Those of you who follow along faithfully in my writing know that I am a reasonable fan of the anti-anxiety tranquilizers–the benzodiazepines. While some docs I know prescribe them only under duress, I find them a useful option when my patients are suffering from extreme anxiety. Those docs who are reluctant often have a history of being burned by a patient (or patients) who have misused the medicine or have become inappropriately dependent on them. I tend to think that not prescribing them at all is like throwing the baby out with the bath water. That said, there are patients who cannot and should not take them. The trick is knowing when to refuse to prescribe them.
A unique challenge is presented by the patient who is very very anxious, and not getting any relief from even high doses of benzos. Despite the high rate of successful treatment with these medicines, some patients stand out as treatment resistent. For example, I will typically start Klonopin at a dose of 0.5 mg daily for one week then move up to 1 mg daily if needed. This takes care of 90-95% of my patients. Another few percent of patients will respond when I move the dose up to 1.5 or 2 mg daily. Above that, my antenna start wiggling. Some people, it seems, just get no relief from these medicines–or get partial relief which teases them into wanting more and more. My experience is that if you do not get adequate partial relief or full remission of anxiety with 2-3 mg of Klonopin, it is unlikely that this is the medicine for you. Rather than stay with an inadequate treatment, it is better to get off Klonopin and try something else. By that, I don’t necessarily mean another benzodiazepine. For most (not for all), one is as good as another and if one does not work, the rest will likely not work.
When benzos don’t work, it may be time to re-evaluate the patient and make sure the diagnosis is correct. It may be time to try a atypical antipsychotics (such as Seroquel). It may be time to try off-label options such as Neurontin. It is definitely time to re-evaluate the non-pharmacologic issues in the patient’s life and aggressively address them in therapy. Life-style adjustments that include more exercize, more time outside, more stress-free activities and more fun are very important. Internal thought and attitude adjustments need to be addressed as well. Changing how you process and how you think about issues can go a long way to decreasing your anxiety responce to life. Getting over anxiety (or even just dealing with it) is a lot of work. Just throwing medicines at it is typically not the best solution. Taking an active role in addressing the root cause (if there is one) and changing your mental and physical responces to your anxiety typically is the best solution.
–Dan Hartman, MD
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?