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Episode 156 Repost of 37

  • What are the benzodiazepines used for anti anxiety?

  • What’s the difference between them?

  • Are benzodiazepines ever safe?

Ativan, Xanax and Klonopin are some of the most prescribed medications in America for anti anxiety.. What’s the difference between them? Tune in to this week’s episode of All Things Substance.

Helpful Links

Lorazepam – StatPearls – NCBI Bookshelf

Adverse performance effects of acute lorazepam administration in elderly long-term users: pharmacokinetic and clinical predictors

Specific Effects of an Amnesic Drug: Effect of Lorazepam on Study Time Allocation and on Judgment of Learning | Neuropsychopharmacology

Lorazepam – StatPearls – NCBI Bookshelf

Ativan (Lorazepam): Uses, Dosage, Side Effects, Interactions, Warning

Lorazepam (Ativan) | NAMI: National Alliance on Mental Illness

Alprazolam (Xanax) | NAMI: National Alliance on Mental Illness

Clonazepam (Klonopin) | NAMI: National Alliance on Mental Illness

Ativan vs. Xanax: Similarities and differences

Alprazolam – StatPearls – NCBI Bookshelf

StatPearls – NCBI Bookshelf

Clonazepam – StatPearls – NCBI Bookshelf

Klonopin (Clonazepam): Uses, Dosage, Side Effects, Interactions, Warning

Klonopin vs. Xanax for Panic and Anxiety: Differences & Side Effects

Addiction: Part I. Benzodiazepines-Side Effects, Abuse Risk and Alternatives – American Family Physician

Held Hostage by an Rx: My Klonopin Nightmare

Klonopin for Social Anxiety: Dosage and Side Effects

A Clinical Review of the Treatment of Catatonia

Catatonia Diagnosis: The Lorazepam Challenge – Psychopharmacology Institute

Adolescent Catatonia Successfully Treated with Lorazepam and Aripiprazole

FDA Finally Approves the Ativan Diffuser for all Hospital Units | Snopes.com

A Case of Concurrent Delirium and Catatonia in a Woman With Coronavirus Disease 2019

Unexpected cancellation on a catatonic patient’s electroconvulsive therapy due to the coronavirus pandemic

Case Report: A Case of Pediatric Catatonia: Role of the Lorazepam Challenge Test

Oral clonazepam versus lorazepam in the treatment of methamphetamine-poisoned children: a pilot clinical trial

A Case of Catatonia in a Man With COVID-19

The Efficacy and Safety of Clonazepam in Patients with Anxiety Disorder Taking Newer Antidepressants: A Multicenter Naturalistic Study

Xanax, My Friend, My Nightmare. Trying not to let benzodiazepines take… | by Karolína Fialka | Invisible Illness | Medium

How Xanax Became the British Teenager’s Drug of Choice

Rise in fake benzodiazepines in the UK may put people at risk of serious harm

Flualprazolam found in fake ‘Xanax’ tablet :: High Alert

Korn’s Jonathan Davis On Xanax Addiction: ‘Benzos Are The Devil’

So, you’re taking Xanax for the first time. This is what you need to know

Lorazepam for psychogenic catatonia | American Journal of Psychiatry

A Clinical Review of the Treatment of Catatonia

Lena Dunham Reveals She’s 6 Months Sober After Misusing Klonopin | Vogue

Clonazepam Basic Seizure Medication | Epilepsy Foundation

Risks Associated with Long-Term Benzodiazepine Use – Editorials – American Family Physician

Benzodiazepines Drug Class: List, Uses, Side Effects, Types & Addition

https://www.psychiatrictimes.com/view/benzodiazepine-use-risk-dementia

Risk of Dementia in Long-Term Benzodiazepine Users: Evidence from a Meta-Analysis of Observational Studies

Frontiers | Benzodiazepines and Related Drugs as a Risk Factor in Alzheimer’s Disease Dementia | Frontiers in Aging Neuroscience

Benzodiazepines: Revisiting Clinical Issues in Treating Anxiety Disorders

The epidemiology of benzodiazepine misuse: A systematic review*

High enhancer, downer, withdrawal helper: Multifunctional nonmedical benzodiazepine use among young adult opioid users in New York City

Patterns in Outpatient Benzodiazepine Prescribing in the United States

Antidepressants plus benzodiazepines for adults with major depression

Benzodiazepine Use and Misuse Among Adults in the United States

Benzodiazepine Pharmacology and Central Nervous System–Mediated Effects

Benzodiazepine use, misuse, and abuse: A review

Withdrawal effects of benzodiazepines | Mind, the mental health charity – help for mental health problems

Tolerance to benzodiazepines among long-term users in primary care | Family Practice | Oxford Academic

Research suggests benzodiazepine use is high while use disorder rates are low | National Institute on Drug Abuse (NIDA)

Benzo withdrawal: Timeline and symptoms

Mechanisms Underlying Tolerance after Long-Term Benzodiazepine Use: A Future for Subtype-Selective GABAA Receptor Modulators?

