In responce to my blarticle about the limits of usefulness of Klonopin, e-chimp writes in with the following barrage of thought provoking questions and comments:
What’s your opinion on the thin line between mis-use and self-medication? Say someone’s prescribed a small supply of 2mg diazepam, finds that this dosage does nothing and adjusts it up to a higher dose than prescribed? Would you class this as mis-use? If a patient admitted that they’d done this, would you prescribe it at that level or refuse to continue to prescribe it due to concerns with potential abuse?
I have another question, which I suspect will be more controversial. I’ve found benzodiazepines fairly ineffective in dealing with anxiety. I have, however, found a drug that does help. This drug happens to be codeine. Obviously this isn’t something that is usually prescribed for psychiatric conditions and, indeed, I haven’t been prescribed it. Now, in one sense I’m abusing an opiate, because I use high doses in a way that hasn’t been authorised by a doctor. In another sense I’m self-medicating, because it certainly does help lower anxiety and it’s often a better choice than self-injury. This is a very occasional thing, so tolerance and addiction aren’t an issue. I have no interest in increasing the doses I use in frequency or amount. Would you class this as use, mis-use, abuse or something else? If a patient told you this, would you be wary about prescribing other drugs to them? Obviously prescribing opiates for this sort of thing would be dangerous for the prescriber due to the politics surrounding the issue; aside from that, do you think opiates should be investigated as psychiatric drugs?
WOW!!!
I’ll address your first paragraph and then the second. Self-adjustment of the dose of benzodiazepine (whether it is Klonopin, Xanax or Valium (the above mentioned diazepam), is as predictable as sunrise. I would guess that a large majority of the patients who get a prescription for this class of medicine take a little more or a little less, depending on how they are doing. Because of the nature of the medication, it can be changed in that manner and still provide benefit for the patient. That strategy is not effective for, say, antidepressants, mood stabilizers or antipsychotics, because they need to be present in a consistent way to provide for the blood levels that provide the benefits. This is not always true, however. There is something to be said for consistent administration of the medicine. Especially when it comes to Klonopin. If I hear that someone has a repetitive pattern of feeling good and droping their dose of medicine and then runs into a string of days where they feel more anxious and have to take more, ddduuuuuhhhhh . . . take the medicine on a consistent basis. Do I refuse to treat patients who self adjust their medicine? No. Unless I feel that they are abusing it. But that, again, is all about communication. For example, if someone is prescribed Klonopin 1 mg at bedtime and comes back in and tells me that it didn’t work so he started taking it twice a day and it did work, I will prescribe him Klonopin 1 mg twice daily. We will have a talk about self adjusting meds and the benefits of giving me a call . . . but I don’t yell. If that same guy comes back in and says, it stopped working as well so he started taking three mg daily . . . I start to get worried. I may go up . . . but I am worried and I will have a serious chat about my concerns. Further adjustment upward after “the second talk” may be cause to discontinue the medicine and try something else. I don’t refuse to treat, I change MY treatment strategy. As we have discussed on this site before, some people get transient benefit from these meds and start sponging them up without getting clinical benefit. If that starts to happen, it is way better to catch it early and start diverting attention and patient expectations toward another avenue of treatment. If not, you do end up with a hefty benzo addiction. Discharge from my care will happen if you are lying to me (no therapeutic relationship there) or are getting additional benzos from another doctor (again, can’t split the thereapeutic relationship). In cases like that, I am just being used for my prescribing ability . . . not as an agent for life improvement. It is all about communication and honest, just like any other successful relationship.
Now, codeine for something other than pain . . .
I am intregued. But nervous. I did have one adult patient who suffered from chronic focus and concentration difficulties that were unresponsive to any medication that he was given. On his own, he found he did better when he took narcotics for his (very ligitimate) back pain. He went on to use the narcotics for both purposes, ended up getting hooked on them and then having to detox off. This is a standard story for narcotics and pain management. It is unlikely that narcotics, as they are now formulated, will ever hit mainstream psychiatric practice because of the liability of addiction that they have. Would I feed into that and prescribe them? It all depends on the relationship. If I have a relationship that is honest and trusting with my patient, and they are doing all that I ask them to do (from a conventional standpoint) and still use unconventional approaches occasionally because they work do I sacrifice the whole relationship for principle? Probably not. I may go overboard in my documentation and make sure that there is good communication about the intervention between me, the family doctor, the patients family, etc, so that all are on board with the atypical intervention and all questions are answered etc. Then I would monitor and document over time.
