you straight up– if you are on the verge of finding stability on buprenorphine, you are extremely blessed.  Many people have died before you from opiate dependence, without the opportunity to improve their odds with buprenorphine.  You must do SOME tough things— and one is to learn to deal with life on life’s terms.  If you cannot do that, your chances for avoiding using–even with buprenorphine– are low.   Yes, for a time you are going to be ‘anxious’, or dysphoric, or whatever you want to call it.  You haven’t dealt with life lately, so of course it will be a tough adjustment!  But what do you expect– that you can just be numb and relaxed the whole time, and everything will just fall into place?

People with cancer deal with extreme pain, nausea, surgeries, deformity of body parts…  YOU must deal with your ‘anxiety.’   Why?  It is hard to explain to people who have not been through residential treatment, where a person at least learns some things about what addiction is all about.  Addiction is complicated, and occurs for many reasons– there is not ‘one reason’ for being and staying an actively using addict.  One reason relevant to the benzo issue, though, is that addicts become very aware of their own physical discomfort– we become ‘big babies’, basically.  Benzos only make this worse;  the addict in early recovery feels uncomfortable about many things, and having a pill to take when things get bad enough only makes the addict look inward even more often to decide whether things are  bad enough to deserve a Klonopin.   Another reason people stay addicted is because of distortions of insight, specifically losing the ability to predict what they will do in the future.  The addict says ‘I will take it only for severe anxiety’, but after a few days the addict finds that there is ALWAYS a reason to take another dose of a benzos.  Addicts didn’t know life was so tough until benzos became available, when suddenly EVERYTHING seems like a severe situation–  snowed in, new coworker, lost job, getting a new job, a first date, a break-up, an NA meeting… ALL of these things are great reasons for Klonopin!!

Another problem for addicts taking benzos is that when addicts take a benzo for ‘anxiety’, they don’t focus on the disappearance of their anxiety– they focus on the appearance of the ‘buzz’ from the benzo.  ‘Normal’ people hate that feeling, and so they find benzos to be too sedating or too impairing.   But addicts LOVE that feeling– any feeling– and so they dose until they feel it– not until the anxiety is gone.  And that extra ‘dosing for feeling,’ combined with the fast tolerance  characteristic of benzos, leads to rapid escalation of dose.  And what a surprise– that dose escalation even occurs in people who say ’don’t worry doc– I don’t plan to raise the dose.’

I realize I’m expressing anger with this post, but hey, I have to express it somewhere!  Part of my anger comes from the repeated behavior of addicts– behaviors that I resent that will always remain within myself as well.  I realize my anger is for the addiction, not for the person suffering from the addiction… but sometimes I am frustrated by the unwillingness of addicts who are at the edge of relapse to ‘step up’ and face the challenges, and to fight for their lives.  I was also angry at what happened on a TV show this AM as I was getting dressed.   I shouldn’t admit this… but I was watching MTV, the show about the teens who became pregnant and had babies, which is now a show about teen moms… and one of the teen moms went to the doctor and complained of her ‘anxiety’.  She is young, bored, stuck at home with a crying baby… and she has ‘anxiety.’ Some mornings she ‘just lays in bed and doesn’t want to get up.’   What a surprise that she isn’t just thrilled to get up every morning!  She sees a doc (who could pass for a beetle if he had the right markings on his back) and the doc prescribes… Klonopin.  The next morning the baby is fussing and the teen mom holds the baby at arms’ length, passes him to her BF, and says ‘I have to take my Klonopins.’   A close shot of the bottle shows instructions to take ‘one tab twice per day’ (clonazepam has a half-life of about 24 hours, so the level in her body will increase over several days to a high steady-state level).  The next camera shot the next day shows her laying on the couch, yawning, saying that the medication seems to be working.  Her one-yr-old, meanwhile, is… somewhere….  not sure where I left him… 

But at least she isn’t ‘anxious’!

