Contagious Benzophobia?

I know, I know; I’m on vacation and I should stay away from the blog, but my wife says to me this morning, “Hey, did you see the CNN article about Xanax?” So, of course, heedless of the potential consequences, I read it:

I really didn’t much care for the reporter’s sentence, “Part of alprazolam’s fast rise: It is a go-to anti-anxiety drug for psychiatrists and primary care physicians.” 

You can ask any resident in our psychiatry department and they can tell you I’m “benzophobic.” As a psychiatric consultant in the general hospital, I’ve seen the aftermath of too many of the accidents described in the story. This is because the critical care unit doctors always call me or another consultation-liaison (C-L) psychiatrist to assist in the framing of a triage and recovery plan for patients who are lucky enough to survive these episodes.

Sadly, some of these incidents are not accidents. Suicide attempts by overdosing on prescription medications are very common.

Prescribing doctors are only a part of this problem. We could point fingers in a few different directions, even at the pharmaceutical companies:

I have seen this issue of prescription drug misuse and misprescribing so often, that I often fantasize about scientists creating a new disease, “Contagious Benzophobia.” It would be a man-made malady, except it probably would be more aptly described by a neologism, say “saladrome” (salutary syndrome).

That would make it different from a syndrome like PANDAS or Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. That’s a very bad thing that happens to kids who get a specific bacterial infection.

Zombies_Need_Love_Too_small

We need both passion and braaaaains!

On the other hand a saladrome like Contagious Benzophobia could create a sort of beneficial Zombie Apocalypse (Paladin Illumination?). What if you could infect doctors, patients, and pharmaceutical companies with an X-Files-type infective recombinant protein that would replace whatever redundantly recapitulated evolution-pegged cellular blob is responsibe for making us want things like benzodiazepines, oxycodone, heroin, and even cannabis?

On the other hand, I have to wake up sometimes from this fantasy and think about the difficult conversations entailed by confronting the epidemic of prescription drug misuse. After all, benzodiazepines work, as Psych Practice blogger points out in the post on how psychiatry residents sometimes survive their training–which teaches many how to tolerate and cope with powerlessness.

As I reflect on my own not infrequent sense of powerlessness as a psychiatric consultant in these situations, I struggle. Yes, most of us do wrestle with these issues, we don’t just reach for the “go-to anti-anxiety drug.” I sometimes have to tell patients that I don’t think a particular prescription medication is in their long-term best interests.

This is not always met with warm enthusiasm, which I guess should make me glad that the American Board of Psychiatry and Neurology (ABPN) recently made an announcement that seems to allow psychiatrists to choose feedback surveys other than from patients in order to satisfy Maintenance of Certification (MOC) requirements,

I have this other fantasy. Wouldn’t it be great if giving in to an impulse to protect ourselves and our patients from harm were as easy as it seems to be to give in to other impulses which can injure and even kill us?

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Comments

  1. My residency had a really strong addiction psychiatry program, and it taught me to feel comfortable detoxing patients from Benzos, even in an outpatient setting. What it didn’t teach me, in fact, discouraged, was how to feel comfortable prescribing benzos. The benzophobia was so strong, and had such a moral flavor to it, that I felt like I had to make an effort to unlearn some of what I’d learned.
    I still don’t like Xanax, and I’ve personally seen more morbidity from Xanax withdrawal than overdose. It sold for $10 a “stick” (NYC slang, I guess, “bar” elsewhere) a block from the hospital where I trained. I don’t know what the going rate for the 0.5mg “footballs” was.
    But I’ve eased up a lot with other benzos, and I’ve had good experiences prescribing them for my private patients. Maybe the difference is more about the general systemic problem in psychiatry. I get to know my patients VERY well before I’m willing to write for a benzo, and that takes time. In the age of 15 minute med checks and integrated care, that may not be possible.
    BTW, that paragraph about the Zombie Apocalypse borders on poetry.
    Please try to do some actual vacationing on your vacation.

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  2. Great comment, George. Can I get the Janicak reference from you?

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    • I had to recover from my realization that I did not have the Fifth edition. In the Fourth Edition of “Principles and Practice of Pharmacotherapy” you will find Figure 13-2 on page 529 that shows for severe panic disorder only TCA/SSRI plus alprazolam/clonazepam (for first month) followed by insufficient response then “indefinite” therapy followed by MAOIs and then VPA +/- benzodiazepine.

      In my experience, the insufficient responders often have other problems and don’t seem to respond to benzodiazepines either.

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  3. Jim,

    I don’t know if the reporter is aware of the fact that alprazolam 2 mg “bars” are favorites for people with substance use problems and readily available on the streets. From what I can tell there is a trend in decreasing benzodiazepine prescriptions. I have discovered some primary care clinics who use a gate keeper approach and tell people to see a psychiatrist if they request benzodiazepines. There has been some push back by those with the opinion that benzodiazepines are benign medications, but looking at the literature and modern psychopharmacology texts would suggest that they add very little to treatment. At one point in the 1990’s somebody did advocate for high dose alprazolam for panic disorder. I don’t think anybody does that anymore and the recent text by Janicak, et al recommends clonazepam for a month (at the max) while the person adjusts to an SSRI, but in most cases even that is unnecessary.

    George

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