Again, it is all about relationship. Honest and open and trusting relationship.
–Dan Hartman, MD
I need advice on how to taper off of Lamictal. I am taking 100 mg a day. I would appreciate your thoughts on this.
This question is good enough to write about! see the whole blarticle on tapering lamictal. Thanks!
-DH MD
Great article and response!. I was just doing a search on klonopin and came across this. I’m really glad i did. Time to read some more!
Best_
Daniel
I’m a fifty yr. old woman, with a DX of ‘Severe ADD’.
and Anxiety Disorder. I have had ADD all of my life.. before anyone ever knew much about it. I was dyslexic (sp?), and I couldn’t read or at least comprehend.
Mine was never ‘severe’, until, about three yrs. ago (in my opinion it became perimenopausally exacerbated). I’ve been taking Ritalin to help treat it, ( I recently switched to Dexedrine 60 mg./day – 2 10mg. tabs TID.) They’re all pretty much the same..a band-aid of sorts, and nothing more. Much like wearing glasses to help correct vision problems..at best, a ‘tool’. It does help, in many cases.. but I very much doubt there will ever, in our lifetime, be any kind of a cure. Also, sadly, the great majority of people have no idea how very incapacitating this can be and to what extent it can derail a person’s daily life and their abilitiy (or inability) to function. The reason that I am writing, is because I’d recently read one of your blarticles..about (2 people- ‘chimp’ and??) that had taken pain meds, that had actually helped them to FOCUS,or feel less anxious.. I have never heard anyone mention that before, but I do know that personally, in the past, when I have needed s/thing for pain.. (Vicodin ), has always been a double blessing. Not only was it effective in masking my pain..( migraines, hip surgery..), but simultaneously, I found that it very definately helped me to focus(!!) and with my anxiety…like nothing else..It was perfect. It cleared my mind and helped me to calmly tackle whatever task was at hand! I never felt ‘drugged’ or out of control. I know I would not have liked such feelings. It just seemed to have ‘balanced me’. How interesting that I’m not such an anomally (sp?).. I also realize, that it will never be chosen as a treatment for AD(H)D, ..politics, right..but I do feel that it warrents a second look! I am a Teacher so obviously I need to be able to focus, organize etc..and I see no problem offering it as an option for those for whom it could very well be effective. Have it prescribed ‘off-label’, and PRN, for the times when it is needed. It isn’t more harmful than the ‘speed’ so casually distributed to our youth. If I had a voice in the matter, this med would be my choice. Perhaps they should investigate allowing it ‘off-label’..By the way, I never needed or wanted to take any more than was prescribed, nor did I ever have a problem with dependence… I thought I was just an ‘individual’ or isolated case. Glad to hear I’m not the only one. I feel that more research should be conducted and include this as one alternative. I also, do not believe that there would be anywhere near the number of addiction problems, as claimed, for the vast majority of people. I think that most people are far more capable of ‘controlling’ themselves and of making responsible choices, than they are given credit for. I also feel that most people resent ‘ Big brother’ just casually assuming that Americans are well,..less than intelligent, regarding what they should and shouldn’t be putting into their bodies. Just a thought. Thanks..
I wanted to throw this up on the board (although I did need to edit it down for size quite a bit). I am also fascinated that another person has had the experience of feeling more focued on low doses of opiates. While I would not advocate use of opiates to address ADHD symptoms (they are in a different class altogether and are potentially WAY more dangerous in the long run than stimulants that are used correctly). My question for the ivory tower types in this business would be this: is there a way of capitalizing on the pharmacology of the opiates to enhance attention but avoid the high likelihood of addiction? As they are currently formulated, our legal system will never allow use of opiates to treat ADHD. Thanks for your comments.