I went off on something that I was only going to mention in passing… so I guess I’ll finish the story I intended to write in a few days.  I want to write about a couple studies that looked at the cognitive effects of buprenorphine, methadone, and benzos.  Thanks for letting me vent…    good luck returning to work tomorrow for those of us lucky enough to be working, and I hope those who are looking find somethng soon.

JJ

A note of follow up:  According to TMZ, a variety of medications were found in Brittany Murphy’s apartment under her name and under the name of her husband and mother.  Of course it is possible that the medications actually belonged to her husband and to her mother– but as you read in my last post, I am not surprised that opiates were included on the list.  THe medication list:  

Was her death related to dangerous medication combinations?

1.  Topamax.  Topamax is an anticonvulsant that is also used to treat migraine headaches, and sometimes prescribed as a mild ‘mood stabilizer’–  say for someone who has symptoms of bipolar disorder but who instead has borderline personality or just ‘mood swings’ that don’t quite qualify as full blown bipolar disorder.  The medication is favored by some patients, particularly women with eating disorders, because unlike more effective mood stabilizers like Depakote (valproic acid), Topamax (generic name topiramate) causes weight loss instead of weight gain.  It has the nickname ‘dopamax’ because it can reduce cognitive function to a mild extent.

2.  Methylprednisolone.  This is a steroid anti-inflammatory medication, and I have no idea why she may have been taking it, if she was at all.  It is used to treat severe asthma, rheumatoid arthritis, and a wide range of autoimmune or allergic disorders.  It will create a brief euphoria in some people, and can also cause depression, mania, and even psychosis in others.  It tends to cause significant weight gain if taken for a long period of time.

3.  Fluoxetine.  Also known as Prozac, the well-known SSRI used to treat depression and anxiety (and to a lesser extent mood symptoms and irritability related to ‘periods’ in women).  Tends to decrease appetite slightly;  there is an ‘internet fad diet’ called ‘phen-pro’ which is a combination of phentermine (one of the phen-fen drugs from the heart-damaging diet of a few years ago) with fluoxetine.  Fluoxetine and other SSRIs are generally safe medications, but fluoxetine in particular can reduce the liver’s ability to metabolize some other medications, making the other medications more potent.

4.  Klonopin.   AKA clonazepam, a long-acting benzodiazepine (meds in the Valium or Xanax family).  These medications almost always start out small and become big problems in people with addictive tendencies, as I write here in my psychiatry blog.  They are great for short-term anxiety– say for a couple weeks for a death in the family.  But the person quickly becomes tolerant to the medication and then needs to take it to feel ‘normal’, eventually needing it all the time.  Benzos turn managable anxiety into an ‘anxiety disorder’.  They are also potent respiratory depressants when combined with opiates, and are often half of the equation in the case of overdoses.  They work at brain receptors that are also affected by alcohol, making them essentially ‘brandy in pill form.’  Do yourself a favor, and just say ‘no’ to benzos.  One last thing– the way that they block ‘anxiety’ is through their action as ‘amnestics’– they block the formation of memories.  A drug called ‘versed’ is widely used for dental work or colonoscopies to block memory;  that is what clonazepam and alprazolam (Xanax) do.  You can’t worry about what you cannot remember!

5.  Carbamazepine.  Also known as Tegretol, this medication is an anticonvulsant similar to Topamax but one that is potent enough to actually work for bipolar disorder and seizure disorders.  It is also prescribed for some chronic pain conditions, including a very painful facial condition called trigeminal neuralgia.   Not particularly dangerous with opiates except for effects at the liver where it also blocks or increases the metabolism of other medications in an unpredictable fashion.  It can have other uncommon but serious side effects on blood components.

6.  Ativan.  Also known as lorazepam, this is another benzodiazepine.  Works just like clonazepam but with a shorter duration of action– the half-life of lorazepam is about 12 hours and the half-life of clonazepam is 2-3 times longer.  Again, a lousy, addictive medication that is a disaster in people with addictions.

7.  Vicoprofen.  Ibuprofen combined with the opiate hydrocodone, which is a moderate-strength narcotic.  People who take opiates long term become used to them, and have to keep taking them to avoid withdrawal– as all readers here probably know!