The hidden phenomenon of high dose benzodiazepine use | Pharmaco Vigilance

Free Treatment Tool https://betsybyler.com/treatment-tool/

Transcript

You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective.  I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor.  It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice.   So join me each week as we talk about All Things Substance.

Welcome back to the All Things Substance podcast. This is episode 37.  Today we pick up where we left off last week, talking about benzodiazepines. In the last episode, I went over the basic class of benzodiazepines, the different kinds, what they’re used for, and the risks associated with benzodiazepines in general. 

Today, I wanted to take a little bit of a deeper dive and talk about the three main medications that could be prescribed to our clients for primarily anxiety, but also at times for depression. I don’t know that we’re in the field very long before somebody comes to us and they report they have a prescription for one of these three medications: Ativan, Xanax and Klonopin. 

I don’t know that all of us got great training on psychopharmacology and if we did, it might even be outdated depending on how long we’ve been in practice. I find that I get to communicate a lot with primary care and that they’re willing to work with me, which has been amazing for me and my clients. I live in an area of the United States where psychiatry is pretty limited. I’m going to guess that other people are nodding their head thinking that they have  limited psychiatry too and that you’ve had to use primary care in order to get your clients on medication.

We’re going to be covering these three medications because they fall into the substance abuse and addiction realm. First, we’re going to start with lorazepam or commonly known as Ativan. Ativan is considered a high potency benzodiazepine with a short half-life meaning that it works quickly and wears off relatively quickly. In terms of other benzodiazepines. 

Anti anxiety: Ativan

Lorazepam has been around since 1977 and has a common use as a sedative of choice in an inpatient setting due to the fact that it has a fast onset when administered through an IV. Typically that’s about three minutes for it to get into the bloodstream and take effect. It’s also one of the few sedative hypnotics that has a pretty clean side effect profile. 

The FDA approved it for short term as in four months, according to them relief for anxiety or symptoms related to anxiety. It’s also been approved for use treating insomnia, as premedication for anesthesia or to produce sedation or amnesia of the procedure and treatment of status epilepticus.

There’s a number of off-label, meaning not FDA approved uses.  Sometimes it’s used to rapidly tranquilize an agitated patient. Can also be used for treating alcohol withdrawal, including delirium related to the withdrawal, non anxiety associated insomnia, panic disorder, chemotherapy associated anticipatory nausea and vomiting, as well as psychogenic catatonia.

Ativan binds to the GABA receptors at several sites within the central nervous system. It increases the inhibitory effects of GABA and this inhibitory action in the amygdala helps with anxiety disorders. While the inhibitory activity in the cerebral cortex helps in seizure disorders.

So Ativan  comes in tablets or as a liquid that’s given IV.  The tablets are usually dispensed as a 0.5 milligram, one milligram and a two milligram tablet. The dosage though is going to vary depending on the use of it. When it’s used for anxiety, the initial dose that I found started at two milligrams to three milligrams by mouth. This could be repeated two to three times per day, maxing out at 10 milligrams a day. 

I’m not really sure where that comes from because holy shit, I would be asleep. I mean, on my ass, if I took that much Ativan. I recall before a surgery, I think they gave me one milligram of Ativan and I was high as a kite. So 10 milligrams. Wow. 

For insomnia due to anxiety or stress, the dosage is about 0.5 to two milligrams at bedtime. For people 65 years or older, like we talked about in the last episode, that gets reduced from 0.5 to one milligram. For premedication for anesthesia,  it’s suggested to administer it two hours before surgery with a dose 0.5 milligrams up to four milligrams at the max. For this instance, if you’re over 50, they want to drop that to a max of two milligrams.

In the off-label uses for status epilepticus they’re looking at a 0.1 milligram per kilogram with a maximum dose of four milligrams. They suggest a maximum rate of two milligrams per minute. May repeat in five to 10 minutes. For an agitated patient they’re looking at a maximum single dose of two milligrams with a maintenance dose every two to six hours as needed. Again, maximum dose of less than 10 milligrams.  

For use in alcohol withdrawal we’re talking about this being done IV not something typically that’s done at home that tends to be Librium.  For alcohol withdrawal, being treated in the hospital we’re talking about one to four milligrams, every five to 15 minutes until the patient is calm. That’s for the delirium part. When it comes to alcohol withdrawal syndrome we’re looking at two milligrams to four milligrams per hour.