–DH MD
I am also a sufferer of depression, ADHD and anxiety. I have been prescibed 4-5 meds for the ADHD 3-4 for depression and 1-2 for anxiety and Bi-polar #2. At this point I am feeling somewhere between handicapped and a Guinea pig. I have been to counselor and Psych MD’s since I was an “Underachiving” 12 year old. I don’t know if I would have been any better off had I been diagnosted at that point (who knew) Presently my Pharma inspired Med Cabinet includes Lorazopam, cymbalta, Lamictal, Welbutrin and Provigal.
So now one might ask why so many because that’s my query too!
I am writing because I to have had similar experiences with various opiates and wonder why lower doses, carfully administered why this cannot be a reality. At this point when I do have a real reason for Vicodin and the related types of opiates not only effect my mood (good) but I find myself thinking and working with great incentive; I am looking for stuff to do – of which there is always a large backload of work to do. I am a college professor and the regular critical student evaluation is that I am scattered and dis-organized. This is true. When I did have the opportunity to take Vicodin and teach at the same time the clarity of thought and ability to organize and articulate concepts and critical thinking are more than impressive. So what is up? Do we have to talk ourselves into a back or knee injury in order to be able to function “normally”.
YES!! Me too. However, I would add that in addition to improved focus and concentration, my energy level and motivation also significantly increases. I wonder, is this diagnostic? what’s going on neurochemically?
This is very interesting to me as well. I am a recovering hydrocodone addict and I have had untreated a d d my entire life. After 7 years of sobriety and 2 children it has come to my attention that I can not teach consistency to my 3 and 5 yr. olds if I dont know how to do it myself. When I was actively taking hydrocodone my focus was unbelievable. That is why it became my drug of choice. The first time I ever took a 5 mg hydrocodone a whole new world opened up for me, I was able to focus more than I ever imagined possible. BUT… as time progressed it took more than 5 mg, it then took 10 mg and then 15 mg and finally 20 mg every 4 hours to recieve the same effect. The withdrawal from the hydrocodone was excruciating ( I am talking horrible) and I had to go through it many times before I sought recovery. I have no doubt that this drug does not do wonders for focus in those with add as I have felt it first hand. I am now going to try the adult add medications and hopefully I will be able to find one that works for me. But if it doesn’t, I would not go back to the pain and withdrawal that I experienced before, one does not outweigh the other for me. There is not enough hydrocodone in the world to help someone over a lifetime as your milligrams increase and you would risk overdose over a period of years i believe. If a drug to stop withdrawal was created that was relatively affordable it might be worth it someday, because the person could break from the medicine and then begin after a period of time once the tolerance was reduced. I speak from the other side of the street having tried the narcotics first. I will let you know how the add medicines fair in comparison.
Shante–
Thank you for your story . . . very compelling. I’m glad that you made it through with your life intact. Please write back and let us know. Your story does, however, add to an increasing number of stories of people getting benefit from narcotics for their ADD independent of any sense of “high” (which is not mentioned by you or by others). Perhaps someday there will be a medicine based on this biology that will work without the potential liabilities of the current narcotics.
–DH MD
Hello, as other people from this thread, I suffer from
lifelong brain fog/concentration difficulties/fatigue
issues. I took Vicodin after a recent surgery, and for
several hours felt like a totally different person.
My head worked great, and I had boundless energy.
I scheduled an appointment with a phychiatrist,
and now try to “do my homework”. Given that I
have such a positive reaction to Vicodin, perhaps you can recommend me something that can be both effective for
my brain fog and safe for long-term use?
Thank you in advance – Michael.
Michael–This is a huge problem. As you have probably read on this site, there is a subset of people who get clear and sharp on narcotic medicine. They do not describe a “high” or “numb” but DO describe a “normal” . . . perhaps for the first time in their adult lives. Unfortunately, there is nothing long term that can be used that I would consider safe. The narcotics are addictive in the long run and present all sorts of legal issues for the prescribing psychiatrist. you do not mention other medicine that has been tried so I don’t know of your experience (if any) with the standard agents. You write that you are in with a psychiatrist. Just be honest and straight with that person and be persistent. Good luck.
–DH MD