8.  Propranolol.  This is an old, cheap medication used to treat a number of things.  It is a ‘beta blocker’, meaning it blocks the actions of adrenaline at ‘beta receptors’ at the heart and other brain regions.  It used to be used commonly for high blood pressure, but now many better medications are available.  It is used to prevent migraines, and to block the feeling of adrenaline in a person’s body– so it will be used in prisons as a non-narcotic medication to treat panic attacks or anxiety.  It is commonly used by musicians, politicians, and public speakers to help them feel calm during presentations or public appearances.  For example it will stop that ‘rush’ in a person’s chest, stop the hands from shaking, stop the heart from racing or pounding, and reduce the husky voice some people get when nervous.

9. Biaxin.  An antibiotic also known as Clarithromycin, used to treat a wide range of bacterial infections including acne, sinus infections, bladder infections… again, an old medication with many better modern substitutes.  The use of the medication is limited by the fact that similar to many of the other medications in this list, it interacts with many other medications, making the other medications more or less potent than intended.  The medication can also cause potentially fatal heart arrhythmias, particulary in combination with STEROIDS, such as the methylprednisolone on the list.

10.  Hydrocodone.  Not needing much explanation for readers of this web site, hydrocodone is a moderate-strength opiate narcotic.  It is a component of the Vicoprofen described above.  Like all opiates, it initially works very well to relieve pain.  Some people, though, find that it ‘fits’ very well;  it makes them feel whole, loved, happy, content, warm… at least for a little while.  It works just like heroin, but has a lower potency so more hydrocodone is required– but if enough is taken the same effects will occur.  The person becomes tolerant to hydrocodone fairly quickly, resulting in withdrawal if the medication is discontinued.

All in all, the medications, if they were all taken by Brittany Murphy, would be consistent with someone being treated for migraine headaches, anxiety or panic, and a mood disorder.  Just guessing, of course… and this would NOT  be the ideal way to treat these conditions.  For example, opiates are lousy ways to treat headaches, especially long-term, probably causing far more headaches than they get rid of.  Propranolol is a relatively harmless med for anxiety (providing the person doesn’t have asthma, which propranolol would aggravate).  If the carbemazepine, fluoxetine, and topamax were being used for a mood disorder like bipolar or a personality disorder like borderline personality, then taking the steroid methylprednisolone would be a risky thing to do, as steroids can cause pretty severe mood effects.

These medications have a number of dangeroud interactions, besides the addictive dangers of several of them both alone and in combination.  For those interested in a more detailed list of the dangerous interactions, I have prepared a list of the med/ med interactions in pdf format using the interactions checker provided by epocrates.

JJ

Suboxone Talk Zone

One of the primary insights that I want addicts to gain from reading this blog is the similarity between their own thoughts, feelings, and pattern of use and the thoughts and patterns of use of other opiate addicts.  We are all dealing with the same beast, we have all felt the same desperation, and we have all experienced the same distorted thinking.  I hope that reading the desperate stories of others will help the reader understand that he or she is not alone, and will help readers identify their own distorted thinking.  But tonight I finished the final performance of a Holiday play with Community Theater (I played the psychiatrist who interviews Santa in a take-off on Miracle on 34th Street) and so I want to tell a happy story related to something that I heard from a patient last week.

The treatment of opiate dependence is in a state of flux;  regular readers know all of this very well, but some of the new readers from my last post (!) may not know my ‘philosophy’ on treatment.  I have an article out there somewhere called ‘Suboxone’s complicated relationship with traditional recovery’ that sums things up pretty well for those who want to see how one person (i.e. me) has come to terms with buprenorphine and the twelve steps.  I find the two approaches to be difficult to combine, since ‘getting’ recovery through the steps requires personality change, which requires desperation.  And once on buprenorphine, addicts quickly lose that desperation.  One could say, then, that buprenorphine is ‘bad’ because it gets in the way of ‘stone cold sober’ recovery.  But I would NOT say that myself, because I know that the success rate for treating opiate dependence using the steps is lousy.  The steps have remained as the mainstream treatment for opiate dependence for one reason:  They were all that we had!  The steps saved my life not once, but twice– but they fail for most others.  I got lucky–  maybe having my medical license hanging over my head made the difference.  It is impossible to predict who the lucky ones will be.  All I know is that I am grateful to be one of them.