The last one is psychogenic catatonia, which we’re going to talk about in just a few minutes. This one is going to be in a shot form one to two milligrams, and you could repeat the dose in three hours and again in another three hours. This treatment could be continued for up to five days.

The side effects of Ativan  are the same as the others in the class of benzodiazepines. Of course, because it’s a different medication there’s going to be ones that are a little more likely and a little less likely to occur with each medication. What we want to pay attention to  is the contraindications as they vary for each of the three medications.

This is to be expected, anyone with severe respiratory impairment is on the no-no list for getting Ativan. Except during mechanical ventilation, like during procedures. As well there is caution about anyone with narrow angle glaucoma. Specifically, there are contraindications about using this during pregnancy at all, but specifically during the first and third trimester.

There are documented case reports and case control studies that show an increased risk for cleft palate and cleft lip with the use of Ativan and some of the other benzodiazepines as well. This is the caution for the first trimester. In the third trimester, there’s an increased risk of causing neonatal abstinence syndrome. We talked about this when we went over opiates, and this is where when the infant is born, they start going through withdrawal from the substance.

The caution is there that if Ativan needs to be used during pregnancy, that the benefit of it needs to outweigh the risk. I read that some primary care and some OB GYN  have continued prescribing  some benzodiazepines to pregnant women in order to deal with the increased anxiety. It doesn’t say how much benzodiazepine is a problem. I’m not sure that they’ve documented how much of the Ativan it would take to start causing issues with development in utero.

There have been some studies done specifically with Ativan  in reference to memory recall and allocation of time.  The studies were done on participants  currently either given Ativan at that moment or given a placebo. They found that those taking Ativan had more trouble with memory recall and with placing things in time accurately. Other studies have talked about memory recall being a difficulty as well in longer term use

Ativan has been shown to cause transient amnesia following a single intake. There are a number of studies on this. During the amnesic episode, results have shown that the episodic memory is specifically impaired. These amnesic effects aren’t necessarily  evident to the person taking the Ativan.

So we need to talk about Ativan and catatonia. Catatonia isn’t something that I think we really talk about a lot. Even though on our PHQ-9 one of our questions actually refers to some of the symptoms of catatonia. The DSM used to talk about different kinds of catatonia. Although the current edition doesn’t split them into types.

One type talks about slow movement, such that other people might notice. This is known as a kinetic catatonia. Hyper kinetic catatonia is where a person appears sped up restless and agitated, sometimes engaging in self-harming behavior. So on the PHQ-9, I think it’s question eight where it asks whether or not you have been moving so slowly that others have noticed , or if you’ve been so restless, agitated, unable to sit still.

The third type used to be called malignant catatonia in which a person might experience delirium. There’s often a fever, fast heartbeat and high blood pressure. According to the DSM, there’s several things that can cause catatonia, neurodevelopmental disorders, psychotic disorders, bipolar disorder and depressive disorders. There are other medical conditions  such as cerebral folate deficiency, rare auto-immune disorders and rare paraneoplastic disorders, which are related to cancerous tumors.

Catatonia is going to look different on different people. Most common symptom though, is them being in a stupor where the person isn’t really moving or speaking or responding to stimuli. Unless of course it’s the hyperkinetic kind and then there’s excessive movement and agitated behavior. So catatonia can last anywhere from a few hours to a few weeks to months or even years.  It can recur frequently for weeks and years after the initial episode.

Catatonia has typically been associated with schizophrenia, but now psychiatrists classify it as its own disorder.  I saw data suggesting that about 20% of the people who have catatonia have schizophrenia, and the others are either mood disorders, which they predicted was 45% and the rest from other causes. This is where Ativan comes in and it’s really interesting in what it’s able to do.

They actually use Ativan to determine whether or not what they’re seeing is catatonia. It’s called the lorazepam challenge. This is a for real thing.  The lorazepam challenge is where two milligrams IV are given to a candidate that they believe has catatonia. And that they’re able to predict the response to the benzodiazepines.

Lorazepam has a greater preference for the GABA A  receptor, which makes it ideal in this instance. Positive response to the lorazepam challenge is not necessarily a guarantee. Because there are other conditions that may improve with lorazepam, which can sometimes mimic catatonia. These include seizures, particularly non convulsive, as well as alcohol or benzodiazepine withdrawal states.

Similarly, a negative response to lorazepam challenge doesn’t rule out catatonia because some patients with catatonia will require higher doses of lorazepam while others will not respond to benzodiazepine at all. So without going into a ton of information about catatonia treatment, it does seem to be fairly effective.

It’s not necessarily effective across the board, but they are able to resolve catatonia. Even catatonia that’s been around for several years with some pretty sizable doses of lorazepam given over the span of several days. There are a number of articles of this being used with children and within the pediatric realm for children who have experienced toxicity due to methamphetamine exposure.

It’s also been used with people who have had COVID 19 and experiencing catatonia. I’ve included links to articles that were published within the last year or two if you care to look into it,

I should comment on this part because I don’t think I mentioned it in the last episode. With any of these, there is a chance that there could be a paradoxical effect. A paradoxical effect isn’t limited to just benzodiazepines. I’ve had clients who I’ve  had a paradoxical effect on Gabapentin, Seroquel,  and of course there’s a paradoxical effect for some of the depression medications, where they actually have a chance of making someone worse rather than better. 

By context, you can probably tell that the paradoxical effect is where somebody’s reaction to the medication is opposite of what we would expect. So for the benzodiazepine class, it can be that their anxiety increases. They get agitated, there’s hostility, aggression, and insomnia. Those are things we always want to pay attention to. Clients should always let their doctor know if in the past they’ve had a paradoxical reaction to another benzodiazepine. Because there are warnings about this kind of all over that if you’ve had a reaction to one that you need to be really careful about using a different medication in the same class.

The last thing I’ll say about Ativan is that there was an article that came out in 2015 with the title FDA Finally Approves the Ativan Diffuser for All Hospital Units. The article stating that the FDA had approved of the hospital use of a mechanism  to send anxiety medication throughout the ward. The idea is that it would be like a vaporizer and that Ativan would be equally distributed amongst staff and patients.

This was actually an article sort of like in the Onion. It’s part of the Gomer blog. Gomer is an acronym for Get Out Of My Emergency Room. It’s a hundred percent satire  and like the onion sometimes gets misconstrued as actual news. So no, there is no diffuser for Ativan coming to the units.   

Ativan tends to be the go-to  when it comes to some of the more medical procedures and managing people’s anxiety about them.  There’s another medication that’s also a high potency benzodiazepine with a short half-life and that is Alprazolam or Xanax. Xanax might be in the same category,  but it can act even faster and leave even more quickly than Ativan. This is given in pill form although there are some rapid dissolve tablets that are available.

You can imagine that for panic attacks, something that hits more quickly is desirable. Anyone who’s had a panic attack, knows that every second feels really long and getting relief sooner can be pretty important. It’s also this factor that makes Xanax one of the most abused prescription medications next to opiates. It’s preferred over Klonopin and Ativan hands down. The majority of benzodiazepine emergency department visits are from anti anxiety meds like Xanax, not Klonopin and Ativan

Anti anxiety: Xanax

Xanax is one of the most commonly prescribed psychotropic medications in the United States. If not the top psychotropic medication prescribed in the United States. This means that there’s a lot of Xanax out in the street. Not that it’s necessarily coming all from legitimate means. 

There is a huge market for pressed pills when it comes to Xanax.  Xanax has a pretty rapid effect, which makes it ideal for  using while partying. Remember the last episode, when I talked about the fact that benzodiazepines aren’t typically used alone, when someone’s abusing them. They’re usually using them with something else, alcohol, weed, opiates, et cetera.

Now, specifically with opiates, that’s a different thing that we want to note. If someone is taking an opiate and they drop Xanax on top of that, it’s going to increase the euphoric effect. And this is going to happen, even if they’re on Suboxone, which is a partial agonist therapy for opiate addiction or on methadone. When someone’s on Suboxone or methadone, from what I can tell, they really shouldn’t be using benzodiazepines.

And I qualify that because I am not a medical professional. I am a therapist. I know that in the program that I was involved in, we absolutely had to taper people off their benzodiazepines when they were going onto Suboxone, because it definitely is a way that they can get high. When they’re on Suboxone or methadone, they’re taking a dose that they shouldn’t be getting high on. It’s just something to maintain. So they don’t go into withdrawal, but drop a Xanax on top of that and they are definitely going to get high.

Xanax is FDA approved  to treat generalized anxiety disorder and panic disorder with or without agoraphobia. Off-label, it’s sometimes used for insomnia, for premenstrual syndrome and for depression. There’s some controversy over  whether benzodiazepines should be prescribed to someone who has a primary depressive disorder. I’ll include some links in the show notes. If you’re interested in that.

As I mentioned, Xanax is typically in a pill form that you swallow tablets. Start in 0.25 milligrams, 0.5 milligrams, up to one milligram tablets. There are also two and three milligram tabs available. However, once we get up to a two milligram then we’re looking at something called bars.