At the same time I am haunted by the faces of the people I knew who died from opiate dependence.  And I find the current attitude toward opiate dependence to be heartless– the attitude that leads to discharge of patients from treatment for one ‘dirty’ urine.  I personally know of several people who died after forced discharge from treatment centers.  Who benefits from that approach to ‘treatment’?  Sometimes I am tempted to write to the treatment centers that discharged the dead teenager after his or her ‘dirty urine’, to ask if they are satisfied with the ‘care’ they provided!  Before buprenorphine, we had to accept the fact that 80-90% of young opiate addicts would fail treatment over and over, losing everything– losing dreams of attending college, losing family relationships, and sometimes losing their lives.

New readers are now asking, ‘this is a ‘happy story’?’

Sorry.  I tend to wander a bit.  The point I am leading up to is that I became a fan of buprenorphine treatment because the idea that we can simply ‘treat’ opiate addiction has been mostly myth.  Opiate dependence has been treated successfully in a small fraction of addicts.  Yes, the steps CAN work in those who ‘keep coming back’.  But the truth is that people in their 20′s do NOT ‘keep coming back’.  Instead they relapse over and over until everything is gone, and they have become shadows of their former selves.  But then buprenorphine came along.  Buprenorphine is NOT a panacea;  many people fail treatment with buprenorphine as well.  But in a fatal disease with no real effective treatments, buprenorphine is an exciting step in the right direction.

If you are new to buprenorphine, you will likely have a few months of excitement at the feeling that you have been delivered from opiate dependence.  But then reality will set in, and the work will begin– or at least SHOULD begin if you expect to remain free from active using.   After a few years of treating patients with buprenorphine I have learned that THIS is the point where traditional step work can be helpful to understand what is happening in the mind of the addict, and to guide further treatment.  For example, many (MANY) opiate addicts complain of ‘anxiety’.  I used to worry that the ‘anxiety’ would increase the risk that the patient would use, and I would go to great steps to treat the anxiety- including the judicious use of benzos (the respiratory depressant effect of benzos can be dealt with if they are used properly, but people must NOT combine benzos and buprenorphine without guidance by their doctor).  I found that universally, patients who took benzos did WORSE.  They thought they needed them, and even thought they benefited from them.   But the patients who did the best were the ones who accepted the fact that the ‘anxiety’ was nothing but a craving to be ‘numb’, who then worked on reducing the cravings in HEALTHY ways, without taking benzos.  The patients who eventually wore me down and got me to prescribe a small dose of a benzo only ended up wanting more, and then needing more… until they eventually became people who couldn’t do anything without a benzo on board.  I now realize that the ‘anxiety’ that addicts feel is nothing but the cravings that they taught me about when I was in residential treatment.  When I was in treatment, I felt physically horrible much of the time– nervous, tense, trouble sleeping, etc.  But if I went to a counselor and complained of ‘anxiety’, they would have had a great laugh!   People taking buprenorphine are no different than I was;  they are trying to make HUGE changes in how they deal with their feelings.   Of COURSE they will feel all messed up inside!  But the answer is NOT to find another subsstance to reduce those uncomfortable feelings.  The answer can be found instead in many of the principles that make up the twelve steps.  If a person in ‘sober recovery’ has anxiety, the universal recommendation is to go to a meeting.  I think the same is the case for those taking buprenorphine– not so much for the personality change that is needed to ward off the most severe cravings, but rather to help deal with the more minor cravings that are disguised as anxiety.  Other remedies that are used by twelve steppers include meditation, prayer, reflection, readings, step work, and acting ‘as if’.  All of these techniques will work– if the addict works them.