They’re called Xanax bars on the street. They look like rectangles with four little sections. In Australia and New Zealand there have been a ton of counterfeit Xanax bars going through that are yellow instead of the white. I saw a link online where I could buy a stamper to make Xanax bars that look identical to the stuff that you get from the pharmacy. When someone says they’re doing a Xanax bar, they’re talking about a two milligram bar, which is  about the diameter of a nickel.  

The dosage recommendations depend on what it’s being used for.  For treatment of anxiety disorders the adult dosage is approximately 0.25 to 0.5 milligrams. Up to three times a day. The dosage increase isn’t suggested to stop at four milligrams a day. 

For geriatric population that changes where they’d prefer it to be 0.25 milligrams, two or three times a day. When we’re talking about panic disorders, the adult dosage instead is 0.5 to one milligram a day with a maximum dose of 10 milligrams a day. Holy shit that’s a lot. The geriatric starting dose is listed at 0.5 milligrams a day.

There are warnings all over  the benzodiazepine class about issues with liver and kidneys. There are dosage adjustments listed for most of them. If someone has some impairment in those systems,

Xanax has shown to result in a more severe withdrawal syndrome than other benzodiazepines, even when it’s being tapered according to the manufacturer’s direction.  They suggest  switching a person from alprazolam to something like clonazepam or diazepam and try and titrate down on that  rather than titrating down the Xanax.

In terms of contraindications there are medications  known to impact alprazolam such as specific antifungals and certain antidepressants like fluoxetine. Other drug interactions listed are St. John’s Wort, seizure medications, antihistamines and muscle relaxers. 

In terms of pregnancy, alprazolam is known to cross the placenta. Studies evaluating pregnancy outcomes for women exposed to alprazolam found conflicting results of congenital abnormalities. Positive studies reported the occurrence of cleft lip, inguinal hernia, congenital hip dislocation, neonatal withdrawal syndrome, and congenital malformations to name a few. Again, article on the show notes.

The FDA identified alprazolam as well as other benzodiazepines, as a pregnancy category D which indicates prior evidence of human fetal risk. In addition to the issues in utero, alprazolam is also excreted into breast milk although in low concentrations,

There are several case reports of delirium and psychosis caused by withdrawal from alprazolam. The other two benzodiazepines I mentioned have some reports, but they’re really fewer and farther between than alprazolam.

According to the literature. Xanax is significantly more toxic than other benzodiazepines in cases of overdose and should be avoided in patients that have  increased risk of suicide, or are using alcohol, opioids or other sedated drugs.

In terms of memory recall, there is some impairment. In one study, they found that the chronic administration of Xanax affected memory. However, it didn’t seem to affect attention, or psychomotor performance.

Xanax as I said, is a popular party drug and not just in the United States. There are numerous articles coming from New Zealand, Australia, and the UK talking about the rampant use of Xanax in the teen population, especially. One story talked about a recovering addict at age 17, who had been using approximately six milligrams of Xanax a day and was working on getting clean.

It’s no secret that I grew up in the grunge era and that’s where I became familiar with the band Korn. The lead singer of Korn, Jonathan Davis  was interviewed by Forbes magazine. In it he talked about his addiction to Xanax. He originally got sober 20 years ago from alcohol stating that he just had to stop partying because he had a wife and kids who were depending on him. 

Later on, he was using Xanax to treat his anxiety and depression. He says, “I’ve dealt with anxiety a long-ass time. I got prescribed Xanax a long time ago. Benzos are the fucking devil. They’re horrible drugs. They feel good at the moment. And our quick fix to get you out of a panic attack, but they’re not designed to be taken long-term, especially Xanax.”

He ended up taking about four milligrams. That’s two Xanax bars a day. It took him three tries to get totally clean.  He is sober. He talks about his experience in detox and how terrible it was. 

Remember when we talked about dosing and the dosage said no more than 10 milligrams a day,  this guy was taking only four milligrams a day and developed an incredible tolerance to it and needed it in order to be okay. Now he’s completely free from it and managing his anxiety differently.

He’s quoted as saying “It got to the point where I’d rather have anxiety than deal with having a fucking leash around my neck, to these fucking pills.”

Anti anxiety: Klonopin

The last drug we’re going to cover today is clonazepam or Klonopin. Klonopin is known as a high potency benzodiazepine, but it has a long half-life which is different from Xanax and Ativan which have short half lives. Klonopin is typically used for management  of panic disorder and for epilepsy. It has a number of off-label uses as well, are either monotherapy or adjunctive therapy for treatment of mania, restless leg syndrome, insomnia tardive dyskinesia, and REM sleep behavior.

We’ll talk about seizure disorders first. It’s primary use is for acute management of epilepsy and acute treatment of non convulsive status epilepticus, specifically complex partial seizures or absence seizures. It’s also reported to be effective in controlling minor motor seizures of childhood, particularly petit mal absences, Lennox-Gastaut syndrome, and infantile spasm.  It’s also used as treatment for psychomotor myoclonic epilepsies, grand mal and focal motor seizures. 

It’s not used as first-line for these conditions, more adjunct, or if patients are resistant to the standard treatment  or having breakthrough seizures. It’s often used in conjunction with Depakote to treat certain kinds of seizures and has been known to be useful for seizures brought about by flashing lights.

The problem comes with the long-term treatments because the withdrawal from benzodiazepines  is significant because of the seizure risk. We know that benzodiazepines lose their efficacy over time and cause physical dependence. Clonazepam being used with epilepsy is something that’s done of course, but always carefully monitored.

So when it comes to mental health, clonazepam is used for the short-term management of panic disorders with and without agoraphobia. The reason it’s short-term of course is again because of the dependence and the loss of efficacy over time. It is noted that it may be less likely to cause rebound anxiety when you stop than the other benzos because of its longer half-life.

I found that sort of interesting and contrary to what I’ve seen in my practice over the years.  According to the literature, Xanax has a more severe withdrawal syndrome and Klonopin has an easier one. Which makes me really concerned about people going through withdrawal.

I have had a number of clients over the years who were on significant amounts of Klonopin every day. When they came to my office and I find out they’re taking four or five, six milligrams of Klonopin every day and have for the last five to 10 years, that is a huge problem. Because at that point they’re having rebound anxiety all the time because the Klonopin can’t keep up with it.

It loses its effectiveness because the body gets used to it and they have to take it, even though it’s not working. Otherwise they go into withdrawal and there’s a whole host of other problems. I have watched these clients of mine go through withdrawal even after a long time of tapering down and they were still dealing with withdrawal symptoms for months. 

It made it really difficult to get anything done in therapy because their mood was all over the place. They were in pain and having different issues pop up every week. It really sidetracks things. And I totally get why. If your body is freaking out and thinking that you’re in danger, then  you can’t focus on higher level things. Sort of like in Maslow’s hierarchy of needs. 

When you’re in withdrawal from benzodiazepines, your system is upset  and the nerves are firing all over the place. Remember that benzodiazepines are like putting a weighted blanket on those nerves. Well, we just ripped the weighted blanket off that was not just laying on them, but had become part of them. That takes a really long time to rewire. It completely depends on how much they were taking, how long they were taking it and the person’s physical makeup.

Klonopin is also used to treat acute mania. Clonazepam has an anticonvulsant and serotonin agonist activity. Both of which are associated  with its antimanic effect. Research found that it was significantly more effective than lithium in reducing manic symptoms and that Haldol usage was able to be dropped when people were using clonazepam.

So let’s talk dosage. Klonopin comes in pill form. There are also the rapid dissolve tabs, like we talked about with Xanax. In terms of seizures for adolescents and adults, we’re looking at 0.5 milligram tabs  taken three times a day with a maximum daily dose of 20 milligrams.  The point here is to get seizures under control. So they’re not suggesting that someone is taking up to 20 milligrams every day for a long period of time. This is about getting things under control. For pediatric doses and dealing with epilepsy, it’s going to depend on the weight of the child.  

Treating panic disorder. The suggested starting dose is 0.25 milligrams to be taken twice a day for three days. Then increasing the dose that shouldn’t exceed four milligrams a day.

The contra-indications are similar to the other benzodiazepines we talked about today. Narrow angle glaucoma is one that’s specifically pointed out as well as those with significant liver disease.

In terms of pregnancy clonazepam is also a class D drug. As we’ve talked about. It has links with some facial and cardiac malformations in fetal development. Research suggested that use of clonazepam in late pregnancy could lead to what’s called floppy infant syndrome or severe neonatal withdrawal syndrome. Which could include hypotonia, cyanosis, apneic spells, and impaired metabolic responses to cold stress. Clonazepam goes into the breast milk, like other benzodiazepines, although it’s said to be not in a significant amount.

Things to note is that clonazepam  could cause a worsening of seizures in persons who have multiple types of seizure disorders. Impaired cognitive and motor performance are also associated with use of Klonopin. Additionally the literature points out that there could be an increased risk of falling in elderly patients. Clonazepam is associated with an increased risk of suicidal behavior in some patients. 