Gratitude is another major part of twelve step programs.  And again, I find that the people on buprenorphine who find gratitude are the ones who tend to stay clean.   The patient from last week that I referred to a moment ago is a patient who has done well on buprenorphine who NOT coincidentally, I believe, uses lessons from the steps in her day to day life.  During our appointment she talked about how grateful she was for where she is today in comparison to where she was a few years ago.  She talked about looking around her home at the material things she can now afford, like a TV set (two 80′s of oxycontin), nice furniture (four 80′s), the microwave (one 80), etc.  She was grateful for the positive changes in her relationships as well.  No, things were not perfect– they never are.  But they sure tend to be better when OC and ‘junk’ are taken from the equation.

She may or may not realize how everything ties together.  Not being broke and sick all the time allows a person to start to feel like a contributing member of society.   Being able to go all day without telling her friends or partner a lie has improved her relationships.  Realizing that she is not ‘anxious’, but instead is having normal consequences of positive change, allows her to feel a sense of personal empowerment and self esteem for dealing with the feelings without taking pills.  And feeling grateful is a great antidote to resentments, and resentments are common triggers for relapse.  As I mentioned earlier, those recovering addicts who are grateful tend to do well.

The experience of speaking with her during her appointment helped me understand one more ‘piece of the puzzle’ for how buprenorphine and the steps are best combined.  No, I do not FORCE patients get into the steps, because I see buprenorphine as something that is more effective at blocking the intense desire to use.  But addicts who are past the honeymoon stage of buprenorphine and who are starting to drag a bit would do themselves a favor by checking out a program that has been around for almost 100 years.  As always, your personal health history is YOUR business;  if people at a meeting are asking which meds you are taking I recommend finding a healthier meeting– after telling the person that it is none of his/her business!  If you are experiencing ‘anxiety’, realize that we ALL struggle with those feelings, particularly early in recovery.  You will feel better in every way if you see that anxiety as a form of craving, and learn to deal with it in a non-benzo way.  If you have anxiety or panic that does warrant medication, the proper medication is an SSRI– NOT Xanax.

And as the Holidays approach, take time every day to notice what you are grateful for.  If you cannot find anything, be grateful for being alive, as many opiate addicts have lost even that gift.  With all of the Holiday activities I may be absent for awhile.  My kids– the ones who saw me in a locked psych ward 9 years ago, sick from withdrawal– are coming home from college for a couple weeks.  Back then I thought my life was over– no job, license suspended, anesthesia career effectively over.  I couldn’t imagine going back to do a whole new residency in a new field– but it turned out to be an entirely new calling, and has included experiences that I wouldn’t trade for anything.

One last thing.  I was incredibly self-conscious throughout life up to that point in 2001, even needing to enter from the back of the med school auditorium to avoid feeling like everyone was staring at me– what everyone in AA calls ‘being an egomaniac with an inferiority complex’.  I learned through meetings that EVERYONE with addictions felt that exact same way.  After years of watching Community Theater productions from the seats and wishing I had the guts to get up on stage, I used the two years that I was out of work to act in four productions– including two with major solo singing parts (and I had never even been in choir).    Until the play that ended today, I’ve been too busy to participate.  But today I was on the exact same stage where I stood 9 years ago.  Today I reflected on all that has happened since feeling so hopeless back then.  I am grateful that back then I KNEW that I didn’t know anything about how to stay clean.  I am grateful that I somehow stopped listening to myself, and started listening to those who had the clean time that I wanted so desperately for myself.  Had I continued to insist that I knew what I needed, I would not be here today.

I wish you all a very special Holiday season.

JJ

I wish I had more time to devote to this topic right now, but I am on my way to a short vacation… so I will not be available by e-mail for at least a few days.  Everyone is pacing around the house right now, waiting for me to finish with ‘that stupid computer’.

I had to to write, though, because of a horrible incident in Milwaukee a couple days ago that took the life of a 15-year-old girl named Maddie Kiefer.  According to news stories, she snuck out from her house in Whitefish Bay, one of Milwaukee’s'nicer’ suburbs– by nicer meaning a place where the houses are kept up, many children grow up with two parents, and the public schools send a high proportion of students to colleges.  The suburb lies just north of Milwaukee, and along with other northern suburbs has seen a significant increase in heroin use by young people over the past 5-10 years.  I live another hour or so to the north, and we are seeing more and more heroin ‘up here’ as well;  the opiate addicts that I treat used to report taking oxycodone mostly, followed by methadone, then fentanyl;  now I am hearing histories of heroin use almost as often as oxycodone.

Maddie Kiefer

Most people know about some vague danger of combining Suboxone with ‘benzos’ like Xanax (alprazolam);  the risk is respiratory depression, which can kill a person– and is usually the cause of death in overdose of opiates.  Opiates desensitize the brain’s response to carbon dioxide, causing the person to breathe at a slower rate and allow carbon dioxide to build up.  The high level of carbon dioxide isn’t fatal, but if a person breathes slow enough, or stops breathing altogether, the oxygen level eventually falls… and the low oxygen level either makes the brain stop working– including ceasing the urge to breathe entirely– or the low oxygen level triggers a cardiac arrhythmia that halts the flow of blood, which then affects the brain, causing unconsciousness, apnea (no breathing), and death.

A couple quick points:  Suboxone and benzos are a dangerous combination particularly if a person is naive to both.  If a person is opiate-tolerant, for example is addicted to opiates, then the risk of death from such a combination is very low.  In any case, the risk of Suboxone plus benzos is MUCH LOWER than the risk of combining a benzo with a full opiate agonist, like oxycodone or methadone!  There is nothing especially dangerous about Suboxone in this regard;  in fact, it is much safer than a full agonist.

I suspect that the teen killed in Milwaukee was not used to opiates;  in such a alcase Suboxone alone would almost never be fatal… unless combined with other respiratory depressants, such as alcohol or benzodiazepines.  The story of her death is horrible– it displays the utter lack of concern for others that takes over the soul of a person addicted to opiates.  I will not make any excuse for a person who dumps someone in a driveway who needs life-saving assistance– but I understand how people get that way.  Many opiate addicts do things that are similarly devoid of conscience– and that is behind the ‘split’ that occurs with addiction, where the addict represses the horror of who they have become, and carries a fake outside personna that is cocky, glib, annoying, and easily recognizable to those who understand addiction.

When I talk about tapering, I assume people are working with a physician;  I do not condone the practice of buying Suboxone on the street or sharing it with friends or ‘loved ones’– even out of concern for them.  When people treat themselves, they are fooling themselves;  the addict is firmly in control and there is minimal chance that the person will recover.  People who share or sell Suboxone with others deserve to be incarcerated.  Period.

Rest in Peace, Maddie.  I am so sorry for you.

Jeffrey T Junig MD PhD

A comment on my old blog referred to a discussion about the withdrawal from Xanax, or Alprazolam, a short half-life benzodiazepine:

Clonazepam (Klonopin) actually is not the drug of choice used in benzo withdrawal, rather it is diazepam (Valium). Clonazepam It is not a very long-acting drug, with a half-life of only 18-50 hours; diazepam’s half-life is 20-100 hours, with its metabolite hanging around for twice that long.

Absolutely the worst thing about benzo withdrawal (take it from me) is that it never ends. That is why I still take them.

Sadie

My Response:

The ‘drug of choice’ for benzo withdrawal depends on many factors beyond half-life. Diazepam (aka Valium) is absorbed very quickly and so the onset of action is as fast as 20 minutes; this is useful in some situations, but is also thought to contribute to the increased addictiveness of diazeapam over clonazepam (Klonopin). Both drugs stick around long enough to accumulate with repeated dosing; diazepam has active metabolites, making the effective half-life even longer than the pharmacologic half-life. But who cares? In either case the person coming off alprazolam (Xanax) can take the longer-acting benzo four, three, or two times per day– even once per day could be sufficient to prevent seizures with either drug, providing the dose is high enough.