Klonopin occasionally  makes the news because of someone who’s had a struggle with it. Most recently in 2018, Lena Durham was interviewed by Vogue when she was six months sober from Klonopin. She started taking Klonopin after she was diagnosed with pretty serious PTSD. She had some difficulty with showing up for different events and being in the public eye.

She’s quoted as saying “Nobody I know who was prescribed these medications is told by the way, when you try and get off this, it’s going to be like the most hellacious acid trip you’ve ever had where you’re fucking clutching the walls and the hair is blowing off your head and you can’t believe you found yourself in this situation.”

Now she says “the literal smell of the inside of the bottles makes me want to throw up”. In the interview, she talked about how even after six months, she felt like her body and brain were still adjusting to living without Klonopin. At that point, she was feeling like she’d gotten on the other side and was on her way back to normal.

Stevie Nicks  has also been in the news back in 2011 when she talked about her struggle with Klonopin. She’s quoted as saying, “I didn’t understand right up until the end that it was Klonopin that was making me crazy”. She goes on to say,” I really didn’t realize it was that drug because I was taking it from a doctor and it was prescribed.”

Some people have referred to it as a hidden epidemic, because between 1996 and 2013, the number of adults filling prescriptions for benzodiazepines increased 67% in the United States. Yet benzodiazepines are considered a Schedule 4 drug that has a low potential for abuse or dependence. I really think we need to be rethinking some of these classifications.

I found another article titled “Held Hostage by a Prescription: My Klonopin Nightmare”. In this article, he talks about how he was given Klonopin by his doctor; that he always followed the dosage instructions to the letter.

He said he was first prescribed Klonopin by a former doctor, about nine years before. He stated  that he had a son who was struggling with depression and addiction and it was taxing on the whole family. His anxiety, understandably, skyrocketed and he was having trouble sleeping.

Well, the psychiatrist gave him a prescription of taking 0.5 milligrams five times a day. Which is kind of a lot. So he’s taking 2.5 milligrams a day off the bat. A couple of years later, he said he started feeling depressed and was seeing a therapist. The therapist heard how much he was taking and apparently told him he was “grossly overmedicated”. Apparently she even suggested that his depression could be directly related to Klonopin use. I’d have to say  she’s right in wondering if that was the cause. 

He decided he didn’t want to take Klonopin anymore. So he went home that afternoon, and flushed all his remaining pills down the toilet. The next morning he says, “I felt like I was dying. I had chills, my head hurt and my body was shaking uncontrollably. I couldn’t even get out of bed. Naively. I thought I had come down with a bad case of the flu.”

He goes on to say that he had his wife called a psychiatrist to see if those two things were related. Side note, this was a different psychiatrist than the person who had originally put him on the medication. The psychiatrist said that yes, it could be related and that he shouldn’t have stopped taking Klonopin cold turkey.

The man in the article mentions  that he was never told any information about the negative side effects or the long-term use. He made a decision to slowly taper off the Klonopin. He states that he’s been tapering his dosage for several years now. He says, “Yes. Years. I’ve gone from taking five tablets a day to taking just a little more than half tablet a day. In a few months, I plan on being completely Klonopin free.” He ends by saying “I’m breaking up with Klonopin and I can’t wait until it’s totally out of my life.

Treating anxiety and panic disorders is a big one for all of us. I know sitting with clients that I have felt like I wanted their doctors to just give them some Xanax for fuck’s sake or something like that so that they had it on hand. I’ve been working with clients who have anxiety, panic, and PTSD can be really challenging if they’re having panic attacks all the time or afraid that they’re going to have panic attacks.

These medications are useful when they’re used in a short term, really sporadic way. The problem though, is that they can be abused and dependence can happen pretty quickly. So where does that leave us as therapists? Well, when we’re doing an intake, we talk about medications, right? We ask people what their prescriptions are, what their dosage is, and we leave it at that. 

With benzodiazepines though,  I think we need to know how much they’re taking, how often they take it and if they say just every once in a while, I want to know what that is. Is that once a week? Is that once a month? I have found that people’s version  of what constitutes “a little while” or” not that often” varies wildly.

I had some thoughts that I wanted to share with you in closing about benzos when you’re working with clients. As we’re assessing, get the dose, how long they’ve been taking it for and how often they take it. We want to know when their last panic attack was, how many benzodiazepines did they take in that moment to help with that panic attack?

Was that just one? Was that a couple? Was that for a few days? How did they manage that panic attack? I also want to know when their worst panic attack was because when we’re doing scaling, that is number 10, the worst panic attack they ever had and the scariest one. When they had that panic attack was that while they were taking benzos, were they available?  Were they not available?

I’d like to know whether that dose of benzodiazepine has gone up or down. I’d like to know whether they know that there’s a risk of dependence with the use of this drug. I don’t want to discourage them off of it, but I do want to make sure that they’re informed.

I’d like to know how it feels to have the prescription. Does it help them manage their panic? And if they’re concerned about their use of benzodiazepines, I want to make sure that we set up some parameters that they’re comfortable with in how they’re going to be using it. Not at all that we’re in charge of how they use it or what they’re going to do. Just that we have an idea. 

I’d like to know if they’re using more and I need a baseline in order to do that. If you have somebody who is using them, and it sounds like kind of a lot, you want to start asking about have they ever had a problem? Do they take it every day? Do they have withdrawal symptoms?

They may not recognize it as withdrawal symptoms. They may say that without it, they get crazy anxious and so they have to take it every day. Well, an anxiety could be from their regular anxiety disorder or their panic disorder, or it could be as a result of withdrawal syndrome.

Lastly, I’d like to know what their doctor’s attitude is about them taking benzodiazepines. Is the doctor say anything about it ever or do they just refill it? Typically they’re not huge fans of just refilling over and over. That can cause a lot of anxiety for our people and I totally get that. I’ve had experiences where one of my doctors was out and another one was filling in and they didn’t want to fill one of my medications and I kind of lost my shit. I was like, who the fuck are you? And why are you messing with the medications that my doctor put me on?

In this country where a lot of us don’t see our primary doctor, I think a lot of our clients have had this experience too. They get really anxious when someone messes with her anxiety medication. So we want to be able to help them and monitor and possibly intervene if necessary to let the doctor know how the person is doing on the medication. 

Doctors only see their patients for 20 minutes if that sometimes we see them sometimes four hours a month and we have a much better idea how they’re fairing on their medications. Our information can be super helpful for the doctors. 

When it comes to abuse and dependence, this can be really scary for them to talk about just like anyone who’s addicted to pills. They’re afraid if they share that information, that things are going to go badly and that they’re not going to have their medication and be taken off cold turkey. Doctors know that coming off benzodiazepines are really dangerous and it could be fatal and so  they are going to taper someone off. 

Those clients are going to need our help.  We can work with them while they’re tapering and hopefully help deal with the increased anxiety that’s coming. I think we also need to be checking on suicidal ideation even more than we normally would. Not necessarily so that they feel like we’re always talking about it, but just as part of our normal check-in, how was your week? Did you have any bad days? Did you have a panic attack? Have you had any suicidal thoughts? Things like that. 

Benzodiazepines I think can be really, really useful. There are many cases over my career where I have absolutely supported the use of benzodiazepines for that client for specific reasons. I’ve also run into people who, for whatever reason, we’re still prescribed them for a really long time and coming off them was a nightmare. 

So in your practice, as you’re seeing people and doing their assessment, I would encourage you to get extra information about benzodiazepines. Let them know that you don’t have any judgment about them having benzodiazepines that you’d just like to know where they’re at, so that you know how they’re managing their anxiety and how often those panic attacks are happening. If they are having multiple panic attacks a week, I would suggest that perhaps  the first-line medication isn’t doing a good enough job of managing that anxiety.

They’re having way more than just breakthrough panic attacks and it might be time to have them have their medication reevaluated and possibly move them towards seeing a psychiatry person rather than primary care. 

I know in a lot of places that that’s really hard. I have found in my area that we have a shortage of psychiatry, but that because I’m willing to work with primary care and talk to them, they are way more willing to prescribe if they know that someone is keeping a close eye on the patient.

I have some plans for the podcast that I wanted to share with you. I’m planning on bringing you a series of interviews with therapists and others in our field who are also in recovery. The couple of interviews that I’ve done with folks in recovery have gone over really well with all of you.

There are two other interviews on the channel that you can hop over and listen to. One is called Opiates: A Recovering Addicts View. Where I talk with Justin,  who is a master’s level social worker working as a therapist and a substance abuse counselor, and is in recovery.

Last month. I shared an interview with Anne who is also a licensed clinical social worker and a person in recovery. She works at a residential treatment center in the Detroit area, and she shares her story with us. 

Next week, I’m bringing you an interview with a woman named Heidi. Heidi is a school counselor that I have had the privilege of working with.  I love being able to collaborate with her. She’s also a person in recovery and I’ve never had a chance to actually hear her whole recovery story.  

Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist friends and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know.  Just send a message to podcast@betsybyler.com. I’ll see you on next week’s podcast. And until then have a great week.

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