It is very hard for most people to get off Xanax… or any benzo. For that reason, the best medication for alprazolam withdrawal may be a non-benzodiazepine anticonvulsant. I have used valproic acid (Depakote) or phenobarbital in patients for treatment of benzo withdrawal and/or alcohol withdrawal. Pretty much anything that works for alcohol withdrawal will work for benzo withdrawal– which is consistent with the fact that alcohol, benzos, phenobarb, and valproate all have actions at the GABA receptor. Other factors to consider when choosing a medication for benzo withdrawal include liver function– diazepam in particular lasts forever in patients with bad livers. Phenobarb affects the metabolism and plasma levels of many other medications. Valproic acid can cause liver damage and tends to stimulate appetite; is also causes heartburn and nausea in many patients.

The biggest problem with coming off benzos is losing the fuzzy haze that covers life and tolerating the harsh glare of reality. Patients complain of ‘anxiety’– many times they are simply feeling what everyone feels all of the time, but they have lost the ability to tolerate the normal stresses of life. This is where 12-step programs come in; working the steps provides everything that is needed for a person to learn to tolerate reality. After 15 years of going to meetings, I am still amazed at the value contained in the 12 steps. EVERYTHING is there! How to tolerate one’s self; how to deal with others; how to cope with rejection or loneliness; how to begin to understand a purpose for living… the answers to all of these questions– questions faced by most drug addicts on a daily basis– are contained in the steps. I strongly encourage, and invite, people learning to tolerate reality to come to recovery and join the others who are looking for the same thing– and finding it at AA or NA.

SD

A Question:

I have been taken xanax for over half my life. initially for anxiety and insomnia. then like most was unable to function or handle the withdraw and remained on it. later because of an injury i was introduced to oxycontin. i became addicted and could not step off. one because of “real back pain” the other because of the withdrawl. i would have to go to rehab and or miss work. which is impossible for me because i am the sole provider for my children and i. also my family is very uneducated with these things and have a “zero” tolerance and would be disowned for sure. i no longer want to take opiates but i do feel i need xanax. will taking suboxone while taking xanax be fatal. or is it possible to combine the 2 until i am opiate free?

My Answer:

Thank you for writing;  I feel for you, and have been there.  It sounds like you recognize where things stand, which is miles ahead of many patients on Xanax who misinterpret the withdrawal as their own ‘anxiety disorder’.  I would first suggest that you never give up the courage to get off of the Xanax.  While it is a difficult thing to do, most people will eventually have less anxiety, less insomnia, less fatigue, and less depression if they can get away from benzos.  You CANNOT simply stop the Xanax, as you probably know, as the withdrawal from that class of medication can be fatal, and includes seizures that can just occur suddenly out of nowhere… while you are driving down a highway for example.

I must be cautious to avoid giving medical advice that has the potential to be dangerous; anyone reading my posts MUST make any treatment decisions along with their own physician.  But for the sake of education, yes, people have died from the combination of Suboxone and Xanax (alprazolam) and other benzos (like lorazepam, diazepam, clonazepam, etc.).   But two points deserve mention.  First, the deaths occur from respiratory depression when opiates and benzos are combined– the respiratory depression is ‘multiplied’, not just added together.  The danger is primarily restricted to people who are not tolerant to the medications.  If a person is used to both medications, the risk of having trouble is not all that significant.  So in your case, I would start the Suboxone and if you feel ‘buzzed’ from it I would have you take only half of your Xanax dose until you are tolerant to the Suboxone.  You could probably resume your regular Xanax dose after a couple days.

The second point is that the danger from Suboxone is much less significant than the danger of combining a full opiate agonist (like methadone, oxycodone, or hydrocodone) with a benzo.  The antagonist action of buprenorphine provides a significant measure of safety that is not present with opiate agonists.

One final comment–  the best way to get off the Xanax is to change to a very long acting benzo– clonazepam is usually the best choice– and then go on a slow taper.  If a person is motivated to get clean, and if the taper is done very slowly (over a period of 6 months) the withdrawal is minimal and can be tolerated without the need for inpatient detox.

Take care,

SuboxDoc